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Miscellaneous

In this section we cover the importance of antibiotic prophylaxis, impart knowledge about the effects of addictive substances, emphasize on the calculation of dose and the normal laboratory values which are helpful in assessing the patient's medical status, prescription abbreviation and the importance of writing the prescription.

The medico-legal and ethical principles upon which the practice of dentistry is based, especially those relating to treatment of patients are also indicated.

Antibiotic Prophylaxis

The goal of antibiotic therapy is to aid the body's defence to clear the tissues of microbial pathogens by achieving antibiotic level in the infected area equal to or greater than the MIC (minimum inhibitory concentration).

Prevention of Bacterial Endocarditis

Dental procedures where endocarditis prophylaxis is recommended

  1. Dental extractions.
  2. Periodontal procedures- surgery, scaling and root planing, probing and recall maintenance.
  3. Endodontic instrumentation or surgery beyond the apex.
  4. Sub-gingival placement of antibiotic fibres or strips.
  5. Initial placement of orthdontic bands and not brackets.
  6. Intraligamentary local anaesthetic injections.
  7. Prophylactic cleaning of teeth or implants where bleeding is anticipated.

Dental procedures where endocarditis prophylaxis is not recommended

  1. Restorative dentistry (operative, prosthodontic) with or without retraction cords.
  2. Local anaesthetic injections (non-intraligamentary).
  3. Intracanal endodontic treatment.
  4. Placement of rubber dam, removable prosthodontic or orthodontic appliance.
  5. Postoperative suture removal.
  6. Taking oral impressions, radiographs.
  7. Shedding of primary teeth.

Prophylactic regimens for dental procedures

Standard Agent Regimen
Standard general procedures Amoxicillin Adults: 2.0g orally 1hr before procedure; Pediatric: 50mg/kg orally 1 hr before procedure
Unable to take oral medications Ampicillin Adults: 2.0g I.M. or I.V. within 30 mins before procedure; Pediatric: 50mg/kg I.M. or I.V. within 30 mins before procedure.
Allergic to penicillin Clindamycin or Cephelexin or Azithromycin (Clindamycin) Adults: 600mg orally 1hr before procedure; Pediatric: 20mg/kg orally 1hr before procedure. (Cephalexine) Adults: 2.0g orally 1hr before procedure; Pediatric: 50mg/kg orally 1hr before procedure. (Azithromycin) Adults : 500mg orally 1hr before procedure; Pediatric: 15mg/kg orally 1hr before procedure.
Allergic to penicillin and Unable to take oral medications Clindamycin or Cefazoline (Clindamycin) Adults: 600mg I.V. within 30mins before procedure; Pediatric: 20mg/kg I.V. within 30mins before procedure. (Cefazoline).Adults: 1.0g im or I.V. within 30mins before procedure; Pediatric: 25mg/kg I.M. or I.V. within 30mins before procedure.

Prophylaxis for dental patients with Total Joint Replacement

For the first two years after a joint replacement, all patients may need antibiotics for all high-risk dental procedures. After two years, only high- risk patients may need to receive antibiotics for high-risk procedures.

Incidence stratification of Bacteremic Dental Procedure

Higher Incidence
  1. Dental extractions.
  2. Periodontal procedures including surgery, sub gingival placement of antibiotic fibres/strips, scaling and root planing.
  3. Dental implant placement and replantation of avulsed tooth.
  4. Endodontic instrumentation.
  5. Initial placement of orthodontic bands and not brackets.
  6. Intraligamentary and intraosseous local anaesthetic injections.
  7. Prophylactic cleaning of teeth or implants where bleeding is anticipated.
Lower incidence
  1. Restorative dentistry (operative, prosthodontic) with or without retraction cords.
  2. Local anaesthetic injections (nonintraligamentary and intraosseous).
  3. Intracanal endodontic treatment.
  4. Placement of rubber dam, removable prosthodontic or orthodontic appliance.
  5. Postoperative suture removal.
  6. Taking oral impressions, radiographs.
  7. Shedding of primary teeth.

Suggested antibiotic prophylaxis regimen

Patient type Regimen
Patients not allergic to penicillin: Cephalexin, Cephradine or amoxicillin. 2g orally 1hr prior to dental procedure
Patient not allergic to penicillin and unable to take oral medications: Cefazolin or Ampicillin Cefazolin 1g or Ampicillin 2g I.M. or I.V. 1hr prior to the dental procedure
Patient allergic to penicillin:clindamycin 600mg orally 1hr prior to the dental procedure
Patient not allergic to penicillin and unable to take oral medications: Clindamycin 600mg I.V. 1hr prior to dental procedure

Herbs and Dental Health

Many drugs used in dentistry have their origin in the plant world. Lidocaine and novocaine, derived from cocoa plant (erythroxylum coca); opiods from poppy (papever somniferum); Clove oil which contains eugenol is essential oil of Eugenia caryophyllus; thymol from thyme (thymus vulgaris); are a few to mention.

Chewing sticks as miswak (s.persica) are commonly used in South Asian countries. Studies have suggested that miswak users have shown significant low dental calculus in the posterior sextant but fails in the anterior region.

Camelia and other plant are rich in fluoride. Fagara zanthoxyloides and massularia acuminata reduces acid production and bacterial growth.

Commercial toothpastes have been made from neem (azadiracta indica) and arak (s.persica). Powdered plant used in abrasive dentrifrices include sweet flag root, gum resin of myrrh, yellow dock root.

Essential oils of plants are used in commercial mouthwashes. Ex: Listerene uses thymol, menthol, eucalyptus and methyl salicylate all derived from plants.

Normal Laboratory Values in Adults

Haematologic Examinations

Examination Range
Blood cells
Erythrocytes(rbc)(per mm cube)
Men 4.1-5.9 lakhs
Women 3.8-5.5 lakhs
Leukocytes(WBC)(per mm cube 4100-12300
Differential leukocyte count
Segmented Neutrophils 2500-6000 (40-60%)
Band Neutrophils 0-500 (0-5%)
Juvenile Neutrophils 0-100 (0-1%)
Myelocytes 0 (0%)
Lymphocytes 1000-4000 (15.6-46.6%)
Monocytes 200-800 (2.8-12.9%)
Eosinophils 50-300 (0-6%)
Basophils 0-100 (0-2.3%)
Platelets 140,000-450,000
Haemoglobin(hb)(g/100ml)
Men 13-17.5
Women 11.6-16.2
Mean corpuscular Haemoglobin(MCH)(pg/cell) 28-33
Mean corpuscular Haemoglobin concentration(MCHC)(g/dl) 32-36
Mean corpuscular volume(MCV)(MMcube) 86-98
Haemoglobin, total glycolated(%) 4.0-8.0
Haematocrit(Hct)(%)
Men 40-52
Women 35-47
Erythrocyte sedimentation rate(ESR)(mm/hr)
Men 1.0-13
Women 1.0-20
Coagulation Screening Test
Bleeding time 3-9 mins
Coagulation time(Lee-White)(glass) 5-15 mins
Prothrombin time less than 2 mins deviation from control
Thrombin time + or - 5secs of control
Activated partial thromboplastin time(aPTT) 25-37 secs

Chemical Constituents of Blood

Constituent Range
Proteins(g/100ml)
Total Serum Protein 6.0-8.4
Albumin, serum 3.5-5.0
Globulin, serum 2.3-3.5
A/G ratio 1.5: 1-3.1
Lipids (mg/dl)
Cholesterol
Men 140-284
Women 140-252
HDL cholesterol 40-60
LDL cholesterol 65-170
Triglycerides 30-170
Enzymes
Amylase 4-25U/ml
Creatinine phosphokinase= CPK (mU/ML)
Men 5.0-55
Women 5.0-35
Lactate Dehydrogenase-LDH (IU/ML)
Men 86-272
Women 82-249
Aspartate transaminase (AST)(SGOT)(I/ML)
Men 6.0-37
Women 5.0-37
Alaine transaminase (ALT)(SGPT)(I/ML)
Men 6.0-46
Women 5.0-37
Phosphatase (alkaline) 31-121IU/ml
Urea nitrogen (BUN)
Urea nitrogen 4-24mg/100ml
Uric acid
Men 2.4-8.7
Women 2.1-6.9
Creatinine (mg/100ml)
Men 0.5-1.3
Women 0.4-1.2
BUN/Creatinine
BUN/Creatinine 7.0-20
Oxygen saturation (arterial)
Oxygen saturation arterial 96-100%
PO2
PO2 75-100 mmHg
PCO2
PCO2 35-45mmHg
CO2 Combining power
CO2  Combining power 24-34mEq/L
pH
pH 7.35-7.45
Electrolyte And Inorganic Constituents
Chloride (cl-serum) 94-111mEq/L
Sodium (serum) 135-145mEq/L
Potassium (serum) 3.5-5.0mEq/L
Calcium (serum) 4.3-5.3 mEq/L
Phosphorus (serum)(mg/100ml)
Adults 2.3-5.1
Children 4-6.5
Iron total 50-150mEq/L
Glucose
Glucose, Fasting 70-110mg/100ml
Bilirubin (mg/100ml)
Total 0.3-1.2
Direct 0.0-0.2

Urine Analysis

Component Range
Macroscopic
Colour clear yellow
Specific Gravity 1.010-1.025
pH 4.8-7.5
Microscopic
Bacteria 0
Leukocyte 0-few (single specimen) to 1,800,000/24hrs
Erythrocyte 0-few (single specimen) to 500,000/24hrs
Cast 0 (single specimen) to 5,000/24hrs
Chemical components
Glucose 0 (single specimen) <100mg/dl (25hr specimen)
Albimin 0 (single specimen) 10-150mg/24hrs
Ketones 0 (single specimen) <50mg/24hrs
Creatinine clearance 150-810L/day/1.73m2 surface area

Substance Use Disorders

It is important that the dentist be aware of a patient's substance use history. Some patients may not reveal their history of substance abuse out of shame or fear of judgement or because they fail to understand the importance of this information in their treatment. The following table shows dental implications for people suffering from substance abuse.

Abused substance Facts to aid in diagnosis Drugs that may interact Dental implication
Alcohol
Patient may appear drunk or drowsy and have slurred speech. Odour of alcohol, mouthwash, fruity acetone may be present. Patient may have difficulty keeping head steady. CNS depressants enhance alcohol induced respiratory depression. Metronidazole reacts with alcohol to produce flushing, hypotension, nausea and vomiting. Alcohol-containing mouthrinses and liquid medications that contain high concentration of alcohol should be avoided in dental treatment of recovering alcoholics. Recovering alcoholics with liver disease may require low doses of medications containing acetaminophen Periodontal disease may not respond to treatment.
Benzodiazepines (alprozolam, clonazepam)
CNS depressants are favourites among drug abusers. Benzodiazepines may enhance opioid induced respiratory depression. Dose of opioids should be reduced to avoid enhanced respiratory depression. Xerostomia is frequent side effect.
Barbiturates and gammahydroxybuterates
Patient may appear to be drunk or drowsy and have slurred speech. Patient may have difficulty head keeping head steady. CNS depressants may enhance barbiturate induced respiratory depression. Dose of opioids should be reduced to avoid enhanced respiratory depression.
Cocaine
Patient may act jittery, irritable, unable to sit still. Patient may exhibit tremors dilated pupils, increased blood pressure and heart rate. IV injection of LA containing vasoconstrictor may enhance cocaine induced increased blood pressure and heart rate. Measure blood pressure pre- op and if high postpone the treatment. If the patient is suspected of use of these drugs within 6hrs, avoid the use of LA containing vasoconstrictor.
Amphetamine
Patient may act jittery, irritable, unable to sit still. Patient may exhibit tremors dilated pupils, increased blood pressure and heart rate IV injection containing LA vasoconstrictor may enhance amphetamine induced increased blood pressure and heart rate. Measure blood pressure pre- op and if high postpone the treatment. If the patient is suspected of use of these drugs within 24hrs, avoid the use of LA containing vasoconstrictor.
Opioids
Patient may appear drowsy, lethargic, disoriented, confused and pupils may be constricted. CNS depressants may enhance opioid induced respiratory depression. Avoid prescribing opioids analgesics postoperatively in patients recovering from opioids addiction. Opioids users exhibit profound xerostomia with increased craving for sweet.

Length of time drug abuse can be detected in urine

Alcohol 7-12 hr
Amphetamine 48 hr
Methamphetamine 48 hr
Barbiturate
Short-acting (eg, pentobarbital) 24 hr
Long-acting (eg, phenobarbital) 3 wk
Benzodiazepine
Short-acting (eg, lorazepam) 3 days
Long-acting (eg, diazepam) 30 days
Cocaine metabolites  2-4 dayw
Marijuana
Single use 3 days
Moderate use (4 times/wk) 5-7 days
Daily use 10-15 days
Long-term heavy smoker >30 days
Opioids
Codeine 48 hr
Heroin (morphine) 48 hr
Hydromorphone 2-4 days
Methadone 3 days
Morphine 48-72 hr
Oxycodone 2-4 days
Propoxyphene 6-48 hr

Cessation of Tobacco Use

Dentists can play an important role in making people aware of the ill effects of tobacco.They are the first health care providers exposed to the signs and symptoms of oral cancer and other disease that are caused by the use of either smoked or smokeless tobacco.

The following are the drugs used to aid in tabacco cessation:

Signs and Symptoms may include; Oral sores that do not heal, red or white patches on the oral mucosa, lumps in the head and neck region, difficulty in chewing and swallowing or making tongue or jaw movements.

Name Indications Dosage Interactions with other agents Contraindications
Centrally acting Non-Nicotine Agent
Bupropion As a part of comprehensive behavioural tobacco use cessation program, to relieve nicotine withdrawal symptom Adults :>=18yrs;  initial : 150 mgqd for 3 days; usual:
150mg b.i.d separate dose interval by 8hrs; max: 300mg/day. Initiate the treatment when the patient is still smoking.
Contraindicated with MAO inhibitors, other medication containing bupropion, alcohol, antipsychotic drugs, hepatic enzymes inducers and inhibitors; such agents may inhibit bupropion metabolism so that their plasma level increases thereby increasing the risk of seizures. Contraindicated in patients with anorexia, bipolar disorders, CNS tumours, head trauma, history of drug abuse, recent history of myocardial infarct. Contraindicated with MAO inhibitors and patients sensitive to bupropion.
Varenciline As a part of comprehensive behavioural tobacco use cessation program to relieve nicotine withdrawal symptom. Adults>= 18yrs; Days 1-3: 0.5 mg daily, days 4-7: 0.5mg  bid, day 8 to end of treatment: 1mg bid. Reduced renal clearance with cimetidine. Tobacco-use cessation,
with or without nicotine replacement may require adjustment of doses of other medication.
Nicotine Inhalation System
Nicotine Inhalation System As a part of comprehensive behavioural tobacco use cessation program to relieve nicotine withdrawal symptom. Adults>= 18yrs;
initial: atleast 6 cartridge per day for 3-6 weeks; usual; 6-16 cartridges / day; max: 16 cartridges/day for 12 weeks. Best effect achieved by frequent puffing, continue for 3 months. Wean by gradual reduction.
Should not be used with tobacco products owing to the risk of nicotine toxicity. Tobacco-use cessation, with or without nicotine replacement may require adjustment of doses of other medication. Contraindicated for continuous use for 6 months, in patients having asthma or chronic nasal disorders, patients with immediate post myocardial infarction, with severe dysarrythmia or severe angina pectoris.
Nicotine Nasal Spray
Nicotine Nasal Spray As a part of comprehensive behavioural tobacco use cessation program to relieve nicotine withdrawal symptom. Adults>= 18 trs: initial: 2-4 sprays/hr upto 10 sprays /hr for upto 8 wks; min: 16 sprays/day; max: 80 sprays/day. Do not treat for more than 3 months. Should not be used with tobacco products owing to risk of nicotine toxicity. Tobacco-use cessation,
with or without nicotine replacement may require adjustment of doses of other medication.
Contraindicated for continuous use for 6 months, in patients having asthma or chronic nasal disorders, patients with immidiate post myocardial infarction, with severe dysarrythmia or severe angina pectoris.
Nicotine Gums
Nicotine gum As a part of comprehensive behavioural tobacco use cessation program to relieve nicotine withdrawal symptom. Stop smoking completely before use. <25cigarettes/day: use 2mg, >25cigarettes/day: use 4mg. Chew 1 piece for 30mins; 1-2hr for 6 wks, then 1 piece; 2-4hr 3wks, then 1 piece 4-8 hrs 3wks. Max 24 pieces /day and 12 wks of therapy.Chew atleast 9 pieces/day. Gum should be chewed until tingling is felt. Should not be used with tobacco products owing to risk of nicotine toxicity.Tobacco-use cessation, with or without nicotine replacement may require adjustment of doses of other medication. Do not eat or drink 15 minutes before, during and after use. Contraindicated in non- smokers, immediate post myocardial infarction period, with severe dysarrythmia or severe angina pectoris. Gum is contraindicated for patients who ware prosthesis or with TMJ disorder.
Transdermal Nicotine System
Nicotine Transdermal Patches As a part of comprehensive behavioural tobacco use cessation program to relieve nicotine withdrawal symptom. Depending on the stage of patients health, weight and level of nicotine dependency, dosage can range from 7- 22mg/day. The entire course requires 6-8 weeks. Should not be used with tobacco products owing to risk of nicotine toxicity.Tobacco-use cessation, with or without nicotine replacement may require adjustment of doses of other medication. The following agents may require decreased dose of nicotine on cessation of tobacco use- acetaminophen,
adrenergic antagonists,caffiene
, insulin, pentazosine.
Contraindicated for continuous use >3months. Patients with immediate post myocardial infarction, with severe dysarrythmia or severe angina pectoris. Patients who have hypersensitivity to any component on therapeutic system.

Weights and Measures

Common metric measurements and their abbreviations.

Metric measurements Abbreviations
Weight
gram g
kilogram kg
milligram mg
microgram mcg
Volume
litre L
millilitre ml

Common Metric Equivalent

Metric measurements Equivalent
Weight
0.001 g 1 milligram
1 gm 1,000 milligram
1 kg 1,000 gms
Volume
1 ml 0.001 litre
1,000 ml 1 L

Measures of Volume

Metric measurements Apothecary
5 milliliters 1 teaspoonful
30 mL 1 fluid ounce
480 mL 1 pint
960 mL 1 quart

Measures of Weight

Metric measurement Apothecary
1 gram 15 grains
30 gms 1 ounce
1 kg 2.2 pound

Sample Prescriptions and Prescription Abbreviations

A prescription is a written or verbal order for medication to be used for the diagnosis, prevention or treatment of a specific patient disease by a licensed physician, dentist or veterinarian.

Sample Prescription

1) Rx

Amoxicillin 500mg
Dispense 4 capsules
Sig:Take 2 tablets with water 1 hr before the dental appointment
Substitution: permitted 
not permitted

 

Signature

   

Refill: 0x   1x    2x   3     

     DEA:

2) Rx

Sodium fluoride oral solution 0.5 mg flouride/1ml
Dispense 50 ml
Sig: Give one half dropper ful once daily
Substitution: permitted
not permitted

 

Signature

   

Refill:   0x 1x   2x     3      

        DEA:

 

Prescription abbreviations

Term (latin) Abbreviation Meaning
RX RX receive
ante cibum ac before meals
post cibum pc post meals
pro re nata prn as needed
quaqe 3 hora q3h every 3rd hourly
bis in die b.i.d two times a day
ter in die t.i.d three times a day
quarter in die q.i.d four times a day
quaqe die q.d everyday
quaqe hora qh every hour
per os po by mouth
oculus dexter od right eye
oculus sinister os left eye
quaqe alternis die qod every other day
amp ampule
iv intravenous
capsula cap capsule
tabella tab. tablet
dispensa disp. dispense
signa sig label
stat statim Immediately

Legal Implications of using Drugs in Dentistry

Choosing dental products that are Food Safety and Standards Authority of India and/or IDA approved, is a wise choice concerning their safety and efficacy for approved uses. However, the dentist must show that the product was indicated by a particular patients needs. Uses of approved dental products in non-approved ways or use of non-approved products may be considered as negligence in some malpractice actions, but allowed under standards of resonableness in other situations. The dentist must be able to justify decisions on a scientific basis.

Calculation of Paediatric Doses

Paediatric doses based on formal experiments or the experience of the prescriber are better than those calculated according to a general rule or formula.

Unfortunately, optimal paediatric doses have not been established for most drugs. Thus, where possible, doses for younger children and especially for infants, should be learned as such and not based merely on a formula; doses calculated with a formula (as a fraction of the adult dose based on the body weight or body surface area) are very unreliable for premature infants, but more reliable for children at least 2 years old.

Dosage rules involving a fraction of the adult dose

A General Rule of Dosage
Age (in years) Dose
20 yrs or older Adult dose
10 yrs 1/2 the average adult dose
5 yrs 1/4the average adult dose
21/2 yrs 1/8 the average adult dose
1 yr 1/12 the average adult dose
Clark's Rule
Weight of child(lb)
150
X  Adult dose
Young's Rule
Age of child in years
Age + 12;
X  Adult dose
Fried's Rule
Age in months
150
X  Adult dose

Paediatric dose calculations based on body weight

A more reliable method of paediatric dose calculation than the preceding dosage rules is the dosage on a given amount of drug per pound or kilogram of body weight.

NOTE: Round off all body weights in kilograms to the nearest whole number

Example: The parenteral dose of erythromycin injection is 10 mg/kg/24 hours. Calculate the daily dose of this drug for a 44-pound child

Step1: Convert the weight of the child in Kgs
44 pounds
2.2
=  20 kilograms
Step2: Multiply client's weight by the dose

Child's dose = 20kgs X 10 mg/kg

      = 200mg/24 hrs

Paediatric dose calculations based on surface area

A newer and possibly more accurate method of paediatric dose calculation is based on body surface area. Although this method is not as widely used or accepted as calculations based on body weight, most if not all drugs may have their dosage expressed per square meter of body surface area (m²). This method of relating the surface area of individuals to dosage is simplified using a surface area nomogram in dose calculations.

Example

The doctor has ordered an antibiotic whose average adult dose is 250 mg per day. What would the dosage for this medication be on a child who has a length of 120 cm and weight of 40 kg?

First you must determine the BSA. One method is using the West Nomogram.

Using a straight edge (such as a ruler or piece of paper), align the straight edge so it intersects at the child's height and weight. Doing so will create an intersection in the BSA scale. The boxed in scale is to be used only if the child is of normal height and weight.

Next, enter the BSA value of 1.2 (determined from nomogram) and the adult dose of 250 into the calculator

In this example, 173 mg of medication would be given

Formula :  BSA
173
 X  Adultdose  =  approximate child dosage.

Drugs Controller of India

The National Human Rights Commission(NHRC)has described the manufacture, distribution and sale of unsafe drugs and medical devices as a violation of human rights.

The Drugs and Cosmetics Bill was passed by the Central Legislative Assembly and it received the assent of the Governor General on 10th April, 1940 and thus became the Drugs and Cosmetics Act, 1940.

The Drugs and Cosmetics Act, 1940 is a consumer protection legislation, which is mainly concerned with the standards and quality of drugs and regulates the import, manufacture, sale and distribution of drugs and cosmetics.

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