Pharmacology Chapter 8

Front 1

an addition therapy given to enhance or extend the effect of primary therapy

Back 1

Adjuvant

Front 2

Substances liberated by the body during phases of inflammation that can produce pain

Back 2

Algogenic substances

Front 3

Insensibility to pain without loss of consciousness; and relieving pain by inhibiting specific pain pathways

Back 3

Analgesia

Front 4

Agents that relieve pain by inhibiting specific pain pathways

Back 4

Analgesics

Front 5

capable of reducing fever

Back 5

Antipyretic

Front 6

Originating or produced within the organism or one of its parts

Back 6

Endogenous

Front 7

Equal in the ability for giving pain relief

Back 7

Equianalgesic

Front 8

A test to determine risk of bleeding

Back 8

INR ( International Normalized Ratio)

Front 9

Reduction of circulation to an area

Back 9

Ischemia

Front 10

An initial high dose to quickly achieve a therapeutic blood level

Back 10

Loading Dose

Front 11

Sensory detection and neuronal transmission of pain stimuli

Back 11

Nociception

Front 12

what is a term for Injurious or harmful

Back 12

Noxious

Front 13

Derived from opium; a strong dependence producing analgesic

Back 13

Opioid

Front 14

Characterstic or indicative (diagnostic) of a particular disease or condition

Back 14

Pathognomonic

Front 15

Pain caused by the activation of pain receptors in mucocutaneous and musculoskeletal tissues

Back 15

Somatic Pain

Front 16

Pain caused by the activation of pain receptors in internal organs (kidney, lung, liver, etc.)

Back 16

Visceral Pain

Front 17

Most common complaint causing a person to seek the services of an oral health care provider is?

Back 17

Pain

Front 18

Effective control of pain has several advantages in an health care office. What are those advantages?

Back 18

1. Facilitates delivery of care
2. lowers anxiety about Tx for patient
3. promotes the patient's return for preventive and maintenance care

Front 19

Sporadic dental visits, dental neglects, and episodic care only for acute pain are all reason why a person has a?

Back 19

chronic oral disease that is not associated with pain

Front 20

What is the primary obligation and ultimate responsibility of every clinician?

Back 20

1. restore function
2. relieve and prevent pain

Front 21

This is a an unpleasant sensory and emotional experience associated with actual or potential tissue damage

Back 21

Pain

Front 22

Nocicpetors (pain receptors) are found in most tissues and are especially dense in what two tissues?

Back 22

Oral mucosa & Dental Pulp

Front 23

Stimulation of the dental pulp via heat, cold, vibrations, pressures, sweetness or sourness are all perceives as what?

Back 23

Pain

Front 24

Most pain of dental origin is associated with a recent onset of pain called?

Back 24

Acute Pain

Front 25

Chemical agents that occur naturally in the environment of pain receptors following acute tissue damage and are liberated by the body during phases of inflammation that produce pain are called?

Back 25

Algogenic Substances:

Front 26

What are examples of Algogenic Substances?

Back 26

Adenosine /Adenosine Triphosphate
Serotonin
Histamine/Bradykinin/ Cytokines
Prostaglandins
Neuroactive substances

Front 27

Algogenic Substances are chemicals that initiate the release of three things from nerve terminals what are they?

Back 27

Substance P
Calcitonin-gene related Peptide(CGRP)
Glutamate

Front 28

These are neuromodulators involved in evoking neurogenic inflammation, what are they?

Back 28

Substance P &
Calcitonin-gene related Peptide(CGRP)

Front 29

This is the primary pain neurotransmitter that activates nociceptors which generate impulses that are transmitted along peripheral nerve fibers to the CNS

Back 29

Glutamate

Front 30

Detection of pain stimuli in the orofacial region is conveyed by which cranial nerve?

Back 30

Trigeminal (V)

Front 31

Traumatic injury to the tissue causes cascade of events, what are they?

Back 31

1. macrophages to invade damage area to remove cellular debris and infection
2. Inflammation, which triggers PGs to enhance (-)effects of other algogenic substances
3. Vasoconstriction--causing ischemia
4. CNS modulates signal transmission and inhibits nociceptive impulses
5. Within Brain, endogenous substances are released to cause analgesia

Front 32

What are the endogenous peptides that are released to cause the analgesic affect during tissue injury?

Back 32

Endorphins/ Endomorphins
Enkephalins
Dynorphins
Orphanin FQ or nociceptins

Front 33

When applied to the pain, the terms attention and cognitions refer to the awareness of a noxious sensation, appreciation of negative emotions, and interpretations of the experience is defined as?

Back 33

Perception

Front 34

What are some ways of "attentional" control when treating a patient?

Back 34

1.Hypnotic procedures--redirection of attention of pain
2. Music--distract patient
3.Patients to hold a leg up to control gag reflex

Front 35

Choice of therapeutic intervention for acute odontogenic pain is determined largely by?

Back 35

1. nature of the patient's problems
2.the resources available (elimination of infection, angalgesics)
3. individuals acceptance or attitude toward pain
4. the cost to the patient

Front 36

what are signs of acute odontogenic pain?

Back 36

anguish, postural displays, groaning, wincing, grimacing, limitations of normal activity (functions), excessive rest, social withdrawal, medication demand or intake

Front 37

What are three types of analgesics that are used for the management of acute odontogenic pain?

Back 37

1. Nonopioids ( COX-inhibitors)
2. Opioids
3. Adjuvant drugs

Front 38

what are characteristics of nonopioids angalgesics?

Back 38

1. Not derived from opioids
2. reduce fever
3. inhibit Prostaglandin synthesis (peripherally and centurally)--Act as INHIBITORS
4. Inhibit COX
5. and anti-coagulant except for APAP

Front 39

What are characteristics of Opioid analgesics?

Back 39

1. derive from opioids
2. DONOT reduce fever
3. Act as AGONIST at opioid receptors (peripherally and centurally)

Front 40

What is an examples of Adjuvant agent as an analgesic?

Back 40

Caffeine
Antihistamine hydroxyzine
Corticosteroids

Front 41

What doses of Caffeine enhances the analgesic effect of ASA, APAP, IBU and sometimes Anacin

Back 41

in doses of 65mg to 200mg

Front 42

In what doses of antihistamine hydroxyzine enhances the analgesic effects of opioids

Back 42

in doses of 25mg to 50mg

**remember antihistamine hydroxyzine are ADJUVANT therapy, which may also reduce nausea and vomitting induced by opioids

Front 43

Corticosteroids, through their anti-inflammatory and phospholipase-inhibitory effects, can produce analgesia when pain is of what origin?

Back 43

Inflammatory

Front 44

Lipooxygenase are found only what types of cells?

Back 44

inflammatory cells--- such as
Neutrophils,
Mast Cells,
Macrophages

Front 45

Cyclooxygenous breaks down Arachidonic Acid into prostanoids such as?

Back 45

Prostacyclin I2
Thomboxane A2
Prostanglandin D2
Prostanglandin E2
Prostanglandin F2

Front 46

Prostanglandins are substances that are know to do what?

Back 46

1. lower the pain threshold
2. promote Inflammation & Fever
3. affect vascular tone and permeability

Front 47

what are examples of COX-1 inhibitors that increase the pain threshold and decrease the prostanglandin systhesis and interfere with platelet aggregation?

Back 47

ASA (aspirin) and IBU (ibuprofen) and Naproxen

Front 48

What blocks the synthesis of prostacycline and leads to platelet aggregration and vasoconstrition

Back 48

COX-2 inhibitors

**Celebrex or Vioxx

Front 49

This is a weak inhibitor of peripheral prostoglandin sysnthesis, but it does increases the pain threshold and it has no clinical relevance to anti-inflammatory properties, but very effective in the CNS as it is an antipyretic

Back 49

COX-3( example APAP)

**also known as COX-1b or COX-1v

Front 50

What are characteristics of APAP

Back 50

1. weak inhibitor of PGs
2. increases pain threshold
3. no anti-inflammatory properties
3. has anitpyretic effects--related to ability to inhibit PG systhesis in CNS
4. No relevant effect on platelet fxn

Front 51

What is the MOST powerful analgesic drug taken orally?

Back 51

Dilaudid

Front 52

Although Opioids have analgesics effects both peripherally and centrally, the primary site of action are in the?

Back 52

CNS

Front 53

Opioid-agonist drug produce analgesia by interacting with their receptors located where?

Back 53

Brain
1.Brain stem
2.Spinal cord
3.Trigeminal nucleus
4.Peripheral terminals of primary AFFERENT neurons

Front 54

what are examples exogenous opioid agonist?

Back 54

Codeine
Hydrocodone
Oxycodone

Front 55

Most severe dental pain can be relieved with various combinations of:

Back 55

opioid and COX-inihibitors

**example Hydrocodone with Ibuprofen ( Vicodin), (Lortab)
or Oxycodone with Ibuprofen (Percocet), (Percodan)

Front 56

Endorphins/Endomorphins, work on what opioid receptors and have what effect

Back 56

Mu

Analgesia, Euphoria, Decreased Respiration

Front 57

Enkephalins work on what opioid receptors and have what effect?

Back 57

Delta

Analgesia and Decrease Respiration

Front 58

Dynorphins work on what opioid receptors and have what effect?

Back 58

Kappa

analgesia, Dysphoria, No Resp. effect

Front 59

Orphanin FQ and nociceptin work on what opioid receptors and have what effect

Back 59

Opioid-receptor Like

Analgesia and No Resp. effect

Front 60

COX-inhibitors are rapidly absorbed form the?

Back 60

stomach and small intestine

Front 61

COX-inhibitors reach their appreciable plasma concentration in?

Back 61

30 to 60 minutes

**and peaks at about 2 to 3 hours

Front 62

What determines the rate of absorption of oral drugs?

Back 62

1. formulation (liquid or solid)
2. pKa of drug ( ionized or nonionized)
3. pH at mucosal surface of intestine
4. vascularity of absorptive surface
5. gastric emptying

Front 63

when should an analgesic be taken in relation to eating a meal?

Back 63

30 minutes prior to eating or several hours after eating

Front 64

Metabolism of COX-inhibitors at therapeutic doses normally follow what order of kinetics?

Back 64

First-order

Front 65

Metabolism of COX-inhibitors at larger doses than therapeutic doses normally follow what order of kinetics?

Back 65

Zero-kinetic

Front 66

Metabolites of COX-inhibitors are primarily excreted by kidneys as

Back 66

water-soluble conjugates

**remember they are absorbed as lipid-soluble molecules via passive diffusion

Front 67

Opioid free molecules (ones that are not protein bound) leave the blood and accumulate in which vascular organs?

Back 67

Kidneys
Lung
Liver
Spleen

Front 68

To get optimal dose of analgesic what must be done?

Back 68

1. titration or individualized dose depending on patient
2. used "By-the-Clock"--more effective and reduce the total dosage required for maintenance of pain
3. if prescribing 2 analgesics---must have different MOA

Front 69

What drugs are the Primary line of Treatment?

Back 69

ASA (aspirin) 650mg po q4h ( two tabs of 325mg)
APAP (tylenol) 650mg po q4h

Front 70

What is the prototype drug for the evaluation of orally effective analgesia?

Back 70

ASA

Front 71

650mg of ASA or APAP is equianalgesic to how many mg of IBU and Naproxen Sodium

Back 71

200mg of IBU &
220mg of Naproxen Sodium

Front 72

OTC formulations of what Drugs can be used to treat mild odontogenic pain?

Back 72

ASA, APAP, IBU and Naproxen Sodium

Front 73

What is the traditional adult dose of ASA?

Back 73

650mg tablet po q4h

(2 tablets of 325mg by mouth every 4 hours)

Front 74

Does a single dose of ASA larger than 1,300mg (four 325mg tablets) increase pain relief?

Back 74

NO


**this may prove toxic to some patients

Front 75

The clinical effects of ASA is determined not by the frequent dose around the clock but by the?

Back 75

Total Dose

**should not exceed 4000mg/24hours for adults and 1,200mg/24hours for children

Front 76

For ASA what is the appropriate dose for a child?

Back 76

10-20mg/kg of body weight given in 4 to 6 doses

**not to exceed 1,200mgs/24hours

Front 77

ASA is used as many things, what is it used for?

Back 77

Analgesia
Anti-inflammatory
Anti-pyretic
Anticoagulant

Front 78

For Children the appropriate dose of ASA is?

Back 78

10-20mg/kg of body weight given in 4 to 6 doses.

**The total dose should not exceed 1,200mg/24 hour

Front 79

What is the main analgesic mechanism for APAP?

Back 79

The INHIBITION of prostaglandins in the CNS.

**this is why it has antipyrogenic abilities and little anti-inflammatory effects

Front 80

The frequency of of adverse reactions with therapeutic doses is somewhat_____ than that associated with ASA

Back 80

LESS

Front 81

What is the traditional dose for APAP?

Back 81

650mg po q4hrs.


**the Ceiling does of 1,000mg is usually more effective than 650mg.
**remember this not the cause for ASA

Front 82

What it the single dose of APAP for children?

Back 82

60-120mg depending on the patient's age and weight

**the total dose should not exceed 1,200mg/24hours

Front 83

The daily dose of APAP should not exceed what for an adult?

Back 83

4000mg

Front 84

What drug is recommended by the American Arthritis College of Rheumatology for long-term control of pain associated with OSTEOARTHRITIS?

Back 84

APAP

**it is good for bone-to-bone damage rather than joint inflammation

Front 85

What drug is not recommend for the treatment of inflammatory conditions such as Rheumatoid arthritis

Back 85

APAP

Front 86

What drug can be used safely in patient with liver disease and is the preferred analgesic because of the absence of platelet impairment, GI toxicity, and nephrotoxicity associated with other COX-inhibitors

Back 86

APAP

Front 87

The risk of hemorrhage is measured with a blood test refer to as?

Back 87

International Normalized Ration (INR)

**safe levels of INR are 2 to 3 minutes for surgical procedures
and 3.5 minutes for periodontal procedures

Front 88

What is the safe level of INR for periodontal debridement?

Back 88

3.5

Front 89

What two COX-inhibitors can be used for either the first line of analgesic or second line of analgesic, depending on dosage.

Back 89

Ibuprofen and Naproxen Sodium

Front 90

What is the OTC and Rx formulation of Ibuprofen

Back 90

200mg (OTC)

400mg, 600mg, 800mg (Rx)

Front 91

What is the OTC and Rx formulation for Naproxen sodium?

Back 91

220 (OTC)

RX: 275mg (Anaprox)
550mg (Anaprox DS)
375mg or 500mg (EC Naprosyn)
250, 375,500mg (Naprosyn)

Front 92

Prescription formulations for IBU and Naproxen Sodium with increased doses are indicated for?

Back 92

Increases anti-inflammatory effects

Front 93

The analgesic efficacy of IBU and Naproxen increases as the dose increase? TRUE or FALSE

Back 93

TRUE

Front 94

What is the maximum daily dose for IBU and Naproxen Sodium

Back 94

2,400 for IBU & 1,375 for Naproxen Sodium

Front 95

What are the drug of choice for the management of moderate-to-severe odontogenic pain?

Back 95

COX-1 inhibitors, in combination with APAP, or in combination of codeine or hydrocodone

Front 96

For the management of acute moderate-to-severe odontogenic pain, ceiling doses of COX-1 inhibitors (IBU 2,400mg or Naproxen Sodium 1,375mg) are as effective or more effective as what mg of ASA or APAP?

Back 96

4000mg

Front 97

What is the drug of choice for dental pain for patients who have history of substance abuse (other than alcohol)?

Back 97

COX-1 inhibitors

Front 98

What is the only COX-2 inhibitor on the market

Back 98

Celebrex (celecoxib)

Front 99

What drugs interact with APAP?

Back 99

Cholestyramine
Contraceptive (Oral)
Isoniazid
Phenytoin
Probenecid
Sulfinpyrazone

Front 100

What mg. of IBU has been shown to be more effective than ceiling doses of ASA or APAP?

Back 100

400mg

Front 101

What is more effective?
400mg of IBU or 60mg Codeine w/ 650mg ASA?

Back 101

400mg of IBU

Front 102

What is more effective?
400mg of IBU or
600mg of APAP with 60mg of Codeine?

Back 102

400mg of IBU

Front 103

What doses of IBU has longer duration of action and appears to have a dose-dependent increase in its analgesic and anti-inflammatory efficacy?

Back 103

400-800mg

Front 104

What is more effective?
650mg of APAP w/ 200mg of IBU or
650mg of APAP?

Back 104

650mg of APAP with 200mg IBU

Front 105

What is more effective?
650mg of APAP w/200mg of IBU or
200mg of IBU

Back 105

650mg of APAP w/ 200mg of IBU

Front 106

What mg of Naproxen is equianalgesic to 650mg of ASA?

Back 106

250mg of Naproxen

Front 107

What mg. of Naproxen Sodium is equianalgesic to 650mg of ASA?

Back 107

220mg

Front 108

Which has a longer duration of effect?
Naproxen/Naproxen Sodium or ASA

Back 108

Naproxen/Naproxen Sodium

Front 109

What drug has more GI irritation, IBU or Naproxen?

Back 109

Naproxen

Front 110

What two drugs are converted by CYP2D6 hepatic microsomal isoenzyme into their active morphine analogs?

Back 110

codeine and hydrocodone

Front 111

what is more effective?
60mg of Codeine or 10 mg of hydrocodone OR
650mg of ASA, 650mg APAP, or 200mg of IBU

Back 111

they are the same

Front 112

Which drug is a nonopioid agent that binds to an opioid receptor to produce analgesic effects?

Back 112

Tramadol (Ultram)

Front 113

What drug blocks the re-uptake of norepinephrine and seratonin, which can result in mood alteration?

Back 113

Tramadol (Ultram)

Front 114

What mg of Tramadol is equianalgesic to 60mg of codeine?

Back 114

50mg.

Front 115

What drugs are classified as 2nd line of treatment for moderate-severe odontogenic pain?

Back 115

Ibuprofen
Naproxen/ Naproxen Sodium
COX-1 inhibitors/Opioid Combinations
Tramadol

Front 116

What drugs are considered to be the 3rd line of treatment for Severe Pain?

Back 116

Demerol (non-oral form)
Morphine
Hydromorphone
Methadone
Levorphanol
Oxycodone

**these drugs relieve both Somatic and Visceral Pain

Front 117

What is the drug of choice for the managment of severe odontogenic pain?

Back 117

Oxycodone w/ COX-1 inhibitor (ASA or IBU) or
Oxycodone w/ COX-3 inhibitor (APAP)

Front 118

What mg of oxycodone is equianalgesic to 90mg. of codeine

Back 118

10mg

Front 119

a single dose of what combination is more effective in managing severe pain than either oxycodone or ibuprofen alone?

Back 119

a single dose of 5mg oxycodone/ 400mg of IBU

Front 120

What medication interacts with COX inhibitor/Opioid combination products, such as Codeine/Hydrocodone?

Back 120

Bupivacaine

Front 121

What medication interacts with COX inhibitor/Opioid combination products, such as Oxycodone?

Back 121

Sertraline

Front 122

What is the drug of choice for moderate-to-severe dental pain for an individual with a history of substance abuse?

Back 122

Tramadol/APAP combination
two tabs of 37.5/325mg

Front 123

intolerance to COX-inhibitors are more likely with patients who have history of?

Back 123

asthma
nasal polyps
chronic urticaria

**these occur due to increase of leukotrienes

Front 124

What should not be recommended if there is an allergy to ASA?

Back 124

COX-1 inhibitors

**because of cross-sensitivity

Front 125

what are signs of intolerance to COX-inhibitors?

Back 125

rhinorrhea
urticaria
angioedema
bronochspasm

**all within 3 hours after taking a COX-I

Front 126

High hemorrhagic risk w/ patients taking ASA when they also have what conditions?

Back 126

sever hepatic dz.
Vitamin-K deficiency
Hereditary coagulopathies
taking (warfarin/heparin)

Front 127

What is the normal range PFA (platelet function analyzer-100)

Back 127

85-176 seconds

Front 128

Taking ASA during pregnancy can cause what to the fetus?

Back 128

reduced birth weight

Front 129

administration of COX-1 inhibitor (especially IBU) during pregnancy may lead to what?

Back 129

fetal cardiac failure---premature closure of ductus arteriosus b/t pulmonary artery and aorta

Front 130

During pregnancy what is a suitable substitute for ASA and COX-1 inhibitor (IBU) in the management of mild to moderate pain

Back 130

APAP

Front 131

ASA causes salicylate toxicity, this is called

Back 131

Salicylism

Front 132

In its free acid form, this destroys epithelial cells by producing cellular edema and desquamation and may damage peripheral nerve fiber.. what is this?

Back 132

ASA

Front 133

What are signs of salicylism?

Back 133

tinnitus
headache
mental confusion (delirum)
sweating (hyperthermia)
thirst (dehydration)
hyperventiliation
Renal dysfunction

Front 134

ASA intoxication has mortality of what percent in the young? and the old?

Back 134

2 % Young
25% Old

Front 135

Which enzyme converts APAP?

Back 135

CYP2E1

Front 136

What syndrome has been associated with administration of ASA to children and teenagers with influenza and chickenpox?

Back 136

Reye Syndrome

Front 137

Clinical evidence of hepatic damage (jaundice) will be noted in how may days?

Back 137

2 to 6 days

Front 138

what are signs of renal toxicity when taking COX-inhibitors

Back 138

1. decrease systhesis of renal PGs
2.Decrease renal blood flow
3. fluid retention
4. renal failure

Front 139

What are most common adverse effects of Opioid analgesics?

Back 139

Nausea, Vomiting,constipation

Front 140

Opioids promote the release of what?

Back 140

Histamines

**which causes vasodilation

Front 141

What is the most common cause of death in an opioid overdose

Back 141

Respiratory depression

Front 142

What is pathognomonic for opioid use/abuse such as heroin overdose?

Back 142

Miosis--marked pinpoint pupils

Front 143

Opioid can cause what to the fetus when taken during pregnancy?

Back 143

CNS depression to the fetus and infant

Front 144

What can be taken when pregnant to treat moderate-to-severe odontogenic pain?

Back 144

codeine in combination with APAP

Front 145

In what patient population should opioid be reduced to one half or one fourth to avoid both toxic and paradoxical effects( dizziness, hallucination)

Back 145

Geriatric population

Front 146

This is the resistance to one or several effects of a compound as a result of tolerance developed to a pharmacologically similar compound

Back 146

Cross- tolerance

Front 147

Do patients taking opioid for acute pain experience euphoria?

Back 147

NO

Front 148

Significant dependence for opioids develops only after how long?

Back 148

several weeks of chronic treatment with relatively large doses

Front 149

What are some withdrawal symptoms of opioid abuse?

Back 149

dilated pupils
rapid pulse
gooseflesh
muscle jerks
flu-like syndrome
vomiting, diarrhea,
tremors, yawning, sleep

Front 150

what are signs of Opioid overdose?

Back 150

constricted pupils Miosis)
depressed-to-absent respiration
cynosis (depressed respiration)
hypotension
hypothermia
sedation, stupor, coma, convulsions

Front 151

equal degrees of respiratory depression will be caused by equivalent doses of morphine, oxycodone, and codeine.. what are the doses for these drugs ?

Back 151

10mg of morphine
20mg oxycodone
130mg of codeine

Front 152

What drug is an narcotic antagonist and administered to reverse apnea and other affects of opioid toxicity

Back 152

Naloxone

Front 153

Seizures are managed with IM and IV medications such as?

Back 153

Benzodiazepine ( Diazepam)