Drug Prescribing in Oral Surgery

Dr. Musab Abed

BDS,HS-OMFS,MFD,FFDRCSI,Jord.Board(OMFS) Specialist Oral & Maxillofacial Surgeon Assistant Prof. at Jordan University of Science & Technology

2 Feb. 2014

DRUG PRESCRIBING
BNF (British National Formulary) Is an essential source of information on drug actions, uses and dangers. Within the BNF there is a list of drugs which may be prescribed by dentists. Doses quoted in the BNF are the normal or accepted adult dose. Guidance on suitable childrens doses is included where appropriate.

Essential information to be written :

1. Name of patient. 2. Age of patient. 3. Total number of days of treatment 4. The generic name of the drug, its form and strength (e.g. metronidazole tablets 200 mg) 5. Instructions as to how and when drug is to be taken, written in English with no abbreviations (e.g. one tablet to be taken three times daily with food).

6. Delete any space remaining on the form. 7. Date and prescribers signature.

Example:

PATIENTS AT PARTICULAR RISK

Children Doses should be appropriately reduced by age or body weight. Elixirs/Syrups are preferable for oral ingestion. Sugar-free preparations should be prescribed where available.

Elderly
Elderly people may show exaggerated reactions to drugs. Gastrointestinal (GI) haemorrhage is more likely with NSAIDS & these should be prescribed with caution. Polypharmacy is common in the elderly with possible interactions !!

Pregnancy Only prescribe when absolutely essential. Use the safer preparations(category A, B). Teratogenic effects are most likely in the first trimester. Second and third trimester effects are mainly on growth.

Liver disease : Many drugs are metabolized through the liver. Impaired liver function(cyrihosis or any patho-necrotic) may affect the breakdown of drugs so the drug might accomulate and cousing toxic effect to the patient, so we try to give the pt drug that not metabolize in the liver, eg; paracetamol metabolize in the liver, we give the pt codiene or NSAIDs instead of. Kidney disease : Nephrotoxic drugs should be avoided such as aminoglycosides which should be avoided in pt do dialysis, other safe drugs may require dose reduction according to the degree of impairment either halving the dose or type of the drug.

ANALGESICS;
NSAIDS: Examples of such drugs are: aspirin and ibuprofen. Main actions : analgesic anti-inflammatory antipyretic.

Most NSAIDs interfere with the production or conversion of arachidonic acid to prostaglandins,(COX inhibitors). Ibuprofen mostly used at dosage of 400mg or 600mg TID, For short term use.

Patient groups at risk from NSAIDS

Peptic ulceration

Inhibits P.Gs Increase acid production, decrease mucin, increase risk of GI bleeding !! Bleeding disorders Permanent antiplatlet effect by ASA or temporary by Ibuprofen & others. Anticoagulants Enhance effect of warfarin. Children Under age 12, ASA is contraindicated(Reyes syndrome).

Asthmatics Hypersensitivity may precipitate severe bronchospasm. Pregnancy In the third trimester may cause: *prolongation of labour , * bleeding at birth, * Early closure of ductus arteriosus( Indomethasin). Renal or hepatic disease Renal disease reduce dose or avoid NSAIDS Liver diseases may enhance bleeding !!

Paracetamol
Similar analgesic properties to aspirin Antipyretic little or no anti-inflammatory action No significant GI irritation Not implicated in Reyes syndrome Dose : (500mg1g) orally 46 hourly. Maximum adult dose 4 g daily.

Opioids

Causes Depression of pain center.(not like NSAIDs which work periphrally) But cause Stimulation of vomiting, salivation which are the parasympathatic way. and cause Dependence (addiction), many times we see adult patient seeking opioids for dental pain which is very common, tramadol for dental pain as example Other problem with opioid which is the Tolerance, patient taking opiods for more than 2 weeks he might dont give desierd effect of the opiods, he might need increase the dose,, which we call it tolerance. And it might causeConstipation. Examples: Codeine ; mostly mixed with paracitamol as Revacod 500mg 1-2*3 . Tramadol (Tramal); opioid like analgesic 50-100mg 1*3 PRN( to not couse addiction).

ANTIBIOTICS
Antibiotics are given to prevent or treat infection (theyrabiotic). Different types, spectrum, pharmacodynamics &kinetics.. The wide use of antibiotics may cause Resistance ! Side effects (allergy(maybe fetal to the patient), G.I disturbance(diaria), super-infections(fungal as thrush or bacterial as psedomembranious colites).

Prophylactic antibiotics
Prophylaxis of endocarditis: in the past there was plenty of indication about endocarditis NICE and AHA guidelines Nice; britsh guidelines dont indicate prophylaxis indocarditis for all patients,, there is no need for antibiotic prophylaxis at all. Its a new guidelines for britshguidelines. But we adot to amirican school which is american hash assosation 2007(AHA) they minimize number of patients into 4 small categiores; Patients At Risk: (AHA 2007) history of infective endocarditis Cardiac prosthetic valve replacement A heart transplant with abnormal heart valve function Some conginital cardiac defects (Cyanotic). These are accully very young and we see them in the perdiatric section.

Antibiotic regimens

Prophylaxis against SSI

Its Not indicated in most of cases!! It Might be indicated in cases of low immunity as diabetes and immuno- compromised patients(eg;diabetis) . Generally it is considered in contaminated wounds not the clean or clean-contaminated ones, which means in extraoral surgerys which is clean surgery, so no role of antibiotic treatement, but intraorally, its consider a clean contaminated becouse of saliva. Sometimes if there is pus or forign material we conseder it derty so we might prescribe antibiotic, let say for extraction of present periodontitis or pericoronitis so we can conseder antibiotic in such case.

Treatment of infection
Ideally antibiotics must only supplement drainage. What the treatement of abccess? Incesion and drinage What the treatement of acute periapical abcess? Access What the treatment of gingivitis? Scaling and oral higen. There is no role for antibiotic,, only supplemental of these in cereten people Indications for ABx: Systemic manifestations as fever, malaise, lymphadenopathy. Cellulitis with rapid spread of infection Involvement of fascial spaces, trismus,dysphagia, with risk on airway or vital structures as eyes. Inadeqate drainage though its not an excuse! Immuno-compromised Pt.

Examples on ABx:
Penicillins: Amoxicillin ; Ampicillin oral 500mg 1*3 Flucloxacillin for Staph(in salivary gland infection such as ascending sialdenitis, most of them are mix staph and strep 250mg 3 to 4 times daily Augmentin( co amoxyclav) 625mg 1*3(given 3 times daily). Amoxycalv( amoxycillin+ clavicunic acid) Metronidazol: Flagyl for anaerobic bacteria and parasites 250-500mg 1*3daily. We can supplement in abcess amoxicillin+flagyl together,, in cases of pericoronitis flagyl is the gold standard in treatment

Clindamycin : 150-300mg 1*3 for mix infection aerobes and anaerobes for penicillin allergic pt.s( if the pt hypersensitive to penicillin we sheft to clindamycin or cefalosporin, but mostly clindamycin becouse cyphalosporin has 10% cross sensittivity with penicilin so one of 10 pts might have double seansitivity to cyfalosporin and penicilln) if pts take for a long period of time clindamycin this may lead to antibiotic associated colitis!! Cephalosporins : 10% cross sensitivity as penicillin !! it has 4 generations, it mostly used by dental uses. ex : cephalexin 500mg 1*3 cefuroxine 1gm IV/IM cefutaxime 1gm IV/IM

Antifungals
Miconazol For oral candidiasis and angular chelitis though it is effective against S. Aureus . Oral gel 25mg/ml 2-5 ml 1*4 Cream 2%(extraorally at the angel of the mouth) 1*3 Fluconazole; given systematicly or oral capsules 50-100 mg capsules daily for 2 weeks at least.

Antivirals
Acyclovir For herpes infections(herpes simplex or zoster) Topical cream 5% 1*4 on the lips at the podrum symptoms Oralpreparation called Zoverax 200800 mg daily for 10 days.

Mouth washes
Chlorhexidine(mostly) 0.12-0.2% M.W M.W, Irrigation,toothpaste SE staining Povidone-Iodine 1% C/I Thyroid pts diseases.

Oral ulcerations
Coating agents: Solcoseryl dental gel 1*3 Aloclair dental gel/ M.W 1*4 Anesthetics: Lidocaine M.W or Spray (Trachezan) Benzydamin HCL: 0.15% M.W 1*4 (Tantum Verde) Steroids: cream/M.W/spray Hydrocotison cream1% 1*3 (less 1 week!) Triamcinolone gel 0.1% 1*3 (less 1 week!)

End of the Lecture

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