Prescription Writing

Masoud Yaghmaei Chap 36 (Appendix Peterson 2008 )

Significance of Meds taken by patients in dentistry Commonly Used Meds In OMFS / dentistry Drug Interactions

Larry j . Peterson 1942 - 2002

Dental School + Medical School + Hospital

PDR
Physician's Desk

Reference

PDR NPD Since 1980

Drug Nomenclature Chemical , Generic , Trade Names

EXAMPLE Chemical Name : 2-diethylamino-2,6- acetoxylidide Generic Name : Lidocaine Trade Name : Xylocaine , L-Caine , Dolicaine ,Octocaine , etc

Drug Nomenclature Chemical , Generic , Trade Names

Example Chemical Name : N-acetyl-p-aminophenol Generic Name : Acetaminophen Brand Name : Tylenol , Valadol , tempra ,, phenaphen , etc

Recipe
Prescription Para clinical Examinations ( Imagings & Labs ) Referral Consultation Certification Recommendation letter Admission letter ( to Hospital )

Recipe In the Hospital

Called Orders :
Admission Preoperative Post Operative Discharge
Dentistry in the Hospital Chap 31 Management Of The Hospitalized Patient

Any Prescriptions (meds ) ? Any Paraclinic Examinations ? Any Certifications ?

Limitation

Prescription Writing
Complex in the Past ( = Art )
Written in : Latin & Apothecaries System Of Weights & measures In More RecentYears, 4 Changes have greatly simplified prescription writing 1- proper form & dosage ( Mixing not necessary ) 2- no longer written in Latin 3- metric system replaced the more confusing apothecaries 4-limit or eliminate abbreviation

Metric System

Abbreviations

Qd , bid , tid , qid

Parts Of the Prescription

A Heading B Body

C - Closing

Refill 0-1,2,3

Parts Of the Prescription

A Heading B Body

C - Closing

Heading
Name , degree, NP #, address , Phone Number( x2 ) of the Prescriber patient's name , Address ,Phone , age ,date

Body
R Symbol Name of the drug , dosage form , then amount ( mg/ml ) Dispense = Disp ( # / No / Roman numeral ) Sig ( L. Signa, Write ) = ( Label )

Symbol R
L . Recipe You take Or take thou of

Closing
Prescriber's Signature DEA Number ( Drug Enforcement Administration ) Ask pharmacist for labeling Refill ( No ,1,2,3 )

Drug Legislation
DEA Number ( NO , # )

Single Med Single Recipe

Household measures

A = Heading

B = Body

C = Closing

Rx Nystatin liquid , 100,000 U / ml Disp , 60 ml Sig , Swish 4 ml in mouth for 2 minutes and then swallow q 6 h
A Few drops added to the water used for soaking acrylic prosthesis

Clotrimazole troche For Candidosis

Rx
Clotrimazole troches 10 mg

Disp : 50 troche Sig : Let one troche dissolve in the mouth 5 times a day

If concern is expressed about the sugar content of nystatin and clotrimazole troches , Vaginal tablets ( 100mg ) may be substituted

R Acetaminophen300mg + codein 10 mg No Ten ( X ) Take One by mouth q 4h Prn / Pain

Drug Information
09646 ( Shahid Beheshti ) 82101 ( 13 Aban )

Topical Anesthesia
Rx LidocaineViscous 2% Disp 30 ml bottle Rinse with 1 teaspoonful for 2 minutes every 2 hours and before each meal and spit out

Topical Antiviral Agents

Acyclovir topical ointment 5 % Disp :15 gm tube Sig : Apply to the area every 2 hours during waking hours for 4 days , beginning when symptoms first occur

Secondary Herpes

Herpetic Whitlow

Systemic Antiviral therapy

Rx Acyclovir cap 200 mg Disp : 40 Capsules ( Or 60 ) Sig : Take one Capsule q6h for 10 days ( 2Cap q8h for 10 days )

Current FDA Recommendation is that systemic acyclovir should be used to treat oral herpes only in immunocompromised patients

Acute Odontogenic infection

Rx Penicillin V tablets Disp : 28 Tablets Sig : Take One Tablet 4 times a day

Odontogenic Infection Pediatric

Rx Amoxicillin Susp 125 mg / 5ml Disp : one Bottle Sig : 5 ml PO q 6 h

Odontogenic Infection Pediatric

Rx 1 -Penicillin V Oral Suspension 125 mg / 5 ml # one Bottle Take 5 ml q 6 h 2 Acetaminophen drop 100 mg / ml take 20 drops q 4h Prn / Pain

Acute Odontogenic infection

Rx Penicillin V tablets 500 mg Disp : 28 Tablets Sig : Take One Tablet every 6 hours

Or q6h ( q = Every )

Acute Odontogenic Infection ( Patient Allergic to Penicillin )

Rx Erythromycin Tablets 250 mg Disp : 40 tablets Sig : Take One Tablet q 6 h

If nausea or stomach cramps occur , prescribe enteric coated preparations Or A second - generation erythromycin ( eg , Clarithromycin )

Analgesic

Rx Acetaminophen tablets 325 mg Disp : Ten

Sig : Take 1- 2 tablets every 4 hours as needed for pain ( Limit 4 gm /24 h)

For Moderate to Severe Pain

Rx Acetaminophen 300 mg with codeine 30 mg ( Tylenol # 3 ) Disp :Ten ( X ) Sig : take one tablet every 4 hours for pain

q = Every For pain = As needed = Prn / pain

Acetamiphen With Codein In IRAN

Rx Acetaminophen tab 300 mg with codeine 10 mg Disp :Ten ( X ) Sig : One Tab q 4h Prn / Pain

Angular Chelitis & Chelosis Mixed Inf ( C albicans + Staph + Strep ) Predisposing Factors ( Local habits ,drooling , decreased VD ,Anemia , Immunosupression & Extension Of Oral Infection . CCc

Rx Nystatin Plus Triamcinolone acetonide ointment Disp : 15 gm Tube Sig : Apply to affected area after each meal & at bed time

Concomitant Intraoral Antifungal Treatment may be indicated

Angular Chelitis & Chelosis

Rx Clotrimazole Vaginal Cream ( OTC ) Disp : 1 Tube Sig : Apply small dab to corner of mouth 4 times a day

Rational for Treatment :

May Progress to Malignancy

Actinic Chelitis & Chelosis

Normal Red Translucent Vermillion With Regular Vertical fissuring of a smooth Surface is replaced by a white flat surface that may exhibit periodic Ulceration

Rx Sunscreen with high SPF ( greater than 15 )

Geographic Tongue ( BMG )

Most Assymptomatic & no tx is necessary If Symptomatic ( Secondary C Albicans Infection )

Rx Nystatin-Triamcinolone acetonide Ointment Disp : 15 g tube Sig : Apply to affected areas after meals and at bed time

Rx Nystatin Ointment Disp : 15g Ointment Sig : Apply to affected areas after meals and at bedtime

Xerostomia
Rx Sodium Carboxymethyl cellulose 0/5 % aqueous solution Disp : 120ml Sig :Use as a rinse as frequently as needed Rx Pilocarpine HCl Solution 1 mg / ml Disp : 100ml Sig : Take 1 Teaspoonful q 6 h x Pilocarpine Hcl tablet 5 mg Disp : 100 tablets Sig : Take One tablet q 8 h . An Extra tablet ( 10mg ) may be taken at bed time Dosage should be adjusted to minimizing adverse effects ( Sweating & Stomach Upset ) Xero - Lube

Xerostomia
Radiation > 800 Rad Sjgren,s Syndrome Mikulicz,s disease Antihistamines Tranquilizers Diuretics Atropine-like drugs Women > 40
Artificial Saliva ( Xero-lube ) Contain : Phosphates , Chlorides & Fluoride in addition to the Sodium Carboxymethylcellulose

Rx Xero lube Disp : 150 ml Sig : Use as a Rinse as frequently as needed to relieve Symptoms of dry mouth

Post Radiation Caries 100 times > Normal Population

Rx Fluoride gel , 1 % Sodium fluoride Disp : 60 ml Sig : Place 5 10 drops in bite guard and apply for 5 minutes four times a day

Lichen Planus
Rx Dexamethasone ( Decadrone ) Elixir 0/5 mg / ml Sig : 1- For 3 days , rinse with 1 tablespoonful ( 15 ml ) 4 times a day , and swallow , then . 2- for 3 days ,rinse with 1 teaspoonful ( 5 ml ) qid ,and swallow .then 3 for 3 days ,rinse with one teaspoonful ( 5 ml ) qid and swallow every other time ,then 4 rinse with one teaspoonful ( 5 ml ) 4 times a day , and expectorate

Lichen Planus
Rx Triamcinolone acetonide ( Kenalog ) 01 % Disp : one tube Sig :Apply to affected area s twice daily as directed

Oral Erythema Multiforme

Autoimmune , any age , Med reaction ( Pen,Sulfonamide ) Few Patient Herpetic Inf Occurs Immediately Before the onset of Oral EM Severe Form Is Called Esvense-johnson Syndrome Or EM Major

Crusted Lips Targetoid or bull's Eye Skin Lesions

Oral Erythema Multiforme ( EM )

Rx Prednisone tablets 10 mg Disp : 100 tablets Sig : take 6 tablets in the morning until lesions recede , then decrease by 1 tablet on each successive day

+
Suppressive Antiviral therapy Acyclovir tablets 400 mg Disp : 90 tablets Sig : Take 1 tablet 3 times a day

Chapped Or Cracked Lip

Alternate wetting & drying of the vermilion ,resulting in inflammation & possible secondary infection , Vermilion Surface is rough & may be ulcerated with crusting . Normal Vertical fissuring may be lost . An Anti-inflammatory agent in a petrolatum or adhesive base will interrupt the irritating factors & allow healing .

Rx BetamethasoneValerate Ointment 0/1% Disp : 15 gram Tube Sig : Apply to the lips after each meal and at bed time

GingivalEnlargement
Phenytoin Sodium ( Dilantin ) Calcium Channel Blockers ( Nifedipine & Others ) & Cyclosporine Are Predisposing drugs ( Folic acid depletion Check every 6 Months ) . + Blood dyscrasias & hereditary Fibromatosis Should be Ruled Out By History & Lab tests . Treatment : Including Plaque Control Gingivoplasty Folic Acid Oral Rinse

Rx
Folic Acid Oral Rinse 1 mg / ml Disp : 500 ml Sig : Rinse with 1 teaspoonful for 2 minutes, 2 times a day , and spit out.

Burning Mouth Syndrome No Clinical Signs

Multiple Conditions ( Neurogenic , Vascular , Psychogenic( Xerostomia ,Candidosis , Referred Pain From The Tongue Musculature , Chronic Infection , Reflux Of Gastric acid , Use Of Medication , Blood dyscrasia ,Nutritional deficiency ,Hormonal Imbalance , Inflammatory & Allergic Conditions

Rx
Diphenhydramine ( Children's Benadryl ) 12/5 mg / ml ( OTC )

Children's Benadryl is alcohol free

Disp : 1 bottle Sig : Rinse with 1 teaspoon for 2 minutes before each meal , and swallow

Work Up : CBC , FBS , Iron feritin , folic acid , B12 ,Thyroid profile

Recipe
Prescription Para clinical Examinations ( Imagings & Labs ) Referral Consultation Certification Recommendation letter Admission letter ( to Hospital )

Certification Letter
( May be extended )

Admission Letter

Prescription Writing
Masoud Yaghmaei Chap 36 (Appendix Peterson 2008 )

Significance of Meds taken by patients in dentistry Commonly Used Meds In OMFS / dentistry Drug Interactions

Parts Of the Prescription

A Heading B Body

C - Closing

Dental infection

A = Heading

Specialty

B = Body

C = Closing

Drugs
1. Prescription 2. Over the counter ( OTC )
Unfortunately , every drug has more than One action .
1- Desirable = therapeutic effects 2- Undesirable = adverse effects

PDR

41 % > 6O Taking Meds 1380-81 ( Shahid Beheshti dental School ) 600 patients (25-75 Yo) 38/3 % + Meds If Consider More Than one drug = 56/3 % NSAIDS , Analgesics , Sedatives, Antibiotics , GI , Cardiac , HBP , Thyroid

Drugs Used In dentistry & OMFS

Local Anesthesia ( LA ) Analgesics Sedatives Antibiotics Corticosteroids General Anesthesia ( GA )
Cartridge : Plain & With Adrenaline & Bupivacaine Ointment , Spray

+ Emergency drugs

IRAN 09646 & 82101

Aspirin 80 , 100 , 325 , 500 Enteric coated 80 & Microcoated 500 Mefenemic acid ( Ponstan ) Cap 250 mg Ibuprofen (brufen ) 200 - 400 mg ( 100mg / 5 ml Suspension ) Naproxen 250mg tab , 500 mg Suppository , 500 mg tab delayed release Acetaminophen 80 , 325 , 500 , ( 120mg / 5ml Sol& Susp & 125,325 mg Suppository ) 500mg eff Acetaminophen codeine ( 300 + 10 ) Celecoxib ( Celebrex ) Cap 100 , 200 mg Tramadol Cap & tab ( 50 mg ) , Amp 50mg /ml IM Piroxicam ( o/5 % Gel , 10mg Cap , 20 mg Supp , 20 mg Amp) Diclofenac ( 0/1% phthammic drop, 1% Topical Gel , 50 &100 suppository , 100mg Cap , 25& 50 Tab , 25mg/cc ( Amp 3cc 75 mg ) Indomethacin Cap 25 mg , tab 75 mg , Suppository 50, 100 mg Morphine Sulfate ( MS ) 10 mg / cc Amp Pethidine 50mg / ml Amp Pentazocine ( Talwin ) Amp 30 mg Acetaminophen Inj (Apotel ) 10 mg ml Iv infusion ( 15 min )

Analgesics Narcotics
Opiates ( Morphine,Codeine ) Synthetics opiates
Oxycodone , dihydromorphinone)

Non Narcotics
Salicylic Acid Derivatives
Acetylsalicylic acid Salicylamide
NSAIDS

Opiate congeners
Meperidine , Methadone , Pentazocine , Propoxyphene

Para-aminophenols
Acetaminophen Acetophenetidin ( Phenacetin )

Analgesics
Narcotics Continuous dull pain Greater Analgesic Potency Sedation ( narcosis ) Non - Narcotics Mild - Moderate Somatic Pain No Sedation ( narcosis ) Predominant effects peripheral

NSAIDS
Salicylates Propionic Acid Acetic Acid Fenemic Acid Pyrazolone Oxicam Coxibs ( Aspirin ) ( Ibuprofen , Naproxen ) ( Indomethacin , Diclofenac ) ( Mefenemic Acid ) ( Phenylbutazone ) ( Piroxicam ) ( Celebrex )

NSAIDS
Inhibits Prostaglandin Synthesis from arachidonic Acid

Analgesic Antipyretic Anti Inflammatory

Peripheral Central ( Hypothalamus ) Peripheral

Stimulus Phospholipase Arachidonic Acid Stored in membrane bound phospholipids is released By Cyclooxygenase ( COX ) Prostaglandin E2 , Leukotrienes C4 & E4

Arachidonic Acid
COX
Enzymes

Prostaglandin

Modern Lab Techniques & Biochemical Studies have determined that 2 different isoforms of COX exist COX1 & COX2 Recently COX3

COX 1
Maintain Homeostasis
Constitutive ( Continuously Produced by many cell types throughout the body ) COX 1 Mediated Prostaglandins maintain Homeostasis pathways in the : GI , Kidney , Heart , Brain ,Vasculature, Airway Function Protect GI Mucosal integrity by Stimulation & Production Of Mucus And Bicarbonate , which form a protective barrier against acid Secretion In the Kidney Prostaglandins regulate blood flow , renin release , Renal tubular Salt & Water resorbtion , resulting in an increased rate of Glomerular filtration In the Circulatory System , Prostaglandins regulate Vascular Homeostasis & Platelet Function

COX2
Induced during the inflammatory process at the site of tissue injury ( Specific to Inflamed tissue & much less gastric irritation ) Endogenous prostaglandins mediated by COX2 release the inflammatory mediators ( including histamine,bradykinin, leukotriens ,and Substance P ) during tissue trauma These Inflammatory mediated events result in increased vasodilation & permeability of the peripheral vasculature , edema , erythema , hyperalgesia , loss of function , and pain > Risk of Heart attack , thrombosis & Stroke through a relative increase in thromboxane . Refecoxib ( Brand Vioxx ) Was taken off the market in 2004 because of these Concerns . Some other COX 2 Selective NSAIDs , such as Celecoxib & etoricoxib , are still on the market .

COX1 COX1 & COX2 COX2 Are Expressed in airway cells , where their activities influence functions such as airway hyper reactivity . Clinical data show that mixed COX1 COX1 / COX2 COX2 inhibitors such as Aspirin ,but not COX2 COX2 Selective inhibitors Such as Celecoxib( Celecoxib( Celebrex ) , Induce Bronchoconstriction and Asthma in sensitive individuals .

NSAIDs
Possess many advantages , including Analgesia , Anti inflammatory , And Antipyretic effect , And Unlike Opiods , do not result in :

Sedation Respiratory depression Interfere with bowel & Bladder Function

Recommended Preoperative NSAIDs Protocol for Postoperative pain Control

1. 2.

Ibuprofen ( 400 mg ) 30 Min before the initiation of treatment benefits : Delayed Onset Of Postoperative Pain Gelofen 200-400 Decreased severity Of Postoperative Pain Advifen 200-400

Precautions :
1. 2. 3.

Contraindication ( Allergy , Asthma , GI Ulceration , Bleeding disorders , Renal disease , Hepatic disease , Pregnant or lactating females ) Doses Of Ibuprofen in Excess of 400 mg associated with greater incidence of unwanted side effects & have not been demonstrated to increase Analgesic efficacy NSAIDS May diminish the antihypertensive effect of 3 classes of agents, including the ACE inhibitors , blockers , and diuretics by inhibition of prostaglandin ( at least after 7 - 8 days ) So their Use should be limited to 4 days in patients taking Antihypertensives

Diuretics , adrenergic antagonists , Calcium channel antagonists

ACE( angiotensin-converting enzyme inhibitors , -adrenergic antagonism Direct acting vasodilators )

Ibuprofen ( Brufen ) Tab 400 mg # Ten Take One q 6 h Prn / Pain

Gelofen 200-400 mg Advifen 200-400 mg

Adult Maximum dose / 24 h 3200 mg Pediatric dose 10 mg / kg po q 6-8 h Max dose 40 mg/kg

Selective

COX 2

Inhibitor

Celecoxib ( Celebrex ) Cap 200 mg # X ( Ten ) Take 400 mg initially then 200 mg q 12 h Prn/Pain

More Expensive

Aspirin
Analgesic, Antipyretic , Anti inflammatory + Uricosoric effect & Antiplatelet aggregation

Adult 650-1000 mg q 4-6h Max4000 Children 65 mg / Kg / 24 h divided 4-6 doses Infants only few days < 13 yrs Possible Reye s Syndrome Contraindications ( Allergy, Asthma , GI ulcer , Bleeding disorders , Renal &
Hepatic disease , Pregnant or Lactating females ) Available Regular Enteric coated Sustained released Combination with Antacid ( Buffered tabs) Aspirin + Codein ( Empirin ) Not available in Iran

Analgesics Narcotics
Opiates (Morphine , Codeine ) Synthetis opiates
dihydromorphinone) Oxycodone ,

Non Narcotics
Salicylic Acid Derivatives
Acetylsalicylic acid Salicylamide
NSAIDS

Opiate congeners
Meperidine , Methadone , Pentazocine , Propoxyphene

Para-aminophenols
Acetaminophen Acetophenetidin ( Phenacetin )

Para-Aminophenol Acetaminophen & Phenacetin

Unlike Aspirin does not impact Platelet function GI Upset Uricosuric effect Not Anti inflammatory Analgesic & Antipyretic Severe Hepatic damage (Alcohol abusers ) Long term Nephrotoxicity ( Papillary Necrosis )

Acetaminophen Tylenol
650 - 1000 mg q 4-6 h Max 4000 / 24h
Iran 325 , 500 , 80 , drops , Syrup , Susp , Suppository

Acetaminophen with codeine 7/5 mg Tylenol # 1 15 mg Tylenol # 2 30 mg Tylenol # 3 60 mg Tylenol # 4

IN IRAN Acetamiphen( 300 )+ 10mg Codeine

Acetaminophen ( Tylenol )
The best - selling Over-the-counter antipyretic & Analgesic in the USA

Similar Antipyretic & Analgesic effect ( Like NSAIDs ) Such as Aspirin & Ibuprofen but lacks Anti inflammatory , Anti platelet , & GI effects Generally Supported Hypothesis ( Not literature ) : Acetaminophen act Centrally & Weak Inhibitor of COX1 / COX2 The discovery of COX 3 In Canines seemed to offer a key to unlocking the mechanism of action of Acetaminophen . But the so called COX 3 is just another COX 1 Splice variant Many Results Suggest that Acetaminophen Acts against COX2 and not COX 1 Or COX3

The Exact Mechanism of acetaminophen still remains a Mystery

Narcotic Analgesics
Opiates
Morphine , Codeine ( 1/6 - 1/12 Morphine )
Potent analgesic Addiction Respiratory depression Sedation Oxycodone Emesis , Constipation

Synthetic Opiates
dihydromorphinone

Opiate Congeners
, Methadone , Pentazocine , Propoxyphene

Meperidine

Recent Classification Of Opioids Based on Special receptor binding mu , Kappa , delta

1. 2. 3.

4.

Agonist (Stimulate mu + Kappa ) Morphine , Codeine Antagonist (bind receptors but not stimulate them ( Narcan ) Agonist - Antagonist ( Pentazocine Kappa Agonist & mu Antagonist ) Others ( Tramadol Weak mu agonist + Inhibits Serotonin & Norepinephrine reuptake , Minimal abuse potential & Respiratory depression , For dentistry equal to codeine )

Opioid Adverse Side Effects

Respiratory depression Nausea & Vomiting Mental Clouding Sedation Euphoria Constipation Hypotension Urinary Retention Pruritus

IRAN 09646 & 82101

Aspirin 80 , 100 , 325 , 500 Enteric coated 80 & Microcoated 500 Mefenemic acid ( Ponstan ) Cap 250 mg Ibuprofen (brufen ) 200 - 400 mg ( 100mg / 5 ml Suspension ) Naproxen 250mg tab , 500 mg Suppository , 500 mg tab delayed release Acetaminophen 80 , 325 , 500 , ( 120mg / 5ml Sol& Susp & 125,325 mg Suppository ) 500mg eff Acetaminophen codeine ( 300 + 10 ) Celecoxib ( Celebrex ) Cap 100 , 200 mg Tramadol Cap & tab ( 50 mg ) , Amp 50mg /ml IM Piroxicam ( o/5 % Gel , 10mg Cap , 20 mg Supp , 20 mg Amp) Diclofenac ( 0/1% phthammic drop, 1% Topical Gel , 50 &100 suppository , 100mg Cap , 25& 50 Tab , 25mg/cc ( Amp 3cc 75 mg ) Indomethacin Cap 25 mg , tab 75 mg , Suppository 50, 100 mg Morphine Sulfate ( MS ) 10 mg / cc Amp Pethidine 50mg / ml Amp Pentazocine ( Talwin ) Amp 30 mg Acetaminophen Inj (Apotel ) 10 mg ml Iv infusion ( 15 min )

Paraclinical Examination

Imagings Labs

Para clinic
Chapter 33
Imaging (X-ray, Tomography , CT, MRI, Sonography , Arthrography , Bone Scan) Laboratory Exam.
Chapter 33 43 tests CBC , Coagulation tests , FBS & HA1c , Ca , P , Alkakine phosphatase LFT,s , KFT,s , HIV , HBs Ag , Urinalysis

Indications
Hx ( History ) PE ( Physical Exam ) GA ( General Anesthesia )

Dentists Need to know

Reading the reports Check up ( Patient & Family ) lab tests

For our practice

Careful Interpretation Based on Hx , PE ,

CBC
Hgb ( Hb ) Hct Rbc Smear Wbc & Diff Pc Mcv Mch Mchc
14-18 gm / 100 ml 40-52 % ( 12-16 ) ( 37-47 ) 4/5 - 6/2 million / cc ( 4/5-5/5 )

Shape & Size

5000 - 10000 150000 - 40000 < 60000 Critical 82-92 Cubic microne 27-32 micro micro gram 32 -38 gm /100 ml

Hb x 3 = Hct RBC x 3 =Hb Rbc x 9 = Hct

Smear Report
Normocytic 80 - 96m3 Macrocytic >96m3 Microcytic < 80m3 Normochromic Hyperchromic Hypochromic Anisocytosis (abnoral sizes of Rbc Inc Macro& Microcytic) Poikilocytosis abnormal shapes such as :
Burr cells , Target cells , Sickle cells , Nucleated Red cells

Reticulocyte count ( % ) About 1% of the Circulating Erythrocyte mass is generated by the bone marrow each day . Precursors of RBCs are Reticulocyte , which account for 1% of total Red Cell Count

0 /8 - 2/5 Male 0 /8 - 4/1 Fem Reticulocytosis ( Bleeding , Hemolysis , + Respond to Anemia Treatment ) Reticulocytopenia ( transfusion , aplastic A) Ret Index = Patient Hct / Normal Hct x Ret Count
( % ) Should be 1 if < 1 no good response to Anemia tx even with high Ret count

Anemia
Hb < 12g/dl in W & < 13 g/dl in M Type ? MCV , MCH , MCHC + Reticulocyte Count < 1 % inadequate RBC Production in the bone marrow < WBC & < Pc Generalized bone marrow defect

Many Signs & Symptoms ( Acute / Chronic ) Fatigue , Palpitation , Shortness of breath , Abdominal pain , Bone pain , tingling of fingers & Toes , Muscular Weakness , Jaundice , pallor , cracking , splitting and spooning of the fingernails , increased size of the liver & Spleen , Lymphadenopathy , Blood in the stool , Premature graying of hair and yellowing of the skin ( due to jaundice )

Sore or Painful Tongue ( Glossitis ) Smooth tongue , Redness of the tongue Angular Chelitis Some Patients Complain of loss Of taste Sensation

Anemia
( Classification by Size & Shape Of RBC )

Normocytic MCV 80 - 100m3

Microcytic MCV < 80m3

Iron deficiency Anemia Thalassemias Lead poisoning

Macrocytic ( Megaloblastic ) MCV > 100m3

Pernicious Anemia(B12) )

Sickle cell Anemia Hemolytic Anemia G6PD deficiency Aplastic Anemia Renal Failure
Anemia of Chronic disease

Folate deficiency ) Hypothyroidism

WBC & Differential (diff) 5000 10000 > 10000 Leukocytosis < 4000 Leukopenia

WBC diff
Neutrophil Lymphocyte Monocyte Eosinophil Basophil 50 70 % 20 - 40 % 0 - 7 % 0 - 5 % 0 - 1 %

Shift to the left Band cells or Stab

( Acute Bacterial Infection & Bleeding )

Hemoglobin Electrophoresis Normal Findings

Hb A1 95 98 % Hb A2 2 - 3 % Hb F 08 - 2 % ( newborn 50-80%) Thalassemia Major
CHD , Chronic hypoxia

Hb S Hb C

0 % Sickle Cell Anemia 0 %

American Negro , HC disease & Sickle Cell

HA1c

( Glycosylation Of Hemoglobin A ) Is an electrophoretically fast moving hemoglobin Reflect Glucose levels over 6 - 12 Weeks Up to 100-120 days Normal Level 4 - 6 % Well controlled Diabetes < 7 %

Hemoglobinopathy
Hb F > 3 years > 2 % Abnormal ( chronic hypoxia Such as CHD ) Hb F Thalassemia Trait & major ( Cooley,s Anemia ) Hb S Sickle Cell Anemia & Trait

ESR ( Sedimentation Rate ) Sed Rate

Wintrope 065mm(M),o-15(F) Westergeen O-15mm(M),0-20(F) Non specific in tissue & Organ damage (inflammatory , Infection , degenerative ,Trauma , Tumors ) Usefull in progress of inflammatory autoimmune diseases Such as Temporal artritis ( giant cell artritis,Polymyalgia,RA )

Osteomyelitis Respond to Treatment

Coagulation Tests
Screening Specific

Screening
PT ( second , % , INR ) PTT ( 25 - 40 seconds ) PC (150000 - 400000 ) < 60000 critical BT ( 1- 4 min ) Fibrinogen ( Factor 1 ) ( 200 - 400 mg/100 )

Specific
Coumadin > PT Heparin > PTT ASA > BT , PTT ITP, DIC < PC Hemophilia > PTT, F8 assay Liver dysf > PT + < PC + > BT Malaborption Syndrome (antibiotics) > PT Hemodialysis > PTT + < PC + > BT Chronic Leukemia < PC + > BT
Warfarin , Coumarin , Coumadin , Dicumarol 2-7-9-10 Vit K dependent

PTT
= 25 - 40 seconds PTT = 60 - 70 Seconds
APTT

Anticoagulation therapy 1/5-2/5 Normal

Intrinsic ( 8 , 9 , 11 , 12 ) + Common ( 1 , 2 , 5 , 10 ) Pathways

Factors
1 , 2 , 5 , 8 , 9 , 10 , 11 , 12

PT
Extrinsic ( 7 ) + Common Pathways ( 1 , 2 , 5 , 10 )
Anticoagulation Therapy 1/5 - 3 Normal Factors 1 , 2 , 5 , 7 , 10

PT
Second 11-15 % 70-100 INR < = 1 1/5 Safe = / > 30 % 2/5

Platelet Count ( PC )
150000 - 400000 < 60000 (50000) Critical < 10000 Severe Bleeding

Thrombasthenia
Congenial ( Von willebrand) Drugs (ASA , Plavix ) 7-10 days Diseases (Cirrhosis,Uremia, Pernicious Anemia , LE ..)

PTCA Percutaneous transluminal coronary angioplasty

Bleeding Time
Duke 1- 4 Minute Ivy <4

Hemophilia F8 Def >3% 1 -3 % <3% 0/05 x 70000 x%30= 1050 Units q 12 -24 h + EACA 100mg / Kg q 6h/10days

Bleeding Remember 5 As
1. 2. 3. 4. 5.

Aspirin Anticoagulants ( Coumadin & Heparin ) Antibiotics ( Malabsorption Syndrome ) Alcohol Anticancerous ( Chemotherapy )

Ca , P , Alkaline Phosphatase
( ALP1 In Liver & ALP2 In Bone ) Giant Cell Granuloma & Hyperparathyroidism ( Brown Tumor )
Ca 8/5 - 10/5 mg /100 ml Phosphor 2/5 - 4/5 mg / 100 ml Alkaline phosphatase 1-4/5 Unit ( Bodansky) 4 -13 ( Armestrang ) < 2 years 85-235 ImU /ml 2 - 8 years 65 - 210 Imu / ml 9-15 Years 60 - 300 Imu /ml 16 21 years 30 - 200 Imu / ml

Bone Scan TC 99
Hot Spots Tmj Bones ( Tumors ,Osteomyelitis )

Cholesterol (150 - 300 mg / 100) Ideal < 200 HDL 30-80 LDL 70-190 Less than 1/3 of Cholesterol Is In HDL
Total Cholestrol < 200 & LDL < 100 & HDL >60 ( is Ideal ) High Cholestrol + High LDL + Low HDL + HBP + Smoking ( High Risk for CAHD )

Triglyceride ( VLDL) 40 150 mg / 100

Triglycerides >150 is a separate risk Factor High level usually + Low HDL

Lipoproteins 4 Types
HDL ( alpha LP ) LDL ( beta or s,0-20) VLDL ( prebeta or s,20-400 ) Triglycerides Chylomicrons

10 Indexes to IHD
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Age Hyperlipidemia ( LDL,VLDL) & Low HDL Cigarette Smoking Hypertension Obesity Diabetes Physical Inactivity Hyperuricemia ( Uric acid > 6/9 mg/100 ) + Family Hx of IHD , DM , Hyperlipidemia ..) EKG abnormality

HDL Higher In Women Estrogen>HDL Androgen < HDL

FBS ( NPO / 8 h ) 65-110 mg /100 ml > 126 mg = diabetes ( 1997 ADA Criteria for Diagnosis ) GTT / 3h > 200 ( Urine + )

Glycohemoglubin ( glycosylated hemoglobin ) HbA1c Reflect Glucose levels in blood over the 6 - 12 weeks 100 - 120 days Normal 4 - 6 % In well Controlled DM < 7 %

No NPO

Uric Acid 3-8 mg / 100

Renal Function
BUN 10-20 mg / dl Creatinine (Cr) 0/7 - 1/4 mg / dl Creatinine clearance (Ccr) 85-140 ml /min Urinalysis ( First Void if Specific gravity 1/016 or greater & PH 5/8
Or less & No Glucose & Protein Most likely Kidney Function is WNL

BUN > 30-50 Moderate > 50 / 60 Severe Not Specific Creatine > 2&3 Moderate > 6 Severe RF Creatine Clearance 10-50 Moderate < 10 Severe

Thyroid Function Tests

PBI BEI T3 T4 TSH

Pancreatic Function Tests Vital organ in Homeostasis Amylase Not specific Lipase More Specific Tripsin Most specific

Acute MI
SGOT LDH CPK
( serum glutamate Oxaloacetate transaminase )

( Lactic dehydrogenase 5 Isoenzymes LDH 1 & 2 )

( MB In Myocardium , MM In Muscle , BB In brain )

Troponin T Troponin I
Acute MI Prehospital Phase Management by dentist Hospital Management by Cardiologist

CPK
MM (Muscle) MB (Myocard) BB (Brain)

LDH Isoenzymes 1-5 specific 1 -2

HIV
ELISA 6 -10 Wks Post Exposure + Antigen P24 ( New ) + 2 wks post Exposure CD4 Tcell count (600-1600 Normal) < 600 Immune def Needs Antibiotics

Serum Osmolarity 275 - 295 mosm SIADH D Insipidus

Serum Electroytes
NA K Cl Mg Ca P 135-145 meq /L 3/2 -5/5 meq /L 95 -105 meq /L 1/5 -2 meq /L 8/5 -10/5 mg /100 3 -/5 mg /100

ABGs (arterial blood gases)

PH 7/35 7/45 PCO2 35-45 mm/hg HCO3 22-26 meq /L CCP 55-75 ml co2 /100cc Bass Excess O 2 meq /L PO2 80 100mm / hg O2 Saturation 95-98%

LFT,S
SGOT SGPT Alk Phosphatase Bilirobin PT BSP Serum Albumin

Bilirubin
Total Direct ( Conjugated ) Indirect ( Unconjugated ) Non Icteric Subclinical 0/2 1/2mg /100 < 0/3 mg / dl O/1 1 mg / dl Hepatitis ( TB < 3 )

HBSAG
Carrier HB ( + HBSAG ) Persistent HB ( + HBSAG & + LFT,S ) Active HB ( As above & + Biopsy)

Acid Phosphatase Prostate CA Metastase to bone

Serum Amylase
Pancreas Salivary Glands Intestinal Obstruction Upper GI Surgery

Gram Stain Culture ( A & Anaerobe)& Sensitivity (antibiograme) Actinomycosis C&S

Urinalysis
Physical Chemical Microscopic (Vol,Col,SG ,Smell,Trasp) ( PH,Protein,glucose,Hgb,.) (RBC,WBC,Epith,Casts)

Urinalysis
Volume Color Transp , cloudy Smell Sp gravity PH Protein Glucose Ketone Hgb Billirubin Bens jones protein RBC , WBC Epith cells Casts & Crystas

PSA ( Prostate - Specific antigen )

0 4 ng /ml > 10 ? CA

Stool Examination for Occult blood

( Stool for OB )

CSF
Opening Pressure (100-200mm /H20 ) Color , Appearance Glucose ( Serum 45-80 mg /100 ) Protein ( 15-45 mg/100 ) Cell count ( WBC , RBC) up to 5 all lymphocytes CSF leake ( 2 Transferrin )

Medication Levels
Digoxin 1/3-1/7 ng/ml > 2/4 Carbamazpin 2-8 ug/ml > 12 Chloramphencol 10 - 20 ug/ml > 25 Propranolol 30-100 ug/ml > 150 Xylocaine 0/5-2 ug/ml > 5

Drugs Used In dentistry & OMFS

Local Anesthesia ( LA ) Analgesics Sedatives Antibiotics Corticosteroids General Anesthesia ( GA )
+ Emergency Drugs Hand book of Local Anesthesia Fifth Edition 2004 Mosby

Antibiotics
Pen VK Pen G Procaine Pen Benzatine Pen G ( 6-3-3 ) Ampicillin Amoxicillin Co Amoxicillin Gemtamycin Metronidazole Clindamycine Erythromycine Cephalosporines ( 1st , 2nd , 3rd , 4 th Generation )

Post Op Infection ?

ATS 90% GF 10 %

Adverse Reactions
Allergy GI Side Effects N / V Superinfection ( Candida , AAC = PMC ) Blood dyscrasia Interestitial Nephritis Drug Fever Neurotoxic Drug Interaction Resistance Etc

PenicillinG
Acid Labile ( Only IV Or IM ) G+C & Rods+ Most Anaerobes HL 30 Min ( healthy Kidney ) 2 - 3 MU q 2-4 h ( HL 4 ) Aqueous Crystaline Pen G Pen G ( Na 100mg /1mu Or K 65mg or 1/7 Meq ) Possible Hyperkalemia

Procaine Pen G ( 400000 & 800000 ) ( Only IM ) Peak 1 - 2 h last 24 h 800000 U Q 12 h

Benzathine Pen G Only IM Last 3 - 4 Weeks 1200000 U

Penicillin 6.3.3 Benzathine Pen G 600000 Procaine Pen G 300000 Potassium Pen G 300000

Pen VK Acid Stable ( 65 % absorbed VS Pen G 30 % absorption ) Peak Serum 30 Min Up to 4 h detectable 500 mg po q 4 - 6 h

Penicillinase - Resistant Penicillins

Methicillin ( Acid labile ) IM & IV Less Used

Oral Dicloxacillin Oral Oxacillin Oral , IM , IV Nafcillin Oral , IM , IV

Cloxacillin

Extended Spectrum Penicillins Wider Or Broader Spectrum penicillins Extension G-Rods Not Penicillinase
1. 2.

Ampicillin - like agents ( Ampicillin , Amoxicillin ) Carbenicillin - like agents

Combination Of Extended Spectrum Penicillins & Lactamase inhibitors Amoxicillin + Clavulanic Acid
Co Amoxiclav Cap 625 mg ( 500 +125 ) Cap 375 mg ( 250 + 125 ) Powder 312 mg ( 250 + 62/5 )

Penicillin family
Pen G , Pen Procaine , Benzatine , PenVK Penicillinase Resistant Penicillins Extended Spectrum Penicillins ( Ampicilline & Amoxicillin ) Combination of Extended Spectrum penicillins & Lactamase inhibitors ( Co Amoxiclav )

Adverse Reactions To Pens

Allergy 3-5 % Population & 10 % Previously received ( Simple Skin rash to lethal anaphylaxis ) Anaphylaxis in 0/02 % ( 10 % may be fatal ) GI side Effects ( N/V , diarrhea ) dose related Super infection ( Thrush , PMC = AAC ) Interstitial Nephritis Blood dyscrasia Drug Fever

Cephalosporines New Generations for G - Rods

First G : G + C ( Except Enterococus&Staph Resist To Methicillin ) + E Coli + Klebcilla , P . Mirabilis + Anaerobes : Caphalotin ( Keflin ) Cefazoline ( Ancef ) Cephalexin ( Keflex ) Second G : > Spectrum against G - & Anaerobes Amp Cefamandole Oral Cefaclor ( Ceclor & Ceftin ) Cefoxitin ( B.Fragilis In OMFS ) Third G : > Spectrum Enteric G - & Nosocomial Inf But Less effective Against G + C ( Cefotaxime , Cefdinir , Cefixime .) Fourth G : Cefepime

Erythromycin
2 - 5 % Urinary Excretion Mainly Via Bile Allergy to Pen Macrolid ( Erythromycin ,Azithromycin ,Clarythromycin ,Dirithromycin)
Spectrum like pen Bacteriostatic Main disadvantage

Rapid Few Step Resistance ( Penicillin Slow Stepwise Resistance ) ( Streptomycin Single Step )

Clindamycin
Severe Odontogenic Inf ( Anaerobe Resistant to Pen ) Good Oral absorption ( Even + Food ) Oral & Amp ( Cap 150 mg , Inj 150mg / ml ) Good Bone Penetration ( Osteomyelitis ) No CSF penetration (even Inflammation slight BBB) Liver Metabolism & Then Urinary Excretion Main Complication PMC = AAC & blood dyscrasia BE Prophylaxis ( Pen allergy ) 600 mg po 1h pre op

PMC = AAC
Superinfection Overgrowth ( Clostridium dificile = Toxin )
Severe diarrhea ( 20% With antibiotics 10 % Usual Intestinal Flora changes But 10 % AAC Serious Problem Treatment Vancomycin ,Metronidazole

Tetracyclines
Very Limited in Odontogenic Infection Unless Resistant to Pen & Erythromycin ( C& S ) In Refractory Periodontitis ( Juvenile P ) Good Oral Absorption ( Unless Chelation with Al , Fe , Ca , Mg Containdicated in pregnancy & Children < 12 Good Bone Penetration Doxycycline ( Cap & tab 50 - 100 mg Amp100-200 Syr 50mg / 5ml

Chloramphenicol
Typhoid Specific 3 % more Effective in Odontogenic Infection ( Compare with pen ) but not used routinely Since is highly toxic ( Bone Morrow depression ) For Severe Odontogenic infection Invades Brain & Periorbital ( Meningitis , Brain abcess , Cavernous Sinus thrombosis ) Check CBC routinely Amp 1 gm

Metronidazole Flagyl
1962 for Vincent infection & Tricomonasis Used for parasitic infection Now Used for anaerobes ( Obligate ) Never Use as a Single drug Good BBB penetration Good Oral absorption 2 Major Complications ( Convulsion , Disulfiram ) Tab 250 mg q 8 h & IV 500 mg vial

Aminoglycosides
Gentamycin=Garamycin Kana , Strep , Tobra , Neomycin

Almost no anaerobic effect Aerobe Gram - Rods Never for odontogenic infection Unless C&S ( Enteric Flora )

New Beta - Lactam Antibiotics

Carbapenams , Monobactams , Quinolons

Carbapenems ( Imipenam ) Most Broad Spectrum is Available today . Only for Gram Negative Infection ( Urinary , pulmonary , Abdominal No Oral absorption Only for injection Not Used for odontogenic infection unless ( C&S) Monobactams Spectrum like Aminoglycosides (Aerobe G Rods ) Quinolons ( Ciprofloxacin )