Rational Drug Use In Dentistry PDF

RATIONAL DRUG USE IN DENTISTR Y DT. MÜNÜFE YILDIRIM MECHANISMS OF ACTION OF ANTIBIOTICS Protein synthesis Inhibition of metabolic inhibition pathways or bacterial Effect on cell wall synthesis enzymes...

RATIONAL DRUG USE IN DENTISTR Y DT. MÜNÜFE YILDIRIM MECHANISMS OF ACTION OF ANTIBIOTICS Protein synthesis Inhibition of metabolic inhibition pathways or bacterial Effect on cell wall synthesis enzymes Nucleic acid synthesis inhibition Effect on cell membrane  CLASSIFICATION OF ANTIBIOTICS Cell Wall Synthesis Protein Synthesis Nucleic Acid Antimetabolite Inhibitors Inhibitors Synthesis Effects Inhibitors Penicillin Tetracyclines Nitroimidazoles sulfonamides Cephalosporin Aminoglycosid Metronidazole s es Fluoroquinolon vancomycin macrolides es bacitracin erythromycin azithromycin Lincosamides clindamycin  USE OF PENICILLIN IN DENTISTRY They continue to be the drug of choice for almost all acute dental infections except acute ulcerative gingivitis. In addition, most aerobic gram (+) cocci and anaerobic microorganisms, which are the causative agents of dental infections, are sensitive to penicillins. Their strong bactericidal effect is also among the reasons for their preference.  USE OF PENICILLIN IN DENTISTRY Oral route is generally used in the treatment of dental infections. Penicillin V is preferred because Penicillin G is not well absorbed orally. Penicillin V is effective in the treatment of acute dentoalveolar abscess and dental infections caused by both anaerobic and aerobic bacteria. In dental infections, amoxicillin is superior to ampicillin due to its pharmacokinetic advantages. It forms a high concentration in the area of ​acute infection.  A L U S E O F RATION S T R Y TI C S I N D E NT I ANTIBIO t i cs m e a ns, i n of antibio Rational use h t a n t i b i o t i c i s h e re t h e r ig cases w n t t h e c o s t i n g i n t o a c c o u indicated, ta k r i bi n g i t i n th e a tm e n t , p r e s c of tre r a t i o n , t e d o s e a n d d u app ro p r i a n b le in f o r m a t io u n d e r s t a n d a providing a n t i b i o ti c i n i e n t , u s i n g t h e to the pa t n g y a n d e v a l u a t i t c o r r e c t w a the mos a tm e n t. s u l t s o f th e t r e the r e  A L US E O F RATION S TR Y TICS I N DE N T I ANTIBIO r s a r e us e d f o gh a n t ib i o t i c Althou p u r p os es o r t h e r a p e u t i c prophylacti c s a t io n fo r u s e i , t h e i r in d i c in dentistry i te d. u it e l i m actually q FACTORS TO BE CONSIDERED IN ANTIBIOTIC TREATMENT severity of infection possible cause of infection pregnancy, age, immune system status BASIC PRINCIPLES TO BE The narrowest possible spectrum antibiotic effective against the identified or suspected FOLLOWED IN THE USE organism should be the first choice. Thus, OF ANTIBIOTIC there is minimal change in the patient's normal microflora. Antibiotics that are the least toxic and have the least side effects (allergy, colitis, tooth discoloration, exacerbation of existing liver and kidney diseases, undesirable interactions with other drugs) should be chosen. Antibiotics should be given in appropriate doses and for a sufficient period of time. A mistake made may cause resistance to the patient as well as harm to the patient. Generally, antibiotic treatment should be continued for 3 more days after symptoms have resolved. In some cases involving bone, antibiotic treatment along with other treatment options must last longer. BASIC PRINCIPLES TO BE Bactericidal antibiotics should be preferred to bacteriostatic ones. FOLLOWED IN THE USE The patient should be recommended a OF ANTIBIOTIC healthy diet and plenty of fluids. If the oral route is preferred, the most appropriate time to give the drug is half an hour before or 2-3 hours after a meal. Appropriate analgesics should be given during antibiotic treatment. Antibiotic therapy should always be combined with an appropriate surgical procedure (e.g. incision or drainage, endodontic opening of the tooth or tooth extraction). The patient should be controlled during treatment. Efforts should be made to choose the antibiotic that is most appropriate for the patient's complaint and use (in terms of administration route, dose, dose intervals and side effects) and has the lowest cost. REASONS FOR FAILURE IN ANTIBIOTIC TREATMENT The patient does not comply with the treatment. Giving the antibiotic in an inadequate dose or for a shorter period than necessary. Wrong choice of antibiotics. Giving the antibiotic at the same time as another interacting agent. The agent has not been eliminated and/or drainage has not been provided. The dominant pathogenic bacteria are resistant, resistant strains are developed, or tissues are secondarily infected with resistant bacteria. The antibiotic cannot reach the infection site. Insufficiency in host defense.  As a result, the use of antibiotics in oral infections is an issue that requires great attention. Today, it is not possible to talk about a fully and perfectly effective antibiotic. Each group of drugs has disadvantages as well as advantages. Accordingly, when choosing antibiotics, the patient's systemic condition as well as local findings should be carefully considered, and if possible, an antibiogram test should be performed before use. Thus, a more effective and reliable result will be obtained from empirical use. INTERACTION OF ANTIBIOTICS WITH OTHER DRUGS Every drug has the potential to cause harm as well as benefit. When doctors consider prescribing medication, they must weigh the potential risks against the expected benefits. The use of the drug is not valid when the expected benefits do not outweigh the possible risks. Doctors should also consider the possible consequences of not administering the medication. Potential benefits and risks can rarely be determined mathematically. INTERACTION OF ANTIBIOTICS WITH OTHER DRUGS The factor that determines the benefits and risks of prescribing a drug is the severity of the disease being treated and its effect on the patient's quality of life. For example, minor discomfort from coughs and colds, muscle aches, and occasional headaches can be relieved with over-the-counter medications and a very low risk of adverse effects can be assumed. INTERACTION OF ANTIBIOTICS WITH OTHER DRUGS Over-the-counter drugs used to treat minor diseases have a wide safety margin when taken according to instructions. However, the risk of adverse drug reactions increases sharply if another over-the-counter or prescription drug is used. On the other hand, when a drug is used for a serious or life- threatening disease or condition (stroke, heart attack, cancer, rejection of a transplanted organ), a high risk of drug reactions must be accepted.  INTERACTION OF ANTIBIOTICS WITH OTHER DRUGS Penicillins, imidazole Derivatives, lincosamides, macrolides, cephalosporins and tetracyclines are antibiotics frequently used in dentistry. These antibiotics may interact with oral anticoagulants, oral antidiabetics, cardiac glycosides, antiepileptics, diuretics, antihypertensives and corticosteroids used by patients, which have narrow safety limits or require certain blood levels. Antibiotics can even have an antagonism effect on each other.  INTERACTION OF ANTIBIOTICS WITH OTHER DRUGS As a result, whether antibiotics are used for prophylactic or therapeutic purposes, they will always pose a risk in terms of drug interactions and unwanted side effects. Factors such as polypharmacy, hoarding, wrong indications and poor treatment monitoring are increasingly increasing this risk today. Our duty as physicians is to prevent the use of antibiotics without a physician's recommendation and to diagnose the disease correctly; It is to enable one to act with a sense of duty that determines the benefit-harm balance of the drug. Interaction of Penicillins with Other Drug Groups MEDICINE EFFECT Oral antikoagülanlar’da Antagonist effect Beta blokerler’de Antagonist effect Oral kontraseptifler’de Antagonist effect Interaction of Penicillins with Other Drug Kloramfenikol Groups Antagonist effect Penicillin Concentration and High dose Aspirin (3gr/day) Half-life increases Lityum hypernatremia Metotreksat toxic effect Allopürinol rashes Interaction of Imidazoles with Other Drug Groups MEDICINE EFFECT Alkol Disulfiram reaction: Acute psychosis or seizure develops Oral antikoagülanlar’da Synergistic effect Lityum Toxic effect Simetidin Synergism in metronidozole DRUG INTERACTION OF MACROLIDS MEDICINE EFFECT Oral antikoagülanlar’da Synergistic effect Toxic effect Karbamazepin Siklosporinler Toxic effect Toxic effect Teofilin  DRUG INTERACTION OF MACROLIDS MEDICINE EFFECT Synergistic effect Kortikosteroid Digoxine Synergistic effect Linkozamid Antagonist effect  RATIONAL DRUG USE IN DENTISTRY DT.MÜNÜFE YILDIRIM  ANTIBIOTIC PROPHYLAXIS AND ANTIBIOTIC TREATMENT SHOULD NOT BE MIXED WITH EACH OTHER. ANTIBIOTIC The prophylactic antibiotic plasma level is Prophylaxis higher than the therapeutic antibiotic plasma level and the recommended dose is twice the therapeutic dose. The most commonly used antibiotic prophylaxis in dentistry is infective endocarditis prophylaxis.  INFECTIVE ENDOCARDITIS Endocardium is the membrane that lines the inner surfaces of the heart, that is, its cavities. Most often, the endocardial membrane inside the heart valves becomes infected due to bacterial infection. THERE ARE CLINICALLY TWO TYPES OF INFECTIVE ENDOCARDITIS ACUTE INFECTIVE SUBACUTE INFECTIVE ENDOCARDITIS ENDOCARDITIS Condition in which bacteria rapidly destroy Endocarditis is caused by microorganisms previously normal heart valves with less virulence settling in previously damaged heart valves. Alpha hemolytic streptococci (S. viridans, Highly virulent microorganisms such as S.mutans, S. sanguis) S.aureus, pneumococci, meningococci, influenza. Due to a mortality rate of up to 30%, the American Heart Association has recommended antibiotic prophylaxis before invasive medical and/or bleeding dental procedures since 1955.  Conditions at High Risk of Infective Endocarditis Where Antibiotic Prophylaxis is Absolutely Necessary (AHA 2023) Patients with prosthetic heart valves, including those implanted via catheter and derived from one's own tissue. Patients with previous infective endocarditis. Transplant patients with heart failure due to a structurally abnormal valve Unrepaired cyanotic congenital heart defect or repaired congenital heart defect (with residual shunts or valve regurgitation in or adjacent to the prosthetic patch or prosthetic device.)  IN INFECTIVE ENDOCARDITIS Antibiotic prophylaxis is not recommended for the following dental procedures: Routine dental anesthesia to uninfected tissue filming Removable prosthesis procedures orthodontic bracket Spontaneous loss of milk teeth Bleeding in the lip and oral mucosa caused by trauma Suture removal  IN INFECTIVE ENDOCARDITIS DENTIST APPROACH Antibiotic prophylaxis is mandatory in high-risk patients. Any existing infection is a cause of chronic bacteremia because it is focal. It needs to be treated. If the doctor has consulted to detect focal foci, more radical treatments should be preferred for possible foci. Periodontal diseases are the most common cause of bacteremia! Tooth extraction is more likely to cause bacteremia than endodontic treatment. If the patient is at risk, root canal treatment is recommended instead of extraction without overflowing from the apex. ANTIBIOTIC PROPHYLAXY TABLE RATIONAL DRUG USE IN DENTISTRY Öğr. Gör. Dt. Münüfe Yıldırım OPIOID ANALGESIC DRUGS Opioid analgesics; They have an important place in the treatment of pain due to the strength of their effects, relative ease of application and cheapness. This group of drugs, which includes morphine and codeine, which are opium alkaloids obtained from the fruits of the Papaver somniferum (Papaveraceae) family, as well as semi-synthetic and synthetic drugs that have a similar effect  NARCOTIC ANALGESICS; 1- It has strong analgesic effects. Its analgesic effects are a result of its effects on the central nervous system; It is not dependent on a peripheral effect. 2-It also has depressive effects on the central nervous system. 3- It has no antipyretic or anti-inflammatory effects.  PHARMACOLOGICAL EFFECTS OF OPIOID ANALGESICS With the activation of opioid receptors, presynaptic and Although the transmission of pain postsynaptic responses are impulses is blocked at the level of inhibited by excitatory the spinal cord posterior horn, neurotransmitters such as peripheral nerve conduction is not acetylcholine and substance-P affected. secreted from nociceptive neurons.  CENTRAL EFFECTS OF OPIOID ANALGESICS Reduces pain perception by stimulating opiate receptors (analgesic effect) Reduces mental activity (sedative effect) Eliminates anxiety (tranquilising effect) Improves mood (euphoric effect) Inhibits breathing and cough center (respiratory depressant and antitussive effect) Initially causes nausea and vomiting (emetic effect); but then inhibits the emetic center (antiemetic effect) Causes miosis (miotic effect) Stimulates the release of antidiuretic hormone (antidiuretic effect) Causes the development of tolerance and addiction  ANALGESIC EFFECTS OF OPIOID ANALGESICS The analgesic effects of exogenous opioids occur by mimicking the effects of endogenous opioid transmitters on specific receptors. The strength of the analgesic effects of opioids depends on their affinity to reach and bind to the receptor, in other words, their suitability to the receptor site.  RESPIRATORY All mu agonists cause respiratory depression equally when administered in equal analgesic doses. Clinically, opioid- induced respiratory depression manifests as a decrease in respiratory frequency. High doses of mu agonists or partial agonists cause apnea.  CHANGE IN THE LEVEL OF CONSCIOUSNESS Ağrılı hastalar, opioidin etkilerini; sıcaklık hissi, iyilik hali, uyuşukluk ve öfori şeklinde tanımlamaktadırlar, Bu ruh halinde ve çevreyi algılamada oluşan değişikliklerin Iimbik sistem tarafından yönetildiği düşünülmektedir. Eş analjezik dozlarda uygulanan opioidler arasında hipnotik etki açısından farklar vardır..  ANTITUSSIVE EFFECT Opioids suppress the cough reflex by directly affecting the cough center in the medulla. There is no connection between these effects and the effects of respiratory depression..  EFFECT ON PUPILLAS Many mu and kappa agonists cause miosis. It occurs as a result of the oculomotor nerve stimulating the Edinger-Westphal nucleus. At high doses, "pin-point" pupils may occur. Miosis can be antagonized with atropine. NAUSEA AND VOMITING It occurs with the stimulation of the chemoreceptors of the trigger zone in the medullary area postrema. This effect suggests that opioids act as partial dopamine agonists at dopamine receptors. They also cause nausea and vomiting by slowing gastrointestinal emptying. There is no difference in this effect between equivalent analgesic doses of opioids.  TOLERANCE Continuous use of the opioid progressively reduces the potency of the opioid and higher doses are required to provide the same level of analgesia. This phenomenon, characteristic of opioids, is called “tolerance”. If tolerance occurs to one opioid, incomplete cross-tolerance occurs to other opioids.  FİZİKSEL BAĞIMLILIK Opioid kullanımı kesildiğinde ortaya çıkan ve yoksunluk sendromu ile karakterize olan fizyolojik bir durumdur. Yoksunluğun, başlangıç belirtileri; esneme, göz yaşarması, taşikardi, terleme ve burun akıntısıdır. Bunları abdominal kramplar, bulantı ve kusma izler. 72 saat içerisinde en yüksek düzeye ulaşır. Yoksunluk durumunda opioide olan tolerans kaybolur.  ALIŞKANLIK Psişik, ancak bazen fizyolojik de olabilen bir durumdur, Kişi, ilacın oluşturduğu psişik etkileri tekrar denemek ya da yoksunluğundan dolayı hissettiği huzursuzluğu yok etmek için ilacı devamlı veya periyodik olarak kullanmak zorunluluğu hisseder. Alışkanlığın oluşumunda ilacın kullanımı tek başına majör faktör değildir. Hastanın kişiliği, sosyal çevresi, maddi koşullar gibi faktörler  GASTROİNTESTİNAL SİSTEME ETKİLERİ Opioidler, bağırsakların propulsif peristaltik kontraksiyonlarını azaltırlar. Bağırsaklarda propulsif aktivitenin azalmasına transit süresinin uzaması eşlik eder. Böylece intestinal içerikten daha fazla su absorbsiyonu olur. İçeriğin viskozitesi artar ve konstipasyon gelişir.  KARDİYOVASKÜLER ETKİLERİ Opioidlerin, medulladaki vagal çekirdeği uyarması doza bağlı olarak artan bradikardiye neden olur. Morfin, hem vasküler düz kaslara doğrudan etki ederek hem de histamin salınımına yol açarak arteriyol ve venüllerde dilatasyona neden olur.  OPIOID ANALJEZIK UYGULAMA YÖNTEMLERI Direkt yöntemler; intratekal ve epidural yolla opiyoid uygulanmasını içeren invaziv yöntemlerdir. indirekt yöntemlerde hedef, ilaç veren bir sistem aracılığı ile ilacı kan dolaşımına ulaştırmak ve plazma opioid düzeyinin “terapötik bir çerçeve” içinde, ya da “minimum etkin analjezik konsantrasyon” (MEAK) düzeyinde tutarak etkin analjezi oluşturmaktır. Plazma opioid konsantrasyonunun (MEAK)’un altına düşmesi analjezinin ortadan kalkmasına, artması ise toksisiteye neden olur. Opioidler, ağrı tedavisinde, rektal (nadiren). oral, subkutan, intramüsküler, intravenöz, transdermal, transmukozal, intraventriküler ve iontoforez olmak üzere değişik indirekt yöntemler ile kullanılmıştır. Postoperatif ağrı tedavisinde en çok intramüsküler ve intravenöz yol seçilmektedir.