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Antacids neutralize gastric acid and decrease sis) plaquenil 200 mg overnight delivery, which increases with a recumbent position or bending pepsin production; antimicrobials and bismuth can eliminate over generic plaquenil 200 mg amex. Drugs at a Glance: Representative Antacid Products Antacids Components Magnesium Oxide or Aluminum Calcium Trade Name Hydroxide Hydroxide Carbonate Other Route and Dosge Ranges (Adults) Aludrox 103 mg/5 mL 307 mg/5 mL PO 10 mL q4h quality 200mg plaquenil, or as needed Amphojel 300 or 600 mg/tab, PO 10 mL or 600 mg 5 or 6 times daily 320 mg/5 mL Di-Gel 200 mg/5 mL Simethicone PO 2 tsp liquid q2h, after meals or between 20 mg/5 mL meals, and at bedtime. Gelusil 200 mg/tab 200 mg/tab Simethicone PO 10 or more mL or 2 or more tablets after 25 mg/tab meals and at bedtime or as directed by physician to a maximum of 12 tablets or tsp/24 h Maalox 200 mg/5 mL 225 mg/5 mL PO 30 mL 4 times daily, after meals and at suspension bedtime or as directed by physician; maxi- mal dose, 16 tsp/24 h Mylanta 200 mg/tab, 200 mg/tab, Simethicone PO 5–10 mL or 1–2 tablets q2–4h, between 200 mg/5 mL 200 mg/5 mL 25 mg/tab, meals and at bedtime or as directed by 20 mg/5 mL physician Mylanta 400 mg/tab, 400 mg/tab, Simethicone Same as Mylanta Double 400 mg/5 mL 400 mg/5 mL 30 mg/tab, strength 30 mg/5 mL Titralac 420 mg/tab, Glycine PO 1 tsp or 2 tablets, after meals or as 1 g/5 mL 180 mg/tab, directed by physician, to maximal dose of 300 mg/ 19 tablets or 8 tsp/24 h 5 mL 870 SECTION 10 DRUGS AFFECTING THE DIGESTIVE SYSTEM Drugs at a Glance: Drugs for Acid-Peptic Disorders Generic/Trade Name Indications for Use Routes and Dosage Ranges (Adults) Histamine-2 Receptor Treatment of peptic ulcers and GERD, to Antagonists promote healing, then maintenance to prevent recurrence Prevention of stress ulcers, GI bleeding, and aspiration pneumonitis Treatment of Zollinger-Ellison syndrome Treatment of heartburn Cimetidine (Tagamet) Duodenal or gastric ulcer, PO 800 mg once daily at bedtime or 300 mg 4 times daily or 400 mg twice daily. Maintenance, PO 400 mg at bedtime IV injection, 300 mg, diluted in 20 mL of 0. COMBINATION REGIMENS Bismuth subsalicylate, PO bismuth 525 mg (2 tabs), metronidazole 250 mg (1 tab), metronidazole, and tetracycline 500 mg (1 capsule) 4 times daily for 14 d tetracycline (Helidac) Amoxicillin, clarithromycin, PO amoxicillin 1 g, clarithromycin 500 mg, lansoprazole 30 mg and lansoprazole (Prevpac) twice daily, morning and evening, for 14 d Ranitidine and bismuth PO 400 mg twice daily for 4 wk, with clarithromycin 500 mg citrate (Tritec) 3 times daily for the first 2 wk GERD, gastroesophageal reflux disease, including erosive esophagitis; GI, gastrointestinal; NSAID, nonsteroidal anti-inflammatory drug. Antacids people who ingest large amounts of aluminum-based antacids over a long period, hypophosphatemia and osteomalacia may Antacids are alkaline substances that neutralize acids. They develop because aluminum combines with phosphates in react with hydrochloric acid in the stomach to produce neutral, the GI tract and prevents phosphate absorption. Aluminum less acidic, or poorly absorbed salts and to raise the pH (alka- compounds are rarely used alone for acid-peptic disorders. Raising the pH to approximately Magnesium-based antacids have a high neutralizing capacity 3. Calcium compounds have a rapid onset of aluminum, magnesium, and calcium compounds. Aluminum compounds have a low compounds are rarely used in peptic ulcer disease. In droxide and magnesium hydroxide (eg, Gelusil, Mylanta, 872 SECTION 10 DRUGS AFFECTING THE DIGESTIVE SYSTEM Maalox). Once released, histamine causes con- such as simethicone or alginic acid. Simethicone is an anti- traction of smooth muscle in the bronchi, GI tract, and uterus; flatulent drug available alone as Mylicon. When added to dilation and increased permeability of capillaries; dilation of antacids, simethicone does not affect gastric acidity. It report- cerebral blood vessels; and stimulation of sensory nerve end- edly decreases gas bubbles, thereby reducing GI distention ings to produce pain and itching. Alginic acid (eg, in Gaviscon) pro- Histamine also causes strong stimulation of gastric acid se- duces a foamy, viscous layer on top of gastric acid and thereby cretion. Vagal stimulation causes release of histamine from decreases backflow of gastric acid onto esophageal mucosa cells in the gastric mucosa. The histamine then acts on recep- while the person is in an upright position. Aluminum-based antacids vent or reduce other effects of histamine but do not block his- also are given to clients with chronic renal failure and hyper- tamine effects on gastric acid production. The H2RAs inhibit phosphatemia to decrease absorption of phosphates in food. A single dose of an H2RA can inhibit acid secretion for 6 to 12 hours and a continuous intravenous (IV) infusion can inhibit secre- Helicobacter pylori Agents tion for prolonged periods. Clinical indications for use include prevention and treat- Multiple drugs are required to eradicate H. Effective combinations include two ease, esophagitis, GI bleeding due to acute stress ulcers, and antimicrobials and a PPI or an H2RA. With gastric or duodenal ul- component, two of the following drugs—amoxicillin, cla- cers, healing occurs within 6 to 8 weeks; with esophagitis, rithromycin, metronidazole, or tetracycline—are used. Over-the-counter oral A single antimicrobial agent is not used because of concern preparations, at lower dosage strengths, are approved for the about emergence of drug-resistant H. In addition, antimicrobial– and clients with impaired renal or hepatic function. Dosage antisecretory combinations are associated with low ulcer should be reduced in the presence of impaired renal function. Adverse effects occur infrequently with usual doses and A bismuth preparation is added to some regimens. They are more likely to occur with pro- muth exerts antibacterial effects against H.

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Absorption from abraded cheap plaquenil 200mg without prescription, damaged buy plaquenil 200 mg low cost, or are considered safe and effective in adults and children inflamed skin is much greater than from intact skin cheap plaquenil 200 mg amex. Absorption is increased when and itching during the first week of use but they are not drugs are left in place for prolonged periods. Absorption is increased when topical med- Herbal and Dietary Supplements ications are applied to large areas of the body. Absorption from mucous membranes Many supplements are promoted for use in skin conditions. Absorption from Most have not been tested adequately to ensure effectiveness. Two topical agents for which there is some support of safety and effectiveness are aloe and oat preparations. INDIVIDUAL DRUGS Aloe is often used as a topical remedy for minor burns and wounds (eg, sunburn, cuts, abrasions) to decrease pain, itching, See Drugs at a Glance: Topical Antibicrobial Agents, Drugs and inflammation and to promote healing. Its active ingredi- at a Glance: Topical Corticosteroids, and Drugs at a Glance: ents are unknown. Wound healing is attributed to moisturizing Miscellaneous Dermatologic Agents. Benzoyl peroxide Acne To affected areas, after cleansing, 1–3 times daily Clindamycin (Cleocin T) Acne vulgaris To affected areas, twice daily Erythromycin (Aknemycin) Acne vulgaris To affected areas, after cleansing, twice daily, morning and evening Gentamicin (Garamycin) Skin infections caused by susceptible strains of To infected areas, 3–4 times daily. Cover with streptococci, staphylococci, and gram-negative dressing if desired. Eradication of nasal colonization with methicillin- Other skin lesions: Cream, 3 times daily for resistant S. Eradication of nasal colonization: Ointment from single-use tube, one half in each nostril, morning and evening for 5 d Neomycin (Myciguent) Bacterial skin infections To affected area, after cleansing, 1–3 times daily, small, fingertip-size amount. Silver sulfadiazine (Silvadene) Prevent or treat infection in burn wounds caused by To affected area, after cleansing, once or twice Pseudomonas and many other organisms daily, using sterile technique Sulfacetamide sodium Bacterial skin infections Skin infections: 2–4 times daily until infection clears (Sebizon) Seborrheic dermatitis Seborrhea: to scalp and adjacent skin areas, at bedtime Tetracycline (Topicycline) Acne vulgaris To affected areas, twice daily, morning and evening Combination Products Bacitracin and polymyxin B Bacterial skin infections To lesions, 2–3 times daily (Polysporin) Erythromycin/benzoyl Acne To affected areas, after cleansing, twice daily, peroxide (Benzamycin) morning and evening Neomycin, polymyxin B and Bacterial skin infections To lesions, 2–3 times daily bacitracin (Neosporin) (continued) 954 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS Drugs at a Glance: Topical Antimicrobial Agents (continued) Generic/Trade Name Indications for Use Application Antifungal Agents Amphotericin B (Fungizone) Cutaneous candidiasis To affected areas, 2–4 times daily Butenafine (Mentax) Tinea pedis To affected area, once daily for 4 wk Ciclopirox (Loprox) Tinea infections To affected area, twice daily for 2–4 wk Cutaneous candidiasis Clioquinol (Vioform) Fungal skin infection and inflammation To affected areas, 2–3 times daily. Clotrimazole (Lotrimin, Tinea infections To affected areas, twice daily, morning and evening Mycelex) Cutaneous candidiasis Econazole (Spectazole) Tinea infections Tinea infections: To affected areas, once daily Cutaneous candidiasis Cutaneous candidiasis: To affected areas, twice daily Haloprogin (Halotex) Tinea infections To affected area, twice daily for 2–4 wk Ketoconazole (Nizoral) Tinea infections Tinea infections and cutaneous candidiasis: To Cutaneous candidiasis affected areas, once daily for 2–4 wk Seborrheic dermatitis Seborrheic dermatitis: To affected areas twice daily for 4 wk or until clinical clearing Miconazole (Micatin) Tinea infections To affected areas, twice daily for 2–4 wk Cutaneous candidiasis Naftifine (Naftin) Tinea infections To affected areas, once daily with cream, twice daily with gel Nystatin (Mycostatin) Candidiasis of skin and mucous membranes To affected areas, after cleansing, 2–3 times daily until healing is complete Oxiconazole (Oxistat) Tinea infections To affected areas, once or twice daily for 2–4 wk Sulconazole (Exelderm) Tinea infections To affected areas, once or twice daily Terbinafine (Lamisil) Tinea infections To affected areas, twice daily for 1–4 wk Antiviral Agents Acyclovir (Zovirax) Herpes genitalis To lesions, q3h six times daily for 7 d Herpes labialis in immunosuppressed clients Penciclovir (Denavir) Herpes labialis To lesions, q2h while awake for 4 d Drugs at a Glance: Topical Corticosteroids Generic/Trade Names Dosage Forms Potency Alclometasone (Aclovate) Cream, ointment Low Amcinonide (Cyclocort) Cream, lotion, ointment High Augmented betamethasone Cream, gel, lotion, ointment Ointment very high; cream high dipropionate (Diprolene) Betamethasone dipropionate Aerosol, cream, lotion, ointment Cream and ointment high; lotion medium (Alphatrex, others) Betamethasone valerate Cream, foam, lotion, ointment Ointment high; cream medium (Valisone, others) Clobetasol (Temovate) Cream, gel, ointment, scalp application Very high Clocortolone (Cloderm) Cream Medium Desonide (Tridesilon) Cream, lotion, ointment Low Desoximetasone (Topicort) Cream, gel, ointment Medium Dexamethasone (Decaderm, Aerosol, cream Low Decadron) Diflorasone (Florone, Maxiflor) Cream, ointment Ointment, very high; cream, high Fluocinolone (Synalar, others) Cream, oil, ointment, shampoo, solution High Fluocinonide (Lidex) Cream, gel, ointment, solution High Flurandrenolide (Cordran) Cream, lotion, ointment, tape Medium Fluticasone (Cutivate) Cream, ointment Medium Halcinonide (Halog) Cream, ointment, solution High Halobetasol (Ultravate) Cream, ointment Very high Hydrocortisone (Cortril, Cream, lotion, ointment, solution, spray, Medium or low Hydrocortone, others) roll-on stick Mometasone (Elocon) Cream, lotion, ointment Medium Triamcinolone acetonide Aerosol, cream, lotion, ointment 0. Also available in combination with hydrocortisone and other substances Colloidal oatmeal (Aveeno) Antipruritic Pruritus Topically as a bath solution (1 cup in bathtub of water) Dextranomer (Debrisan) Absorbs exudates from wound Cleansing of ulcers (eg, venous Apply to a clean, moist wound sur- surfaces stasis, decubitus) and wounds face q12h initially, then less (eg, burn, surgical, traumatic) often as exudate decreases Fluorouracil (Efudex) Antineoplastic Actinic keratoses Topically to skin lesions twice daily Superficial basal cell carcinomas for 2–6 wk Masoprocol (Actinex) Inhibits proliferation of keratin- Actinic keratoses Topically to skin lesions morning containing cells and evening for 28 d Salicylic acid Keratolytic, antifungal Removal of warts, corns, calluses Topically to lesions Superficial fungal infections Seborrheic dermatitis Acne Psoriasis Selenium sulfide (Selsun) Antifungal, antidandruff Dandruff Topically to scalp as shampoo once Tinea versicolor or twice weekly 956 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS effects and increased blood flow to the area. Many commonly used drugs may mation and pain may result from inhibition of arachadonic acid cause skin lesions, including antibiotics (eg, peni- metabolism and formation of inflammatory prostaglandins. Commercial products are available for topical use, but • Irritants or allergens may cause contact dermatitis. When used for this For example, dermatitis involving the hands may be purpose, a clear, thin, gel-like liquid can be squeezed directly caused by soaps, detergents, or various other cleans- from a plant leaf onto the burned or injured area several times ing agents. Topical use has not been associated with se- from allergic reactions to clothing. Oats contain gluten, which forms a sticky mass that drainage, and whether the lesion appears infected or con- holds moisture in the skin when it is mixed with a liquid and tains necrotic material. For topical use, oats are contained in described as petechiae (pinpoint hemorrhages) or ecchy- bath products, cleansing bars, and lotions (eg, Aveeno prod- moses (bruises). Burn wounds are usually described in ucts) that can be used once or twice daily. They should not be terms of depth (partial or full thickness of skin) and per- used near the eyes or on inflamed skin. Venous stasis, pressure, and other cutaneous ulcers are usually described in terms of diame- ter and depth. Nursing Process • When assessing the skin, consider the age of the client. School-aged children have a relatively high inci- indicate current or potential dermatologic disorders. Older adults are more likely to • When a skin rash is present, interview the client and in- have dry skin, actinic keratoses (premalignant lesions that spect the area to determine the following: occur on sun-exposed skin), and skin neoplasms. Basal cell carcinoma is the described as specifically as possible so changes can be most common type of skin cancer. Terms commonly used in dermatology in- as a pale nodule, most often on the head and neck. Squa- clude macule (flat spot), papule (raised spot), nodule mous cell carcinomas may appear as ulcerated areas.

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Appel LJ 200mg plaquenil with visa, Moore TJ cheap plaquenil 200mg without prescription, Obarzanek E order plaquenil 200mg on-line, Vollmer WM, risk factor changes in the Minnesota Heart Health Svetkey LP, Sacks FM, et al. Carleton RA, Lasater TM, Assaf AR, Feldman DASH Collaborative Research Group. N Engl J HA, McKinlay S, Pawtucket Heart Health Pro- Med (1997) 336: 1117–24. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Program: community changes in cardiovascular Bray GA, Harsha D, et al. Am J Public pressure of reduced dietary sodium and the Dietary Health (1995) 85: 777–85. Green  2004 John Wiley & Sons, Ltd ISBN: 0-471-98787-5 13 D entistry and axillo-facial MAY C. LO Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong INTRODUCTION Aside from oral diseases there are a number of conditions or disorders of the oral cavity that SCOPE OF THE CHAPTER are of concern. Malalignment and malocclusion of teeth (crooked teeth) is prevalent and severe Dentistry is concerned with the prevention and in many countries and most report a growing treatment of diseases and disorders of the teeth, demand for orthodontic treatment to correct the gums (periodontium) and oral cavity. In the US, it is estimated that most common oral diseases are dental caries around half of the population are in need of some (tooth decay) and periodontal (gum) diseases. Removable prosthesis (dentures or false adults in most countries throughout the world teeth) and fixed prosthesis (bridges) as well as have been affected by dental caries. In addition, implants (screw in teeth) have been used to findings from epidemiological surveys throughout address these problems. The prevalence First, the disease aetiology and measurements of oral cancer varies from country to country, in of dental caries and periodontal disease will most countries it accounts for less than 1% of be presented. Second, clinical trials methods the total cancer incidence whereas in the Indian used in dentistry will then be outlined and subcontinent it can account for 30–50% of the illustrated with examples. Green  2004 John Wiley & Sons, Ltd ISBN: 0-471-98787-5 194 TEXTBOOK OF CLINICAL TRIALS caries, oral rehabilitation, periodontal disease clinical signs. Fourth, the tal disease, usually the depth of the periodontal current issues of evidence-based dentistry and pocket and/or the attachment loss are measured hierarchical data analysis will also be discussed. Last, the impact of clinical trials on dental Following the developments in medical re- practice will be summarised. These have focused primarily on the concept of patient satisfaction and health-related Evidence from animal and epidemiological stud- quality of life measures. A number of question- ies shows that dental caries arise from dem- naires have been developed recently to measure ineralisation of tooth hard tissue due to organic the oral health-related quality of life of peo- acids produced by plaque bacteria on the tooth 3 ple, for example, the Oral Health Impact Profile surface. Frequent intake of fermentable carbo- (OHIP) and the General Oral Health Assess- hydrates, especially sugars, has been shown to 11 4 ment Index (GOHAI). The basic design principles by the caries process can be filled by various and considerations are very similar, thus the direct and indirect restorative materials. There are also various surgical and As with the developments in medical research, non-surgical ways to treat the periodontal pock- randomised controlled trials (RCTs) have become ets that are formed in more advanced periodontal the gold standard in conducting clinical trials disease states. The key features of RCTs are clinical trials to quantify the amount of plaque on treatment modalities being assigned randomly to the tooth surfaces, ranging from a simple dichoto- the subjects and the existence of a control group. In by the presence or absence of bleeding after gen- the perfect setting, RCTs should also be double- tle probing7 or in an ordinal scale using various blinded which requires that both the subjects and DENTISTRY AND MAXILLO-FACIAL 195 the examiners/observers involved in the trials are subjects as their own controls prevents confound- not aware of the assignment of the treatment ing by many characteristics that may influence modalities to the subjects, thus reducing any the outcome. In a crossover study each subject is biases in the comparison of the groups besides given the different treatments (or treatment and randomisation. Informed consent, ethical consideration, data Each subject is his/her own control. The sequence monitoring and pre-study sample size calculation of assignment is generally randomised, so that are also important issues in conducting RCTs. However, since subjects who partici- possibility of any side-effects or risks arising pate in clinical trials with crossover design need from receiving the treatments, and their rights of to receive all treatment regimens and undergo discontinuing participation.

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