Prescribing Meds & Preprosthetic Surgery

1. Prescribing Meds & Preprosthetic Surgery Alex Isom

2. Drug Enforcement Administration • Triplicate prescriptions were necessitated by the DEA • The DEA provides you with a controlled substance number (DEA#) • Some pharmacists want your DEA number for prescribing antibiotics, but that is not necessary

3. Drug Enforcement Administration • DEA# is good for about 5-6 years and costs about $600 • Only schedule 3, 4, and 5 can be called in over the phone • Anyone in your office can call it in. Hygienist, assistant, the office maid etc. • Schedule II must be written on prescription pads

4. Drug Enforcement Administration • On the DEA website it states: • Question – How often are DEA registrations renewed? • Answer – Practitioner registrations must be renewed every three years.

5. Drug Enforcement Administration • On the DEA website it states: • Dispensing or Instructing • Includes Practitioner, Hospital/Clinic, Retail Pharmacy, Teaching Institution • Schedules II thru V • $551 • 3 Years  

6. Prescribing Meds • We no longer use triplicate prescriptions. • As far as Dr. G is concerned, this change does not solve anything. The “tamper resistant security prescription book” can be forged • The security books are only used for controlled substances.

7. Antibiotics-Two Situations • A diabetic or patient with an auto-immune disease walks into your office • You know they don’t heal well, but they don’t have an infection right now • Prophylaxis against an infection • Rx: Amoxicillin – 500mg • (do NOT prescribe a prescription for 250mg because blood levels won’t be high enough) • Disp: 21 tabs • Sig: 1 tab tid until gone • The patient that you traumatized via a procedure • 1 tab tid until gone

8. Antibiotics-Two Situations • A patient comes in with cellulitis or an infection • You can extirpate the pulp of the tooth, but they still have a cellulitis. They also have an elevated temperature, so they are sick. • So now you’re going to give them: • Rx: Amoxicillin 500mg • Disp: 23 tabs • Sig: 2 stat (Latin “statim” for immediately) then 1 tab q8h until gone • So they have to set their alarm clock and even take it in the middle of the night. • This is to always keep them at the therapeutic levels

9. Antibiotics • q8h is different that tid (same amount but differs in administration) • tid means take it three times a day, breakfast, lunch and dinner • q8h means take it every 8 hours (which ends up being 3 times a day as well)

10. Antibiotics • We don’t use erythromycin any more. • We use amoxicillin • Clindamycin is the alternative (either 150 or 300 mg doses) We use 300mg. Typically for patients who are sick.

11. Antibiotics • The sig depends on how sick they are… if they are really sick, dose: • Rx: Clindamycin 300mg • Disp: 21 tabs • Sig: 1 tab qid until gone • QID is for a sick person (active infection and you don’t know the source) • TID until gone (if they are doing a bit better, you know and have treated the source)

12. Pseudomembranous colitis • Have the patient stop taking the clindamycin if they have severe abdominal pain or diarrhea (only when given orally – not IV) • Usually stopping the drug will stop this, but Flagyl or Metronidazole might have to do this. • Also, as a preventive measure, have the patient eat active cultures of yogurt.

14. The Module • Know how to use the drug references in the PDR • Know how to write prescriptions and the different components • Know the different schedules of drugs • Know the children’s dosages based on Clark’s and Young’s rule • Know how the antibiotics work

15. The Module • The prophylactic regimens are old, pass them up • Know the penicillins, clindamycin and the aminoglycosides • On the analgesic sheet, know what we use in the clinic, Vicodin, Codeine, Versed, Valium etc. • Know about the drug, interactions, dosages etc. • He will take questions from the back of each section

16. The Module • Know aspirin, Darvon, Diflunisal • Know the different amounts of codeine in Tylenol 1,2,3,4 • Know Vicodin • For chemically dependant patients you give them Motrin • Forget the appendix (probably the one in the book)

17. Surgeons from UCSD Center for Future of Surgery remove appendix through vagina, a U.S. first. March 26, 2008 They look pretty excited

18. Precautions • Don’t keep narcotics in the office • There is potential for a robbery • You are not allowed to act as a pharmacist, the word will spread and people will flock like the salmon of Capistrano • You are allowed to keep antibiotics for people who need to be prophylaxed

19. Vestibuloplasty (From Module) • This is a technique which increases the relative height of the alveolar process by apically repositioning the alveolar mucosa and the buccinator, mentalis, and mylohyoid muscles as they insert into the mandible • Following vestibuloplasty, the periosteum is uncovered

20. Vestibuloplasty (From Module) • Occasionally this wound is allowed to granulate but this usually results in relapse, especially on the labial surface • To prevent this, a skin or mucosal graft is usually placed over the periosteum • The skin is removed from the outer surface of the thigh, while the mucosa can be taken from either the cheek or the palate

21. Vestibuloplasty (From Module) • There are advantages and disadvantages to both, but most oral and maxillofacial surgeons and prosthodontists currently favor the use of mucosal grafts

22. Vestibuloplasty (From Module) • Vestibuloplasty can be limited to the buccal and labial surfaces, but it usually includes the lingual surface of the mandible as well • When performing a mandibular vestibuloplasty the surgeon must be careful not to injure the mental nerve, which exits through the mental foramina

23. Vestibuloplasty (From Module) • In advanced resorption the foramina may be seen to exit from the ridge crest • The mental foramen originates in the body of the mandible which clinically may become the ridge crest when alveolar bone has resorbed

25. Vestibuloplasty (What he said) • Vestibuloplasty can only be done when there is good bone. • We can lower the floor of the mouth, however, when you do that there will be this big ridge that only has periosteum on it • A split thickness skin graft takes care of this (skin is harvested from the thigh and transplanted into the mouth. • One of the problems with harvesting the skin is you get into the follicle layer.

26. Vestibuloplasty (What he said) • A dermatome is used to harvest the skin off of the thigh. • It is like those machines that you can buy from television for slicing cheese in thin layers (“set it and forget it!”) • Harvest the skin, but don’t go too deep – or you might get hair growth in the mouth! • Place a membrane over the donor site • We have a splint that already fits the mandible, we place a splint which acts as a barrier to prevent relapse

28. Dermatome

29. Dermatome