Notes
Drugs Prescribing and Therapeutics
Oxygen (15 L/min)
Full size D cylinder : 340L ~ 22 mins
Full size CD cylinder : 460L ~ 30 mins
Full size E cylinder : 680 L ~ 45 mins
Drugs for Medical Emergencies
Adrenaline - 0.5 ml 1:1000 IM
Aspirin - 300 mg tab (75 g for prophylaxis)
Glucagon - 1 mg IM
GTN spray - 2 puffs 400 mcg / metered dose sublingually
Midazolam - 10 mg buccal
Oral glucose - 10 - 20 g fast acting glucose
Oxygen - 100% 15 L/min
Salbutamol - 4 puffs 100 mcg / actuation through large-volume spacer
Mild allergy - Cetirizine 10 mg tab / Chlorphenamine 4 mg tab / Loratidine 10 mg tab
Anxiety - Diazepam 5 mg tab 2 hr before procedure
Prescriptions
Cellulitis / spreading infection / systemic involvement
C. Amoxicillin 500 mg TDS 5 days
T. Phenoxymethylpenicillin 500 mg QID 5 days
T. Metronidazole 200 mg TDS 5 days (✖ warfarin, alcohol → disulfiram-like action)
2nd-line antibiotic for dental abscess
C. Clindamycin 150 mg QID 5 days (✖ diarrhoea)
T. Co-amoxiclav 250 / 125 mg TDS 5 days (✖ hepatic dysfunction, jaundice)
T. Clarithromycin 250 mg BD 7 days (✖ hepatic, renal impairment, pregnant, nursing, warfarin, statins)
NUG / NUP / Pericoronitis
C. Amoxicillin 500 mg TDS 3 days
T. Metronidazole 200 mg TDS 3 days
Sinusitis (self-limiting 2 1/2 weeks)
Ephedrine nasal drops 0.5% 10 ml 1 drop TDS max 7 days (✖ HPT, < 12 y/o)
C. Amoxicillin 500 mg TDS 5 days
C. Doxycycline 100 mg 2 cap (1st day), 1 cap OD 7 days (✖ hepatic impairment, pregnant, nursing, < 12 y/o, warfarin)
Pseudomembranous candidosis / erythematous candidosis / denture stomatitis
C. Fluconazole 50 mg OD 7 days (✖ warfarin, statins)
Miconazole oromucosal gel 20 mg / g 80g, pea-sized after food QID 7 days after lesions have healed (✖ warfarin, statins)
Nystatin oral suspension 100,000 units / ml, 30 ml, 1 ml after food QID 7 days - continue for 48 hrs after lesions have healed
Angular cheilitis
Miconazole cream 2% 20 g , apply to angle of mouth BD, continue use for 10 days after lesions have healed
Sodium fusidate ointment 2% 15 g, apply to angle of mouth BD, max 10 days
Miconazole 2% & hydrocortisone 1% cream or ointment, apply to angle of mouth BD, max 7 days (✖ warfarin, statins)
HSV infection
CHX mouthwash 0.2% 300 ml, 10 ml 1 min BD
H2O2 mouthwash 6% 300 ml, 15 ml diluted in half a tumbler warm water 2 mins TDS
T. Aciclovir 200 mg 5 times / day 5 days
VZ infection (within 72 hrs of rash - reduce severity of post-herpetic neuralgia)
T. Aciclovir 800 mg 5 times / day 7 days
Mild to moderate odontogenic pain
T. PCM 1000 mg QID 5 days
T. Ibuprofen 400 mg QID 5 days (✖ pregnant, peptic ulcer, hypersensitivity)
T. Aspirin 600 mg QID 5 days (✖ Xn/MOS, hypersensitivity, nursing, peptic ulcer, < 16 y/o)
Moderate inflammatory / post-op pain
T. Diclofenac sodium 50 mg TDS 5 days (✖ IHD, cerebrovascular disease, peripheral arterial disease, heart failure, hypersensitivity, aspirin, peptic ulcer)
Peptic ulcer (PCM alone not sufficient)
C. Lansoprazole 15 mg OD 5 days
C. Omeprazole 20 mg OD 5 days
Trigeminal neuralgia
T. Carbamazepine 100 mg BD 10 days
TMJ dysfunction (+ ibuprofen)
T. Diazepam 2 mg TDS 5 days
Mucosal Ulceration (e.g. RAS)
① Antimicrobial m/w
CHX
H2O2
T. Doxycycline dispersible 100 mg dissolved in water, 2 mins, QID 3 days (✖ pregnant, nursing, < 12 y/o)
② Local analgesics
0.15% Benzydamine m/w 15 ml every 1 1/2 hr max 7 days
0.15% Benzydamine oromucosal spray 4 sprays every 1 1/2 hr
5% Lidocaine ointment rub sparingly and gently on affected areas
10% Lidocaine spray apply as necessary with cotton bud
③ Topical corticosteroids
Beclometasone diproprionate inhaler 50 mg, 1- 2 puffs BD
T. Hydrocortisone oromucosal 2.5 mg dissolved next to lesion BD
👉 Suspected adverse drug reactions → reported to Medicines & Healthcare Products Regulatory Agency (MHRA)
Therapeutic index = safety of drug
Latency = from administration of drug → onset of action
Idiosyncrasy = abnormal physical reaction → food / drug
Drug best absorbed : ↓ molecular weight, unionized, lipid soluble
Mechanism of Action
Gentamicin : blocks protein synthesis 30s ribosomal subunit
Erythromycin : blocks protein synthesis 50s ribosomal subunit
Rifampicin : blocks mRNA synthesis
Vancomycin : blocks peptidoglycan synthesis
Penicillin : blocks cell wall synthesis
Sulphonamides : interfere with folinic acid production
Metronidazole : inhibits nucleic acid synthesis
Management of Patient on Bisphosphonate
👉 reduce bone resorption : hindering formation, recruitment and function of osteoclasts
👉 e.g. alendronic acid, zoledronic acid, etidronate disodium etc.
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) = necrotic bone in Mx / Mb that has persisted for > 8 weeks and no history of radiation therapy to jaw
- delayed healing following dental extraction / oral surgery
- pain
- soft tissue infection
- swelling
- numbness
- paraesthesia
- exposed bone
👉 extremely rare condition
Guidance
① Avoid extraction / oral surgery if there is an alternative treatment option
② If any extraction / oral surgery is necessary, assess patient risk
low : before / taking bisphosphonate for prevention / management of osteoporosis
high : previous diagnosis of BRONJ, malignant condition, non-malignant systemic condition affecting bone (e.g. Paget's disease), rare medical condition (e.g. osteogenesis imperfecta), concurrent use of systemic corticosteroids / immunosuppressants, coagulopathy, chemotherapy, radiotherapy
Management of Patient on Anticoagulants
Antiplatelets - aspirin, dipyridamole, clopidogrel : interfere with platelet aggregation
Oral anticoagulants - warfarin, acenocoumarol, phenidione : inhibit vitamin K-dependent modification of prothrombin and other coagulation factors
Novel oral anticoagulants - dabigratran : direct inhibitor of coagulation factor thrombin, apixaban, rivaroxaban : inhibit Factor Xa (❌ require monitoring)
Injectable anticoagulants - heparin, dalteparin, enoxaparin, tinzaparin : bind to antithrombin III
Cranial Nerves
1, 2, 8 → sensory (nose, eyes, ears)
5, 7, 9, 10 → mixed
others → motor
Ⅰ Olfactory - cribriform plate
Ⅱ Optic - optic canal
Ⅲ Oculomotor - superior orbital fissure (SOF)
Ⅳ Trochlear - SOF
Ⅴ Trigeminal
- opthalmic - SOF
- maxillary - foramen rotundum
- mandibular - foramen ovale
Ⅵ Abducens - SOF
Ⅶ Facial - enter internal acoustic meatus (IAM), leave stylomastoid foramen (SMF) - salivation SM, SL gland
Ⅷ Vestibulocochlear - IAM
Ⅸ Glossopharyngeal - jugular foramen - salivation P gland, gag reflex
Ⅹ Vagus - jugular foramen - uvula pointing away, hoarseness, gag reflex
Ⅺ Accessory - jugular foramen - SCM, trapezius
Ⅻ Hypoglossal - hypoglossal foramen - pointing towards
