DH Boards; Pharmacology
About this set
Created by:
krissyDH on March 20, 2012
Subjects:
Classes:
Pharmacology for the Dental Hygienist, SB-Class 2013, DHYG 1206, NTCC Dental Hygiene 13
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262 terms
Terms | Definitions |
|---|---|
 What is a function of the amount of a drug to produce an effect? | Potency |
| Potency is GREATER when the dose is ??? | Smaller |
| Maximum intensity of effect or response that can be produced by a drug regardless of dose? | EFFICACY |
| Administering more drug will NOT increase efficacy of the drug but will often increase the probability of what? | ADVERSE DRUG REACTIONS |
| B*Efficacy and potency of a drug are...** | UNRELATED |
| ____-___ equals half the amount of time for a drug to fall to half of the original blood level; relates to DURATION of effect. | Half-life |
| Routes of administration affects what? | Onset and duration |
| ROA when drug is placed directly into the GI tract by oral or rectal? | Enteral |
| ROA when drug bypasses the GI tract; includes INJECTION, inhalation, topical administration? | Parenteral |
| What ROA is considered the safest, least expensive, and most convenient? | ORAL Route |
| Where is the largest absorbing area in the enteral route? | Small intestine |
| ROA -slower onset -stomach or intestinal irritation -drugs may be inactivated by GI acidity/enzymes like INSULIN -drug leves are LESS PREDICTABLE -Necessitates greater pt. cooperation | ORAL ROUTE |
| Oral adminstered drugs must first pass through what? | hepatic portal circulation Known as first-pass effect |
| **B* Drugs with high first-pass effect require what?* | *Require a larger dose* |
| Phase I reactions are carried out in the liver by what? | cytochrome P-450 enzymes AKA mixed function oxidase |
| Why would the rectal route be chosen? | Vomiting or unconscious |
| What route produces the most rapid drug response and the absorption phase is bypassed? | Intravascular route |
| Route of choice for emercency situation? | Intravascular route |
| What are disadvantages of IV route? | phlebitis-caused by local irritation Drug irretrievability allergy side effects of high plasma drug concentrations |
| What does massage do to drug in intramuscular route? | Massage Increases absorption |
| how does intramuscular route absorption occur? | due to high blood flow has a sustained effect |
| What ROA is local anesthetics and insulin injections? | Subcutaneous route |
| This is the route used to adminster protein products and may produce a sterile abscess? | Sub-cutaneous route |
| This ROA is injected into epidermis like a TB skin test? | Intradermal route |
| This route provides rapid delivery of a drug across a large surface area of repiratory mucosa? | Inhalation for asthma and nitrous oxide |
| Topical ROA is contraindicated when? | if surface is ulcerated, burned or abraded |
| Topical ROA conciderations: | -have increased concentration of the drug -most effective with less keratinized tissue -used when Local effect is desired -may have systemic effect |
| Study of how a drug is absorbed, distributed, metabolized and excreted? ADME | Pharmacokinetics |
| Rate and efficiency of absorption depend on what? | Route of administration |
| absorption of a drug may be what? | active or passive |
| What type of drugs are the only drugs to pass the blood-brain barrier and readily move across MOST biological membranes by diffusion? | Lipid soluble drugs |
| Absorption is dependent of what several factors? | -Drug solubility -Circulation at deposition site -Total surface area available for absorption -Drug PH -Temperature at site -Mechanical factors |
| After being absorbed, drugs are distrubuted to where? | Oral dose-->LIVER Sublingual dose--> HEART |
| Distribution is dependent on what x3? | Blood flow capillary permeability (Blood-brain-barrier) Binding of drugs to protiens ALBUMIN |
| If a drug binds to ALBUMIN, what do you do>? | Increase dose |
| What is the major site for drug metabolism? | LIVER; liver disease may impair metabolism |
| Drug elimination _________ drug effects? | TERMINATES |
| Drugs are most often eliminated by biotransformation and/or excretions into what? | Urine or bile |
| What is the most important means of excretion? | KIDNEY/Renal |
| What are other means of excretion? | liver lungs bile GI sweat milk exhalation sweat SALIVA GINGIVAL CREVICULAR FLUIDS |
| Are FAT suluble vitamins excreted in urine? | NO, they need to be metabolized into water soluble form in the liver first. |
| How is fluoride eliminated from the body? | Excretion through urine |
| What is the most accurate rule to determine childs dose of drug is safe to administer? | Surface area rule |
| Amount of desired effect is excessive; dose related? | Toxic reaction |
| dose related reaction that is not part of the desired therapeutic outcome; ex. drowsiness with antihistamine? | Side effect |
| Abnormal drug response that is usually genetically related? | Idiosyncratic reaction |
| hypersensitivity response to a drug to which the patient has been preciously exposed; NOT DOSE RELATED? | Drug Allergy |
| Causal relationship between maternal drug use and congenital abnormalities? | Teratogenic Effect |
| What did Thalidomide induce? | Antinausea drug caused phocomelia (shortened limbs) |
| Drug interactions may result in what? x2 | toxicity lack of efficacy |
| Gingival hyperplasia associated with phenytoin/dilantin generally occurs where? | Anterior |
| Mouthbreathing would exhibit inflamed gingiva where? | Anterior |
| What are the 2 systems of the autonomic nervous system? | Parasympathetic nervous system Sympathetic nervous system |
| Neurotransmitter for the Parasympathetic nervous system? | **acetylcholine** |
| functions of the PANS? | REST and DIGEST; dilates blood vessels-->increasing blood flow constricts bronchiolar diameter constricts pupil Stimulates salivary gland secretion peristalsis digestion/absorbtion of food |
| What x3 type of drugs are used to mimic the effects of the parasympathetic nervous system? | Paraympathomimetics Cholinergic agents Muscarinic drugs |
| What are the previous drugs used to treat? | Xerostomia Urinary retention Glaucoma |
| What are examples of cholinergic agents derived from plant alkaloids? | Pilocarpine nicotine |
| *B*Contraindications for cholinergic/parasympathomimetic drugs? | **Asthma-->causes bronchonstriction Peptic Ulcer-->increase GI secretions Cardiac disease-->decrease heart rate GI/Urinary obstruction-->increase GI motility** |
| What are examples of anticholinergic drugs? | immodium-tx diarrhea *Atropine*-->to decrease salivary flow in the dental setting Scopolamine-->motion sickness |
| Effects of anticholinergic drugs? | ABCD A anticholinergic agents B blurred vission & bladder retention C constipation D dry-mouth |
| What is the neurotransmitter for the Sympathetic Autonomic nervous system? | Norepinephrine |
| *B* what else is a neurotransmitter for the SANS? | Acetylcholine |
| Functions of the SANS? | Fight or Flight -Vasoconstriction Dilates bronchioles of the lung -Increase heart rate Dilates pupils |
| Examples of Sympathomimetics or Adrenergic agents? | EPInephrine ALBUTEROL Pseudoephedrine Ritalin Adderall |
| Adverse effects of adrenergic agents? | CNS disturbances (ANXIETY,fear, tension...) Cardiac arrythmias Cerebral hemorrhage pulminary edema |
| Contraindications for Sympathomimetics or Adrenergic agents? | ANGINA Uncontrolled HYPERtension Uncontrolled HYPERthyroidism Cocaine, Meth abuse |
| Oral signs of methamphetamine abuse? | rampant caries and burned mucosal surfaces from the route of administration of meth, not the meth |
| TX for meth? | NO meds; councling only |
| What is albuterol? | Adrenergic drug drug of choice for acute asthma Bronchodilator |
| Where are beta-1 receptors located? | Heart 1 heart |
| where are beta-2 receptors located? | all over the body, but mainly in the lungs 2-lungs |
| What is the action of B-adrenergic blocking agents on the heart? | lower heart rate and blood pressure and are useful when the heart itself is deprived of oxygen |
| When are beta blockers prescribed? | Often after heart attacks |
| **when should non-selective beta blockers not be used? | with patients with asthma or any reactive airway disease-->can block the effects of beta=2 agonists, such as ALBUTEROL |
| What is the prototype for Beta-adrenergic blockers? | Propranolol |
| What does Propranolol have an effect on? | Heart...lowers cardiac output Lungs...bronchoconstriction |
| What is a cardioselective B-blocker used for tx. hypertension when pt. is asthmatic because it has no effect on lungs? | Atenolol Metoprolol |
| *B* If a pt. is taking a cholinergic drug (Albuterol); what must the pt. take to treat hypertension? | A cardioselective b-blocker (heart only/no lung) Atenolol Metoprolol |
| What is the Prototype of non-narcotic analgesics and is considered an NSAID? | ASPiRIN |
| What are the uses for Aspirin? | Analgesia-pain Antipyretic-fever Antiinflammatory-inflammation |
| What is the mechanism of action for Aspirin? | Inhibition of prostaglandin synthesis |
| through an action on what does aspirin reduce fever? | An action on the HYPOthalmus-thermostat for body |
| What are the side effects of aspirin? | interferes with blood blotting (CX w/ coumadin) GI irritation (CX w/peptic ulcers) Hypersensitivity (~15% pts. allegic) REYE's Syndrome in kids/adolecents, give tylenol instead |
| What is a term for asprin toxicity? | Salicylism |
| What are symptoms of Salicylism? | TINNITUS-ringing in the ears GI upset Confusion/dizziness Dim vision Coma Respiratory and metabolic acidosis Death from respiratory failure |
| Prostoglandins cause what? | Inflammation/pain |
| What is the prototype for NSAIDS? | Ibuprofen |
| What is the mechanism of action for ibuprofen? | Inhibition of prostoglandin synthesis |
| What is the actions of ibuprofen? | Analgesic-pain Antipyretic-fever Antiinflammatory-inflammation |
| What are side effects of Ibuprofen? | Interferes with blood clotting-CX w/coumadin GI irritation, less than aspirin, CX with peptic ulcers |
| NOTE IBUPROFEN | IBUPROFEN is available in suspended form for pediatric use as an antipyretic-fever reducer |
| B What drugs can ibuprofen reduce the pharmacological effects of? | BOARD ACE inhibition Asprin Beta Blockers Corticosteroids Cyclosporines Lithium Loop diuretics |
| What are the actions of Acetaminophen? | Analgesic-pain Antipyretic-fever |
| Is Aspirin an NSAID? | NO; it has no antiinflammatory effect |
| what is acetaminphen a drug of choice for? | for patient in anticoagulants (coumadin) or with Peptic ulcer disease |
| What can an overdose of Acetaminophen result in? | Hepatotoxicity Liver necrosis DEATH |
| What is the post-opperative pain med recemmendation following root planning? | ACETAMINOPHEN |
| When nonopiods fail at reducing pain, what is the drug of choice?> | Narcotics/opiods |
| What is the mechanism of action of an opiod drug? | Blocks pain receptors in the brain without loss of consiousness |
| What is the prototype for opiods? | Morphine |
| what are other examples of opiod drugs? | Demerol Dilaudid Codeine |
| What is the most commonly used opiod in dentistry? | Codeine |
| What schedule drug is codeine alone? | II |
| What schedule drug is codeine with acetaminophen? | III |
| Codeine is what? | Antitussive-cough suppressant |
| Codeine is a stopper; what does it stop? | Coughing breathing-Side effect...respiratory depression pooping-Side effect...constipation |
| What is a sign of codeine/opiod addiction/use? | Pinpoint PupilsB Boards love their pupil ?'s |
| What is an opiod ANTAGONIST? used to treat opiod overdose and should be in dental emergency kit? | NARCAN what can stop codiene, NarCAN can stop Codiene OD |
| What drug is used for TX of narcotic withdrawal and dependence of heroin, morphine, and other opiods? | METHADONE |
| B Pupils for heroin? Pupils for cocaine? | Heroin...pupils are pinpoint; Cocaine...pupils are dilated |
| B What is the best pain medication for heroin users? | NSAIDS |
| What appointment consideration should be done for IV drug users? | Antibiotic Pre-medication; becuase they dirty people |
| What is the most commonly prescribed antibacterial in the dental proffesion? | Pennicillin VK |
| What % of bacteria is penn VK effective against? | 90% |
| Why is Penn VK preferred over Penn G? | Because Penn VK has less erratic absorbion; Penn G is inactivated by Gastric acids |
| Why is Amoxicillin preferred over Penn VK? | pt. compliance; Amoxicicillin is TID instead of QID dosing |
| What is the mechanism of action for Pennicillins? | Destroys bacterial cell wall integrity leading to LYSIS of bacteria |
| When is the bacteria more susceptible to penn? | while rapidly growing organism; during sex they are too distracted and are killed easier |
| B What antibiotics is most likely to produce an Anaphylactic reaction? | Penicillin; if pt. allergic to penn, will be allergic to all derivatives |
| What is the most common manifestation of Penn allergy? | Rash |
| Can Penicillin be given to pregnant women? | YES |
| Penicillinase is an enzyme released from some gram - bacteria that breaks down penicillin, AKA? | Beta lactamase |
| If culture is positive for beta lactamase, what is used in conjuction with Amoxicillin and its called what? | Clavulanic acid; Augmentin |
| When taking tetracyclines, what should be avoided? | Dairly products antacids iron tablets -because they cause chelation of tetras. which reduces the GI absorbtion |
| Tetracyclines are used in perio, why? | because they have the ability to **concentrate in gingival crevicular fluid** |
| Tetracyclines are often used TOPICALLY to treat WHAT? | AGGRESSIVE Perio |
| Tetracyclines are used SYSTEMICALLY to treat what? | NUG/NUP |
| What type of bacteria is metronidazole effective against? | obligate anaerobes ONLY |
| What should be avoided with metronidazole? WHy? | ALCOHOL, mouthrinse; because of anabuse-like reaction |
| What are side effects of antibiotics? | GI upset Secondary fungal infection; candidiasis, yeast Allergic reaction |
| What are the 4 ANTItuberculosis agents the pt. must take all of? RIPE | RIPE Rifampin Isoniazid Pyrazinamide Ethambutol |
| If a pt. is taking ISOIAZID only; what is it most like being used for? | TB PREVENTATIVELY |
| IS TB caused by a virus or Bacteria? | Bacteria |
| What test is used to test for TB? | Mantoux skin test |
| What does a positive Mantoux skin test mean? | that the pt. has been previously exposed to TB |
| What is the antigen used in the Mantoux skin test? | PPD; purified protein derivative |
| B Know meds for TB vs. HIV | TB...RIPE |
| What is the TOPICAL drug of choice for Candida? | Nystatin |
| What is the SYSTEMIC drug of choice for Candida? | Diflucan/Fluconazole |
| When does someone with joint replacement need premed? | Less than 2 years following replacement Previous prosthetic joint infection ALWAYS consult orthopedic surgeon when in doubt |
| Shunts=Premed? Stents=Premed? | Shunts=YES Stents=NO |
| RX abbrviation: ac | before meals |
| pc | after meals |
| hs | at bedtime, husshh! go to sleep |
| bid | twice a day |
| gt | drop |
| po | by mouth |
| prn | as needed |
| q3h | every 3 hours |
| qd | every day |
| qid | 4 times a day |
| tid | 3 times a day |
| stat | immediately |
| tab | tablet |
| bsig | label; instructions for use |
| ud | as directed |
| *How are class II drugs handled?* | *Written RX with providers signature only, NO REFILLS* ex. Codeine |
| how are class III drugs handled? | RX may be phoned in; No more than 5 refills in 6 months... ex. Tylenol III with codeine |
| how are class IV drugs handled? | Same as schedule III drugs; RX may be phoned in; No more than 5 refills in 6 months |
| Any RX for a controlled substance requires what? | DEA number |
| Any RX for a schedule II drug must what? | Be written in pen or typed |
| Some states require what for Class II drug Rx? | Triplicate prescription blanks |
| What are the 2 major classes of Antianxiety agents? | Barbiturates Benzodiazepines |
| What is the principle effect of barbiturates? | CNS depression |
| What is a long-acting barbiturate used in the TX of EPILEPSY? | Phenobarbital (pheno...like pheny-toin for seizures barbital...barbiturates) |
| Does Barbiturates provide an anelgesic effect? | NO pain relief |
| What are Benzodiazepines useful in treating? | SHORT-term anxiety, insomnia, alcohol withdrawel |
| All benzodiazepines have what properties? | Sedative properties |
| All Benzodiazepines have NO what activity? | NO antipsychotic activity NO analgesic activity DO NOT affect the ANS |
| Benzodiazepines + other CNS depressents (alcohol) = | additive effect (death) |
| what reduces the effectiveness of Benzodiazepines? | Smoking |
| How is Benzodiazepines used in the dental setting? | relax fearful patient muscle relaxant/TMD BReverse status epilecticus and siezures associated with local anesthetic OD |
| Examples of Benzodiazepines? | Diazepam, (Valium) Lorazepam, (Ativan) Xanax (Alprazolam) Tranxene |
| What do general anestheics produce? | Reversible loss of consciousness and insensitivity to painful stimuli |
| What is nitrous oxide considered? | incomplete anesthetic |
| Nitrous oxide used in the dental setting, maintains the patient in what stage of anesthesia? | Stage I |
| The end of stage I is marked by what? | Loss of consciousness |
| Stage II is associated with what? | involuntary movement, delirium, excitement |
| What stage is most major surgeries performed in? | Stage III |
| What happens in stage IV? | Respiratory cessation, DEATH NOT the ideal stage! |
| What may be given prior to general sedation? | BENZODIAZEPINES (Valium) |
| What is the most common inhaled anesthetic? | Nitrous Oxide |
| How does Nitrous work for pain control? | Raises pain threshold |
| What color are Nitrous tanks? | Blue |
| What is used for the removal of nitrous from air? | Scavenger system |
| What is route of excretion for Nitrous? | Exhalation |
| What is the side effect sweating caused by while using nitrous? | vasodilation of extremities |
| *What are CX to the use of Nitrous Oxide?* | COPD Upper respiratory infection, stuffy nose Emotion.behavioral instability Pregnancy **Cystic fibrosis** Lack of communication |
| *B* What can long-term recreational abuse of N20 lead to? | Neurological symptoms similar to Parkinsons Vitamin B12 deficiency...numbness/tingling in extremities |
| What is the leading cause of death in the US? | Heart disease (Cardiovascular disease) |
| What does cardiovascular disease include? | Hypertension Angina Heart attach Congestive heart failure Arrhythmias Cerebrovascular accident |
| What are cardiovascular CX to dental tx? | Myocardial infarction (3-6 months) Unstable/recent angina Uncontrolled congestive heart failure Uncontrolled arrhythmias significant/Uncontrolled/Unknown hypertension |
| What are Digitalis Glycosides used to treat? | Congestive heart failure; increase contractive strength (make heart stronger) |
| BWhat is the most common Digitalis Glycoside?* | *Digoxin/Lanoxin) |
| What needs to be avoided with Digoxin/Lanoxin? | sympathomimetics (VASOCONSTRICTORS in LA) can lead to Cardiac Arythmias |
| What effect does Tetracycline and Erythromycin have on Digoxin/Lanoxin? | increases Digoxin levels in blood |
| What oral side effects does Digoxin/Lanoxin have? | increased salivation increased gag reflex |
| What is the drug of choice for ACUTE Angina? | Nitroglycerin |
| How does nitroglycerin work? | vasodilates, smooth muscle relaxant |
| Where is nitroglycerin given, and following absorption, where does it go? | Sub-lingually, goes to heart |
| What is the most common of all cardiovascular diseases? | Hypertension; asymtomatic |
| What is the first line of therapy for hypertension? | Diuretics |
| how do diuretics work to lower blood pressure? | promote excretion of sodium and water, which decreases blood volume and pressure |
| What are the two major types of diuretics? | Thiazide and Loop diuretics |
| What is the most commonly used thiazide diuretic? | Hydrocholorothiazide (HCTZ) |
| Side effects of Hydrocholorthiazide? | Xerostomia Orthostatic hypotension |
| What is the most common loop diuretic? | Furosemide (Lasix) |
| what patients use Furosemide (Lasix)? | Hypertensive patients with Congestive heart failure |
| how do Calcium channels work? | By producing systemic vasodilation by BLOCKING vasoconstriction in smooth muscle blood vessels |
| Calcium channel blockers are one of the few antihypertensive agents whose effect is? | NOT REDUCED by NSAIDS |
| Common oral side effects of CCB is? | Xerostomia **Gingival enlargement** |
| Common calcium channel blocking agents include? | Nifedipine (Procardia, Adalat) Cardizem Norvasc Verapamil |
| What do ACE inhibitors stand for? | Angiotension Converting Enzyme Inhibitors |
| Common suffix for ACE inhibitors? | -PRIL |
| What are ACE inhibitors used for? | To lower Blood Pressure |
| What are adverse reactions for ACE inhibitors? | DRY COUGH [going to ACE hardware store will give you a cough from the -dril (-pril)] Hypotension Allergic Reactions |
| What ACE inhibitor is used for someone who has Congestive heart failure to lower their high blood pressure? | Enalapril |
| What is the effects of NSAIDS on ACE inhibitors? | NSAIDS decrease the effectiveness of ACE inhibitors! |
| What is the most serious drug interaction of warfarin/coumadin? | ASPIRIN (increases bleeding tendecies) |
| How does Coumadin work? | Vitamin K helps clot blood; coumadin inactivates Vitamin K |
| What other drug category has an effects on warfarin? | Antibiotics; due to effect on vitamin K |
| Who decides to reduce warfarin dose prior to TX? | PHYSICIAN |
| What is the most commonly emplayed anticoagulants given by injection in hospitalized patients only? | Heparin; rat poison |
| What is the most common barbiturate used to treat epilepsy? | Phenobarbital |
| Trigeminal neuralgia AKA? | Tic del la rue; suicide disease |
| what anticonvulsant is used to treat trigeminal neuralgia and partial seizures and is similar to a tricyclic antidepressants? | Caramazepine (Tegretol) |
| What are side effects of Benedryl? | Xerostomia Sedation :) |
| What is the mechanism of action for Benedryl? | blocks histamine receptors |
| what are the 2 types of histamine receptors? | H1 receptors (bronchospasm/vasodilation)-where antihistamines work H2 receptors (gastric and secretion) |
| What is the most common adverse reaction associated with insulin? | Hypoglycemia/Insulin shock |
| most common Type 2 diabetes meds? | metaformin (glucophage) |
| What is the most common short-acting bronchodilator inhaled B-agonist? | Albuterol |
| What is used long term to preven asthma attacks? | Corticosteroids EX. FLOVENT (fluticasone) |
| What is a combination of a corticosteroid and a long-acting bronchodilator? | ADVAIR |
| What is used to treat chronic asthma and the bronchospasm associated with emphysema and chronic bronchitis? | THEOPHYLLINE |
| *What can increase serum levels of THEOPHYLLINE and cause toxicity* | *erythromycin* |
| What NSAID should Asthmatics avoid? Why? *Board | ASPIRIN many asthmatics are allergic to aspirin (4-19%) |
| B What can albuterol cause? | INSOMNIA |
| what are the first line of treatment for COPD? | Anticholinergic drugs |
| What is the drug of choice for long-term management of COPD? | Ipratropium (Atrovent) |
| what are used as "cough suppressants" for the relieft of a non-productive cough? | Antitussives (Opiods are used because they are a stopper) |
| What drugs can Antacids inhibit? | Tetracyclines Digitalis Iron |
| What is the most prevalent GI disease in the US? | GERD |
| What are the 2 ways to treat GERD? | Histamine 2 blocking agents Proton Pump Inhibitors (PPI) |
| What should be avoided with Histamine 2 blocking agents? | ANTACIDS-it disrupts absorption |
| What are examples of Histamine2 blocking agents? | cimetidine (TagametHB) famotidine (Pepcid AC) |
| What is a POTENT Proton PUMP Inhibitor (PPI)? (Think P's) | Priolosec (omePrazole) |
| Pt. who lists TAGAMENT on health history is likely being treated for what? | Gastric ulcers |
| If a pt. is suddenly taken off Synthroid (hypothyroid drug), what would occur? | Myxedema coma |
| What does Iodine deficiency cause? | Goiter |
| What does Alcohol in combination with Nitroglycerin result in? | Dangerously Low Blood Pressure |
| Flagyl AKA? | Metronidazole |
| What is CX with Flagyl (metronidazole)? | Alcohol-antabuse like reaction |
| What does Chantix do? | Blocks nicotinic receptors in the brain |
| Common side effects of Estrogen? | NOT XEROSTOMIA Nausea/vomiting may cause gingival inflamation -May promote endometrial carcinoma and breast cancer in post-menopausal women |
| What is lipitor? | high cholesterol drug |
| What does lipitor do to warfarin? | increases the anticoagulant effect |
| Prednisone treats what? | Autoimmune disorders Addisons disease inflammatory symptoms allergies |
| Side effects of Prednisone? | Cushings disease like symtoms |
| Hypothyroidism in children can lead to what? | Cretinism |
| Symptoms associated with Cretinism? | Mental/physical retardation Expressionless/puffy face Dwarfism uncooperatice *ORal conditions* -Delayed tooth eruption -malocclusion -increased caries/perio |
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