PHAR 266: LO3 LS3-5 :Determine the DH Implications of Drugs used in Dentistry

general anesthesia

-anesthesiologist administers inhaled and IV drugs to produce gneralized, reversible depression of CNS

-results in loss of consciousness, amnesia and immobility but not necessarily analgesia

-usually done in hospital or OR

intubation

-insertion of a breathing tube into airway

-oral or nasal intubation (nasal for. dental procedures)

-care must be taken to avoid fracturing teeth

what are the stages of anesthesia?

1. induction

2. maintenance

3. recovery

stage 1 of anesthesia: induction

-drugs administered

-patient becomes unconscious

-intubation

stage 2 of anesthesia: maintenance

-surgical anesthesia

stage 3 of anesthesia: recovery

-end of surgical procedure until patient is fully responsive

IV drugs for induction of anesthesia

-ultra-short acting barbiturates

-etomidate

-propofol (Diprivan)

-ketamine

-opioids

-benzodiazepines

IV drugs for induction of anesthesia: ultra-short acting barbiturates

-thiopental (Pentothal)

IV drugs for induction of anesthesia: opioids

-adjuncts to provide analgesia during and after surgery

-morphine, fentanyl (Sublimaze)

IV drugs for induction of anesthesia: benzodiazepines

-diazepam (Valium)

-midazolam (Versed)

-anxiolytics

inhalation drugs for induction & maintenance remember ANE

-halothane

-methoxyflurane

-enflurane

-isoflurane

balanced general anesthesia

-rapid induction with IV and inhalation agents

-maintenance w/ inhalation agents

-can give lighter level of general anesthesia for dental procedures if administer local anesthetic nerve blocks prior to start of surgical procedure

when is general anesthesia used in dentistry?

-extensive dental treatment in young children

-extensive treament in ppl w/ extreme dental anxiety

-oral maxillofacial surgery (orthognathic surgery, cleft lip & palate repairs, tumor resection, cyst enucleation)

how can we help clients cope w/ fear?

-good communication

-progressive muscle relaxation

-guided imagery

-hypnosis

-distraction (music/videos)

-anxiolytics (anti-anxiety drugs)

CNS depressant

-drugs that reduces activity in the CNS

-often causes drowsiness as a secondary effect

-examples: alcohol, opioids, anti-anxiety drugs

sedative-hypnotics

-drugs that produce different levels of CNS depression, depending on dose administered

-low dose: sedation (relaxation and decreased anxiety)

-higher dose: hypnosis (sleep)

levels of anesthesia: stage I: sedative level

-mild CNS depression

-small dose of anxiolytic drug

-reduces simple anxiety

levels of anesthesia: stage I hypnotic level

-deeper CNS depression

-larger dose of anxiolytic drug

-causes sleep

levels of anesthesia: stage II excitement

-less aware of surroundings and may become unconscious

-may experience nausea/vomiting and become excited or unmanageable

levels of anesthesia: stage III general anesthesia

-unconscious

-no pain and no sensation

-requires management of airway

levels of anesthesia: stage IV respiratory failure/cardiac arrest

-must be quickly reversed to prevent death

indications for anxiolytics in dentistry

-very young children who are unable to cooperate

-anxious children/adults

-clients undergoing extensive treatment (implants, surgical exos)

timing of administration: pre-medication

-administered prior to dental treatment

-oral route

timing of administration: intra-operative

-administered during dental treatment

-IV or inhalation route

benzodiazepines

-very commonly used anti-anxiety med

-used in dentistry and in medicine for procedures & treatment of anxiety disorders

-oral & IV route

benzodiazepine meds

-diazepam (Valium)

-midazolam (Versed)

-lorazepam (Ativan)

-triazolam (Halcion)

nitrous oxide

-gas inhaled into the lungs

-popular in dentistry (especially for children)

barbiturates

-first sedative-hypnotic drugs developed

-originally used for anxiety and insomnia but now replaced by benzodiazepines bc better safety profile

-now only used as anti-convulsants and to induce general anesthesia

oral route

-drug is swallowed 30-60 min prior to appt

-easy to use

-difficult to obtain an ideal level of sedation

-slow recovery (considered impaired for 24 hrs)

-example: benzodiazepines

IV route

-administered into vein

-need special training to perform venopucture

-slow recovery (considered impaired for 24 hrs)

-titrate to achieve ideal level of sedation

-example: diazepam (Valium) and midazolam (Versed)

inhalation route

-need special equipment and training to administer

-need scavenger system for occupational health & safety to protect dental team

-easy to use

-rapid recovery

-example: nitrous oxide gas

adverse reactions to anxiolytics

-hypo-responder (still very anxious)

-hyper-responder (too deep- risk airway obstruction)

-toxicity (too much CNS depression & causes respiratory depression)

-drug interactions (combo w/ CNS depressants such as alcohol causes too much CNS depression)

-hypersensitivity

-teratogenic if chronic occupational exposure to non-scavenger unit

effect on memory

-cause anterograde amnesia (client will not remember)

-advantage (no bad memories of ppt)

-disadvantage (2 members of dental team should be present at all times)

-warn to not make important decisions until recovered

precautions when using anti-anxiety drugs

-may need empty stomach

-do not use other CNS depressants

-do not leave unattended

-monitor vital signs (pulse oximeter)

-no driving/operating dangerous equipment, machinery or tools for 24 hrs

-be prepared for medical emerg

-obtain informed consent before drug is administered

sleep aids for insomnia

-anti-histamines

-sedative hypnotics

-often cause anterograde amnesia

-some ppl may still have effects the next day (who do you think is most at risk?)

-may become addictive

anti-histamines

-OTC

-contain diphehydramine

-Excedrin PM, Nytol, Tylenol PM

sedative hypnotics

-prescription

-zopiclone (Imovane)

-zolpidem (Ambien), chloral hydrate (Noctec), triazolam (Halcion), eszopiclone (Lunesta)

sleep aid protocol

-cannot give valid informed consent if under the influence

-may fall asleep during appt and be more difficult to rouse

-may not remember what happened during appt or important instructions

saline rinses

-microbial

-promote wound healing

-reduce risk of dry socket

-soothing

indications of saline rinses

-post extraction, gingivitis/periodontitis, perio infection, oral ulcers

analgesics: topical

-saline rinses

-diphenhydramine liquid

-topical anesthetic- OTC (Orajel) or prescription (Xylocaine viscous 2%)

analgesics: systemic

-non-opioid & opioid analgesics

-use best practices & follow algorithm

chlorhexidine gluconate rinse

-broad spectrum anti-microbial

-chlorhexidine rinse 0.12%, rinse for 30 sec w/ 15mL BID (AM and PM)

indications of chlorhexidine gluconate rinse

-NUG

-uncontrolled gingivitis/perio as adjunct to home care and NSPT for up to 6 months

-after perio surgery

-dry socket

-pericoronitis (inflammation around partially erupted teeth)

adverse reaction of chlorhexidine gluconate rinse

-staining

-increased calc formation

-mucosal irritation

-taste perversion

anti-fungals

-indicated for oral Candida albicans infection

-anti-fungal rinses (nystatin oral suspension)

-clotrimazole troches

-fluconazole (Diflucan) oral for chronic infections

-screen for pre-disposing factors such as uncontrolled diabetes, recent broad-spectrum antibiotics, inhaled steroids, HIV/AIDS

anti-viral meds

-indicated for recurent herpes labialis infections

-OTC docosanol 10% topical (Abreva)

-topical acycolvir (Zovirax) if occasional lesions

-systemic anti-virals (acyclovir, valcyclovir, famciclovir) or immune compromised and/or frequent infections

-systemic anti-viral prophylaxis if very frequent

-most effective if taken during prodrome phase

anti-inflammatory drugs

-indicated for all inflammatory conditions (signs of inflammation, etiology)

-NSAIDS

-corticosteroids

-immune modulators

corticosteroids

-indications: symptomatic immune conditions such as aphthous ulcers, lichen planus

-treated w/ topical steroids (triamcinolone, fluocinonide)

-systemic steroids: prednisone

-immune suppression therapy if severe

burning mouth/tongue syndrome

-many possible etiologies, including adverse drug reaction, xerostomia, candidasis, acid reflux, nutritional deficiencies of vit B12, folic acid or iron, immune reaction, hormone changes, inflammatory process

-may not be any observable lesions to note

-treatment is to avoid known triggers

-topical diphenhydramine (Benadryl) rinses

xerostomia

-etiology: drug side effect, diabetes, Sjogren's syndrome, radiation therapy, age

-anti-cariogenic agents, artificial saliva, refer to consult about med change (not common)

magic mouthwash

-used to treat mouth sores for chemo and head/neck radiation

-formulated at a compounding pharmacy

-swish with 10mL for 1-2 min then expectorate or swallow, every 4-6 hours

active ingredients in magic mouthwash

-2% viscous lidocaine (for pain)

-antacid solution (to help coat intraoral tissues)

-diphenhydramine (antihistamine for swelling)

-prednisolone (steroid for inflammation)

-tetracycline antibiotic

-nystatin suspension antifungal

-distilled water

dental local anesthetics components

-LA drug

-+/- vasoconstrictor drug

-sterile saline

-preservatives

active ingredients in LA

-lidocaine is the most used injectable amide LA

-other include mepivacaine, prilocaine, articaine

-vasoconstrictor: epinephrine is the most common vasoconstrictor)

epinephrine

-sympathomimetic amine - mimics the sympathetic nervous system

-max safe dose is 0.2 mg for average sized healthy client

max dose must be limited for some clients due to risk of adverse reactions - to 0.04 mg (cardiac conditions, thyroid conditions, many medications)

epinephrine contraindications

-cocaine/meth in last 24 hrs (increased risk of med emergencies)

-sulfite allergies (preservatives)

-pheochromocytoma (adrenal gland tumor- life threatening arrhythmias and HBP)