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153 Cards in this Set
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an addition therapy given to enhance or extend the effect of primary therapy
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Adjuvant
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Substances liberated by the body during phases of inflammation that can produce pain
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Algogenic substances
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Insensibility to pain without loss of consciousness; and relieving pain by inhibiting specific pain pathways
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Analgesia
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Agents that relieve pain by inhibiting specific pain pathways
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Analgesics
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capable of reducing fever
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Antipyretic
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Originating or produced within the organism or one of its parts
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Endogenous
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Equal in the ability for giving pain relief
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Equianalgesic
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A test to determine risk of bleeding
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INR ( International Normalized Ratio)
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Reduction of circulation to an area
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Ischemia
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An initial high dose to quickly achieve a therapeutic blood level
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Loading Dose
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Sensory detection and neuronal transmission of pain stimuli
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Nociception
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what is a term for Injurious or harmful
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Noxious
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Derived from opium; a strong dependence producing analgesic
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Opioid
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Characterstic or indicative (diagnostic) of a particular disease or condition
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Pathognomonic
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Pain caused by the activation of pain receptors in mucocutaneous and musculoskeletal tissues
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Somatic Pain
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Pain caused by the activation of pain receptors in internal organs (kidney, lung, liver, etc.)
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Visceral Pain
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Most common complaint causing a person to seek the services of an oral health care provider is?
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Pain
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Effective control of pain has several advantages in an health care office. What are those advantages?
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1. Facilitates delivery of care
2. lowers anxiety about Tx for patient 3. promotes the patient's return for preventive and maintenance care |
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Sporadic dental visits, dental neglects, and episodic care only for acute pain are all reason why a person has a?
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chronic oral disease that is not associated with pain
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What is the primary obligation and ultimate responsibility of every clinician?
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1. restore function
2. relieve and prevent pain |
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This is a an unpleasant sensory and emotional experience associated with actual or potential tissue damage
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Pain
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Nocicpetors (pain receptors) are found in most tissues and are especially dense in what two tissues?
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Oral mucosa & Dental Pulp
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Stimulation of the dental pulp via heat, cold, vibrations, pressures, sweetness or sourness are all perceives as what?
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Pain
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Most pain of dental origin is associated with a recent onset of pain called?
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Acute Pain
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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?
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Algogenic Substances:
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What are examples of Algogenic Substances?
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Adenosine /Adenosine Triphosphate
Serotonin Histamine/Bradykinin/ Cytokines Prostaglandins Neuroactive substances |
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Algogenic Substances are chemicals that initiate the release of three things from nerve terminals what are they?
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Substance P
Calcitonin-gene related Peptide(CGRP) Glutamate |
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These are neuromodulators involved in evoking neurogenic inflammation, what are they?
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Substance P &
Calcitonin-gene related Peptide(CGRP) |
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This is the primary pain neurotransmitter that activates nociceptors which generate impulses that are transmitted along peripheral nerve fibers to the CNS
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Glutamate
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Detection of pain stimuli in the orofacial region is conveyed by which cranial nerve?
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Trigeminal (V)
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Traumatic injury to the tissue causes cascade of events, what are they?
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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 |
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What are the endogenous peptides that are released to cause the analgesic affect during tissue injury?
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Endorphins/ Endomorphins
Enkephalins Dynorphins Orphanin FQ or nociceptins |
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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?
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Perception
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What are some ways of "attentional" control when treating a patient?
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1.Hypnotic procedures--redirection of attention of pain
2. Music--distract patient 3.Patients to hold a leg up to control gag reflex |
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Choice of therapeutic intervention for acute odontogenic pain is determined largely by?
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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 |
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what are signs of acute odontogenic pain?
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anguish, postural displays, groaning, wincing, grimacing, limitations of normal activity (functions), excessive rest, social withdrawal, medication demand or intake
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What are three types of analgesics that are used for the management of acute odontogenic pain?
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1. Nonopioids ( COX-inhibitors)
2. Opioids 3. Adjuvant drugs |
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what are characteristics of nonopioids angalgesics?
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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 |
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What are characteristics of Opioid analgesics?
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1. derive from opioids
2. DONOT reduce fever 3. Act as AGONIST at opioid receptors (peripherally and centurally) |
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What is an examples of Adjuvant agent as an analgesic?
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Caffeine
Antihistamine hydroxyzine Corticosteroids |
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What doses of Caffeine enhances the analgesic effect of ASA, APAP, IBU and sometimes Anacin
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in doses of 65mg to 200mg
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In what doses of antihistamine hydroxyzine enhances the analgesic effects of opioids
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in doses of 25mg to 50mg
**remember antihistamine hydroxyzine are ADJUVANT therapy, which may also reduce nausea and vomitting induced by opioids |
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Corticosteroids, through their anti-inflammatory and phospholipase-inhibitory effects, can produce analgesia when pain is of what origin?
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Inflammatory
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Lipooxygenase are found only what types of cells?
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inflammatory cells--- such as
Neutrophils, Mast Cells, Macrophages |
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Cyclooxygenous breaks down Arachidonic Acid into prostanoids such as?
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Prostacyclin I2
Thomboxane A2 Prostanglandin D2 Prostanglandin E2 Prostanglandin F2 |
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Prostanglandins are substances that are know to do what?
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1. lower the pain threshold
2. promote Inflammation & Fever 3. affect vascular tone and permeability |
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what are examples of COX-1 inhibitors that increase the pain threshold and decrease the prostanglandin systhesis and interfere with platelet aggregation?
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ASA (aspirin) and IBU (ibuprofen) and Naproxen
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What blocks the synthesis of prostacycline and leads to platelet aggregration and vasoconstrition
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COX-2 inhibitors
**Celebrex or Vioxx |
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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
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COX-3( example APAP)
**also known as COX-1b or COX-1v |
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What are characteristics of APAP
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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 |
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What is the MOST powerful analgesic drug taken orally?
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Dilaudid
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Although Opioids have analgesics effects both peripherally and centrally, the primary site of action are in the?
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CNS
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Opioid-agonist drug produce analgesia by interacting with their receptors located where?
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Brain
1.Brain stem 2.Spinal cord 3.Trigeminal nucleus 4.Peripheral terminals of primary AFFERENT neurons |
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what are examples exogenous opioid agonist?
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Codeine
Hydrocodone Oxycodone |
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Most severe dental pain can be relieved with various combinations of:
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opioid and COX-inihibitors
**example Hydrocodone with Ibuprofen ( Vicodin), (Lortab) or Oxycodone with Ibuprofen (Percocet), (Percodan) |
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Endorphins/Endomorphins, work on what opioid receptors and have what effect
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Mu
Analgesia, Euphoria, Decreased Respiration |
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Enkephalins work on what opioid receptors and have what effect?
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Delta
Analgesia and Decrease Respiration |
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Dynorphins work on what opioid receptors and have what effect?
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Kappa
analgesia, Dysphoria, No Resp. effect |
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Orphanin FQ and nociceptin work on what opioid receptors and have what effect
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Opioid-receptor Like
Analgesia and No Resp. effect |
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COX-inhibitors are rapidly absorbed form the?
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stomach and small intestine
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COX-inhibitors reach their appreciable plasma concentration in?
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30 to 60 minutes
**and peaks at about 2 to 3 hours |
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What determines the rate of absorption of oral drugs?
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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 |
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when should an analgesic be taken in relation to eating a meal?
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30 minutes prior to eating or several hours after eating
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Metabolism of COX-inhibitors at therapeutic doses normally follow what order of kinetics?
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First-order
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Metabolism of COX-inhibitors at larger doses than therapeutic doses normally follow what order of kinetics?
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Zero-kinetic
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Metabolites of COX-inhibitors are primarily excreted by kidneys as
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water-soluble conjugates
**remember they are absorbed as lipid-soluble molecules via passive diffusion |
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Opioid free molecules (ones that are not protein bound) leave the blood and accumulate in which vascular organs?
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Kidneys
Lung Liver Spleen |
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To get optimal dose of analgesic what must be done?
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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 |
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What drugs are the Primary line of Treatment?
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ASA (aspirin) 650mg po q4h ( two tabs of 325mg)
APAP (tylenol) 650mg po q4h |
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What is the prototype drug for the evaluation of orally effective analgesia?
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ASA
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650mg of ASA or APAP is equianalgesic to how many mg of IBU and Naproxen Sodium
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200mg of IBU &
220mg of Naproxen Sodium |
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OTC formulations of what Drugs can be used to treat mild odontogenic pain?
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ASA, APAP, IBU and Naproxen Sodium
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What is the traditional adult dose of ASA?
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650mg tablet po q4h
(2 tablets of 325mg by mouth every 4 hours) |
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Does a single dose of ASA larger than 1,300mg (four 325mg tablets) increase pain relief?
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NO
**this may prove toxic to some patients |
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The clinical effects of ASA is determined not by the frequent dose around the clock but by the?
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Total Dose
**should not exceed 4000mg/24hours for adults and 1,200mg/24hours for children |
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For ASA what is the appropriate dose for a child?
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10-20mg/kg of body weight given in 4 to 6 doses
**not to exceed 1,200mgs/24hours |
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ASA is used as many things, what is it used for?
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Analgesia
Anti-inflammatory Anti-pyretic Anticoagulant |
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For Children the appropriate dose of ASA is?
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10-20mg/kg of body weight given in 4 to 6 doses.
**The total dose should not exceed 1,200mg/24 hour |
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What is the main analgesic mechanism for APAP?
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The INHIBITION of prostaglandins in the CNS.
**this is why it has antipyrogenic abilities and little anti-inflammatory effects |
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The frequency of of adverse reactions with therapeutic doses is somewhat_____ than that associated with ASA
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LESS
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What is the traditional dose for APAP?
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650mg po q4hrs.
**the Ceiling does of 1,000mg is usually more effective than 650mg. **remember this not the cause for ASA |
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What it the single dose of APAP for children?
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60-120mg depending on the patient's age and weight
**the total dose should not exceed 1,200mg/24hours |
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The daily dose of APAP should not exceed what for an adult?
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4000mg
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What drug is recommended by the American Arthritis College of Rheumatology for long-term control of pain associated with OSTEOARTHRITIS?
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APAP
**it is good for bone-to-bone damage rather than joint inflammation |
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What drug is not recommend for the treatment of inflammatory conditions such as Rheumatoid arthritis
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APAP
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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
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APAP
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The risk of hemorrhage is measured with a blood test refer to as?
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International Normalized Ration (INR)
**safe levels of INR are 2 to 3 minutes for surgical procedures and 3.5 minutes for periodontal procedures |
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What is the safe level of INR for periodontal debridement?
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3.5
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What two COX-inhibitors can be used for either the first line of analgesic or second line of analgesic, depending on dosage.
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Ibuprofen and Naproxen Sodium
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What is the OTC and Rx formulation of Ibuprofen
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200mg (OTC)
400mg, 600mg, 800mg (Rx) |
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What is the OTC and Rx formulation for Naproxen sodium?
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220 (OTC)
RX: 275mg (Anaprox) 550mg (Anaprox DS) 375mg or 500mg (EC Naprosyn) 250, 375,500mg (Naprosyn) |
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Prescription formulations for IBU and Naproxen Sodium with increased doses are indicated for?
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Increases anti-inflammatory effects
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The analgesic efficacy of IBU and Naproxen increases as the dose increase? TRUE or FALSE
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TRUE
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What is the maximum daily dose for IBU and Naproxen Sodium
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2,400 for IBU & 1,375 for Naproxen Sodium
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What are the drug of choice for the management of moderate-to-severe odontogenic pain?
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COX-1 inhibitors, in combination with APAP, or in combination of codeine or hydrocodone
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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?
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4000mg
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What is the drug of choice for dental pain for patients who have history of substance abuse (other than alcohol)?
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COX-1 inhibitors
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What is the only COX-2 inhibitor on the market
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Celebrex (celecoxib)
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What drugs interact with APAP?
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Cholestyramine
Contraceptive (Oral) Isoniazid Phenytoin Probenecid Sulfinpyrazone |
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What mg. of IBU has been shown to be more effective than ceiling doses of ASA or APAP?
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400mg
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What is more effective?
400mg of IBU or 60mg Codeine w/ 650mg ASA? |
400mg of IBU
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What is more effective?
400mg of IBU or 600mg of APAP with 60mg of Codeine? |
400mg of IBU
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What doses of IBU has longer duration of action and appears to have a dose-dependent increase in its analgesic and anti-inflammatory efficacy?
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400-800mg
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What is more effective?
650mg of APAP w/ 200mg of IBU or 650mg of APAP? |
650mg of APAP with 200mg IBU
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What is more effective?
650mg of APAP w/200mg of IBU or 200mg of IBU |
650mg of APAP w/ 200mg of IBU
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What mg of Naproxen is equianalgesic to 650mg of ASA?
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250mg of Naproxen
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What mg. of Naproxen Sodium is equianalgesic to 650mg of ASA?
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220mg
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Which has a longer duration of effect?
Naproxen/Naproxen Sodium or ASA |
Naproxen/Naproxen Sodium
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What drug has more GI irritation, IBU or Naproxen?
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Naproxen
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What two drugs are converted by CYP2D6 hepatic microsomal isoenzyme into their active morphine analogs?
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codeine and hydrocodone
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what is more effective?
60mg of Codeine or 10 mg of hydrocodone OR 650mg of ASA, 650mg APAP, or 200mg of IBU |
they are the same
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Which drug is a nonopioid agent that binds to an opioid receptor to produce analgesic effects?
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Tramadol (Ultram)
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What drug blocks the re-uptake of norepinephrine and seratonin, which can result in mood alteration?
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Tramadol (Ultram)
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What mg of Tramadol is equianalgesic to 60mg of codeine?
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50mg.
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What drugs are classified as 2nd line of treatment for moderate-severe odontogenic pain?
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Ibuprofen
Naproxen/ Naproxen Sodium COX-1 inhibitors/Opioid Combinations Tramadol |
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What drugs are considered to be the 3rd line of treatment for Severe Pain?
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Demerol (non-oral form)
Morphine Hydromorphone Methadone Levorphanol Oxycodone **these drugs relieve both Somatic and Visceral Pain |
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What is the drug of choice for the managment of severe odontogenic pain?
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Oxycodone w/ COX-1 inhibitor (ASA or IBU) or
Oxycodone w/ COX-3 inhibitor (APAP) |
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What mg of oxycodone is equianalgesic to 90mg. of codeine
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10mg
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a single dose of what combination is more effective in managing severe pain than either oxycodone or ibuprofen alone?
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a single dose of 5mg oxycodone/ 400mg of IBU
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What medication interacts with COX inhibitor/Opioid combination products, such as Codeine/Hydrocodone?
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Bupivacaine
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What medication interacts with COX inhibitor/Opioid combination products, such as Oxycodone?
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Sertraline
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What is the drug of choice for moderate-to-severe dental pain for an individual with a history of substance abuse?
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Tramadol/APAP combination
two tabs of 37.5/325mg |
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intolerance to COX-inhibitors are more likely with patients who have history of?
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asthma
nasal polyps chronic urticaria **these occur due to increase of leukotrienes |
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What should not be recommended if there is an allergy to ASA?
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COX-1 inhibitors
**because of cross-sensitivity |
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what are signs of intolerance to COX-inhibitors?
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rhinorrhea
urticaria angioedema bronochspasm **all within 3 hours after taking a COX-I |
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High hemorrhagic risk w/ patients taking ASA when they also have what conditions?
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sever hepatic dz.
Vitamin-K deficiency Hereditary coagulopathies taking (warfarin/heparin) |
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What is the normal range PFA (platelet function analyzer-100)
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85-176 seconds
|
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Taking ASA during pregnancy can cause what to the fetus?
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reduced birth weight
|
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administration of COX-1 inhibitor (especially IBU) during pregnancy may lead to what?
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fetal cardiac failure---premature closure of ductus arteriosus b/t pulmonary artery and aorta
|
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During pregnancy what is a suitable substitute for ASA and COX-1 inhibitor (IBU) in the management of mild to moderate pain
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APAP
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ASA causes salicylate toxicity, this is called
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Salicylism
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In its free acid form, this destroys epithelial cells by producing cellular edema and desquamation and may damage peripheral nerve fiber.. what is this?
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ASA
|
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What are signs of salicylism?
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tinnitus
headache mental confusion (delirum) sweating (hyperthermia) thirst (dehydration) hyperventiliation Renal dysfunction |
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ASA intoxication has mortality of what percent in the young? and the old?
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2 % Young
25% Old |
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Which enzyme converts APAP?
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CYP2E1
|
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What syndrome has been associated with administration of ASA to children and teenagers with influenza and chickenpox?
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Reye Syndrome
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Clinical evidence of hepatic damage (jaundice) will be noted in how may days?
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2 to 6 days
|
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what are signs of renal toxicity when taking COX-inhibitors
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1. decrease systhesis of renal PGs
2.Decrease renal blood flow 3. fluid retention 4. renal failure |
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What are most common adverse effects of Opioid analgesics?
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Nausea, Vomiting,constipation
|
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Opioids promote the release of what?
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Histamines
**which causes vasodilation |
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What is the most common cause of death in an opioid overdose
|
Respiratory depression
|
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What is pathognomonic for opioid use/abuse such as heroin overdose?
|
Miosis--marked pinpoint pupils
|
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Opioid can cause what to the fetus when taken during pregnancy?
|
CNS depression to the fetus and infant
|
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What can be taken when pregnant to treat moderate-to-severe odontogenic pain?
|
codeine in combination with APAP
|
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In what patient population should opioid be reduced to one half or one fourth to avoid both toxic and paradoxical effects( dizziness, hallucination)
|
Geriatric population
|
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This is the resistance to one or several effects of a compound as a result of tolerance developed to a pharmacologically similar compound
|
Cross- tolerance
|
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Do patients taking opioid for acute pain experience euphoria?
|
NO
|
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Significant dependence for opioids develops only after how long?
|
several weeks of chronic treatment with relatively large doses
|
|
What are some withdrawal symptoms of opioid abuse?
|
dilated pupils
rapid pulse gooseflesh muscle jerks flu-like syndrome vomiting, diarrhea, tremors, yawning, sleep |
|
what are signs of Opioid overdose?
|
constricted pupils Miosis)
depressed-to-absent respiration cynosis (depressed respiration) hypotension hypothermia sedation, stupor, coma, convulsions |
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equal degrees of respiratory depression will be caused by equivalent doses of morphine, oxycodone, and codeine.. what are the doses for these drugs ?
|
10mg of morphine
20mg oxycodone 130mg of codeine |
|
What drug is an narcotic antagonist and administered to reverse apnea and other affects of opioid toxicity
|
Naloxone
|
|
Seizures are managed with IM and IV medications such as?
|
Benzodiazepine ( Diazepam)
|