The Importance of Pharmacology in the Delivery of Quality Dental Care

Mary Govoni, CDA, RDA, RDH, MBA; Richard L. Wynn, PhD

March 2015 Course - Expires March 31st, 2018

American Dental Assistants Association

Abstract

Although dental assistants do not prescribe drugs for patients, they should have a good understanding of the basic categories of medications and recognize their implications for dental treatment. Dental assistants also should be able to recognize side effects that may occur from certain medications and know the contraindications for prescribing medications. Because many dental assistants are responsible for reviewing health histories with patients, knowledge of medications can be invaluable in alerting the treating dentist to situations that could affect the patient’s overall health.

You must be signed in to read the rest of this article.

Login Sign Up

Registration on CDEWorld is free. You may also login to CDEWorld with your DentalAegis.com account.

GLOSSARY

ACE: angiotensin enzyme inhibitors used to treat hypertension
ADD/ADHD: attention deficit disorder/attention deficit hyperactivity disorder
adverse effect or reaction: an abnormal, unexpected, and usually intolerable response to a drug that may cause injury
allergy: an abnormal biological response in which the body creates antibodies to a drug or other stimulus, usually resulting in an unpleasant reaction such as skin rash or itching
analgesic: a drug that is used to relieve pain
anaphylaxis: a severe, possibly life-threatening, allergic reaction; extreme hypersensitivity to a drug or other stimulus
anemia: a condition in which the blood is deficient in red blood cells, hemoglobin, or total volume
anesthetic: an agent that causes a loss of sensation or consciousness
anorexiant: a drug that suppresses appetite
antagonistic: describes an interaction of two drugs that results in a lesser effect than one drug used alone
anti-coagulant: an agent that interferes with or prevents blood clotting
anti-emetic: an agent to prevent vomiting
anti-fungal: an anti-infective agent used to treat infections caused by a fungus
anti-hypertensive: an agent that acts to lower blood pressure
anti-infective: an agent that fights infections, for example, antibiotics, anti-virals, and anti-fungals
anti-pyretic: a drug that treats fever by lowering body temperature
anti-tussive: a cough-suppressing agent
anti-viral: an agent that fights viral infections
arthropathy: a disease of the joints
arrhythmia: abnormal heart rhythm
bacteriocidal: having the ability to destroy bacteria
bacteriostatic: having the ability to inhibit bacterial growth
beriberi: a disease caused by thiamine deficiency and characterized by neurological symptoms, cardiovascular abnormalities, and edema
bradycardia: slow heart rate
brand name: the registered trade name given to a drug by its manufacturer
contraindication: a condition or disease that precludes the use of a particular drug
controlled substances: drugs that have a potential for abuse, for example, stimulants, narcotics, and sedatives
cystitis: inflammation of the urinary bladder
dermatitis: skin irritation
diaphoresis: excessive sweating
diuretic: a drug that increases the output of urine by altering kidney function
dose: a measured amount of a drug
drug interaction: reaction occurring when two or more drugs are taken simultaneously; may be helpful (that is, may improve effectiveness) or detrimental (as in a toxic reaction)
embolism: obstruction of a blood vessel by a blood clot or other foreign substances
edema: swelling caused by accumulation of fluids
expectorant: an agent that promotes removal of secretions from mucous membranes, for example, cough syrup
FDA: the US Food and Drug Administration, which is responsible for regulating drugs marketed in the United States
fluorosis: tooth discoloration caused by high doses of fluoride
gastritis: inflammation of the mucous membrane of the stomach
gastroenteritis: inflammation of the mucous membrane of the stomach and intestines
generic name: the official, common, or public designation for a drug as assigned by the FDA
glaucoma: eye disease characterized by increased intraocular pressure
hematogenous: formation of blood cells
hemophilia: a sex-linked hereditary blood defect that occurs almost exclusively in males and is marked by delayed clotting (and in turn, difficulty controlling hemorrhage even after minor injuries)
hemostasis: a stopping or slowing of blood flow
hyperglycemia: high blood sugar
hypersensitivity: allergy to a drug, an over-responsiveness
hypervitaminosis: an abnormal state resulting from excessive intake of one or more vitamins
hypnotic: a drug that causes sleep
hypoglycemia: low blood sugar
hypoxia: decreased levels of oxygen in blood or tissues
idiosyncratic: unusual or unexpected, as in a reaction to a drug
immunosuppressive: an agent that suppresses immune response, drugs used to prevent rejection of transplanted organs
intravenous: within a vein
IU: abbreviation for International Unit; a unit of dosage in vitamins
laryngospasm: contraction of the laryngeal muscles
lymphadenopathy: unusually enlarged lymph nodes, indicative of an immune response
MAO inhibitors: class of drugs that inhibits the monoamine oxidase production, which is responsible for breaking down monoamine neurotransmitters in the nervous system; used to treat depression
myalgia: muscle pain
myasthenia gravis: a disease characterized by the progressive weakening of voluntary muscles without atrophy or sensory disturbance; caused by an autoimmune attack
narcolepsy: uncontrolled periods of drowsiness or sleep
neuritis: an inflammatory lesion of a nerve marked by pain, sensory disturbances, and impaired or lost reflexes
NSAID: a non-steroidal anti-inflammatory drug
orthostatic hypotension: a drop in blood pressure upon arising from a seated or reclining position
osteomalacia: a disease of adults characterized by softening of the bones; analogous to rickets in children
osteonecrosis of the jaw (ONJ): bones of the jaw begin to die, and decay; associated with high dose bisphosphonate treatment. 
overdose: a single drug dose that exceeds the normal recommended range or the accumulation of daily doses of drugs
over-the-counter: describes drugs that can be purchased without a prescription
pallor: paleness of the skin
paresthesia: sensation of pricking, tingling, or creeping of the skin having no objective cause; usually associated with injury or irritation of a sensory nerve or nerve root
parenteral: administration of a drug other than through the intestinal canal; usually refers to injections
pellagra: a disease marked by dermatitis, gastrointestinal disorders, and nervous symptoms; associated with niacin and protein deficiency
pernicious anemia: a severe blood condition marked by a progressive decrease in number and increase in size and hemoglobin content of red blood cells; presents clinically as pallor, weakness, and gastrointestinal and nervous disturbances
photosensitivity: a drug-induced change in the skin that results in a rash or sunburn on exposure to the sun or ultraviolet lights
prothrombin: chemical in the blood involved in the clotting process
psychoneurosis: a neurosis based on emotional conflict in which an impulse that has been blocked seeks expression in a disguised response or symptom
psychosis: a serious mental disorder characterized by defective or lost contact with reality, often with hallucinations or delusions
Recommended Daily Allowance: the amount of a substance (for example a vitamin or mineral) that is officially recommended for daily consumption by a governmental board of nutrition experts
rheumatic: relating to, characterized by, or affected with rheumatism (inflammation of pain in muscles, joints, or fibrous tissues)  
rhodopsin: a red photosensitive pigment in the retinal rods that contributes to vision in dim light
rickets: a deficiency disease affecting the young during skeletal growth; characterized by soft and deformed bones
sedative: an agent that calms or tranquilizes
side effect: a normal, expected, and predictable non-therapeutic response to a drug that accompanies the intended response to the drug
stenosis: a narrowing or constriction of the diameter of a bodily passage or orifice
sublingual: under the tongue
superinfection: a secondary infection caused by organisms that are not susceptible to the drug used to treat the original infection
supine: lying on the back
synergism: interaction of two drugs causing a greater effect than the sum of each drug acting alone
systemic lupus erythematosus: an inflammatory connective tissue disease of unknown cause that occurs chiefly in women
tachycardia: fast heart rate
tetralogy of Fallot: a congenital abnormality of the heart marked by pulmonary stenosis, an opening in the interventricular septum, malposition of the aorta, and excessive development of the right ventricle
thrombosis: blood clot that remains stationary
tinnitus: ringing in the ears
toxicity: the capacity of a drug to impair body function, damage tissue, or cause cell death
toxicology: the study of adverse drug reactions
urticarial: hives
vasoconstrictor: an agent that constricts or contracts the walls of blood vessels
vasodilator: an agent that relaxes the walls of blood vessels
vertigo: dizziness
viral load: a term used in reference to HIV/AIDS patients to describe the amount of HIV virus present in the body at a given time
xerostomia: dry mouth caused by decreased salivary flow

INTRODUCTION

Pharmacology is the study of drugs. Drugs are defined as any chemical substance that affects biological systems. Because many substances fit this description, the scope of pharmacology is extremely broad. It includes such things as over-the-counter (OTC) pain relievers like aspirin and acetaminophen; narcotic pain medications such as Demerol and Vicodin; vitamin supplements; local anesthetic agents; fluorides; and much more. This course provides dental assistants with a broad overview of various categories of drugs and their implications for dental patients and treatment.

It is becoming more and more common for dental professionals to encounter patients who are taking a number of medications, many of which have oral side effects or some effect on the patient’s dental treatment. Because dental assistants often are the frontline healthcare workers who review medical histories with patients, they should be knowledgeable about the medications that a patient may need or may already be taking.

REGULATION OF DRUGS

The US Food and Drug Administration (FDA) is the federal agency that determines which drugs can be sold in the United States. It oversees the development, approval for marketing, and ongoing control of prescription and non-prescription (“over-the-counter”) drugs or medications. The FDA also sets quality standards for drug manufacturing, safety, and effectiveness. In addition, the FDA also regulates labeling and advertising of drugs in the United States and has the authority to remove drugs from the marketplace that are deemed unsafe.

Drug safety standards can vary greatly from country to country, and many drugs available in Europe and South America are not sold in the United States because they do not meet the FDA standards.

The federal Drug Enforcement Administration (DEA) is the agency responsible for enforcing US controlled substances laws and regulations. It regulates the manufacture and distribution of drugs that have a potential for abuse, such as stimulants, narcotics, and sedatives. Such drugs are classified by “Schedule,” as listed in Table 1.

CLASSIFICATION OF DRUGS
Most broadly, every drug falls into one of two categories: OTC (non-prescription) or prescription. Prescription drugs may only be dispensed to patients by the “order” or prescription of a physician or dentist. These drugs must be given directly to the patient by his/her healthcare provider, or they must be dispensed by a licensed pharmacist. In addition, certain restrictions apply to prescribing substances with a potential for abuse, for example, Schedule IV drugs. These drugs cannot be refilled more than five times in a 6-month period.

Non-prescription drugs, such as aspirin, may be purchased anywhere that the medications are sold and need no order or prescription. Although these drugs are not as strictly controlled as prescription medications, potentially dangerous side effects can occur from taking the drugs in higher than recommended doses and in situations where the drug is contraindicated.

Behind-the-counter medications, are OTC medications that are kept behind the counter and must be asked for even though they do not require a prescription. Due to possible abuse or potential for overdose, anyone who wishes to purchase these types of medications must speak to a pharmacist first and in some states a signature may be required. Examples of medications that are commonly kept behind the counter are lower concentration fluoride rinses and gels (0.4%) and pseudoephedrine-containing cold medications.

As holistic medicine becomes more popular in this country, two other groups of medications are becoming increasingly popular: herbal remedies and nutritional supplements. Herbal remedies are plant-derived medicines with claims of health benefits. Many users prefer to use herbal and nutritional supplements to treat various ailments, because they regard them as “safe” and “natural.” Users don’t always recognize that herbal remedies can be dangerous if taken in large or “mega” doses. Even nutritional supplements can be harmful at doses that exceed the FDA’s Recommended Daily Allowance (RDA). In some cases, RDAs have not been established, and little information is known about some supplements’ affects on the body. Nonetheless, many patients take daily doses of compounds such as St. John’s Wort, melatonin, ginseng, and vitamins—possibly in extremely high doses—that can cause undesirable side effects. Most of these medications are OTC nutritional supplements, and they are not controlled or even tested by the FDA for safety and efficacy.

DRUG CLASSES

In addition to “prescription” or “OTC,” drugs are further classified according to their chemical action on the body. Within these classes, drugs are referred to by both their generic as well as their brand names. Most dental professionals may be more familiar with the brand names than the generic identifiers. Appendix A charts the many classes of drugs, their intended actions, examples of some important drugs in the class, possible side effects, contraindications for use, and drug interactions. Side effects do not always occur in every patient, and severity may vary from one patient to another. It should be noted that although a pre-existing condition may contraindicate the use of a drug, the benefit of taking the drug may outweigh the risk of the contraindication. In other cases, drug interactions may be possible, but like side effects, they do not always occur. Patients should be monitored carefully for any signs of drug interactions or side effects.

Please note that the drug class appendix is not all-inclusive. New medications are rapidly being introduced. Healthcare professionals should always consult the Physician’s Desk Reference (PDR) or another drug reference when prescribing any medication or identifying possible side effects that a patient may be experiencing.

NUTRITIONAL SUPPLEMENTS

Vitamins
Vitamins are organic compounds that are essential for good health; they perform various important functions in the body. Although eating a well-balanced diet should provide all daily vitamin requirements, a growing number of people in the United States are using vitamin supplements to compensate for poor diets or as extra insurance for good health. Some people even take very large mega-doses of various vitamins, based on claims by popular nutrition gurus that such doses can cure common illnesses, prevent cancers, and delay the aging process. Some evidence suggests that some vitamins, such as vitamin E, do in fact play a role in some of these processes, but no studies have demonstrated conclusively that taking mega-doses of vitamins is recommended for all children and adults.

The FDA updates its list of RDAs for nutrients considered essential for health every 5 to 10 years. Revisions are based on current research findings. Physicians do not recommend exceeding the RDA for vitamins, especially the fat-soluble vitamins such as vitamin A because the buildup of excess amounts of these substances in body tissues can have toxic effects. The potential for toxicity is not as great with water-soluble vitamins (for example, vitamin C) because the kidneys excrete excessive amounts daily. Table 2 presents a summary of the 13 essential vitamins, their RDA, and the action that each has on the body.

Vitamin Toxicity/Hypervitaminosis
In doses too large, vitamins can represent “too much of a good thing.” The results can be toxic.

Vitamin A. More than 50,000 international units (IU) daily of vitamin A can produce toxic effects in adults; for children, a toxic dose is only 18,500 IU each day. Symptoms of vitamin A toxicity include hair loss, nausea, vomiting, diarrhea, scaly skin, blurred vision, rashes, bone pain, irregular menstruation, fatigue, headaches, and liver enlargement. Overdoses of vitamin A can be fatal.

Vitamin D. More than 20,000 mg daily for an extended period can have toxic effects in adults. In children, toxic effects can be seen when more than 1,800 mg are ingested daily. Signs of toxicity include stunted growth, weight loss, unusual thirst, sore eyes, itching skin, vomiting, diarrhea, urinary urgency, and abnormal calcium deposits in the blood vessel walls, liver, lungs, kidneys, and stomach.

Vitamin E. Early studies of the benefits of mega-doses of vitamin E indicated that doses greater than the recommended daily allowance (400 IU), in some cases >2,000 IU, might prevent certain cancers, heart disease and the onset of Alzheimer’s disease. According to the National Institutes of Health (NIH), however, recent studies indicate that the therapeutic benefit of vitamin E may have been overestimated, an in some cases might have been linked to some deaths. The NIH recommends that daily doses of vitamin E do not exceed two times the recommended daily allowance, or 800 IU.

Vitamin K.  Doses of vitamin K greater than 500 mcg are not recommended. Administration of this amount may cause brain or liver damage, jaundice, and destruction of red blood cells.

Mineral Supplements
In addition to vitamins, minerals are another essential group of nutrients that the body requires. Minerals maintain the electrical conductivity of the heart (sodium, calcium, and potassium) and the production of hemoglobin (iron), and some supplements can help prevent diseases or conditions like osteoporosis (calcium). Table 3 lists the essential minerals, their function, and RDAs. Taking mega-doses of minerals, however, can have toxic effects on the body.

Mineral Toxicity
As with vitamins, mega-doses of minerals also have been linked to toxicity.

Calcium. Daily intake of more than 2,000 mg may cause hypercalcemia.

Iodine. Doses of 500 mcg daily can decrease thyroid activity.

Iron. A dose of 3 g or higher can be fatal to a child, and high doses of iron have been shown to cause heart disease in men.

Magnesium. Large doses over extended periods can be toxic to individuals with impaired kidney function.

Phosphorus. Excess amounts may interfere with iron absorption and cause osteoporosis.

Potassium. An intake of 18 g or higher can be fatal.

Selenium. Doses of 5 mg can cause toxic effects, such as hair and nail loss, nerve damage, skin lesions, fatigue, diarrhea, nausea, vomiting, and abdominal cramps.

Sodium. Excess intake contributes to edema and hypertension.

Zinc. Foods (especially acidic fruit drinks like lemonade) stored in galvanized containers can react with zinc. When ingested, they can cause vomiting and diarrhea. Early evidence suggests that excess levels of zinc may be linked to Alzheimer’s disease.

Miscellaneous Nutritional Supplements
In addition to the essential vitamins, other nutritional supplements have gained popularity over the last several years. In most cases, however, conclusive studies have yet to prove the effectiveness of these compounds. Early studies and anecdotal reports suggest that further investigation is warranted. As with essential vitamins, users can overdose on these supplements, causing unpleasant—and sometimes irreversible—side effects. Because they are not considered essential dietary elements, the FDA has no established RDAs for these compounds. Table 4 summarizes the most common supplements and their suggested uses.

DELIVERY SYSTEMS

The method by which drugs are delivered into the body is an important consideration. Administration can occur by a variety of methods, depending on the medication and its purpose. Some medications may be available in several different types of delivery systems to best complement the age and/or preferences of the patient. For example, infants and young children may have difficulty swallowing tablets or capsules, so many pediatric medications are offered in elixir or liquid formulas that are easier to administer. Table 5 describes the various routes of administration and the general classes of drugs typically administered by each.

SIDE EFFECTS

Taking any medication, whether it is OTC or prescription, can cause drug-specific side effects. Drug companies are legally required to disclose all possible side effects for any medication. Side effects are noted when drugs are being researched (that is, prior to their being available on the market) or they may be reported under the FDA’s MedWatch Program. MedWatch requires all health professionals to report any adverse effects they encounter from drugs or other medical devices (see Appendix B).

Any drug reference, like the PDR or Drug Information Handbook for Dentistry, lists the most common side effects (for example, dry mouth, blurring of vision, drowsiness, excitement). Not all patients experience the listed side effects when taking a medication, and those who do typically experience only one or two (usually not all) possible side effects. If the side effect of a drug is more detrimental than its therapeutic effect, a physician or dentist may prescribe or recommend a different drug within the same class that does not cause the side effect(s).

Blurred or double vision is an adverse effect of a significant number of drugs. It may occur shortly after starting a drug, or it may present after long-term use of the drug. In most cases, blurred and double vision are reversible. Other more serious changes, which may not be reversible, are cataract development and damage to the retina or optic nerve. Drugs known to cause blurred vision include anti-arthritic/anti-inflammatory drugs, anti-depressants, antihistamines, atropine-like drugs, chorthalidone, ciprofloxacin, cortisone-like drugs, diethylstilbestrol (DES), fenfluramine, norfloxacin, oral contraceptives, phenytoin, sulfonamides, tetracyclines, and thiazide diuretics.

Drugs known to cause double vision include (drug class or generic name) anti-depressants, anti-diabetic drugs, antihistamines, aspirin, barbiturates, benzodiazepines, carbamazepine, chloroquine, chlorproxithene, ciprofloxacin, cortisone-like drugs, digitalis, digitoxin, digoxin, hydroxychloroquine, indomethiacin, isoniazid, levodopa, morphine, nitrofurantin, norloxacin, pentazocaine, phenothiazines, phenytoin, primidone, propanolol, quinidine, and thiothixene, tranquilizers.

Photosensitivity is another common side effect. Drugs that can induce this adverse reaction include barbiturates, benzocaine, diphenhydramine, estrogen, hexachlorophine, ibuprofen, ketoprofen, naproxen, oral contraceptives, tetracycline, and tretinoin.

Some drugs may cause liver damage. Reactions can range from mild, temporary liver changes to complete liver failure and death. Use of some of the following drugs may require regular monitoring with liver function tests: acetaminophen, anabolic steroids, aspirin, anti-thyroid drugs, methotrexate, NSAIDs, oral contraceptives, penicillins, sulfonamides, tamoxifen, tetracyclines, tricyclic anti-depressants, and vitamin A (in excessive doses).

Osteoporosis is a condition where bone tissues thin and bone density decreases over time. Bisphosphonates are a class of drugs used to treat osteoporosis. Common bisphosphonates are Fosamax®, Boniva®, and Actonel®. In recent years, bisphosphonates taken in high doses, for example during cancer treatment, have been linked to osteonecrosis of the jaw (ONJ). Additional events such as dental infection and trauma (such as a dental extraction) can add further complications to the disease process. It has been suggested that treatments including bisphosphonates should be postponed until after any dental treatment to reduce the possibility of ONJ.

Some drugs may interact with alcohol, causing excessive sedation, confusion, increased intoxication, increased stomach irritation, and increased liver toxicity. Such drugs include amphetamines, anti-depressants, barbiturates, carbamazepine, chlorprothixene, chlorzoxazone, disulfiram, ergotamine, fenfluramine, furazolidone, haloperidol, MAO inhibitors, meperidine, meprobamate, methotrexate, narcotic drugs, phenothiazines, propoxyphene, reserpine, chloral hydrate, flurazepam, methaqualone, and tricyclic anti-depressants.

With other drugs, interaction with alcohol can include increased liver toxicity, increased anti-coagulant effects, excessive lowering of blood pressure, excessive hypoglycemia, excessive sedation, or rapid heart rate. With these drugs, alcohol should be used only in small amounts: acetaminophen, amantadine, anti-arthritic/anti-inflammatory drugs, anti-coagulants, anti-diabetic drugs, antihistamines, anti-hypertensives, aspirin, benzodiazepines, diuretics, NSAIDs, nitrates, and tranquilizers.

With respect to drugs, the kidneys perform two major functions. First, they alter the drug to help remove it from the body. Second, they eliminate drugs from the body in urine. The following drug classes/generics may affect kidney processes: beta-blockers, diuretic/NSAID combinations, lithium/tricyclic anti-depressant combinations, NSAIDs, aminoglycoside antibiotics, oral contraceptives, adrenocortical steroids, aspirin, and acetaminophen.

In addition to side effects, patients who consume prescription and non-prescription drugs can suffer accidental or intentional overdose. In such cases, emergency treatment is needed to help prevent permanent effects or death. In the United States, a network of 24-hour Poison Control Centers is available to provide treatment or antidote information. Staffed by physicians, nurses, and pharmacists trained to resolve potentially toxic situations that arise either in the home or in a hospital, thesehese centers have computerized databases containing information on hundreds of thousands of substances. Appendix C lists location and contact information for the Poison Control Centers throughout the country. Callers in states that do not have a Poison Control Center can contact the center closest to their location.

DRUGS COMMONLY ADMINISTERED IN CONJUNCTION WITH DENTAL TREATMENT
In addition to encountering patients who are taking various medications and supplements for general health or management of medical conditions, the dental healthcare provider also uses a number of drugs to alleviate patient pain during or after a dental procedure, to manage or prevent oral infections, and to strengthen teeth to resist decay. Drugs commonly used in conjunction with dental treatment are summarized in Appendix D.

ANTIBIOTIC PROPHYLAXIS FOR DENTISTRY

In 2007, the American Heart Association changed its recommendations for short-term dental antibiotic prophylaxis. The American Heart Association along with the American Dental Association established the current guidelines for dentistry based on growing scientific evidence that shows the risks of taking preventive antibiotics outweighing the benefits for most dental patients. Some of the risks included adverse reactions to the prescribed antibiotics ranging from mild to potentially severe and, in very rare cases, death.

Inappropriate use of antibiotics has also lead to the development of drug-resistant bacteria, a growing concern in the medical community. The new guidelines are aimed at patients who would have the greatest danger of a bad outcome if they developed a heart infection. Under the new guidelines, individuals who have taken antibiotics prior to dental treatment routinely in the past but no longer need them are included in Table 6. Preventive antibiotics prior to a dental procedure are still advised for the patients described in Table 7. Table 8 lists the types of antibiotics used and their dosages.

For the emergency patient with one rheumatic fever episode with uncertainty about residual damage to the heart, a preventative prophylaxis should be administered prior to performing the procedure with a referral to the patient’s physician for a consultation.

Endocarditis is an inflammation of the endocardial layer of the heart. Endocarditis can occur due to a bacteria or virus entering the bloodstream from places such as the mouth or intestinal tract.  Those patients susceptible to endocarditis may carry a card to explain their physician’s recommendations. When these patients arrive for their appointments, the dental team must verify that they have taken their prescribed form of premedication. Appendix E offers and example of an endocarditis wallet card.

Patients receiving any artificial joint replacements historically received antibiotic prophylaxis before any dental treatment. When the regimens were reviewed in 2009, the American Academy of Orthopaedic Surgeons released the following information:

“Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for joint replacement patients with one or more of the following risk factors prior to any invasive procedure that may cause bacteremia:”

  • All patients with prosthetic joint replacement
  • Immunocompromised/immunosuppressed patients
  • Inflammatory arthropathies (eg, rheumatoid arthritis, systemic lupus erythematosus)
  • Drug-induced immunosuppression
  • Radiation-induced immunosuppression
  • Patients with co-morbidities (eg, diabetes, obesity, HIV, smoking)
  • Previous prosthetic joint infections
  • Malnourishment
  • Hemophilia
  • HIV infection
  • Insulin-dependent (Type 1) diabetes
  • Malignancy
  • Megaprostheses

PRESCRIPTION WRITING AND DISPENSING OF MEDICATIONS

The following is the classical or Latin description of the parts of a prescription:

Superscription: Contains the patient’s name, address, date (age is sometimes included), and the symbol “Rx,” which is Latin for “recipe” or “take thou.”

Inscription: Contains the name of the drug, the dose form, and the amount.

Subscription: Directions to the pharmacist.

Transcription: Directions to the patient.

The more modern, practical description is:

Heading: Name and address of the prescriber (telephone number also may be included), name and address of the patient (age and telephone number also may be included), and date of the prescription.

(Law requires the name and address of the prescriber and the patient. It is helpful to have the telephone numbers listed in case the dispensing pharmacist has questions about the prescription. The date is required for the dispensing pharmacist to intercept prescriptions that have not been filled at the time of writing. Listing the patient’s age allows the pharmacist to determine if the dosage is correct.)

Body: Contains the Rx symbol, the name and dosage size or liquid concentration of the drug, the amount to be dispensed, and directions to the patient.

The name of the drug being prescribed is listed first after the Rx symbol, followed by the size in milligrams (mg) of the tablet or capsule prescribed. If liquids are prescribed, the name of the drug is followed by the concentration in milligrams per milliliter (mg/ml). The amount or quantity of the drug to be dispensed is listed next (that is, the number of tablets/capsules or milliliters of liquid). Frequently the symbol “#” is used in place of the word “dispense.” The prescriber also should write the number to be dispensed both in numerals and in long hand to prevent patients from altering prescriptions for narcotic and other controlled drugs (for example, to prevent a patient from changing an amount written as “6” to 60.)

Directions to the patient are preceded by the abbreviation “Sig.,” which is Latin for “to write.” The prescriber uses the abbreviations listed in Figure 1 in shorthand to save time when writing the prescription. The pharmacist translates them into English. Table 9 lists the common abbreviations used on prescriptions.

DRUG REFERENCES

Every dental practice should have a comprehensive drug reference on hand that lists drugs by both their generic and brand names and includes information on their recommended use, dosage, contraindications, possible side effects, and drug interactions. Every member of the team should be able to access this reference at any time, if questions arise about a patient’s medications or writing/dispensing medications to patients. Table 10 provides a list commonly used drug reference materials.

The Physicians’ Desk Reference and Drug Information Handbook for Dentistry are the most often used drug reference for dentists. The PDR is organized into six sections (Table 11).

The electronic version of the Drug Information Handbook for Dentistry includes a drug identification guide and a drug interaction compound. Its extensive cross-referencing allows users to locate information about a particular drug, even when little information is known. For example, if the user only knows what a medication looks like (for example, tablet), but not the name or type of drug, the Product Identification Guide displays pictures to compare to the tablet to help identify it. Once the drug is identified, the user then can access additional information on it in the Product Information section.

SUMMARY

Life expectancy continues to increase with continuing medical advancements. Patients are often provided with a variety of medications to improve health and quality of life. Dental professionals must be armed with a working knowledge of common nutritional supplements and medications and their effects on their patients’ overall health. As drug reference materials change, it is important to have access to reputable resources for current drug information. The dental team must know the basic dental medications prescribed most often, their preferred delivery system, and how these are prescribed in written format. Having this knowledge will aid the dental team in providing excellent, quality patient care.

REFERENCES

Adnan S, Dajani MD, Kathryn A, et al. Prevention of Bacterial Endocarditis. JAMA.1997;277:1794-1801.

Wynn RL, Meiller TF, Crossley HL. Drug Information Handbook for Dentistry, 17th edition. Lexi-Comp, Inc, 2011-2012

Essential Guide to Prescription Drugs, 1998 edition, HarperCollins Books.

No longer accessible - http://www.acpmedicine.com/sam/chapters/ch0718.htm:[Online] December 2004

No longer accessible - http://www.fda.gov/medwatch/REPORT/CONSUMER/1INSTRUCT.HTM [Online] February 3, 2005 [Online] August 9, 2005

No longer accessible - http://www.ohioheartsurgery.com/endocarditis.htm#2: [Online] February 3, 2005

http://www.hmc.org.qa/hmc/heartviews/prev2.htm [Online] February 3, 2005

No longer accessible - http://www/pharmacytimes.com/articles.cfmn?ID= 1314 [Online] February 6, 2005

No longer accessible - www.usoj.gov/dea/agency/mission.htm [Online] February 3, 2005.

Merck Manual of Diagnosis and Therapy, 19th edition, 2011 Merck & Company, Inc.

Anderson J, Deskins B. Nutrition Bible. William Morrow & Company, Inc., 1995.

Physicians’ Desk Reference for Prescription Drugs, Medical Economics Company, 59th edition, 2011.

American Heart Association Endocarditis Prophylaxis Information (April 2011). Retrieved February 16, 2012 from http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/TheImpactofCongenitalHeartDefects/Infective-Endocarditis_UCM_307108_Article.jsp

http://www.onj-net.org [Online] Accessed August 23, 2011

Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements. (2009) American Academy of Orthopaedic Surgeons. http://www.aaos.org/about/papers/advistmt/1033.asp.  Accessed February 15, 2012.

ABOUT THE AUTHORS

Mary Govoni, CDA, RDA, RDH, MBA, is an internationally recognized speaker, author and consultant on clinical efficiency, ergonomics, OSHA & HIPAA compliance, infection control and team communication. Mary is a past president and a life member of the American Dental Assistants Association, a member of the American Dental Hygienists Association, a consultant to the American Dental Association Council on Dental Practice, a member of the Organization for Safety and Asepsis Procedures, the National Speakers Association, and the Academy of Dental Management Consultants and the Speaking and Consulting Network. She is also a featured speaker on the ADA Continuing Education and lifelong learning seminar series.

Richard L. Wynn, PhD is a professor of pharmacology at the Dental School, University of Maryland, Baltimore. He was awarded the BS, MS, and PhD degrees all from the University of Maryland. He chaired the Department of Pharmacology at the University of Maryland Dental School from 1980 to 1995. Previously he chaired the Department of Oral Biology at the University of Kentucky Dental School in Lexington. He has to his credit over 300 publications including original research articles, textbooks, book chapters, and monographs. He has given over 500 continuing education seminars to dental professionals in the US, Canada, Mexico, and Europe. Dr. Wynn has been a consultant to the drug industry for 25 years and his research laboratories have contributed to the development of new analgesics and anesthetics. He is a consultant to the Academy of General Dentistry, and is a featured columnist for the journal General Dentistry, published by the Academy of General Dentistry. He is the lead author and chief editor of Drug Information Handbook for Dentistry. His chief interest is teaching pharmacology to dental and dental hygiene students, and in keeping dental professionals informed of current and new drug information relative to dental practice.

Figure 1

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

Table 7

Table 8

Table 9

Table 10

Table 11

LOGIN    or    SIGN UP
CREDITS: 0
COST: $0
PROVIDER: American Dental Assistants Association
SOURCE: American Dental Assistants Association | March 2015

Learning Objectives:

  • Differentiate between over-the-counter medications, nutritional supplements, and prescription drugs.
  • Identify the federal agencies that control distribution and prescription of drugs.
  • List the types of drugs used in conjunction with dental treatment.
  • Identify the types of drugs that are used to treat various medical conditions.
  • Differentiate between a generic and a brand name prescription and non-prescription drug.
  • Name the classes of drugs with known oral side effects.
  • Explain the pharmacological action of different classes of drugs.
  • Describe the components of a drug prescription and the purpose of each.
  • Recall the different schedules of drugs and the implications for prescribing and abuse.
  • Recognize the classes of drugs that contraindicate dental treatment.
  • Identify US Food and Drug Administration Pregnancy Risk Categories for various drugs.
  • Recite the current guidelines for antibiotic prophylaxis for dental treatment.
  • Locate resources for obtaining information on over-the-counter and prescription drugs.

Disclosures:

The author reports no conflicts of interest associated with this work.

Queries for the author may be directed to jromano@aegiscomm.com.