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Clincal Pharmacology cases for dentists

Dr Sameh AM Abdelghany

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Analgesics Cases

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Case(1)

You complete endodontic treatment on a32 y.o. male and expect mild to moderatepain. His medical history is significant for arecent GI (gastrointestinal) bleed fromstomach ulcers.

Which medication is the best choice? & why?Ibuprofen, Aspirin or Acetaminophen

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Aspirin and NSAID induced GI injury results from twoknown mechanisms

1. Local irritation of the mucosal lining allowsdiffusion of acid into the lining with subsequenttissue damage

2. Inhibition of gastric prostaglandins that inhibitsecretion of gastric acid and promote secretion ofcytoprotective mucus

Aspirin and NSAIDs are contraindicated in patientswith GI ulcers

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Case(2)

You see a 25 y. o. male with a very painfulabscessed tooth #31 on Monday morning. Hehas been in pain since Friday night. He has notslept in 48 hours and has been taking 6 extrastrength Acetaminophen every 2 hours for thelast two days. He is nauseated, has vomitedseveral times recently and is very tired. What is the problem? What do you do?

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Acute acetaminophen overdose 6 tabs = 3 grams q2h = 12 grams in 8 hours. Usual dosage not to exceed 4000 mg/day Hepatic toxicity may occur following ingestion of 7.5 to 10 gramsover a period of 8 hours or less

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1. Stomach wash and administeringactivated charcoal

2. Administration of sulfhydrylcompounds (e.g.acetylcysteine)which probably

3. replenish hepatic stores ofglutathione.

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Case(3)

Your patient a 37 y. o. female has recentlyhad inpatient Oral Surgery for bone graftingto the maxilla from the iliac crest. While inthe hospital she was given Ketorolac 30 mgIV. She also was given Ketorolac 10 mg(disp.20), one PO qid. She has run out of this painmedication and would like you to refill it.

What will you do?

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Refill the prescription Give another NSAIDs e.g Ibuprofen Give acetaminophen May add narcotic analgesic

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Case(4)

A 64 y. o. male presents for treatment of an acutelypainful tooth #13. You determine that the tooth isnon-restorable and requires extraction. He has beentaking 2 ibuprofen every 3 hours to control his pain.Past medical history is significant for use of oralanticoagulant(e.g warfarin)as prophylaxis for atrialfibrillation. The patient supplies you with a note fromhis physician that shows that his INR is 2.0 and givesclearance for extraction of this tooth.

What is the problem?

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Oral anticoagulants prevent the synthesis of clottingfactors II, VII, IX and X in the liver (Vitamin Kdependent factors). (Monitored with INR) Ibuprofen reversibly interferes with platelet

function Severe bleeding could occur following extraction

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Case(5) You complete the removal of impacted wisdom teeth

on an 18 y. o. female who requests narcotic analgesic because acetaminophen doesn't work for her. You prescribe Ibuprofen and narcotic analgesic as breakthrough medication. The next morning you receive a phone call that your patient has severe Nausea and Vomiting and "cannot keep anything down." The patient states that she is in severe pain

What has caused this problem? How are you going to treat this problem?

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Nausea and vomiting are common adverse sideeffects of any narcotic with no documenteddifferences among agents Patient has not taken any of Ibuprofen Instead she has taken only the Narcotic analgesic onan empty stomach Because of vomiting she is unable to absorb any ofthe pain medication prior to vomiting it back up

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Stop the narcotic medication Take non-narcotic analgesics with foods Use antinausea medications Naloxone will not reverse nausea, in fact itmay trigger it or make it worse.

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Case(6)

A 35 year old female presents to your officefor evaluation of TMJ pain. She has been seenby another dentist across town who has beentreating her pain with NSAID and narcotic thelast week. the patient states that she has nothad a bowel movement since she has startedon the pain medication.

What has caused this problem? How are you going to treat this problem?

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Constipation is a common side effect of opioidmedications Narcotics depress peristaltic contractions Constipation is dose-dependent and is noted

more with repeated administration

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Stop the narcotic analgesic Prescribe a stool softener, or refer to

primary care MD

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Case(7) You sedate a very nervous 84 y. o. female patient with

Fentanyl and Versed in order to extract an impactedwisdom tooth. The patient becomes apneic just afterthe administration of the sedative medications. Yousupport her respiration, administer local anesthesiaand extract the tooth in 2 minutes, much quicker thananticipated. Whenever you stop supporting thepatient's respiration, she becomes apneic

What is happening? How are you going to treat this problem?

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Respiratory Depression All opioids depress respiration Caused by a dose dependentdecrease in the response of therespiratory center to carbondioxide

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Continue to support the patient's respirationOR Administer Naloxone.

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Case(8) A 45 y. o. female patient is transferred to you for

management of TMJ with a bite splint. Upon evaluationshe states that she has been managed over a period ofmonths by another dentist with first Acetaminophen,then narcotic, He recently refused to refill anyprescriptions and instead referred her to you formanagement. While in your office the patient developsgoose bumps, dilated pupils, nausea and becomesanxious and somewhat hostile. What is happening? What will you do?

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Physical dependence Symptoms of withdrawal syndrome include: irritability, tremors, vomiting, diarrhea, colicky pain , arrhythmia and may be circulatory collapse.

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1.Hospitalization2.gradual withdrawal of morphine 3.replacement with methadone which is less addictive then gradual withdrawal of methadone

4.Clonidine5.sedative

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Antimicrobials Cases

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Case(1)

A 25-year-old female patient presents withlocalized periodontitis with a 6mm pocketalong the mesial root of tooth #14. A decision ismade for treatment with gingival flap surgery.The patient's medical history is remarkable forprosthetic mitral valve placement and forpenicillin-induced angioedema.

Treat with: Clindamycin, Azithromycin orclarithromycin

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Who are considered high Risk patients requiringantibiotic prophylaxis

1. Prosthetic valves2. Hx of infective endocarditis3. Unrepaired cyanotic congenital heart disease (CHD)4. Repaired CHD with prosthetic material or device during first 6

months post-procedure5. Repaired CHD with residual defects at/or near the site of

prosthetic patch or device6. Heart transplant recipients with valvular disease7. Rheumatic heart disease if prosthetic valves or prosthetic

material used in valve repair

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What are some of the dental procedures for whichprophylaxis is reasonable?

1. Extractions2. Periodontal procedures3. Orthodontic initial band placement4. Dental implantation, re-implantation or implant

removal5. Endodontic procedures6. Ligamentary local anesthetic injections7. Cleaning of teeth or implants8. Any other procedure that may involve BLEEDING

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When do you take an antibiotic before a dentalappointment?

1 hr before the procedureAmoxicillin - Ampicillin – Clindamycin – Cephalexin

What antibiotic is used to when you are unable totake oral medication?

Ampicillin

What antibiotic is used when allergic to penicillin? clindamycin

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Case(2)

A 35-year-old obese female patientpresents in the office with a canine fossaabscess associated with the root remnant oftooth #6. Incision and drainage of theabscess, extraction of the root remnant, andantibiotics are scheduled.

What are antibiotics you will prescripe?

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Case(3)

This patient is complicated withPseudomembranous coilitis (Superinfection)

What antibiotics are most commonlyassociated with this?

How to treat this problem?

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Penicillins, such as amoxicillin and ampicillin Clindamycin Cephalosporins, such as cefixime Treatment of pseudomembranous colitis:1. Discontinue the antibiotics2. Oral metronidazole or vancomycin

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Case(4)

44 y male with a generalized palatal lesionnoted by clinical examination, patientreports pain and burning for over 2 months.Diagnosed as Atrophic candidiasis

How can u treat Atrophic candidiasis ? What is the primary organisms responsible

for most fungal infections in the oral cavity?

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Clotrimazole troches would be highlyrecommended Alternative systemic treatment(Fluconazole)

Candida is the most common organism

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Case(5)

57 year old, edentulous patient presentswith generalized asymptomatic erythemabeneath her maxillary denture. She reportswearing the denture even at night.Diagnosed as Atrophic candidiasis

How would you treat this?

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Instruct to leave denture out at night andsoak in commercial denture cleanser afterwashing(Most commercial denture cleansershave antifungal activity) Nystatin powder to place inside denture

during day or Nystatin cream

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THANK YOU