R. John Brewer NREMT-P Dental Education Inc.

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1 R. John Brewer NREMT-P Dental Education Inc.

2 The administration of drugs is common in the practice of dentistry and oral surgery. The majority of the drugs used in dentistry can be divided into four categories. 1. Local anesthetics 2. Analgesics 3. Antibiotics 4. CNS Depressants

3 Important part of the dental treatment plan when potentially painful procedures are considered.

4 Prescribed for relief of preexisting pain or alleviation of potential post-operative pain.

5 Used in the management of infections

6 Prescribed for all phases of the dental treatment for the prevention and management of dentistry related fears.

7 Whenever a drug is administered, a rational purpose should exist for its use. Indiscriminate administration of drugs is one of the major reasons the number of incidents of serious or life threatening emergencies in the medical and dental office have increased.

8 It is estimated well over 100,000 patients have died in hospitals due to adverse drug reactions. It is estimated that over 2 million patients have suffered serious but non fatal adverse drug reactions.

9 Toxicology is the study of the harmful effects of chemicals on biological systems. These effects range from minor to serious, or even cause death. Whenever a drug is administered, two types of reactions may be noted. - Desirable drug reaction - undesirable drug reaction

10 General principles of toxicology - No drug ever exerts a single action. - No useful drug is entirely devoid of toxicity. - The potential toxicity of the drug rests in the hand of the user.

11 Our goal is to give the correct drug in the correct dose, via the correct route to the correct patient at the correct time for the correct reason. It is very important you know about the drugs that you have in the office or prescribe to the patient.

12 Most Adverse drug reactions do not pose a threat to the patients life. There are three responses to drugs that are life threatening: - Overdose reaction - Allergic reaction - Idiosyncrasy reaction

13 A condition that results from exposure to toxic amounts of a substance that does not cause adverse effects when given in smaller amounts.

14 Defined as a hypersensitive response to an allergen to which the individual has been previously exposed, and now has developed antibodies. Allergic reaction is possible with any drug or substance.

15 The drugs and substances most likely to cause allergic reactions. - Aspirin - Penicillin - Bisulfites - Latex

16 An individuals unique hypersensitivity to a particular drug, food, or other substance. Management is to position the patient, ABC S are vital.

17 The major cause of drug related emergency situations in the dental office is the administration of local anesthetics. Although true Adverse reactions occur,most reactions are related to the injection(seeing the needle)

18 Syncope and hyperventilation are the most common drug related emergencies. These episodes usually result from emotional stress receiving the local, not from the drug itself.

19 Locals is the most widely used drugs, are the safest, and most effective drugs for the prevention, and management of pain. It is important to stress again that most adverse drug reactions to locals are a result of the administration, not the drug.

20 The next most common adverse drug reaction is the toxic reaction. This is produced by a relative overdose secondary to accidental intravascular injection. True documented allergic reactions to locals is extremely rare.

21 Prescribed to treat established active infections Should only be used when indicated due to resistant bacteria strains and allergies.

22 Pain relieving drugs make up a significant portion of scripts written by dentists.

23 Two categories of analgesics mild- non opioid strong opioid

24 Mild- asa, ibuprofen, Tylenol Strong- Opioid- codeine, demerol, diludid, vicodin oxycontin

25 Adverse drug reactions to the mild analgesics are GI upset, nausea, constipation, itching Adverse drug reactions to the opioids are nausea, vomiting, and orthostatic hypotension, respiratory depression, respiratory arrest.

26 Aspirin, Tylenol and Codeine remain the most commonly prescribed drugs.

27 The use of these drugs for all phases of dental care has increased significantly over the years. The most common drugs prescribed is the benzodiazepines.

29 An overdose of a local is related to the blood level of the local in the myocardium and Central nervous system. There are several factors which influence the rate at which blood levels increase or for which blood levels remain elevated. These factors could be drug or patient related.

30 Normal distribution curve. This is where the majority of patients responds appropriate with normal dose, However some are less responsive, and some become more responsive to the local.

31 Age Due to absorption, metabolism, and excretion drug doses should be decreased for patients under 6 years and over 65 years. - Weight > Lean body weight more of the drug the patient can tolerate. ***A lack of consideration of body weight is one of the major causes of overdose reactions.

32 Pathological process Presence of Pre-existing disease may alter bodies ability to transform a drug into a biologically inactive substance. Patients with CHF demonstrate blood levels of locals 2x those found in healthy patients receiving the same dose.

33 Patients with chronic lung disease are at increased risk for local overdose. CO2 retention results in the decrease of the seizure threshold for local anesthesia. If a patient has a PCO2 of their seizure threshold is lowered by approx 53%.

34 Genetics It is been reported that there are certain individuals that possess genetic deficiencies that alter their response to certain drugs.

35 Attitude It has been shown that the seizure threshold for locals is lowered in patients who are overly stressed.

36 Vasoactivity Locals that are more lipid soluble and more highly protein bound are retained longer, therefore having a slower absorption rate. This increases the margin of safety. The greater the degree of vasodilatation, the more rapid the local is absorbed.

37 Dosage : The larger the dose the higher the peak blood level.

38 Route of Administration: Inadvertent intravascular is the factor that causes most overdoses.

39 Rate of Injection The rate of injection is vital in the cause or prevention, of overdose reactions to all drugs.

40 Local Anesthetic overdose reactions can result from the combination of inadvertent intravascular injection, combined with too rapid a rate of ingestion. Both 100% preventable

41 The more vascular the area, the faster the absorption rate will be.

42 The addition of a vasoconstrictor to a local results in a decrease rate of systemic absorption of the drug.

43 Low to moderate overdose - Confusion - Talkativeness - Apprehension - Excitedness - Slurred speech - Generalized stutter - Muscular twitching, tremor to face,and extremities

44 Nystagmus Elevated blood pressure Elevated heart rate Elevated respiratory rate

45 headache Feeling lightheaded dizziness Blurred vision Ringing in ears Numbness of tongue Flushed or chilled feeling Drowsiness Disorientation and loss of consciousness

46 Management is based on its severity. -again most cases are mild in nature requiring little or no treatment. Most local overdoses again are self limiting. Rarely should you go beyond just administering a little 02. Over treatment has the potential to become a problem.

47 It is imperative when administering a local, that the patient remain under continual observation, during and after administration of the local. Again mild local reactions, will begin in 5-10 minutes following injection.

48 Terminate procedure Position of comfort ABC s 02 administration Vital signs Iv access Administration of anti-convulsant. EMS

49 If signs symptoms appear immediately (seconds to 1 minute)intravascular injection is the most likely cause. Clinical findings are going to be much more severe and rapid. Patient may immediately become unconscious, and have seizures.

50 Position patient supine - remove syringe 911 ABC s 02 administration Protect patient Vital signs IV therapy/ anticonvulsant Manage the postictal patient

51 Anxiety after injection Tremors of limbs Diaphoresis Headache Tachycardia/ Bradycardia Elevated blood pressure

52 Terminate procedure Position semi sitting ABC s Reassurance of the patient Vital signs every 5 minutes 911 If hypertensive administer vasodilator(ntg) esmolol Transfer to hospital

53 Whenever CNS-depressant drugs are administered, the possibility exists that an exaggerated degree of CNS depression may develop. There have been several deaths both Adult and Pediatric due to this.

54 The clinical efficacy of a drug is dependent on its absorption into the cardiovascular system and its blood levels in different target organs.(brain) Only the inhalation and IV routes of drug administration permit titration of the drug to a precise clinical effect. Drug absorption via oral or IM is erratic.

55 The use of a CNS depressant to obtain deep sedation via a route of administration in which titration is not possible is an invitation to overdose and cannot be recommended.

56 Recent administration Decreased level of consciousness Unconscious Respiratory depression Loss of motor coordination Slurred speech

57 Terminate dental procedure Place Supine ABC s 911 Oxygen administration Vitals IV therapy Reversal agents

58 Over sedation and respiratory depression are the primary clinical findings. However they may have : - Altered level of consciousness - Constricted pupils

59 RECOGNIZE THE PROBLEM!!!!! Discontinue treatment Position ABC s Oxygen Vitals IV therapy Reversal agent

60 A majority of the overdoses involve the administration of more than one drug. Whenever more than one CNS depressant drug is administered, the doses of both drugs must be reduced to prevent exaggerated, undesirable effects. A reminder that locals are CNS depressants themselves.

61 When administering locals in conjunction with CNS depressants, the dose of the local anesthetic should be minimized. Ensuring a cooperative patient who maintains protective reflexes is the primary goal of sedation.

62 Be prepared for emergencies Individualize drug dosages Recognize and expect adverse drug effects Common Factors to those offices that had deaths: -Improper preoperative evaluation - lack of knowledge of drug pharmacology - lack of adequate monitoring.

63 The monitoring process should include -(CNS) direct verbal contact with patient -Respiratory system (Capn0graphy) Pulse OX Cardiovascular system continuous monitoring of vital signs. EKG

64 Case #1 Death of a 28 lb. pediatric patient. Patient was given 7.5cc of local.

65 Case #2 Robert Pauley 73 y/o gentleman undergoing IV sedation, at some point stops breathing, cardiac arrest. No vitals No Pulse ox No Reversal drugs given Wrong ACLS drugs given Suite filed/ Plaintiff s family $1,135,000

66 Dec Georgetta Watson 46 y/o female Root Canal No history was taken prior to doing procedure Patient monitored with pulse oximeter

67 Pulse ox decreasing Irregular breathing pattern noted. Eventually EMS contacted EMS arrives finds patient in cardiac arrest. Transported to hospital pronounced DEAD.

68 Reports indicate a combination of 2 sedation drugs were given in excessive amounts. No patient history is documented Patient was not placed on a monitor no documentation of vital signs being recorded No CPR being performed Staff did not have BLS training. NO record of staff training MD s license suspended 8/08

69 Aug. 13, million dollar awarded to family in wrongful death lawsuit. This patient went into cardiac arrest 40 minutes after given a combination of 2 sedation drugs.

70 The patient received the following: - 7mg versed iv push - 75mg Demerol iv push -.7mg atropine - 6mg decadron 1 carpule 2% lidocaine 1: 100,000 3 carpules 3% mepivacaine

71 Oct. 15, 2007 Henry Dillow age 25 has 4 wisdom teeth removed. Dead x3 days after surgery from necrotizing fasciitis.

72 John Coleman was a 47 y/o male patient Needed multiple extractions. Given 2mg halcion. Patient did not respond well to drug. Staff restrained patient do DMD could finish procedure.

73 Following procedure patient given flumazenil. Apparently at that point patient went into cardiac arrest. EMS transported patient to hospital, anoxic brain death, taken off ventilator the next day and pronounced dead.

74 Wife files suit against office stating the following: Office not prepared to handle emergency Patient was over sedated Delay in 911 call In addition DOCS also being sued since they did the training.

75 This patient had a history of obesity, diabetic, and colon cancer.

76 A patient in Wheeling, was administered 17 tablets of 0.25 mg halcion, for total dose of 4.25mg. A reminder an overdose can occur at 2 mg.

Physiology and Pharmacology

Pharmacokinetics Physiology and Pharmacology Pharmacokinetics of Local Anesthetics Uptake Oral Route Topical Route Injection Distribution Metabolism (Biotransformation) Excretion Uptake Vasoactivity Local