10- Future Trends, Consultations, Rx writing introduction PC 1, 2023 updated Blackboard.pdf

Future Trends in Pain Control, Consultations, and Introduction to Prescription Writing Pain Control 1: October 19, 2023 RICHARD D’INNOCENZO DMD, MD CLINICAL PROFESSOR DEPT. OF ORAL AND MAXILLOFACIAL SURGERY Future Trends in Pain Control   Computer – Controlled Local Anesthetic Delivery (C-CLA...

Future Trends in Pain Control, Consultations, and Introduction to Prescription Writing Pain Control 1: October 19, 2023 RICHARD D’INNOCENZO DMD, MD CLINICAL PROFESSOR DEPT. OF ORAL AND MAXILLOFACIAL SURGERY Future Trends in Pain Control   Computer – Controlled Local Anesthetic Delivery (C-CLAD) EMLA  Onpharma: Buffering of LA  OraVerse: Phentolamine mesylate – Reversal of soft tissue anesthesia caused by LA with vasoconstrictors  Ropivacaine  Experal Local Anesthesia  Electronic Dental Anesthesia  Transcutaneous Electrical Nerve Stimulation (TENS) Malamed Eutectic Mixture of Local Anesthetics (EMLA)  Intact skin acts as a barrier to LA  Consists of a 5% cream containing 25 mg/g lidocaine and 25 mg/g prilocaine  Applied to the skin 1 hour prior to the anticipated procedure. It is covered with an occlusive dressing  Useful in peds including venipuncture, vaccination, suture removal, etc.  Contraindicated in patients under 6 months of age due poss. of developing methemoglobinemia Onpharma  Designed for precision buffering of local anesthetic, which provides rapid onset of analgesia and less injection pain  Sterile, nonpyrogenic, solution of sodium bicarbonate (NaHCO3) in water for injection  It is added to Lidocaine with Epinephrine as a neutralizing agent immediately prior to administration OraVerse (phentolamine mesylate)  Indicated for the reversal of soft-tissue anesthesia and the functional deficits resulting from an intraoral submucosal injection of a local anesthetic containing a vasoconstrictor  It is not recommended for use in children less than 3 years of age or weighing less than 15 Kg OraVerse (phentolamine mesylate)  It should be administered following the dental procedure using the same location(s) and technique(s) (infiltration or block injection) employed for the administration of the local anesthetic Malamed Ropivacaine: The Next Dental Local Anesthetic? ALL-ATABAKHSH A, ROSENBERG M. JOURNAL OF THE MASSACHUSETTS DENTAL SOCIETY VOL. 61/NO. 1 SPRING 2012 Ropivacaine  Has pharmocokinetic and pharmacodyanmic profiles that may make it a possible alternative to bupivaciane for administration in dental procedures  Causes less CNS and CV toxicity than bupivacaine, but is more toxic than lidocaine  Metabolized by the cytochrome oxidase liver enzymes subcategory 1A2 (can interfere with cimetidine, fluvoxamine, imipramine, and theophylline) Ropivacaine  Has vasoconstrictive properties  Has a 70 to 75% greater margin of safety than bupivacaine  Maximum dose of 0.5% ropivacaine for nerve blocks and infiltration is 200 mg, or about 3 mg/kg. (Bupivacine is 90mg, or about 1.5 mg/kg)  Not available in dental cartridges: need to withdraw from multi-dose vials Conclusion:  “Ropivacaine, in concentrations of 0.5% or higher, had been shown to be an effective alternative to bupivacaine with epinephrine for mandibular nerve blocks in patients. Its advantages are lower CV toxicity and no need for epinephrine to achieve prolonged duration. We see its potential role in dentistry as providing prolonged anesthesia and, thus, avoiding or lowering the need for postoperative analgesics. The limiting factor for the introduction of ropivacaine as a popular choice for routine dental local anesthesia administration will still remain the fact that it is not available in dental cartridges” EXPAREL® (bupivacaine liposome injectable suspension)  Encapusulated bupivacaine which is released over time  It is a local anesthetic that produces postsurgical anesthesia in patients aged 6 years or older  EXPAREL single dose administration presently available as a 10 or 20 ml single-use vial  Dosing related to the following: size of the surgical site, volume to cover: Max dose should not exceed one 20 ml vial  4mg/kg, up to a maximum of 266 mg Administration:  Inject into soft tissue site using a 25 gauge needle slowly, with frequent aspiration  Use a series of injections, as it does not diffuse through tissues EXPAREL® (bupivacaine liposome injectable suspension)  Dosing Example:  Patient undergoing extraction of 4 impacted 3rds: After extraction of the teeth and primary closure:  For the maxillary sites, 1-2 ml of EXPAREL is infiltrated into each surgical site, 2-4 ml total – buccal aspect of teeth #1 and #16  For the mandibular sites, 3-4 ml of EXPAREL is infiltrated into each surgical site, 6-8 ml total – lateral aspect of mandible: 4 separate injections on each side, aspirate, and inject as with drawing needle, creating a column effect Compatibility:  Wait 20 minutes after administrating other non-bupivaciane based LA before administering EXPAREL into the same site: Otherwise, there can be an immediate release of bupivacaine from EXPAREL  Formulations of bupivacaine other than EXPAREL should not be administered with 96 hours following the administration of EXPAREL Safety Information:  Non-bupivacaine-based LA may cause an immediate release of bupivaciane from EXPAREL if administered together locally. Delay for 20 mins or more.  Bupivacaine should not be administered within 96 hrs following administration of EXPAREL  Use with caution in patient with hepatic disease  Most common adverse rxns were nausea, constipation, and vomiting Kovanaze: Intranasal Local Anesthesic Malamed Kovanase  IN (intranasal) instillation of LA has been employed in medicine primarily in the realm of ear, nose and throat (ENT) procedures  Tetracaine (ester LA): Patients undergoing these procedures noted that their upper teeth felt “numb”  Kovanase: Tetracaine (LA) and Oxymetazoline (vasoconstrictor)  Obtain pulpal anesthesia from 1st premolar to 1st premolar, may obtain up to the 2nd premolar Malamed Request to Physician for Medical Consult MEDICALLY OPTIMIZED NOT MEDICALLY CLEARED The Dentist Who Performs the Procedure is Ultimately Responsible for His or Her Treatment Decisions Case A patient presents to your office for routine dental care, which will involve restorative, scaling and two extractions. On reviewing her medical history, it is noted that the patient has a PMH (past medical history) significant for A-Fib and is presently taking coumadin. Does this patient need a medical consult? A-Fib: Atrial Fibrillation – a quivering or irregular heartbeat or arrhythmia. Can lead to blood clots, stroke, heart failure Coumadin: An anticoagulant, which reduces the formation of blood clots What questions to ask:  Latest PT/INR  PT: prothrombin time – used to evaluate the extrinsic pathway and common pathway of coagulation  INR: International normalization ratio  If < 3.0 while on Coumadin, usually safe to extract 1 to 2 teeth  Any recent change in Coumadin dosage?  Is the patient medically optimized to undergo procedure?  Please provide perioperative recommendations Case A patient presents to your office for routine dental care. His PMH is significant for DM(Diabetes Mellitus) and HTN(Hypertension). The patient is not sure what medications he is taking, however, his physician has just changed his DM medications. BP today is 135/85. Does this patient need a medical consult? Questions to ask:  Patients latest HbA1c  Patients present Insulin/medication regime  Is the patient medically optimized to undergo procedure?  Please provide perioperative recommendations Case A patient presents to your office as an emergency patient for a painful tooth #12, which will require an extraction. He has four other teeth that will need to be removed. No swelling or trismus(limited ability to open) is noted. He does state that he has a “liver problem” but does not know what it is. On questioning the patient, he states that he bruises easily, and that cuts take “a long time” to stop bleeding. Does this patient need a consult? Concerns with this patient:  Bleeding problems that may occur with invasive procedures  Can request certain lab work  Metabolism of certain medications that are metabolized through the liver  Is the patient medically optimized to undergo procedure  Can the physician provide perioperative recommendations Case A patient with a PMH of HTN(Hypertension) presents to your office for routine dental care. His BP(Blood pressure) today is 124/74, with a Pulse of 84 beats per minute. He takes HCTZ(hydrochlorothiazide: diuretic) only for his HTN, and his medication has not be changed for over 2 years. He sees his physician regularly every 6 months. Does this patient require a medical consultation? Prescription Writing Prescription Writing  Doctor’s Name  Address  Phone Number  Patients Name/Date  Patient’s Address/Age Prescription Writing  Doctor’s Signature State License Number DEA Number Rx  Drug Name/Dosage Size  Disp: Number of tablets, capsules, to be dispensed {write out as precaution for abused drugs: Example – Dis #15 (fifteen) tabs}  Sig: Direction on how the drug is to be taken Common Abbreviations i, ii, iii: one, two, three q every (like every 6 hours) d day h hour prn as needed bid twice a day tid three times a day qid hs four times a day before bed time Example:  A patient requires antibiotic prophylaxis for a dental procedure due to a specific cardiac condition. The patient has NKDA(No Known Drug Allergies). The regime for antibiotic prophylaxis requires the patient to receive two grams of Amoxicillin one hour prior to the appointment. How would you write the Rx? Amoxicillin  Dosage forms:  Capsule   Oral Suspension   125mg/5cc, 200mg/5cc, 250mg/5cc, 400mg/5cc Tablet   250mg, 500mg 500mg, 875mg Tablet (chewable)  125mg, 200mg, 250mg, 400mg Example  Rx Amoxicillin 500 mg Disp: 4 (Four) tablets Sig: Take four tabs. 1 hr before the procedure Post-operative Pain Control - Most uncomplicated dental procedures produce only mild pain and can be treated with non-steroidal anti-inflammatory drugs (NSAIDs): ASA(aspirin) or ibuprofen(Motrin or Advil) - If cannot tolerate NSAIDs, acetaminophen (Tylenol) can be used Post-operative Pain Control  Surgical procedures are associated with more postoperative pain  It may require use of an opioid  When writing an Rx, need to know for how long you think you will need to provide pain relief in regards to the procedure performed Drug Therapy in the Dental Practice  Nonopioid Analgesics  Opioid Analgesics  Hydrocodone  NSAIDs  Oxycodone  Acetaminophen  Meperidine  Propxyphene  Tramadol The most important and useful nonopioid analgesics in dentistry are APAP and NSAIDs APAP: ACETAMINOPHEN NSAIDS: NON-STEROIDAL ANTIFLAMATORY DRUGS Motrin IBUPROFEN Motrin  Produces anti-inflammatory, analgesic, and antipyretic effects by inhibiting prostaglandin synthesis  Maximum daily dose: not to exceed 3.2 grams in a 24 hour period Motrin: Adverse Reactions  CNS(Central Nervous System): HA, dizziness  CV(Cardiovascular): Fluid retention, edema  GI(Gastrointestinal): Peptic ulceration, heartburn  GU(Genitourinary): Acute renal failure  Hematologic: Prolonged bleeding time  Hepatic: Elevated liver enzymes  Respiratory: Bronchospasm Some Motrin Drug Interactions  Antihypertensives: May decrease the effectiveness  ASA(aspirin), Corticosteriods: Increased risk of adverse Gastrointestinal (GI) reactions  May increase the plasma levels or effects of several medications and can decreased the clearance of others and thus increased toxicity  Motrin 600 mg  Dis: #15 (fifteen)  Sig: One tab q 6 hrs prn pain  Refills: none Acetaminophen  Action: Thought to produce analgesia by blocking generation of pain impulses, probably by inhibiting prostoglandin synthesis in the CNS or the synthesis or action of other substances that sensitize pain receptors to mechanical or chemical stimulation.  Thought to relieve fever by central action in the hypothalamic heat regulating center Dosage(Adult)  Mild pain or fever: 325 to 650 mg P.O. every 4 to 6 hours; or 1 g P.O. three times a day as needed. Acetaminophen (Tylenol,Panadol)  Effective nonopioid analgesic with antipyretic activity but little antiinflammatory activity  APAP may function by inactivating the COX enzymes responsible for the final catalytic reaction Acetaminophen  USFDA has recently alerted practitioners and consumers about potential liver toxicity associated with excessive dosing with APAP  Hepatic toxicity induced by APAP has been reported when a daily dose of 4000 mg is exceeded Acetaminophen  The FDA had requested that the dose of APAP contained in prescription opioid APAP analgesics be limited to a maximum of 325 mg Acetaminophen  Continuing concerns of potential hepatic toxicity has resulted in Tyenol’s manufacturer to voluntarily reducing its maximum APAP daily dose recommendation from 4000 mg to 3000 mg Opioid Analgesics  Produce analgesia but can also cause: sedation, euphoria, cough suppression, constipation, miosis, and respiratory depression  Have an important and longstanding role in medical and dental practice Opioid Analgesics  In managing acute pain, dental practitioners generally select a full agonist with minimal first-pass metabolism  To improve the analgesic response, the selected orally administrated analgesic will include a nonopoid as a component of the formulation to provide added analgesia Opioid Analgesics  Comparative oral dosing equivalents:  5mg of oxycodone = 10 mg hydrocodone = 65 mg codeine = 75 mg tramadol What are some of the Opioid Medications We May Use in Our Practices?  Tylenol #3: Tylenol with Codeine  Percocet: Tylenol (acetaminophen) with Oxycodone  Norco: Tylenol (acetaminophen) with Hydrocodone Take Home Case:  A healthy 24 y.o. male presents to your office with complaint of pain and swelling associated with tooth #2. On examination, there is inflammation in the buccal vestibule adjacent to tooth #2. The patient wants tooth #2 extracted. The patient’s vital signs are stable, and he is not taking any medications and has no allergies.  Please answer the following questions: Take Home Case: What injection technique/s would you perform to obtain adequate anesthesia and why?  What local anesthetic agent would you use and why? Assume it will be a simple extraction  What pain medication would you prescribe for this patient after completion of the procedure? Please write out the Rx.  What antibiotic would you prescribe? Please write out the Rx.  Johnny Molar Date:10/16/14 1 Wisdom Tooth Way Boston, MA Age: 24 RX: DIS: SIG: Dr_________________________ Address:____________________ Phone:_____________________ DEA:_______________________  Motrin 600 mg  Dis: #15 (fifteen)  Sig: One tab q 6 hrs prn pain  Refills: none  Rx: Amoxicillin 500 mg  Dis: 21 (twenty-one) capsules  Sig: one capsule P.O. tid until completed  Refills: none Amoxicillin  Action: An aminopenicillin that inhibits cell-wall synthesis during bacterial multiplication.  Bacteria resist amoxicillin by producing penicillinases (enzymes that hydrolyze amoxicillin) Amoxicillin  Dosage (Adult): :250 – 500mg P.O. every 8 hours