TECHNIQUES TO INCREASE ATTACHED GINGIVA (ROOT COVERAGE)

The following is a list of techniques used for gingival augmentation coronal to the recession (root coverage):

  1. Free gingival autograft
  2. Free connective tissue autograft
  3. Pedicle autografts: • Laterally (horizontally) positioned flap • Coronally positioned flap; includes semilunar pedicle (Tarnow)
  4. Subepithelial connective tissue graft (Langer)
  5. Guided tissue regeneration
  6. Pouch and tunnel technique

Subepithelial connective tissue graft (Langer) 🔎

Indication:

  • Larger and multiple defects with good vestibular depth and gingival thickness to allow a split-thickness flap to be elevated.

Adjacent to the denuded root surface, the donor connective tissue is sandwiched between the split flap as shown in the figure.

Subepithelial connective tissue graft for root coverage.
cont’d F to J, Facial views. F, Gingival recession. G, Vertical incisions to prepare recipient site. H, Split-thickness flap reflected. I, Connective tissue sutured over denuded root surface. J, Split-thickness flap sutured over donor connective tissue.

Surgical Technique Steps:

Step 1. Raise a partial-thickness flap with a horizontal incision 2 mm away from the tip of the papilla and two vertical incisions 1 to 2 mm away from the gingival margin of the adjoining teeth.

Step 2. Thoroughly plane the root, reducing its convexity.

Step 3. Obtain a connective tissue graft from the palate by means of a horizontal incision 5 to 6 mm from the gingival margin of molar and premolars. The connective tissue is carefully removed along with all adipose and glandular tissue. The palatal wound is sutured in a primary closure.

Step 4. Place the connective tissue on the denuded root. Suture it with resorbable sutured to the periosteum.

Step 5. Cover the graft with the outer portion of the partial-thickness flap and suture it interdentally.

Step 6. Cover the area with dry foil and surgical pack.

After 7 days, the dressing and sutures are removed. The esthetics are favorable with this technique since the donor tissue is connective tissue.

Dentowesome|@drmehnaz


Source: Carranza’s Clinical Periodontolgy, 10th Ed

Differential Diagnosis of Periapical Radiolucencies

PA radiolucencies identification made easy! Happy learning..😀📖

  • Periapical radiolucencies are most commonly odontogenic. Nonodontogenic radiolucencies tend to be not localized and span across the mandible or maxilla within the alveolus and sometimes extend inter-radicularly.
  • The most common PA pathologies can be diagnosed based on the vitality responses from the teeth. Ruling out the tooth associated pathologies is an important step in securing a diagnosis from differential diagnosis panel of PA radiolucencies.
  • Inter-relationship of possible results of periapical inflammation:

When formulating radiological differential diagnosis, features should be evaluated carefully, such as

  1. location
  2. locularity
  3. relation to dentition
  4. density of lesion
  5. margin
  6. type of radiological change (radiolucent/radiopaque/mixed)
  7. periosteal reaction
  8. cortical integrity, and
  9. clinical presentation.

🌫 General Radiographic features:

Location: With periapical inflammatory lesions, which are pathological conditions of the pulp, the epicenter typically is located at the apex of a tooth.

Periphery: Ill defined

Effects on surrounding structures: Periapical lesions cause widening of PDL space at apical region of the root.

PA Radiolucencies: (Classification)

PERIAPICAL RADIOLUCENCIES

Developmental

Lateral periodontal cyst

  • Definition: lateral periodontal cysts are cystic lesions that tend to occur on the lateral aspect of vital teeth. Epidemiology: lateral periodontal cysts account for fewer than 1% of the reported cases of odontogenic cysts.
  • Clinical findings: most lateral periodontal cysts area located in the mandibular incisor-canine-premolar area.
  • Radiographic findings: radiographically, lateral periodontal cysts present as a unilocular radiolucent lesion between the roots of teeth or associated with the lateral aspect of a tooth.
  • Management: surgical enucleation with preservation of involved teeth is an appropriate treatment of lateral periodontal cysts. Recurrence is rare. The multiloculated variant called botryoid odontogenic cysts has been reported to demonstrate a higher recurrence rate than its unilocular counterpart.

Inflammatory Lesions

Apical periodontitis, periapical abscess

  • Definition: spectrum of inflammation involving the PA area of teeth that results from pulpal infection by microorganisms.
  • Epidemiology: apical periodontitis is the most frequent inflammatory lesion related to teeth in the jaws.
  • Clinical findings: apical periodontitis can be classified as either asymptomatic or symptomatic; clinical examination of percussion and palpation of the tooth yields negative results in the former and usually positive results in the latter. The results of pulp sensitivity tests for both conditions, however, are negative. In the early stage of PA inflammation, the PA PDL can exhibit acute inflammation without abscess formation. This localized alteration may or may not proceed to abscess formation.
  • Radiographic findings: in apical periodontitis, radiographs may show a thickened PDL space. If an abscess develops after a long-standing apical periodontitis, radiographs reveal a radiolucent area around the root apex.
  • Management: apical periodontitis is an inflammatory disease caused by a persistent infection of the root canal system. The recommended treatment is the removal of the dead nerve and bacteria either through extraction of the tooth or root canal treatment. Antibiotics are recommended only when there is severe infection that has spread from the tooth into the surrounding tissues.
Mandibular left molar PA radiograph showing the initial apical changes in relation to the first molar secondary to a symptomatic gross carious lesion. If the offending causes remain, this will continue to an apical osteitis, resulting in loss of trabecular bone and possibly even cortical bone before it shows up radiographically.
Cropped panoramic radiograph showing localized osteomyelitis secondary to PA infection in relation to the mandibular left first and second molars (arrows).

Cystic Lesions

Periapical (radicular) cyst

  • Definition: radicular cyst is a cyst of inflammatory origin associated with a nonvital tooth.
  • Epidemiology: radicular cysts represent the most common odontogenic cyst. Radicular cysts are most commonly associated with at the tooth apex, but a lateral radicular cyst can be associated with a lateral root canal.
  • Clinical findings: radicular cysts are always associated with a nonvital tooth, and this is an important criterion for diagnosis.
  • Radiographic findings: radiographs often show a well-defined radiolucent lesion at the apex of a tooth. Radicular cysts can displace or resorb the roots of adjacent teeth.
  • Management: the treatment of radicular cysts can include nonsurgical root canal therapy to surgical treatment, such as apicoectomy.

Odontogenic keratocyst

CBCT panoramic reconstruction of maxilla showing a large well-defined lytic area coronal to the impacted right canine. Histologically confirmed as an odontogenic keratocyst.
  • Definition: an odontogenic cystic lesion with distinctive histologic features. Recently reclassified back into a cystic category in the recent 2017 WHO Classification of Head and Neck Tumours. Current evidence seemed lacking to justify the continuation of classifying it as a tumor.
  • Epidemiology: odontogenic keratocysts are the third most common cyst of the jaws.
  • Clinical findings: most common location of odontogenic keratocysts is the mandibular molar region.
  • Radiographic findings: odontogenic keratocyst size can be variable, ranging from a unilocular radiolucent lesion surrounding the crown of an unerupted tooth, resembling a dentigerous cyst, to a large size that results in facial deformity and destruction of surrounding structures. Lesions tend to grow in a posteroanterior direction, however, that results in a lack of cortical expansion.
  • Management: odontogenic keratocysts tend to be more aggressive in its growth pattern with a higher recurrence rate than other odontogenic cysts. Recurrence may be due, however, to incomplete removal or the presence of satellite (daughter) cysts. Treatment includes enucleation (with or without peripheral ostectomy, treatment with Carnoy solution), marsupialization, or resection.

Glandular odontogenic cyst

  • Definition: a developmental cyst with features that resemble glandular differentiation.
  • Epidemiology: glandular odontogenic cysts represent less than 1% of odontogenic cysts.
  • Clinical findings: there is a predilection for the mandible.But in the maxilla, the canine seems commonly involved. Swelling and expansion were the most common presenting complaints.
  • Radiographic findings: radiographically, glandular odontogenic cysts present as a well-defined unilocular or multilocular radiolucency associated with the roots of teeth; association with impacted teeth is rare.
  • Management: glandular odontogenic cysts have a tendency to recur especially when lesions are removed with simple enucleation.

Benign Tumors

Ameloblastoma

  • Definition: benign, slow-growing epithelial odontogenic neoplasm with unmitigated growth potential.
  • Epidemiology: ameloblastomas are the most common odontogenic tumors, excluding odontomas.89 In the United States, African Americans seem to have an overall 5-fold increase risk of disease compared with whites.
  • Clinical findings: tumor often presents as an asymptomatic swelling of the posterior mandible and can be associated with an unerupted tooth. Buccal and lingual expansion often is observed.
  • Radiographic findings: radiographs commonly show corticated multilocular (soap- bubble) radiolucency.
  • Management: the unmitigated growth potential and tendency to recur require operative management involving segmental or marginal resection. When treated by enucleation alone, much higher rates of recurrence are reported.
Panoramic radiograph showing a large well-defined, multilocular radiolucency extending from the area of first molar on the left into the ramus area. Note the expansion and thinning of the cortices. Ameloblastoma was confirmed histologically.

Malignant Tumors

Ameloblastic carcinoma

  • Definition: a rare, malignant counterpart for ameloblastoma. Not to be confused with metastasizing ameloblastoma, this is a histologically benign ameloblastoma metastasizing to distant sites. In the recent WHO Classification of Head and Neck Tumours, metastasizing ameloblastoma has been separated from ameloblastic carcinoma and included as a type of conventional ameloblastoma.
  • Epidemiology: incidence rate was 1.79 per 10 million person/year with male and black population predominance. The overall survival is 17.6 years.
  • Clinical findings: the most common site is the posterior mandible. Often, pain and expansion are the first clinical manifestations. Most cases arise de novo, but some arise in preexisting ameloblastomas.
  • Radiographic findings: radiographically, ameloblastic carcinomas can present as poorly defined, irregular radiolucencies consistent with a malignancy, or indistinguish- able from a benign radiolucency.
  • Management: generally considered radio-resistant tumor, radical surgical resection is the first line of treatment.

Differential Diagnosis: 🔍

  • The 2 type of lesions that most often must be differentiated from periapical inflammatory lesions are Periapical cemental dysplasia & enostosis (dense bone island, osteosclerosis) at the apex of the tooth.
  • In the early radiolucent phase of Periapical cemental dysplasia, the D/D rely solely on clinical examination and a test of tooth vitality.
  • With long standing periapical inflammatory lesions, the pulp chamber of involved tooth may be wider than adjacent tooth.
  • More mature PCD show radio-opaque mass within radiolucent area which helps in D/D.
  • Also the common site for PCD is mandibular anterior region. External root resorption is more common with periapical inflammatory lesions than PCD.
  • When enostosis is centered on the root apex, it may mimic inflammatory lesion but the PDL space has normal width. Also the periphery of enostosis is well defined and does not blend with surrounding trabaculae.
  • Small radiolucent periapical lesions with well-defined periphery may be either granulomas/cysts.
  • Differentiation may not be possible unless other characteristics of cyst such as displacement and expansion of surrounding structure is not present.
  • Larger lesions >1cm are usually radicular cysts.
  • If the patient has had endodontic treatment or apical surgery, a periapical radiolucency may remain that resemble periapical rarefying osteitis.
  • Metastatic lesions such as leukemia may grow in periapical segment of PDL space with malignant bone destruction.
Periapical radiographs of case showing Enostosis (see arrows) in the mandibular left quadrant, in close proximity with the roots of the adjacent teeth
  • Enostosis are common findings that seldom require treatment; however, caution should be exercised when undertaking orthodontic movement in the area of a DBI due to a potential risk of root resorption. Accurate identification and multidisciplinary management are of utmost importance. Monitoring size changes is recommended until completion of patient’s growth.

Dentowesome|@drmehnaz🖊


References:

  1. https://link.springer.com/article/10.1007/s40368-020-00596-w
  2. https://www.researchgate.net/profile/Eugene-Ko-2/publication/
  3. SlideShare, Study Notes✍🏻

CORTICOSTEROIDS IN DENTISTRY

🔷 Introduction:

Steroids are a group of hormones produced naturally in the body.

The adrenal cortex consists of 3 zones:

  1. Zona Glomerulosa synthesizes Aldosterone, the most potent Mineralocorticoid in humans.
  2. Zona Fasciculata – produces hydrocortisone (a glucocorticoid)
  3. Zona Reticularis produces Adrenal Androgens

• Glucocorticoid secretion is regulated by ACTH produced in the anterior pituitary. Cortisol has a -ve feedback on ACTH production.

• In Addison diseases, Glucocorticoid secretion impaired & ACTH is ⬆️

🔷 Corticosteroid Action & its regulation

  • Glucocorticoid – Hepatic Glycogen deposition
  • Mineralocorticoid – Sodium, electrolyte-fluid balance.
  • Glucocorticoid play critical role in body’s response to stress.

Stress

⬇️

Release of cytokines (IL-1)

⬇️

⬆️ cortisol levels

🔷 Classification:

Adrenocortical Hormones & Related Drugs

🔷 Steroid synthesis:

The substrate for steroid production is cholesterol. It is mobilized from the outer to the inner mitochondrial membrane by the steroidogenic acute regulatory (StAR) protein.

🔷 Glucocorticoids:

1) Hydrocortisone

Action: Anti-allergy, anti-inflammatory

Therapeutic Uses:

  • intralesional injection in dose of 20-50 mg/mL
  • Topical application
  • Tablet in dose of 100mg/day can be given systemically to relieve burning sensation.
  • Tab. Cortisol(25mg) combined with dexamethasone(90mg) can be given at biweekly interval.*

Action: Fibrinolytic,Anti-allergic, anti-inflammatory*

It causes ⬇️ fibroblastic production & deposition of collagen*

  • Topical application with orabase
  • Intralesional injection of hydrocortisone acetate (25mg/ml)
  • Topical application (0.25-0.5%) to the affected area
  • Intra-articular injection (25mg/ml)
  • 20-30mg/day in divided doses

Trade Name: CORTEF, ORABASE-HCA

• Preparation:

  1. Oral: 5 – 20 mg tab.
  2. Topical – 1% eye drop solution; 0.025 nasal drops, 0.25-2.5% skin creams

• Hydrocortisone acetate 25-50 mg/mL for soft tissue suspensions

• Hydrocortisone sodium phosphate: 50mg/mL IV, IM, SC

2) Cortisone:

• Uses:

  1. OSMF
  2. Addison disease
  3. Hodgkin lymphoma

3) Prednisolone:

Action: Anti-allergic, anti-inflammatory, immunosuppressive

• Uses:

  1. Rheumatoid arthritis: 10mg/day in divided doses
  2. Collagen disease: 1mg/kg
  3. SLE: IM/IV; Topical application 2-3 times daily
  4. Leukemia: ALL as maintenance dose
  5. Erythema multiforme, pemphigus, bullous pemphigoid, behchet’s syndrome
  6. Bronchial asthma: 40-60 mg
  7. Post-herpetic neuralgia
  8. Amyloidosis, cyclic neutropenia, purpura

Trade name: DELTA-CORTEF, PRELONE

4) Triamcinolone:

• Uses:

  1. Lichen planus: Topical application 3-4 times daily
  2. Erythema multiforme: 40-100 mg/day or inhalation doses
  3. Recurrent aphthae: Oral (2-4 mg/day)
  4. Desquamative gingivitis, OSMF, contact chelitis – intralesional (2-3 mL/day)

Trade name: Kenolog cream

5) Dexamethasone:

Uses:

👉🏻Mainly used for adrenal cortical suppression

  • Allergic diseases, serum sickness, urticaria, hay fever, angioneurotic edema: IV; topically 2-4 times a day
  • Benign migratory glossitis: Topical application
  • Shock, cerebral edema, occular diseases.

Trade name: DECADRON

6) Betamethasone:

Action: Anti-allergy, anti-inflammatory

Uses: Lichen planus, pemphigus, Aphthae ulcer

Dr. Mehnaz Memon🖊


References: Self Notes, Image chart source: Classification of Drugs with DOC by Vikas Seth (Third Edition)

Types Of Caries

• Clinical Classification of Caries:

1️⃣ According to Anatomical Site –

  • Pit & fissure caries
  • Smooth Surface Caries
  • Cervical
  • Root caries

2️⃣ According to rate of caries progression –

  • Acute dental caries
  • Chronic dental caries

3️⃣ According to nature of attack-

  • Primary
  • Secondary

4️⃣ Based on chronology –

  • Infancy caries
  • Adolescent caries

A. Pit & Fissure Caries:

https://dentowesome.in/2020/05/11/pit-fissure-caries/

B. Smooth surface caries:

  • On proximal surface of teeth or gingival 3rd of buccal & lingual preceded by formation of plaque.
  • Early while chalky spot – decalcification of enamel.

C. Linear Enamel Caries:

  • Atypical form
  • Found in primary dentition
  • Gross destruction of labial surface of incisor teeth

https://dentowesome.in/2020/05/07/dental-caries/

D. Root caries:

  • Soft progressive lesion that is found everywhere on root surface that has least connective tissue attachment & is exposed to oral enviornment.
  • Older age group & gingival recession

E. Acute Dentinal Caries:

  • Rapid clinical course
  • Early pulp involvement
  • Initial lesion is small, while rapid spread of process at DEJ & diffuse involvement of dentin produce large internal excavation.

F. Rampant Caries:

Sudden, rapid & almost uncontrolled destruction of teeth affecting surface that are relatively caries free.

G. Nursing bottle caries (Baby bottle syndrome)

Affect deciduous teeth due to prolonged use of nursing bottle containing milk, sugar or honey.

💬 What is 👶 bottle decay? What causes it and how to prevent it? 👇🏻

H. Chronic dental caries: (Slower progress)

I. Recurrent caries: (Presence of leaky margins)

J. Arrested caries:

  • No tendency of future progression, caries become static.
  • Brown pigmentation in the hard tissue.

Dentowesome|@drmehnaz🖊


Image Source: Google.com

CHOOSING APPROPRIATE ANTIBIOTIC

Antibiotics can be divided into 2 classes based on their mechanism of action:-

  • Bactericidal
  • Bacteriostatic

➡️ Bactericidal antibiotics kill bacteria by inhibiting cell wall synthesis. Example:

  • Beta-lactams (Penicillins, Cephalosporins, Carbapenems, Monobactams)
  • Glycopeptides viz. Vancomycin
  • Aminoglycosides
  • Fluoroquinollines
  • Others: Bacitracin, Cycloserine, Metronidazole

➡️ Bacteriostatic antibiotics limit the growth of bacteria by interfering with bacterial protein production, DNA replication or other aspects of bacterial cellular metabolism.

They must work together with immune system to remove the micro-organisms from the body. Example:

  • Tetracyclins
  • Sulphonamides
  • Macrolides
  • Lincosamides
  • Chloramphenicol
  • trimethoprim

Most antimicrobial agents in clinical use are bactericidal,

Note that while it is rational to favor bactericidal agents over bacteriostatic agents, neither has ever been shown to be superior (probably because true recovery from infection cannot occur until the body is able to mount an appropriate immune response, thus “buying time” may be just as good as active killing)

Minimum inhibitory concentration (MIC) versus minimum bactericidal concentration (MBC).

➡️ The MBC is the minimum concentration of drug which can kill the micro-organisms.

➡️ The MIC is the minimum concentration of drug which can inhibit the growth of micro-organisms.

🔷 CHOOSING APPROPRIATE ANTIBIOTIC (A Clinician’s guide to the CARAT criteria)

Council for Appropriate and Rational Antibiotic Therapy (CARAT) criteria for accurate use of antibiotic therapy
● Evidence-based results ●Therapeutic benefits
● Safety
● Cost-effectiveness
● Optimal drug dose and duration —Shorter-course, more aggressive therapy

(i) Evidence-based results:

In choosing an antibiotic, clinicians should consider the clinical evidence demonstrating that the drug is clinically and microbiologically appropriate, the efficacy of that drug in well-designed clinical trials, and the antibiotic resistance patterns of the local region. Clinicians should then use their professional judgment to choose the optimal antibiotic.

(ii) Therapeutic benefits:

If possible, the clinician should identify the causative pathogen and use surveillance data on regional antibiotic resistance patterns in selecting the optimal therapeutic agent.

(iii) Safety:

In treating patients with a particular drug, safety must be weighed against efficacy. Clinically applicable treatment strategies should be chosen to maximize efficacy while minimizing side effects.

(iv) Optimal drug for optimal duration:

Optimal drug selection requires finding the antimicrobial class and the specific member of that class that is best suited to treat a particular infection. Because empiric therapy is necessary in most cases, multiple factors have to be considered. Among these are whether the etiologic agent is likely to be gram-positive or gram-negative, whether a narrow or broad-spectrum agent should be chosen, the resistance patterns of the likely pathogen to this drug, both nationally and regionally, and the individual patient’s medical history, including recent antibiotic exposure.

Optimal duration means prescribing the selected drug for the shortest amount of time required for clinical and micro- biologic efficacy. There are many reasons for reducing an- timicrobial therapy to the shortest appropriate duration. They include the potential for reduced occurrence of adverse effects, increased patient adherence, decreased promotion of resistance, and decreased costs.

(v) Cost-effectiveness:

Choosing inappropriate therapy is associated with increased costs, including the cost of the antibiotic and increases in overall costs of medical care because of treatment failures and adverse events.

Dentowesome | @drmehnaz🖊


References:

  1. https://www.amjmed.com/article/S0002-9343(05)00381-5/pdf
  2. https://microbeonline.com/minimum-inhibitory-concentration-and-minimum-bactericidal-concentration-mbc/

ANALGESICS AND ANTI-INFLAMMATORY DRUGS(NSAID’s) IN DENTISTRY

💊Analgesic is a drug that selectively relieves pain by acting in the CNS or on the peripheral pain mechanisms without significantly altering consciousness.

💊They are divided into 2 groups:

  1. Opiod/Narcotic/Morphine like
  2. Non-opiod/Non-Narcotic/antipyretic (Aspirin like drugs)

The antipyretic analgesics & NSAID’s are more commonly employed for dental pain because tissue injury and inflammation due to abscess, caries, tooth extraction etc. is major cause of acute dental pain.

🔆 CLASSIFICATION:

Image: 1
Image: 2

🔆 ANALGESIC/NSAID’s IN DENTISTRY:

  • The antipyretic analgesics used mainly for dental pain is Paracetemol.
  • Paracetemol (Acetaminophen) is most frequently used to relieve toothache in Pregnancy. It has week anti-inflammtory effect & causes no teratogenesis in the developing fetus.
  • Pain during invasive dental procedures is alloyed by a local anesthesic before & after is treated with NSAID’s.

💊 NSAID’s use during Pregnancy: (The devastating effects to the infant) 👇🏻

Image: 3

🔆Use of OPIOIDS in Dental Pain:

  • Less used than analgesics
  • Mostly codeine is used for dental patients because other opioids cause dullness & short lasting pain.
  • Other alternative Opioid Analgesics used are – Tramadol, Pentazocine.

💊MORPHINE – Depressant actions‼️

🔻Adverse effects:
  1. Sedation, mental clouding, lethargy, nausea, vomitting, diarrhoea.
  2. Respiratory depression, blurring of vision.
  3. Allergic conditions, rashes, urticaria, itching, swelling.
  4. May develop tolerance & dependance.
🔻Contraindications:
  1. Urinary retention – infants & elderly
  2. Asthma patients
  3. Hypotensive states
  4. Hypovolaemic states

💊NSAID’s :

  1. Analgesic, antipyretic, anti-inflammatory effect.
  2. Effectively relieves inflammatory tissue, injury related pain, signs of inflammation like pain, tenderness, swelling are suspected.
  3. Cellular metabolism is increased & due to increased Glucose utilization there is decrease in blood sugar.
  4. Has teratolytic & mild-antiseptic properties
  5. Irritates gastric mucosa
  6. Interferes with platelet aggregation & bleeding time prolonged.
🔻Adverse effects:
  • Nausea, vomiting, diarrhoea, blood loss in stools.
  • Haemolysis in G6PD deficient patients.
  • Nephrotoxicity & hepatotoxicity in long term use.
  • Allergic reactions – rashes, urticaria, photosensitivity.
  • Pregnancy & Infancy – Refer Image 3
🔻Contraindications:
  • Nursing and pregnancy
  • Serious bleeding
  • Allergy/Asthma/Angioedema
  • Impaired renal function
  • Drug (anticoagulant)

Dr. Mehnaz Memon🖊


References:

  1. Flowcharts: Classification of Drugs with DOC by Vikas Seth (Third Edition)
  2. KD TripathiEssentials of Medical Pharmacology 7th Edition; Internet

How to prevent excessive bleeding during Dentoalveolar Surgery❓

Types of bleeding are:

  1. Primary (during or immediately after surgery)
  2. Reactionary (Upto 48 hours due to a defective suture or as clot in the vessels has got disturbed)
  3. Secondary (8-14 days due to wound getting infected and capillaries have eroded surfaces)

To prevent excessive blood loss during surgery we need to understand the source of bleeding i.e. possible reason for bleeding.


Dr. Mehnaz Memon🖊

Drugs of choice in respiratory diseases

🔗Refer Asthma First Aid & Prevention tips on Page 2‼️

ASTHMA

Mild intermittent

💊 Short acting β2-agonists (e.g. Salbutamol, Terbutaline) inhalations when needed.

💊 Anticholinergics (e.g. Ipratropium, Tiotropium) inhalations when needed, alone or in addition to beta-2 agonists

💬 Patient is asymptomatic between the dyspnoea episodes, so no daily medication required!

ASTHMA

Mild persistent

💊 Short acting β2-agonists (e.g. Salbutamol, Terbutaline) inhalations ➕ Corticosteroid inhalation (low dose)

💊 Short acting β2-agonists ➕ Mast cell stabilizer or Leukotriene antagonist or Theophylline sustained release

💬 Beta-2 agonist inhalation is needed every day, so once daily corticosteroid inhalation if given for asthma control.

ASTHMA

Moderate persistent

💊 Long acting beta-2 agonists (e.g. Salmeterol, Formeterol) inhalations ➕ Corticosteroid inhalation (low to high dose)

💊 Long acting beta-2 agonist tablets or Theophylline sustained release ➕ Corticosteroid inhalation (medium dose)

💬 The dose of corticosteroid inhalations depends on the severity of symptoms.

ASTHMA

Severe persistent

💊 Long acting beta-2 agonists (e.g. Salmeterol, Formeterol) inhalations ➕ Corticosteroid inhalation (high dose) ➕ Corticosteroid tablets/syrup

💊 Long acting beta-2 agonist tablets or Theophylline sustained release ➕ Corticosteroid inhalation (high dose) ➕ Corticosteroid tablets/syrup

💬 Systemic corticosteroids have significant adverse effects, so after adequate asthma control, are gradually withdrawn.*

ASTHMA

Acute severe asthma

💊 Oxygen 60% ➕ Nebulized beta-2 agonists (e.g. Salbutamol) in high dose ➕ Systemic corticosteroids

💬 An emergency condition, earlier called as status asthmatics. Aminophylline is no longer recommended.

* After adequate control of severe persistent asthma, systemic corticosteroids are withdrawn, and the patient then would be managed as moderate persistent type. This is called "step down" approach of management. In this approach, it is considered better to manage patients assuming in the next higher type and then, after reviewing in 1-6 months, to step-down, instead of "step-up" after failure in asthma control.

Aspirin induced

asthma

💊 Leukotriene antagonists (e.g. Montelukast, Zafirlukast)

Exercise induced

asthma

For Prophylaxis: Mast cell stabilizers or beta-2 agonists or Leukotriene antagonists💊

COPD

  • For smoking cessation: I line: Behaviour therapy; II line: Nicotine replacement therapy; III line: Antidepressants e.g. Bupropion
  • For respiratory infections: Antibiotics
  • For bronchodilatation: I line: Anticholinergics; II line: beta-2 agonists; III line: Theophyline
  • For hypoxemia: I line: Ambulatory oxygen; II line: Long term oxygen therapy

Dry cough

💊 Cough suppressants (e.g. Dextromethorphan) + Treat the cause e.g. post nasal drip by antihistaminics and decongestants.

Productive cough

💊 Expectorants (e.g. Pot iodide) &/or Mucolytics (e.g. Acetylcysteine) ➕ Treat the cause e.g. allergy by antihistaminics and bacterial infection by antibiotics

References: CLASSIFICATION OF DRUGS WITH DRUGS OF CHOICE 3RD EDITION BY VIKAS SETH


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