Pharmacology in Endodontics

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???