L I S A M A Y O , R D H , B S D H
C O N C O R D E C A R E E R C O L L E G E

KEY STUDY POINTS
• Know what drugs a patient may be taking
• Conditions for which drugs are used
• Pharmacological effects
• Adverse drug reactions
• Usual indications
• Contraindications

RX ABBREVIATIONS
• Gt=drop
• Ac=before meals
• Hs=bedtime
• Pc=after meals
• Po=by mouth
• Tab=tablets
• Stat=immediately
• Prn=as needed
• Ud=as directed
• Qd=every day
• Bid=2x/day
• Tid=3x/day
• Qid=4x/day
• Sig=label, instructions for use

TERMS
• Log dose-effect curve
• Therapeutic range of the drug is plotted where the dose is increasing sharply
• Max response of a drug may exhibit is plotted where the curve plateaus
Max Response

TERMS
• Potency (Jack Daniels)
• Function of the amount of a drug to produce an effect
• Potency is greater when the dose is smaller
• Efficacy (Beer & Jack Daniels)
• Max intensity of effect or response what can be produced by drug regardless of dose
• Administering more drug will NOT increase the efficacy of the drug but will often increase the probability of adverse drug rxn
• Efficacy and potency of a drug are unrelated!!

I
Schedule
II
III
IV
V
Abuse Potential
Highest
High
Moderate
Less
Least
Handling
No accepted medical use
Written Rx w/provider’s signature only
No Refills
Rx may be phones in
No more than 5 refills in
6mo
Same as Schedule III
Can be purchased OTC

• Any Rx for a controlled substance requires a DEA #
• A designate of the dentist may write the Rx but the prescriber must personally sign the Rx in ink
• Certain states require the use of triplicate Rx blanks for Schedule II drugs

ROUTES OF ADMINISTRATION
• ENTERAL: oral & rectal
1.
Oral (PO)
• Slow onset
• Safest, least expensive and most convenient
• Large absorbing area present in small intestine which causes slower onset of the drug’s effects and may result n stomach or intestinal irritation including nausea and vomiting
• Drugs derived from PRO sources may be activated by GI acidity or enzymes (ex: insulin)
• Drug blood levels are less predictable
• Necessitates greater patient cooperation

ROUTES OF ADMINISTRATION
• ENTERAL: oral & rectal
1.
Oral (PO)
• Mechanism of uptake:
• Orally delivered drugs must pass through hepatic portal circulation FIRST (can inactivate other drugs) = called PHASE 1
REACTIONS or FIRST PASS EFFECT (next slide)
• Amt of drug available to produce systemic effect is reduced by first pass

ROUTES OF ADMINISTRATION
1.
Oral: Phase I Reactions
• Drugs with high first-pass effect have LARGER oral to parental dose ratio (ex: morphine), they require a
LARGER dose
• Carried out by microsomal or cytochrome P-450 enzymes (also known as mixed function oxidases) in
LIVER
• Concentration of these enzymes can be affected by drugs and environmental substances (ex: smoking)
• Alcohol tolerance is a common example of P-450
INDUCTION: metabolize drug more rapidly = need larger drug dose for effect

ROUTES OF ADMINISTRATION
• ENTERAL
2.
Rectal
• suppositories, creams, enemas
• Can be used if pt is vomiting (EMESIS) or unconscious
• Poorly and irregularly absorbed rectally
• Poor pt compliance

ROUTES OF ADMINISTRATION
• PARENTERAL
1.
Intravascular
2.
Intramuscular
3.
Subcutaneous
4.
Intradermal
5.
Inhalation
6.
Topical
7.
Sublingual

ROUTES OF ADMINISTRATION
• PARENTERAL
1.
Intravascular
• Most rapid drug response – almost immediate
• Absorption phase bypassed
• More predictable response
• Route of choice for emergency situation
• Disadv: phlebitis (caused by local irritation), drug irretrievability, allergy, side effects of high plasma drug concentrations
2.
Intramuscular (next slide)

ROUTES OF ADMINISTRATION
PARENTERAL
2.
Intramuscular
• Absorption occurs due to high blood flow in skeletal muscles
• Useful to provide sustained effect
• Deltoid or gluteal regions most common injection sites
• Massage increases absorption

ROUTES OF ADMINISTRATION
• PARENTERAL
3.
Subcutaneous
• Route used to administer PRO products
• May produce sterile abscess or hematoma
• Ex: insulin and local anesthetics
4.
Intradermal
• Injected into epidermis
• Ex: TB test
5.
Inhalation
• Provides rapid delivery of drug across large surface area of respiratory mucosa
• Ex: inhalers, nitrous oxide

ROUTES OF ADMINISTRATION
• PARENTERAL
6.
Topical
• Directly to body surface
• Contraindicated if surface is ulcerated, burned, or abraded
• Local effect results, may have systemic uptake
7.
Sublingual
• Rapid, easily administered
• Ex: nitroglycerine

• Pt compliance
• Pt weight
• Tolerance
• Pathologic state (kidneys, liver issues)
• Time and Route of Admin
• Sex
• Age
• Genetic variation

PHARMACOKINETICS
1.
Absorption
2.
Distribution
3.
Drug metabolism
4.
Elimination
5.
Factors that alter drug effects

PHARMACOKINETICS
1.
Absorption
• Transfer of drug from site of administration to blood stream
• May be active or passive
• Rate and efficacy of absorption depend on route of administration
• Lipid soluble drugs readily move across MOST biological membranes by diffusion (only drugs to pass blood-brain barrier)
• Absorption occurs at MANY sites in the body
• Dependent on several factors: drug solubility, circulation at deposit site, total surface area available for absorption, drug pH, temperature at site, mechanical factors
(massaging site)

PHARMACOKINETICS
2.
Distribution
• Process by which a drug reversibility leaves the blood stream and enters the system
• After being absorbed, drug is distributed to organ with the highest blood flow (oral doses go to LIVER, sublingual goes to HEART)
• Dependent on: blood flow, capillary permeability
(blood-brain barrier), binding of drugs to PRO (esp plasma albumin)

PHARMACOKINETICS
3.
Drug Metabolism
is major site for drug metabolism
Liver disease or present/past substance abuse can impair metabolism

PHARMACOKINETICS
4.
Elimination
• Terminates the drugs effects
• Drugs most often eliminated by BIOTRANSFORMATION and/or EXCRETION into urine or bile
• Renal excretion most important and most common via
URINE
• May be excreted unchanged or as metabolites
• Fat soluble drugs are NOT excreted in urine (need to be metabolized into water soluble by liver)
• Other elimination routes: Liver, kidney, lungs, bile, GI, sweat, milk, exhalation, saliva, gingival crevicular fluid

PHARMACOKINETICS
5.
Factors that Alter Drug Effects
• Pt compliance
• Psychological factors
• Tolerance
• Pathologic state
• Time of admin
• Route of admin
• Sex
• Genetic variation
• Drug interactions
• Age, weight
• Environment

ADVERSE EFFECT - TERMINOLOGY
• Adverse side effect: undesirable response, doserelated, ex: GI upset with aspirin
• Toxic effect: excessive dose, ex: chemotherapy
• Local effect: ex: necrosis at site of injection (NBQ)
• Idiosyncratic rxn: abnormal drug response that is usually genetically related
• Drug Interactions: effect of one drug is altered by another, may result in toxicity or lack of efficacy

ADVERSE EFFECT - TERMINOLOGY
• Allergic rxn: an immune response, not dose-related
• NBQ: What are the characteristics or sign and symptoms of an allergic rxn?
• Latex allergy may be on boards
• Inflammation, itchy skin, watery eye, nose
• Bronchoconstriction: severe → anaphylaxis
• Teratogenic effect: drug induced birth defect
(NBQ), ex: Thalidomide induction of phocomelia
(shortened limbs)

HELPFUL HINTS
• What meds would you use to treat:
Mild allergic rxn?
Severe reaction?

HELPFUL HINTS
• Answer: mild= antihistamine (Benadryl) severe=epi

HELPFUL HINTS
• Drugs that DO NOT cause hyperplasia: digoxin, beta blockers, tegretol
• Know which drugs will cause gingival overgrowth/hyperplasia:
• Cyclosporin
• Phenytoin (Dilantin)
• Ca-channel blockers (Nifedipine)
Antihypertensive
• Mouth-breathing
• Genetic factors
Organ Transplant
Anticonvulsant

AUTONOMIC NERVOUS SYSTEM
• Automatic Nervous System
• Self-governing, involuntary
• Responsible for blood pressure, heart rate, GI motility, salivation, bronchial/smooth muscle tone
• Required neurotransmitters
• 2 Divisions:
1) Sympathetic(SANS): Fight or Flight
2) Parasympathetic (PANS): Day to day activities, ensuring energy

PANS
• Rest and digestion system
• Functions
1) Dilates blood vessels leading to the GI tract, increase blood flow
2) Constricts bronchiolar diameter
3) Causes constriction of pupil and lens
4) Stimulates salivary gland secretion
5) Accelerates peristalsis
6) Activity mediates digestion of food and indirectly, the absorption of nutrients
• NT: Acetylcholine
• Pre/post-ganglionic synapse of PANS
• Pre-ganglionic synapse SANS

PANS & DRUGS THAT ALTER
• Cholinergic Agents/Muscarinic Drugs
• Used to mimic effects of PANS
• Used to tx: xerostomia, urinary retention, glaucoma
• Ex derived from plant alkaloids
• Pilocarpine: stimulates saliva (NBQ)
• Nicotine
• Contraindications
• Asthma: causes bronchoconstriction
• Peptic ulcer: ↑ GI secretions
• Cardiac disease: ↓ heart rate
• GI/Urinary obstructions: ↑ GI motility

PANS & DRUGS THAT ALTER
• Cholinergic Agents
• What do these drugs cause? (MIS)
• MyOsis: constrict pupils
• Increase bodily secretions: sweat, saliva, gastric juice
• Slowing of heart
• Adverse Rxns: SLUD
• Salivation
• Lacrimation
• Urination
• Defecation

PANS & DRUGS THAT ALTER
• Anticholinergic Agents
• Dry like the Sahara Desert
• What do these drugs do?
• Dilation of pupils mydriasis (Dilation eye exams)
• Decrease of bodily secretions: decrease fluid flow
• Dental implications: decrease salivary flow (NBQ)
• Adverse Effects: NBQ
• Blurred vision
• Constipation
• Dry Mouth
• Uses
• Atropine: used to control secretions
• Scopolamine: used for motion sickness (NBQ)

SANS
• NT: norepinephrine
• Acetylcholine is also the NT for the sympathetic preganglionic synapses, some post-ganglionic synapses and at some sites in the CNS
• Fight or slight
• Functions:
1) Vasoconstriction
2) Dilates bronchioles of lung: allow greater alveolar oxygen exchange
3) Increases heart rate
4) Dilates pupils

SANS & DRUGS THAT ALTER
Adrenergic agents
• Mimic fight or flight response
• Uses
• Colds
• Asthma
• Anaphylactic shock
• Glaucoma
• Vasoconstrictors
• Cardiac arrest
• CNS stimulation
• ADD

SANS & DRUGS THAT ALTER
Adrenergic agents
• Examples/Uses (BIG ON BOARDS!)
• EPI
• Cardiac stimulation (cardiac arrest)
• Anaphylaxis
• Hemostasis in dentistry
• Used in local anes and retention cord
• Stops bleeding and prevents systemic toxicity
• Overdose: elevate BP

SANS & DRUGS THAT ALTER
Adrenergic agents
• Examples/Uses (BIG ON BOARDS!)
• Albuterol
• Proventil, Ventolin
• Other
• Amphetamine, dextroamphetamine
(Dexedrine)
• Pseudoephdrine: decongestant
• Methylphenidate (Ritalin): AD/HD

SANS & DRUGS THAT ALTER
Adrenergic agents
• Adverse effects- epi overdose
• CNS palpitations, nervousness or tremor, tachycardia (NBQ)
• Cardiac arrhythmias
• Cerebral hemorrhage
• Pulmonary edema
• Anxiety, fear
• Contraindications
• Angina
• Uncontrolled Hypertension
• Uncontrolled Hyperthyroidism

SANS & DRUGS THAT ALTER
ß-Adrenergic Blocking Agents
• 2 types of beta receptors: ß-1 & ß-2
• ß-1 are in heart (memory hint: 1 heart)
• Heart rate, BP
• Drugs that block ß-1 receptors lower heart rate and BP and are useful when the heart itself is deprived of oxygen
• Rx: after heart attacks
• ß-2 are in lungs, muscles, arterioles (memory trick 2 lungs)
• Non-selective ß-blocker affect ß-1 and ß-2 receptors
• Should not be used n pt’s w/asthma or any reactive airway disease – doing so can block the effects of ß-2 agonists
• Ex: such as albuterol leading to airway and vascular restriction

SANS & DRUGS THAT ALTER
ß-Adrenergic Blocking Agents
• Useful in treating
• Hypertension, angina, cardiac arrhythmias, MI
• Hyperthyroidism, migraines, headaches, glaucoma, performance anxiety
• Drugs to Know (NBQ)
• Metoprolol (Lopressor)
• Cardio-selective ß-blocker
• Used to tx hypertension, prevention of myocardial infarction and angina
• Atenelol
• Cardios-elective ß-blocker
• Eliminates bronchoconstriction effect
• Used to tx hypertensive asthmatic patients

SANS & DRUGS THAT ALTER
ß-Adrenergic Blocking Agents
• Drugs to Know (NBQ)
• Timolol: Timoptol, Timoptic
• Reduces aqueous humor in the eye
• Used topically in tx glaucoma
• Inderol (Propranolol)
• Prototype of non-selective ß-blockers
• Lowers BP by lowering cardiac output
• Adverse rxn: bronchoconstriction, arrhythmias
• Limit epi-containing local anes to 2 carpules in pt’s taking non-selective ß-blockers due to potential increase BP
• Be able to differentiate ß-blocker from diuretics & other meds used in tx High BP

CARDIAC

• Know suffixes of blockers, Ca-Channel blockers,
ACE Inhibitors, etc…
• Know sign and symptoms of each condition
1.
Angina & Anti-Angina Agents
2.
CHF
3.
Heart Disease
4.
Arrhythmias & Anti-arrhythmics
5.
Hypertension
6.
Anticoagulants
7.
Anti-hyperlipidemics

• Cardiovascular Contraindications to Dental Tx
• Acute myocardial infarction (w/in the preceding
3-6mo)
• Unstable (or recent onset) angina
• Uncontrolled CHF
• Uncontrolled arrhythmias
• Significant, uncontrolled hypertension

• Angina
• Not enough O
2 to the heart cell
• Induced by stress, exercise, emotional state, anxiety
• Tx
• Nitroglycerine
• Amyl nitrate (NBQ)
• Mechanism of Action
• Used to dilate blood vessels and stop attack of angina
• Reduce the frequency of angina when admin prophylactically
• Drug Interactions
• Should not be taken 24HRS of taking sildenafil citrate
(Viagra)

Drugs need to know for Boards:
Nitroglycerin
• Drug of choice for acute angina
• Works as vasodilator (specifically, nitroglycerin acts as a smooth muscle relaxant)
• Generally given sublingually to treat angina attacks
• Dental emergency kit should contain

2. CHF
• Weakened heart muscle, decrease ability to pump
O
2
• Blood can back up into lungs, liver, organs
• Class Symptoms
• Edema in legs, shortness of breath
• Caution
• With epi = can lead to cardiac arrhythmias
• Digitalis, Glucosides; Digoxin (Lanoxin)
• Strengthen heart muscle: increase for of myocardial contractions
• Atrial fib

2. CHF
Digitalis glycosides
• Most common type of drug used in tx CHF
• Digoxin (Lanoxin) is most commonly used product
• Considerations
• In combo w/ sympathomimetic, digoxin can lead to cardiac arrhythmias; therefore, vasoconstrictors added to local anes should be used w/caution
• Tetracycline and erythromycin increase digoxin levels (in 10% of pt)
• Increases gag reflex and salivation

3. HEART DISEASE
• Heart Failure/Myocaridal Infarction
• Occurs when O dying
2 starved areas of the heart begin
• Can be a result of: Hypertension, Arrthymias,
Heart Valve Disorder, Disorders of the coronary artery, Cardiomyopathy
• Tx
• MONA: morphine, oxygen, nitroglycerine, aspirin

• Normal cardiac rhythm altered by cardiac diseases or injury
• Types
• Atrial tachycardia's
• Ventricular tachycardia's
• Tx
• Essentially any of the cardiovascular agents
• Lidocaine (sodium channel blockers) (NBQ)
• Other blockers
• Ca-Channel
• Adrenergic
• Sodium Channel
• Potassium Channel

5. HYPERTENSION
• Silent killer
• KNOW BP RANGES FOR ADULTS AND KIDS
120/80
130/90
Normal
Pre-HPT
140/100 HyperT
108/70
114/74
122/78
3yrs
6yrs
12yrs

5. HYPERTENSION
• Anti-Hypertensive – Diuretics
• Thiazide Diuretics
• Hydrochlorothiazide
• AE: hypokalemia (decrease potassium)
• Loop Diuretics
• Furosemide (Lasix)
• AE: hypokalemia
• Potassium Sparing Diuretics
• Triamterene (Dyrenium) reduce amt potassium lost
• Drug Interactions
• NSAID’s decrease effects

5. HYPERTENSION
Drugs need to know for Boards
Thiazide diuretics
• HCTZ is the most commonly used thiazide
• Frequently assoc w/ xerostomia
• Must avoid orthostatic hypotension
Loop diuretics
• Flurosemide (Lasix) is the most common
• Used in management of hypertension patients w/CHF

5. HYPERTENSION
• Anti-Hypertensive: Blockers
• End in “olol”
• Adrenergic agents such as alpha and beta-blockers
• Frequently Used
• Propranolol (Inderol) Non-Selective
• Metopropol (Lopressor) Selective beta-blocker
• Atenolol (Tenormin) Selective beta-blocker
• Clonodine Older drug but frequently used
• Adverse Effects
• Xerostomia
• Postural hypotension (fainting because of drug)

5. HYPERTENSION
• Anti-Hypertensive: CCI & ACEI
• Calcium channel blockers
• Many end with “pine”
• Nifedipine (Procardia)
• Amylodipine (Norvasc)
• Dilate the main coronary arteries by blocking Ca 2+ into cell
• Adverse Effects
• Gingival hyperplasia
• Xerostomia

5. HYPERTENSION
Calcium Channel Blockers
• Work by producing systemic vasodilation by BLOCKING vasoconstriction in smooth muscle of blood vessels
• One of the few antihypertensive agents whose effect is NOT reduced by NSAIDs
• Common oral manifestations: xerostomia, gingival enlargement
• Common drugs: know these!
• Cardizem (Dilitiazem)
• Norvasc (Amylodipine)
• Verapamil (Isoptin, Calan)
• Nifedipine (Procardia, Adalat)

5. HYPERTENSION
Angiotensin Converting Enzyme (ACE) Inhibitor
• BP lowered when these drugs block the conversion of angiotension I to angiotension II (causes vasodilation)
• Dysgeusia (altered taste) is common
• Adverse rxn: hypotension, allergic rxns, dry cough
• NSAIDS decrease effectiveness of ACE Inhibitors
• Avoid postural hypotension w/ACE inhibitors
• Common drugs: know!
• Lisinopril (Prinivil, Zestril)
• Captopril (Capoten)
• Enalapril (Vasotec)

6. ANTICOAGULANTS
• Interferes with clotting
• Warfarin (Coumadin)
• Dicumarol (NBQ)
• Drug interactions
• Aspirin
• Vit K
• Uses
• Thrombosis (coronary)
• Arrhythmia’s
• Post-heart attach
• Heart valve replacement

7. ANTI-HYPERLIPIDEMICS
•
•
•
•
•

CARDIAC DRUGS
Anticoagulants: therapy attempts to ↓ intravascular clotting
• Coumarins: Wafarin (Coumadin) is the most common
• Most serious drug interaction of warfarin is w/aspirin
• Prevents conversion of inactive Vit K to its active form
• ABX can also potentiate the effects of Warfarin (due to effect on Vit K)
• Consider dose reduction ONLY w/advise of treating
MD; allow several days for a change in effect if dose of warfarin is changed due to latent onset time
• Heparin
• One of the most commonly employed anticoagulant agents in hospitalized pts
• Given by injection only

RESPIRATORY AGENTS

RESPIRATORY AGENTS
• Adrenergic agents :1 st line of tx (NBQ)
• Albuterol (Proventil, Ventolin)
• Corticosteroids
• Beclomethasone (NBQ)
• Oropharyngeal candida can occur
• Xanthines
(how to say: zan-thenes
• Theophylline (Theo Dur)
)
• PO (old therapy)
• Emergency
• Status Asthmaticus – EPI!!!

RESPIRATORY AGENTS
• Seasonal Allergy Tx
• Histamine released due to inflammatory response
• H1 Blocker: antihistamine
• Block or inhibit histamine at the receptor site (NBQ)
• EX
• Benadryl (Diphenhydramine)
• Adverse Rxn: sedation, xerostomia
• Claritin
• Cetirizine (Zyrtec)
• Fexofenadine (allegra)
• Not used to tx anaphylaxis (EPI)

RESPIRATORY AGENTS
1.
Asthma
2.
COPD
3.
Upper Respiratory Infections

RESPIRATORY AGENTS
1.
Asthma
• Mild = inhaled ß-agonist as needed
(Albuterol)
• Isoproternol rapidly alleviates an acute attack of asthma when taken by inhalation but is rarely used as a bronchodilator:
• Metaproterenol (Alupent) produces dilation of the bronchioles & improves airway function
• Useful as a bronchiodilator in tx asthma and to reverse bronchospasm

RESPIRATORY AGENTS
1.
Asthma
• Types inhalers
1.
Short-acting bronchodilators: Albuterol,
Pirbuterol. Immediate relief of asthma symptoms
2.
Corticosteroids: used long-term to prevent asthma attacks. Flovent, Pulmicort, Azmacort,
Aerobid
3.
Corticosteroids + long-acting bronchiodilator:
Advair
4.
Long-acting brochodilators: Serevent and Foradil.
Relieve asthma symptoms for longer periods of time

RESPIRATORY AGENTS
2.
COPD
• Anticholinergic’s are 1 st line of defense
• Controversial information concerning oxygen admin w/pt’s with COPD
• Ipratropium (Atrovent) is the drug of choice for long-term management of COPD

RESPIRATORY AGENTS
3.
Upper Resp Infections
• Nasal decongestant are ß-adrenergic agonists that act to constrict the blood vessels of the nasal mucosa. Should not be used for more then a few days – rebound swelling & congestion
• Expectorants – drugs that promote the removal of exudate or mucus from the resp passages
• Antitussives (cough suppressants) may be opioids or related agents used for the symptomatic relief of a nonproductive cough

RESPIRATORY AGENTS
• Theophylline is an oral med used to tx chronic asthma and the bronchospasm assoc w/emphysema and chronic bronchitis
• Erythromycin can increase serum levels of theophylline and toxicity may result
• Aspirin should be avoided in asthmatics (4-19% of asthmatics have aspirin hypersensitivity)
• Albuterol CAN cause insomnia

GI DISORDERS
• Gastrointestinal Reflux: GERD, Peptic Ulcer
• H2 Blockers
• Blocks histamine and reduce gastric secretions
• Ex: Cimetidine (Tagamet), Ranitidine (Zantac) (NBQ)
• Proton-Pump Inhibitors
• Most effective – completely blocks production of hydrochloric acid
• Ex: Esomeprazole (Nexium), Lansoprazole (Prevacid)
• Ex: Pantoprazole (Protonix), Omeprazole (Prilosec)
• Antacids (TUMS)
• Neutralize gastric hydrochloric acid OTC agents used for the relief of indigestion, etc…
• Tip: Aspirin exacerbates

GI DISORDERS
• The pt who lists Tagament on hl hx is likely treated for gastric ulcers
• Gastric ulcerations do NOT cause gingival bleeding

DRUGS FOR DIABETES
• Type I
• Insulin dependent
• Insulin by subcutaneous injection is most common tx
• Hypoglycemia most common adverse rxn (Insulin
Shock)
• Shortness breath is NOT assoc w/hypoglycemia
• Type 2
• Non-insulin dependent
• Oral hypoglycemics are used to tx
• Metaformin (glucophage) & glyburide (DiaBeta,
Micronase) are common examples of oral hypoglycemics

CNS

CNS AGENTS
1.
Benzodiazepines
2.
Barbiturates
3.
Anticonvulsants
4.
Antidepressants
5.
Antipsychotics

1. BENZO’S
• “Pam-Lam” – end of drug names usually end in pam or lam
• Tx dental anxiety (NBQ) and TMD
• Used to tx short-term: stress, anxiety, insomnia, alcohol withdrawal
• Anxiolytic agent (antianxiety, antipanic)
• No antipsychotic, analgesic activity, not affect
ANS
• All have sedative properties
• Smoking reduced effectiveness

1. BENZO’S
• Reverse status epilepticus and seizure assoc w/local anes overdose
• Ex
• Alprazolam (Xanax)
• Diazepam (Valium)
• Lorazepam (Ativan)
• Dental implications (NBQ)
• Xerostomia
• Drowsiness

2. BARB’S
• Lots of drug/drug interactions
• Was Rx as a sedative (Benzo’s have now replaced)
• Therapeutic used currently
• Sedative/Hypnotic (pre-anesthesia)
• Primarily used as anticonvulsant (NBQ)
• Ex
• Phenobarbitol: long-acting, used to tx epilepsy, no analgesia effects
• Butabarbital (Buticaps) – anticonvulsant
• Secobarbital (Seconal)
• Pentobarbital (Nembutal)
• Thiopental

3. ANTICONVULSANTS
• Hydantoins – Phenytoin – Dilantin
• Adverse Effect: gingival hyperplasia (50%)
• Barbiturates: Phenobarbital, Primidone
• Used alone or in combo (NBQ)
• Carbamazepine (Tegretol)
• Trigeminal neuralgia (NBQ) – sharp pain in face
• Bi-polar depression
• Recently used in dentistry more to tx trigeminal neuralgia
• No gingival hyperplasia!!
• Dental implications
• Xerostomia
• Glossitis
• Stomatitis

4. ANTIDEPRESSANTS
• Tricyclic antidepressants
• Elavil (Amitryptuline)
• Side Effect: severe xerostomia (NBQ)
• Serotonin-Specific Re-Uptake Inhibitors (SSRIs)(NBQ)
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Tobacco cessation
• Buprioprion (Zyban)(Varcenicline) (Wellbutrin)
• Chantix
• Bi-Polar Disorder
• Mania Tx – Lithium
• Drug interaction – w/NSAID’s

5. ANTIPSYCHOTIC AGENTS
• Work by blocking dopamine
• 1 st generation: Thiazides
• Chlorpromazine (Thorazine)
• Haloperidol (Haldol)
• 2 nd generation: Clozapine (Clozaril)
• Adverse Rxns
• Extrapyramidal, ie: tardive dyskinesia and parkinson’s-like symptoms(NBQ)
• Schizophrenia
• Assoc with increased dopamine (NBQ)

PARKINSON’S DISEASE
• Decrease dopamine
• S&S
• Bradykinesia, tremors, rigidity, poor balance,
Parkinson’s gait (shuffling)
• Difficulty swallowing, excessive salivation, sweating
• Tx
• Levodopa (L-DOPA)
• Levodopa + carbidopa (Sinemet, Sinemet CR)

GENERAL ANESTHETICS
• Potent CNS depressants
• Produce reversible loss of consciousness and insensitivity to painful stimuli
• Nitrous oxide is considered an incomplete anesthetic
• IV anes: unusually short acting barbiturates, benzo’s used for sedation
• Benzo (Valium), may be given prior to general sedation
• Stages and Planes of Anesthesia
1.
Stage I – Analgesia
2.
Stage II – Delirium or Excitement
3.
Stage III – Surgical Anesthesia
4.
Stage IV – Respiratory or Medullary Paralysis

GENERAL ANESTHETICS
• Stages and Planes of Anesthesia
1.
Stage I – Analgesia: 3 planes
• Reduced pain sensation (development of analgesia)
• Pt remains conscious & can still respond to command
• Respiration & reflexes are regular
• Nitrous oxide, as used in dental setting, maintains the patient Stage I plane 1&2
• End of this stage = marked loss of consciousness

GENERAL ANESTHETICS
• Stages and Planes of Anesthesia
2.
Stage II – Delirium or Excitement
• Begins w/unconsciousness & is assoc w/involuntary movement and excitement
3.
Stage III – Surgical Anesthesia
• Most major surgery is performed
4.
Stage IV – Respiratory or Medullary Paralysis
• Complete cessation of all respiration, if this stage not immediately reversed = death

NON-OPOID ANALGESICS
• NSAIDs / NSAIAs
• Know what they do
• Analgesic: relief of pain
• Antipyretic: lowers fever, effects hypothalamus (NBQ)
• Anti-inflammatory: reduce inflammation
• Anti-platelet effect – interferes with clotting
• Aspirin (irreversible), ibuprofen (reversible)
• Mechanism of action
• Inhibit the synthesis of prostaglandin (lipid compound derived from fatty acids, are messenger molecules)
• Side effects
• GI bleeding
• Reduced effect of blood pressure meds

PROSTAGLANDINS
Examples of prostaglandin antagonists are:
• NSAIDs (inhibit cyclooxygenase)
• Corticosteroids (inhibit phospholipase A2 production)
• COX-2 selective inhibitors or coxibs
• Cyclopentenone prostaglandins may play a role in inhibiting inflammation
Clinical uses: Synthetic prostaglandins are used:
• To induce childbirth (parturition) or abortion
• To prevent and treat peptic ulcers (PGE)
• As a vasodilator in severe Raynaud's phenomenon
• In pulmonary hypertension
• Tx glaucoma
• Tx erectile dysfunction
• Ingredient in eyelash and eyebrow growth beauty products

NON-OPOID ANALGESICS
• Know classifications and examples
• Propionic acid, acetic acid, salicylates
• Diclofenac (Voltaren)
• Ibuprofen (Advil, Motrin)
• Ketoprofen (Orudis), naproxen (Anaprox, Aleve)
• Indomethacin (Indocin) and sulindac (Clinoril)
• Diflunisal (Dolibid)
• Aspirin considered a salicylates (Bayer, Emprin,
St.John, Anacin)
• Coupled with opioids: dose-sparing effect –(can give less)
• Best dental analgesic = ibuprofen

NONOPIOID ANALGESICS
Aspirin
• Prototype of non-narcotic analgesics
• Considered a non-steroidal anti-inflammatory drug (NSAID)
• Uses:
• Analgesia (reduce pain)
• Antipyretic (reduce fever)
• Antiinflammatory (reduce inflammation)
• Mechanism of Action: inhibition of prostaglandin synthesis
• Fever reduced through action of hypothalamus
• Side effects
• Interferes w/clotting (contraindicated w/coumadin/warfarin due to drug interaction
• GI irritation (contraindicated w/peptic ulcer)
• Hypersensitivity: 15% pt’s , fatal anaphylactic shock rare

NONOPIOID ANALGESICS
Aspirin
• Reye’s Syndrome
• Kids w/ chicken pox or flu, use of aspirin has been epidemiologically assoc w/ REYE’S SYNDROME
• Acetaminophen used in pediatrics for both its analgesic and antipyretic action
• Toxicity (termed salicylism)
• GI upset/vomiting
• Confusion and dizziness
• Dim vision
• Tinnitus
• Coma
• Respiratory& metabolic acidosis
• Death from respiratory failure

NONOPIOID ANALGESICS
Ibuprofen
• NSAID
• Mechanism action: inhibition of prostaglandin synthesis
• Action
• Analgesic
• Antipyretic
• Anti-inflammatory
• Side effects
• Interferes with clotting (contraindicated w/coumadin/warfarin due to drug interaction)
• GI irritation (contraindicated w/ peptic ulcer disease, irritation is
LESS than w/aspirin)

NONOPIOID ANALGESICS
Ibuprophen
• Available in suspension form for pediatric use as an antipyretic
• Know effects & contraindications of NSAIDs for boards
• Can decrease pharmacological effects of MANY drugs including
• ACE inhibitors
• Aspirin
• Beta blockers
• Corticosteroids
• Cyclosporin
• Lithium
• Loop diuretics

NONOPIOID ANALGESICS
Acetaminophen - Tylenol
• Used as: analgesic and antipyretic only
• No anti-inflammatory effects (not an NSAID, no clotting effects)
• No GI upset, preferred drug for pt’s on coumadin and/or peptic ulcer drugs
• Contraindication: liver conditions
• Drug of choice for post-op pain w/ compromised systemic illness and for patients on anticoagulant therapy
• Side effects rare
• Overdose: hepatoxicity, liver necrosis, death

OPIOID/NARCOTIC ANALGESIC
• What do they do?
• Provide analgesia by blocking pain receptors in brain w/out loss of consciousness (alter perception of pain)
• Varying degrees based on strength of agent
• Used to manage pain when nonopioids fail
• Mechanism of action: blocks pain receptors in brain without loss of consciousness
• Be familiar with types of Morphine (protype)
• Demerol, Dilaudid, Codeine, Hydrocodon
• Codeine can cause emesis, and constipation
• Signs of addiction – pinpoint pupils
• Overdose – leads to resp. depression - death

OPIOID/NARCOTIC ANALGESIC
• Methadone
• Efficacious for the tx of narcotic withdrawal and dependence
• Taken orally once a day, methadone suppresses narcotic withdrawal for between 24-36 hours
• Only effective in cases of addiction to heroin, morphine, other opioid drugs (not methamphetamine addiction!)
• Narcan
• Opioid antagonist
• Used to tx opioid overdose
• Should be in dental emergency kit

OPIOID/NARCOTIC ANALGESIC
• Will exhibit pinpoint pupils during use (cocaine)
• IV drug abusers need to be pre-medicated with antibiotics prior to tx due to high vascular bacteremia load
• NSAIDs are the best medication for heroin addicts
(no pain therapy should be recommended that alters consciousness)

• Commonly used in dentistry with acetaminophen
• Tylenol #2-4
• Schedule III drug
• Antitussive effect – suppresses cough
• Naloxone (Narcan) and naltrexone (Trexan)
• Blocks the action of opioids on their receptors
• Used to tx narcotic overdose

DRUGS OF ABUSE
• Marijuana: dilated red bloodshot eyes
• LSD: dilated pupils, flashbacks, hallucinogen
• Heroin: pinpoint pupils
• Cocaine: rapid heart rate, sweating, dilation of pupils, elevated body temp
• NBQ: If you knew someone was on cocaine and suspected they had taken in the last 24HRS, you would
NOT inject local anes agent for the risk of overdose

ENDOCRINE PHARM
• Corticosteroids
• Uses: not curative – palliative – short term tx
• Allergic rxns
• Rheumatic or collagen disorders, lupus
• Skin conditions, mild to severe
• Acute resp disorders: asthma
• Malignancies: leukemia, lymphoma, Hodgkin’s disease
• Dental uses: oral lesions, TMD, oral surgery
• Under stressful conditions watch for adrenal crisis
• Rule of 2s = 20mg for 2 weeks within 2 years (needs consult)

ENDOCRINE PHARM
Pancreas: Secretes insulin and glucagon
• Insulin: secrete in response to high blood glucose
(hyperglycemia)
• Glucagon: secreted in response to low blood glucose
(hypoglycemia)
• Hyperglycemia: Glucose over 140, Excess glucose in blood
• Leads to complications – Diabetes Mellitus
• Contributing factors that precipitate hyperglycemia
• Wt gain, cessation of exercise, pregnancy, hyperthyroidism, thyroid meds, epi therapy, cortisone therapy, acute infection, fever, stress
• S&S: acetone breath, hot dry skin, rapid breathing
• Tx: insulin, oral hypoglycemic agents (sulfonylureas)

ENDOCRINE PHARM
• Pancreas: Hypoglycemia
• Bl glucose level low: 70mg/dl and 110mg/dl normal levels
• Symptoms: varies person to person
• Difficulty concentrating, sweating, nervousness, lack of coordination, trembling, slow thinking, pounding heart
• Cause from
• Oral hypoglycemic
• Tx
• CHO, orange juice, sugar, candy, coke
• Risk
• Insulin shock
• Rapid onset

ENDOCRINE PHARM: THYROID
• Secretes T3 and T4 hormone
• Hypothyroidism
• Metabolic rate decrease, decrease mental and physical stamina, increase weight
• Tx: generally life-long replacement therapy
• Synthyroid, Levoxyl, Armour
• Hyperthyroidism
• Excessive heat, increase motor activity, increase sen to pain
• Epi contraindicated (NBQ)
• Require higher doses than usual of sedatives, analgesics, local anes
• Tx: radioactive Iodine, kills thyroid cells w/out affecting other cells

FEMALES SEX HORMONE
• Secretes: estrogen, progesterone
• Know therapeutic uses and types
• Used in contraception
• Replacement therapy in post-menopausal women
• Premarin, Femert
• Side effects
• Risk thromboembolic disease, blood clots, hemorrhage

MALE SEX HORMONES
• Secretes – testosterone hormone
• Androgenic: development of secondary male sex char.
• Androgenic steroids: used in tx of breast cancer or replacement therapy
• Anabolic steroids: results in tissue PRO and nitrogen retention (treated as Schedule III controlled drugs – abuse potential)

ANTIBACTERIAL AGENTS
• Bactericidal: ability to kill bacteria, irreversible action
• Bacteriostatic: ability to inhibit or slow the multiplication or growth of bacteria
• Minimum Inhibitory Concentration (MIC): lowest concentration needed to inhibit visible growth of an org
• Resistance: natural or acquired ability of an organism to be immune to or to resist the effects of an anti-infective agent
• Spectrum: range of activity of a drug
• Synergism: Occurs when the combo of 2 antibiotics produces more effect than would be expected if their indiv effects were added
• Antagonism: occurs when a combo of 2 agents produces less effect than either agent alone

ANTIBIOTICS
PENICILLIN
• Tx and prevention of dental infections
• Effective against 90% bacteria involved in dental infections
• Pen VK most popular, less erratic absorption then Pen G
• Pen G: inactivated by gastric acids
• Amox used for prophylaxis regimen
• Not effective against penicillinase: enz produced by some bacteria which produced resistance
• Derivatives: Amoxicillin, Ampicillin, Augmentin (amox & clavulanic acid)
• Work by destroying bacterial CELL WALL integrity which leads to lysis
• Most effective against rapidly growing org (Log Phase)

ANTIBIOTICS
PENICILLIN
• Adverse effects / manifestations
• GI distress / Candida
• Anaphylactic rxn: greatest danger of pen use (NBQ)
• Those allergic to pen = also allergic to cephalosporin’s and all derivatives of penicillin
• Most common allergic rxn = skin rash
• CAN be given to pregnant women
• Amoxicillin NOT effective against penicillinase (also known as ‘beta lactamase’)
• Clavulanic acid in combo w/amox (Augmentin) =
PREVENTS penicillinase from breaking it down

ANTIBIOTICS
TETRACYCLINE
• Drug interactions, do not take with: dairy products, antacids, iron tablets, calcium
• Cause chelation of tetracycline's which reduces GI absorption
• Mixing tetra w/other antibiotics = results in antagonism
• Ability to concentrate in gingival crevicular fluid
• Often used topically to tx aggressive perio d.
• Inhibit collagenase production (may be used for chronic perio
• May be used systemically to tx NUG/NUP

ANTIBIOTICS
TETRACYCLINE
• Bacteriostatic: work by inhibiting PRO synthesis (not act on cell walls)
• Previous boards
• Antacids decreases up to 50% tetracyc
• Ca-containing foods inhibit absorption
• Know how to id tetracycline staining and how occurs

ANTIBIOTICS
Macrolides
• Erythromycin – 1 st generation
• GI effects
• Clarithromycin, Azithromycin (Zithromax) - 2 nd
• Used to tx resp. inf.
• Drug Interactions
• Increase serum conc. of theophylline, anticoagulants, digoxin, carbamazepine

ANTIBIOTICS
•
•
•
•

ANTIBIOTICS
SIDE EFFECTS
• Most common: GI upset
• Secondary: fungal infections
• Allergic rxns

ANTITUBERCULOSIS AGENTS
• Transmitted through inhalation of infected bact
• (-) test indicated no further testing
• (+) indicated a chest x-ray
• Sputum smear = most definitive test to determine TB
• 3 consecutive negative sputum smears necessary to determine person w/ Hx TB no longer contagious
• PPD (purified PRO derivative) is an antigen used to aid in diagnoses of TB exposure = known as
Mantoux skin test

ANTITUBERCULOSIS AGENTS
• Rxn measured in mm of induration at the site approximately 48-72 hours after PPD has been determined (NBQ)
• Positive test does NOT indicate person has active disease, only that they have been exposed to the disease (NBQ)

ANTITUBERCULOSIS DRUGS
• Rifampin
• Red urine, tears, saliva
• Isoniazid
• May lead to hepatoxicity
• Pyrazinamide
• May lead to hepatoxicity
• Ethambutol
• Decrease red/green color discrimination
• Decrease visual acuity
• All 4 drugs used at same time to be effective

ANTITUBERCULOSIS DRUGS
• Pt indicates taking isoniazid or rifampin ONLY =
Rx could be to prevent from developing TB
•
pyrazinamide
•
rifampin
• Ethambutol also known as Myambutol
•
ethambutol

ANTIFUNGAL AGENTS
• Candidiasis: candida albicans is a yeast like fungus
• Common after ABXor steroid use and in immunocompromised patients
• Conditions contributing to disease
• Xerostomia
• Diabetes
• Poor oral hl
• Prosthetic appliances
• Suppression immune system
• Tx
• OTC: Nystatin (Mycostatin), Clotrimazole (Mycelex)
• Stronger: Ketoconozole (Nizoral), Fluconazole (Diflucan)
• Nystatin commonly used in dentistry

ANTIVIRAL AGENTS
• Colds, influenza, hepatitis, Epstein-Barr, Mononucleosis
• Herpes Simplex Virus: cold sores
• Acyclovir (Zovirax): will not cure, will help heal faster
• HIV
• Zidovudine (AZT, Retrovir): Nucleoside Reverse
Transcriptase Inhibitor (NRTIs) was 1 st drug approved for tx
HIV
• Protease Inhibitors: Saquinavir(Invirase), Ritonavir(Norvir)
• Blocks some component of replication cycle of HIV which is classified as a retrovirus
• Know oral manifestations and management: Oral
Kaposi’s sarcoma, hairy tongue, leukoplakia, papillomavirus, herpes

PREMED IN DENTISTRY
• 2007 AHA Guidelines
• Need
• Artificial heart vales
• A hx of infective endocarditis
• Cardiac transplant that develops valvular problems
• Specific congenital heart defects such as
1) Unrepaired or incompletely repaired cyanotic congenital heart disease
2) Completely repaired congenital heart defect with prosthetic material or devise during the first 6 months after the procedure
3) Any repaired congenital heart defect with residual defect at the sire or adjacent to the site of a prosthetic patch or devise

PREMED IN DENTISTRY
• Those cardiac conditions NO LONGER requiring antibiotic premedication include:
• Mitral valve prolapse (with or without regurgitation)
• Rheumatic heart disease
• Bicuspid valve disease
• Calcified aortic stenosis
• Certain congenital defects
• Ventricular septal defect
• Atrial septal defect
• Hypertonic cardiomyopathy

PREMED IN DENTISTRY
• Oral antibiotic drug regimen for cardiac conditions:
• If a patient is NOT allergic to penicillins, administer:
• Amox 2000mg (2g), 30min to one hour prior to invasive procedure (calculate 50mg/kg for kids)
• If patient is allergic to penicillins, administer:
• Cephalexin: or other 1 st generation oral cephalosporin
• Clindamycin
• Azithromycin
• Clarithromycin

PREMED IN DENTISTRY
• Prosthetic Joint Prophylaxis
• Current premed guidelines by the ADA do not reflect the views of American Academy of Orthopedic
Surgeons (AAOS)
• Therefore, although current AAOS recommendations stipulate that prosthetic joint replacements require antibiotic premedication for life, the Board will likely use the ‘older’ guidelines listed below:
• Joint replacement may be need antibiotic coverage in the following cases:
• Less than 2yrs following replacement surgery
• Previous prosthetic joint infections
• Multiple joint replacements

PREMED IN DENTISTRY
• Non-cardiac Medical Conditions
• Much controversy
• Renal dialysis shunt
• Ventricular hydrocephalic shunt
• NOT requiring antibiotic premed
• Splenectomy
• Lens and Breast Implants
• Stents
• Any procedure NOT producing much bleeding
• Non-Invasive Procedures: not needing premed
• Block injections, Radiographs, Impressions, Sealant placement, Fl tx

MISC BOARD MUST-KNOWS
• Corticosteroid meds such as Prednisone may lead to adrenal suppression
• Statin drugs used to lower cholesterol include
• Lipitor
• Lescol
• Mevacor
• Livalo
• Pravachol
• Zocor
• Crestor

MISC BOARD MUST-KNOWS
• HIV drugs
• AZT
• Didanosine
• Zalcitabine
• Stavudine
• Laminivudine
• HIV Pretease Inhibitors

MISC BOARD MUST-KNOWS
• Hypothyroidism
• Most common tx = thyroid hormone replacement
• Levothyroxine common = synthyroid
• Levoxyl, Levothroid, Unithroid
• Synthyroid dose too low=pt cold intolerant
• Use caution w/ epi-containing anes
• Myxedema coma may result if pt taken off synthyroid suddenly
• Iodine insufficiency may cause thyroid gland to enlarge producing a goiter (iodine supplement often warranted)
• Synthyroid
• Given 1x/day due to long half-life
• Toxicity indicated by nervousness, heart palpitations/tachycardia, intolerance to heat

MISC BOARD MUST-KNOWS
• Pupil dilation sign of cocaine use
• Alcohol in combo w/nitroglycerine will result in dangerously low blood pressure
• Flagyl (metronidazole) is an anti-infective agent that has an anabuse-like rxn when used in conjunction w/alcohol
• HRT = linked to osteoporosis and gingival inflammation
• Pregnancy drugs that are acceptable = local anes, acetaminophen, clindamycin, nystatin
• Local anes = will NOT affect a nursing baby
• NSAIDs decrease effectiveness of muscle relaxants

MISC BOARD MUST-KNOWS
• Zyban is an antidepressant used for smoking cessation
• Chantix = non-nicotine med designed to BLOCK nicotinic receptors in brain
• SSRIs: selective serotonin inhibitors are a class of antidepressants
• Fluoxetine: Prozac, Prozac weekly
• Sertraline: Zoloft
• Citalopram: Celexa
• Escitalopram oxalate: Lexapro
• Paroxetine: Paxil, Paxil CR

MISC BOARD MUST-KNOWS
Estrogen
• Steroid hormone
• Estradiol is the most potent estrogen produced by women (estrone, estriol have 1/10 th the potency)
• Common side effects: nausea, vomiting
• May promote endometrial carcinoma and breast cancer in postmenopausal women
• May cause increase in gingival inflammation
• Lowers LDL, increases HDL levels
• Examples: Premarin, Estraderm
• Frequently used for:
• Contraception
• Post-menopausal hormone therapy
• Menstrual disturbances
• Steroid hormone

MISC BOARD MUST-KNOWS
• Mevacor (Lovastatin)
• Antihyperlipidemic agent
• Inhibits HMG-CoA reductase and increases catabolism of
LDL
• Lipitor
• Antihyperlipidemic agent which limits cholesterol synthesis and increases catabolism of LDL
• Been shown to decrease triglyceride levels
• GI upset common
• Can increase the anticoagulant effect of Warfarin

MISC BOARD MUST-KNOWS
• Prednisone
• Intermediate-acting glucocorticoid
• Dramatically reduces inflammatory response and suppresses immunity
• Increases risk of infection and delays healing
• Symptoms of infection may be masked
• Can exacerbate hypertension
• Osteoporosis is common w/ long-term use
• Adrenal crisis possible under stress: steroid supplementation may be necessary if patient has been taking 5-10mg prednisone longer than 2 weeks – check with MD!!!
• Uses: autoimmune disease, Addison’s disease, Relief of inflammatory symptoms, Tx allergies
• Side effects: edema, Buffalo-hump, moon face, peptic ulcers, mental disturbances, increase body hair growth, insomnia