Rational Use of Medicine II

Prof. Beena Rani Goel

As dentists, we have a professional responsibility for emergency dental care. When patients come with trauma, acute spread of infection, or hemorrhage, it is our duty to render treatment so that he gets relief in a reasonable time. In many acute dental conditions, extirpation of the pulp or extraction of the tooth will be necessary. Prescribing antibiotics is an adjunct in many such situations. When it is clinically indicated, it is definitely of therapeutic benefit to the patient. But systemic antibiotics should be used with caution because of the possibility of toxicity, side effects, the development of resistant strains of microbes, and allergic reactions.

According to the American Dental Association, the following guidelines should be observed when prescribing antibacterial drugs:

1. make an accurate diagnosis;
2. use appropriate antibiotics and dosing schedules;
3. consider using narrow-spectrum antibacterial drugs (Clindamycin, Metronidazole, penicillin V Potassium) in simple infections to minimize disturbance of the normal micro flora, and preserve the use of broad-spectrum drugs (ampicillin, amoxicillin, erythromycin, tetracycline, etc.,) for more complex infections
4. avoid unnecessary use of antibacterial drugs in treating viral infections;
5. if treating empirically, revise treatment regimen based on patient progress or test results;
6. obtain thorough knowledge of the side effects and drug interactions of an antibacterial drug before prescribing it;
7. educate the patient regarding proper use of the drug and stress the importance of completing the full course of therapy (that is, taking all doses for the prescribed treatment time).

American Academy of Pediatric Dentistry (AAPD) has given recommendations for clinical guideline on appropriate use of antibiotic therapy. Conservative use of antibiotics is indicated to minimize the risk of developing resistance to current antibiotic regimens. Whenever an antibiotic is prescribed to a female patient taking oral contraceptives to prevent pregnancy, the patient must be advised to use additional techniques of birth control during antibiotic therapy and for at least 1 week beyond the last dose as the antibiotic may render the oral contraceptive ineffective.

American Academy of Pediatric Dentistry recommends the following general principles when prescribing antibiotics for the pediatric population. When a child presents with a facial swelling secondary to a dental infection, he should receive immediate dental attention. Depending on clinical findings, treatment may consist of treating or extracting the tooth/teeth in question with antibiotic coverage. Severity of the infection, the ability to obtain adequate anesthesia, and the medical status of the child should be taken into consideration.

Bacteria can gain access to the pulpal tissue through caries, exposed pulp or dentinal tubules, cracks into the dentin, and defective restorations. While rendering treatments like pulpotomy, pulpectomy, or extraction, antibiotic therapy usually is not indicated if the dental infection is contained within the pulpal tissue or the immediately surrounding tissue. In such a case, there will be no systemic signs of an infection (i.e., no fever and no facial swelling).

Viral conditions such as acute primary herpetic gingivostomatitis should not be treated with antibiotic therapy unless there is strong evidence to indicate that a secondary bacterial infection exists.

Analgesics are another group of drugs commonly prescribed by dentists. Our pain management goals should be: Pain Management Goals

1. To maintain maximal patient comfort
2. To minimize unwanted drug side effects, and
3. To rapidly return injured tissue to function

Pre-procedural analgesia can be employed for delaying the onset of postoperative pain and to reduce its magnitude. But it has disadvantages like GI upset in patient with empty stomach and GI upset in anxious patient. Ibuprofen 400mg � hour before appointment can be prescribed for this purpose.

Among the analgesics used in dentistry, nonopioid analgesics are the most commonly prescribed. Low doses of aspirin are known to cause some adverse effects such as gastrointestinal disturbances and risk of bleeding. The most commonly reported side effect is nausea. Aspirin significantly increases the bleeding time by inhibiting the aggregation of platelets. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) may cause acute episodes of urticaria or angioedema. As a result of wide use and ready availability, salicylate is frequently the cause of intoxication. Poisoning or serious intoxication often occurs in children and is sometimes fatal.

Overdoses of paracetamol are an increasingly common cause of acute liver failure. The inclusion of paracetamol in numerous medications in addition to its frequent use must be a matter of concern not only for acute but also for chronic paracetamol toxicity. Paracetamol, salicylamide, and fenylbutazone are the analgesic and anti-inflammatory drugs most commonly used during pregnancy, although there are studies reporting teratogenic effects of these drugs on renal development of human fetus.

Personal drug (P-drug)

Most dentists use a limited number of drugs routinely. Keeping a list of these personal drugs enables you to avoid repeated searches for a good drug in daily practice. To make a medicine your P-drug, you need to know its

• Pharmacological substance
• Dosage form
• Dosage schedule
• Duration of the treatment

Search for institutional and international standard treatment guidelines based on good scientific evidence and consensus between experts. Through compiling your own set of P-drugs you will know the alternatives when your P-drug choice cannot be used. Always remember that the latest and most expensive drug is not necessarily the best, the safest or the most cost-effective.

If you don�t periodically evaluate drug related information, you will not be able to update your p-drug list and will end up prescribing medicines that are dictated to you by your colleagues or sales representatives.

Rational drug use
(From WHO Guide to Good Prescribing)

Step 1: Define the patient�s problem
Step 2: Specify the therapeutic objective
Step 3: Verify whether your p-treatment is suitable for this patient
Step 4: Start the treatment
Step 5: Give information, instructions and warnings
Step 6: Monitor (stop) the treatment

Finally, your drug selecting criteria should be efficacy, safety, suitability, and cost of the medicine.

References:

1. Y. M. Dailey1 and M. V. Martin :Are antibiotics being used appropriately for emergency dental treatment? British Dental Journal OCTOBER 13 2001, VOLUME 191, NO. 7, PAGES 391-393
2. American Academy of Pediatric Dentistry (AAPD). Clinical guideline on appropriate use of antibiotic therapy for pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2005. 3 p.
3. ADA Association report ; J Am Dent Assoc, Vol 135, No 4, 484-487. � 2004 The American Dental Association
4. Marcos Luciano Pimenta Pinheiro, Filipe Polese Branco, Maria Cristina Volpato, Eduardo Dias de Andrade: Analgesic choice in dentistryPart II : The toxicity: Braz J Oral Sci. October-December 2005 - Vol. 4 - Number 15
5. Lane JE, Belson MG, Brown DK, Scheetz A. Chronic acetaminophen toxicity: a care report review of the literature. J Emerg Med. 2002; 23: 253-6
6. Guidelines for dental treatment: dentistry and pregnancy. Aust Dent J. 1984; 29: 255-6.

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