Transcript
Good MORnING
PHARMACOLOGY IN ENDODONTICS
Two Major Origins
REVERSIBLE PULPITIS IRREVERSIBLE PULPITIS ACUTE APICAL ABSCESS
GINGIVAL ABSCESS PERIODONTAL ABSCESS NUG PERICORONITIS
Types of Odontogenic Infections
PULPAL PERIODONTAL
Sequelae:
• Draining sinus
•Cellulitis
•Fascial space infections
COMPROMISED HOST DEFENCE
INAPPROPRIATE TREATMENT
Microbiology of odontogenic infectionsAerobes/Facultative Anaerobes
Anaerobes
Gram +ve cocci Viridans Streptococci
S.Oralis
S.Sanguis
S.Mitis
Gram-ve cocci
Peptococcus
Peptostreptococcus
Streptococcus
Veillonella
Gram +ve bacilli
Gram -ve bacilli E.Coli
H.Influenzae(rare)
Lactobacillus
Actinomycetes
Fusobacterium
Prevotella,Bacteroides
INFECTION CONTROL
Bacterial Pathways To Pulp
- Dental Caries - Periodontal Disease - Fractures - Dentinal Tubules - Anachoresis
MEDICAL HISTORY
Rheumatic feverArtificial heart valvesCoronary artery diseaseHypertensionDiabetesHepatitisBlood dyscrasiasDrug allergy……..
ANALGESICS
CLASSIFICATION
(Acc. to Tripathi)
A. Analgesic and Antiinflammatory :
Aspirin, Salicylamide, Benorylate, DiflunisalSalicylates
Phenylbutazone, oxyphenbutazonePyrazolone derivatives
Indomethacin, sulindacIndole derivatives
Ibuprofen,Naproxen, Ketoprofen, Fenoprofen, Flurbiprofen.
Propionic acid derivatives
Mephenamic acid Anthranilic acid derivative
Diclofenac, Tolmetin Aryl-acetic acid derivatives
Piroxicam, Tenoxicam, Meloxicam.Oxicam derivatives
Ketorolac.Pyrrolo-pyrrole derivative
NImesulideSulfonanilide derivative
NabumetoneAlkanones
B. Analgesic but poor Antiinflammatory:
Paracetamol (Acetaminophen)Paraaminophenol derivative
Metamizol (Dipyrone), propiphenazone Pyrazolone derivatives
NefopamBenzoxazocine derivative
Acc. to Goodman and Gillman
A. Non selective Cox inhibitor
Aspirin, sodium salicylate, choline magnesium trisalicylate, salsalate, diflunisal, salfasalazine, olsalazine.
Salicylic acid derivatives
Acetaminophen Para amino derivatives
Indomethacin, sulindacIndole & indene acetic acid
Tolmetin, diclofenac, ketorolac. Heteroaryl acetic acid
Ibuprofen, naproxen, flurbiprofen, ketoprofen, fenoprofen, oxaproxin.
Aryl propionic acid
Mefenamic acid, meclofenamic acid Anthranilic acid (fenamates)
Oxicams (piroxicam, Meloxicam) Enolic acid
Nabumetone. Alkanones
RofecoxibDiaryl substituted furanones
B. Selective cox-2 inhibitor
Celecoxib Diaryl substituted Pyrazoles
Etodolac Indole acetic acid
NimesulideSulfonanilides
COMMON PROPERTIES OF ALL NSAIDS
Analgesia Antipyresis
Anti-inflammatory
Dysmenorrhoea
Antiplatelet aggregatory
Ductus arteriosus
closureParturition
Gastric mucosal damage
Renal effects
Anaphylactoid reactions
Analgesics after certain endodontic procedures
ANALGESICS USED IN DENTAL PROCEDURES
- Canal debridement - Primarily Used Is Aspirin- Tylinol Can Also Be Used . If More Needed , then Give Analgesic With Quarter Gram
Codeine- Canal debridement where considerable
overinstrumentation has occurred -Then give analgesic with quarter gram Codeine
ANALGESICS IN ENDODONTIC
PROCEDURES Canal Filling Where Overfilling Has Occurred
And Periapical Tissues Are Normal, Then Give Analgesics With Quarter Gram Codeine
Root Amputation Without Flap – Aspirin And Tylinol Can Be Given
Periapical Or Amputational Surgery With Minimal Trauma – Aspirin And Tylinol Can Be Used
Extensive Surgery With Considerable Trauma - Analgesics With Half Gram Codeine
PAIN MANAGEMENT STRATEGY
3D iagnosis efinitive Rx
rugs
Definitive treatment :
•Pulpotomy, pulpectomy, Root Canal Treatment
•Extraction
•Incision & drainage
Drug :
•Pretreat with NSAIDs
•Prescribe by clock
•Long acting LA
•Flexible prescription plan
Flexible analgesic prescription plan
Aspirin like drugs indicated
Aspirin like drugs contra indicated
Ibuprofen 200 mgAcetaminophen 600-1000mg
NSAIDs (alone max.effective dose) OR NSAID +
acetaminophen
Acetaminophen 600-1000 mg + codine 60 mg
Ibuprofen 400 mg/4 hrly and equivalent of acetaminophen 600 mg / codine 60 mg 4 hrly
Acetaminophen 1000 mg with equivalent of oxycodone 10
mg
NSAID (max. dose) & acetaminophen / oxycodone
10 mg combination
Mild pain
Moderate pain
Severe pain
ADVANCES Selective cox-2 inhibitors :
Celecoxib, rofecoxib, valdecoxib, etoricoxib, meloxicam,
diisopropyl flurophosphate.
Action
Celecoxib P L
Use-osteoarthritis, rheumatoid arthritis
Dose – 200 mg / day OD or 100 mg BD.
Commercial names – Celebrex, Celib, Celfast, Celact etc.
Banned – July 2001 Rofecoxib P L
Dose – 12.5 mg OD (max. dose 25 mg)
Commercial name – Vioxx, Dolib MD, Roff, Rofaday
Banned – September 2004
Valdecoxib
Dose – 10-20 mg OD
Commercial name – Valed, Valus, Vorth, Bextra
Banned –7 April 2005.
Other drugs banned by FDA
Benoxaprofen
Phynylbutazone
Oxyphenbutazone
Saprofen
Piroxicam
SEDATIVES & TRANQUILIZERS
SEDATIVES AND TRANQUILIZERS IN
ENDODONTIC PROCEDURES-Sedatives , barbiturates
- Pento Barbital – Hypnotic dose 100 mg at bed time. To be reduced in elderly and debilitated patients - Secobarbital – 50 mg at bed time and 50 mg 30 minutes before appointment
-Sedatives, non barbiturates
- Flurazepam – hypnotic dose is 15-30mg at bed time , 15 mg for elderly or debilitated patients -Triazolam – 0.125 – 0.25 mg for adult patients
TRANQUILIZERS
Diazepam (valium)
- 5 or 10 Mg Tablets Available- 1 Tablet At Bed Time ,1 Tablet 1-
2 Hours Before AppointmentOxazepam
- 10-30 Mg Capsules And Tablets-1 Tablet At Bed Time And 1
Tablet 1-2 Hour Before Appointment
ANTIBIOTICS
CLASSIFICATIONCHEMICAL STRUCTURE
Sulfonamides- Sulfadiazines, Sulfones, Dapsone, Paraaminosalicylic Acid(pas)
Diaminopyrimidines- Trimethoprim -Lactam Antibiotics- Penicillins,
Cephalosporins, Monobactums
Tetracyclines- Oxytetracycline, Doxycycline
Nitrobenzene Derivative- Chloramphenicol
Aminoglycosides- Streptomycin, Gentamycin, Neomycin
Macrolide Antibiotics- Erythromycin, Roxithromycin
Polypeptide Antibiotics- Polymixin-B , Colistin, Bacitracin
Nitrofuran Derivatives- Nitrofurantoin, Furazolidone
Nitroimidazoles- Metronidazole, TinidazoleQuinolones- Nalidixic Acid, Norfloxacin,
CiprofloxacinNicotonic Acid Derivatives- Isoniazid,
Pyrazinamide, Ethionamide
Polyene Antibiotics- Nystatin, Amphotericin-B, Hamycin
Imidazole Derivatives- Miconazole, Ketoconazole, Clotrimazole
Others- Rifampicin, Clindamycin, Vancomycin, Cycloserine, Ethambutol.
TYPE OF ORGANISMS AGAINST WHICH PRIMARILY ACTIVE
Antibacterial- Pencillins, Aminoglycosides, Erythromycin
Antifungal- Griesofulvin, Ketoconazole
Antiviral- Acyclovir, Zidovudine
Antiprotozoal- Chloroquine, Metronidazole
Antihelminthic- Mebendazole
SPECTRUM OF ACTIVITY NARROW SPECTRUM BROAD SPECTRUM
- Penicillin –G - Tetracyclines- Streptomycin -
Chloramphenicol- Erythromycin
TYPE OF ACTION PRIMARILY BACTERIOSTATIC
- Sulphonamides - Tetracyclines - Chloramphenicol- Erythromycin
PRIMARILY BACTERICIDAL
-Penicillin -Cephalosporins-Aminoglycosides-Polypeptides-Ciprofloxacin
ANTIBACTERIAL THERAPY ??? The Big Question!
BACK TO BASICS!
Infections are ultimately cured by the host, not by Antibiotics.
One has to avoid:
RATIONAL ACTIVISM
REFLEX PRESCRIBING
When do Antibiotics help?Especially virulent bacteria.
Host overwhelmed by bacteria.•Physiological depression of host defence
•Pathological:
•Defective immune system:
•Drugs:
Agammaglobulinaemia
Multiple Myeloma
Total body radiation
Cytotoxic drugs
Glucocorticoids
Azathioprine
Cyclosporine
Malnutrition, Cancer & Leukemia
INDICATIONS FOR ANTIBACTERIAL THERAPY
Acute onset infection.
Diffuse swelling.
Compromised host defence.
Severe Pericoronitis.
Cellulitis.
Involvement of Fascial spaces.
Osteomyelitis.
Where is Antibiotic use unnecessary ?
Reversible / Irreversible Pulpitis.Acute Apical / Periodontal abscess.Gingival / Periodontal abscess.Dry socket.Chronic well localized abscess.Mild Pericoronitis.Minor Vestibular abscess.
Selection of the Antibacterial agent
Malaise,Fever,Chills,Trismus,Rapid Respiration,Lymphadenopathy,Swelling,Abscess & Cellulitis
Systemic considerationsPolypharmacyHistory of adverse drug reactions
Establish a clear indication
Determine patient’s health status
Selection of appropriate agent , with:
Dosage regimen
Duration of therapy
Patient compliance
Narrow spectrum
Low toxicity
Definitive therapy
Gram’s smear
Culture & Sensitivity
Empirical therapy
History
Clinical criteria
THE RATIONAL APPROACH
Reversible Pulpitis Precludes any benefit from Antibiotics
Irreversible Pulpitis
Acute Apical/Perio./Ging. Abscess
ANUG
Elimination of source of infection/inflammation without concurrent,routine use of Antibiotics
Pericoronitis Empirical antibiotic therapy based on signs& symptoms
Cellulitis Empirical antibiotics+ I & D + Culture & Sensitivity of purulent exudate
ANTIBIOTIC PROPHYLAXIS
NEEDED IN
Heart patients - Artificial valves
- Bacterial endocarditis
Artificial joint patients - Immuno compromised
- Rheumatoid arthritis
- Radiation
- Immunosuppression
ANTIBIOTIC PROPHYLAXIS
Other patients- IDDM - Malnutrition - Hemophilia
NOT NEEDED IN» Coronary artery bypass graft» Rheumatic fever without valve
damage» Pacemakers
ANTIBIOTIC PROPHYLAXIS
• Prophylaxis for dental treatment needed in
-Extractions-Periodontal procedures-Sub gingival antibiotic fiber placement-Oral prophylaxis -Implants-Instrumentation beyond apex-Intra ligamentry injection-Orthodontic band placement
ANTIBIOTIC PROPHYLAXIS
• Prophylaxis not needed in – Restorative treatment even with
retraction cord– Radiographs– Local anesthesia, except PDL– Impressions and partial dentures– Fluoride treatments– Endoscope within canal– Rubber dam – Suture removal– Shedding of primary teeth
PROPHYLACTIC REGIMEN FOR DENTAL PROCEDURES
ADULTS (WT>25KG) 3gm Amoxycillin (orally) 1hr prior to procedure.
1.5gm Amoxycillin 6hr after initial dose.
CHILDREN (WT<25KG) 40mg/kg Amoxycillin orally 1hr prior to
procedure.
20mg/kg Amoxycillin 6hr after initial dose.
Other drugs given are:
ADULTS:
Clindamycin 600mg orally 1hr before procedure
OR Cephalexin or Cefadroxil 2.0gm/kg
orally 1hr before procedure
OR Azithromycin or Clarithromycin 500mg
orally 1hr before procedure.
CHILDREN:
Clindamycin 10mg 1hr before procedure, then half doses 6hrs after initial dose.
OR
Cephalexin or Cefadroxil 50mg/kg orally 1hr before procedure.
OR Azithromycin or Clarithromycin
15mg/kg orally 1hr before procedure.
GOLDEN RULES FOR ANTIBIOTIC USAGE
-Don't use antibiotics unnecessarily
-Avoid broad spectrum Antibiotics as far as possible
-Don’t prolong the antibiotic therapy unnecessarily
-In cases of chronic infections like Tuberculosis, Leprosy, etc employ multiple drug regime.
TIME TO WAKE UP ANY QUESTIONS???
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