Pharmacological clinical cases for dentists part1 case studies for practical pharmacology for dentists

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Clincal Pharmacology cases
for dentists
Dr Sameh AM Abdelghany

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Analgesics Cases

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Case(1)
 You complete endodontic treatment on a
32 y.o. male and expect mild to moderate
pain. His medical history is significant for a
recent GI (gastrointestinal) bleed from
stomach ulcers.
 Which medication is the best choice? & why?
Ibuprofen, Aspirin or Acetaminophen

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 Aspirin and NSAID induced GI injury results from two
known mechanisms
1. Local irritation of the mucosal lining allows
diffusion of acid into the lining with subsequent
tissue damage
2. Inhibition of gastric prostaglandins that inhibit
secretion of gastric acid and promote secretion of
cytoprotective mucus
 Aspirin and NSAIDs are contraindicated in patients
with GI ulcers

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Case(2)
 You see a 25 y. o. male with a very painful
abscessed tooth #31 on Monday morning. He
has been in pain since Friday night. He has not
slept in 48 hours and has been taking 6 extra
strength Acetaminophen every 2 hours for the
last two days. He is nauseated, has vomited
several times recently and is very tired.
 What is the problem?
 What do you do?

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

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1. Stomach wash and administering
activated charcoal
2. Administration of sulfhydryl
compounds (e.g.acetylcysteine)
which probably
3. replenish hepatic stores of
glutathione.

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Case(3)
 Your patient a 37 y. o. female has recently
had inpatient Oral Surgery for bone grafting
to the maxilla from the iliac crest. While in
the hospital she was given Ketorolac 30 mg
IV. She also was given Ketorolac 10 mg(disp.
20), one PO qid. She has run out of this pain
medication and would like you to refill it.
 What will you do?

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

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Case(4)
 A 64 y. o. male presents for treatment of an acutely
painful tooth #13. You determine that the tooth is
non-restorable and requires extraction. He has been
taking 2 ibuprofen every 3 hours to control his pain.
Past medical history is significant for use of oral
anticoagulant(e.g warfarin)as prophylaxis for atrial
fibrillation. The patient supplies you with a note from
his physician that shows that his INR is 2.0 and gives
clearance for extraction of this tooth.
 What is the problem?

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 Oral anticoagulants prevent the synthesis of clotting
factors II, VII, IX and X in the liver (Vitamin K
dependent factors). (Monitored with INR)
 Ibuprofen reversibly interferes with platelet
function
 Severe bleeding could occur following extraction

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Case(5)
 You complete the removal of impacted wisdom teeth
on an 18 y. o. female who requests narcotic analgesic
because acetaminophen doesn't work for her.
You prescribe Ibuprofen and narcotic analgesic as
breakthrough medication. The next morning you
receive a phone call that your patient has severe
Nausea and Vomiting and "cannot keep anything
down." The patient states that she is in severe pain
 What has caused this problem?
 How are you going to treat this problem?

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 Nausea and vomiting are common adverse side
effects of any narcotic with no documented
differences among agents
 Patient has not taken any of Ibuprofen
 Instead she has taken only the Narcotic analgesic on
an empty stomach
 Because of vomiting she is unable to absorb any of
the pain medication prior to vomiting it back up

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

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Case(6)
 A 35 year old female presents to your office
for evaluation of TMJ pain. She has been seen
by another dentist across town who has been
treating her pain with NSAID and narcotic the
last week. the patient states that she has not
had a bowel movement since she has started
on the pain medication.
 What has caused this problem?
 How are you going to treat this problem?

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 Constipation is a common side effect of opioid
medications
 Narcotics depress peristaltic contractions
 Constipation is dose-dependent and is noted
more with repeated administration

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 Stop the narcotic analgesic
 Prescribe a stool softener, or refer to
primary care MD

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Case(7)
 You sedate a very nervous 84 y. o. female patient with
Fentanyl and Versed in order to extract an impacted
wisdom tooth. The patient becomes apneic just after
the administration of the sedative medications. You
support her respiration, administer local anesthesia
and extract the tooth in 2 minutes, much quicker than
anticipated. Whenever you stop supporting the
patient's respiration, she becomes apneic
 What is happening?
 How are you going to treat this problem?

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 Respiratory Depression
 All opioids depress respiration
 Caused by a dose dependent
decrease in the response of the
respiratory center to carbon
dioxide

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 Continue to support the patient's respiration
OR
 Administer Naloxone.

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Case(8)
 A 45 y. o. female patient is transferred to you for
management of TMJ with a bite splint. Upon evaluation
she states that she has been managed over a period of
months by another dentist with first Acetaminophen,
then narcotic, He recently refused to refill any
prescriptions and instead referred her to you for
management. While in your office the patient develops
goose bumps, dilated pupils, nausea and becomes
anxious and somewhat hostile.
 What is happening?
 What will you do?

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

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1.Hospitalization
2.gradual withdrawal of morphine
3.replacement with methadone
which is less addictive then
gradual withdrawal of methadone
4.Clonidine
5.sedative

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Antimicrobials Cases

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Case(1)
 A 25-year-old female patient presents with
localized periodontitis with a 6mm pocket
along the mesial root of tooth #14. A decision is
made for treatment with gingival flap surgery.
The patient's medical history is remarkable for
prosthetic mitral valve placement and for
penicillin-induced angioedema.
Treat with: Clindamycin, Azithromycin or
clarithromycin

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 Who are considered high Risk patients requiring
antibiotic prophylaxis
1. Prosthetic valves
2. Hx of infective endocarditis
3. Unrepaired cyanotic congenital heart disease (CHD)
4. Repaired CHD with prosthetic material or device during first 6
months post-procedure
5. Repaired CHD with residual defects at/or near the site of
prosthetic patch or device
6. Heart transplant recipients with valvular disease
7. Rheumatic heart disease if prosthetic valves or prosthetic
material used in valve repair

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What are some of the dental procedures for which
prophylaxis is reasonable?
1. Extractions
2. Periodontal procedures
3. Orthodontic initial band placement
4. Dental implantation, re-implantation or implant
removal
5. Endodontic procedures
6. Ligamentary local anesthetic injections
7. Cleaning of teeth or implants
8. Any other procedure that may involve BLEEDING

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 When do you take an antibiotic before a dental
appointment?
 1 hr before the procedure
Amoxicillin - Ampicillin – Clindamycin – Cephalexin
 What antibiotic is used to when you are unable to
take oral medication?
 Ampicillin
 What antibiotic is used when allergic to penicillin?
 clindamycin

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Case(2)
 A 35-year-old obese female patient
presents in the office with a canine fossa
abscess associated with the root remnant of
tooth #6. Incision and drainage of the
abscess, extraction of the root remnant, and
antibiotics are scheduled.
 What are antibiotics you will prescripe?

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Case(3)
 This patient is complicated with
Pseudomembranous coilitis (Superinfection)
 What antibiotics are most commonly
associated with this?
 How to treat this problem?

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

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Case(4)
 44 y male with a generalized palatal lesion
noted by clinical examination, patient
reports pain and burning for over 2 months.
Diagnosed as Atrophic candidiasis
 How can u treat Atrophic candidiasis ?
 What is the primary organisms responsible
for most fungal infections in the oral cavity?

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 Clotrimazole troches would be highly
recommended
 Alternative systemic treatment(Fluconazole)
 Candida is the most common organism

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Case(5)
 57 year old, edentulous patient presents
with generalized asymptomatic erythema
beneath her maxillary denture. She reports
wearing the denture even at night.
Diagnosed as Atrophic candidiasis
 How would you treat this?

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 Instruct to leave denture out at night and
soak in commercial denture cleanser after
washing(Most commercial denture cleansers
have antifungal activity)
 Nystatin powder to place inside denture
during day or Nystatin cream

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THANK YOU