Good MORnING

PHARMACOLOGY IN ENDODONTICS

Types of Odontogenic Infections

Sequelae:
Two Major Origins
Draining sinus
Cellulitis
Fascial space infections

PULPAL
REVERSIBLE PULPITIS IRREVERSIBLE PULPITIS ACUTE APICAL ABSCESS

PERIODONTAL
GINGIVAL ABSCESS PERIODONTAL ABSCESS NUG PERICORONITIS

COMPROMISED HOST DEFENCE INAPPROPRIATE TREATMENT

Microbiology of odontogenic infections

Aerobes/Facultative Anaerobes
Gram +ve cocci
Viridans Streptococci S.Oralis S.Sanguis S.Mitis Peptococcus Peptostreptococcus Streptococcus

Anaerobes

Gram-ve cocci
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 fever Artificial heart valves Coronary artery disease Hypertension Diabetes Hepatitis Blood dyscrasias Drug allergy..

ANALGESICS

CLASSIFICATION
(Acc. to Tripathi)
A. Analgesic and Antiinflammatory :
Salicylates
Pyrazolone derivatives Indole derivatives Propionic acid derivatives Anthranilic acid derivative Aspirin, Salicylamide, Benorylate, Diflunisal Phenylbutazone, oxyphenbutazone

Indomethacin, sulindac
Ibuprofen,Naproxen, Ketoprofen, Fenoprofen, Flurbiprofen. Mephenamic acid Diclofenac, Tolmetin Piroxicam, Tenoxicam, Meloxicam. Ketorolac. NImesulide Nabumetone

Aryl-acetic acid derivatives

Oxicam derivatives Pyrrolo-pyrrole derivative Sulfonanilide derivative Alkanones

B. Analgesic but poor Antiinflammatory:

Paraaminophenol derivative Pyrazolone derivatives Benzoxazocine derivative Nefopam Paracetamol (Acetaminophen) Metamizol (Dipyrone), propiphenazone

Acc. to Goodman and Gillman

A. Non selective Cox inhibitor

Salicylic acid derivatives Aspirin, sodium salicylate, choline magnesium trisalicylate, salsalate, diflunisal, salfasalazine, olsalazine. Acetaminophen Indomethacin, sulindac Tolmetin, diclofenac, ketorolac.

Para amino derivatives

Indole & indene acetic acid Heteroaryl acetic acid

Aryl propionic acid Anthranilic acid (fenamates) Enolic acid

Ibuprofen, naproxen, flurbiprofen, ketoprofen, fenoprofen, oxaproxin. Mefenamic acid, meclofenamic acid

Oxicams (piroxicam, Meloxicam)

Alkanones Nabumetone.

B. Selective cox-2 inhibitor

Diaryl substituted furanones Diaryl substituted Pyrazoles Celecoxib Indole acetic acid Sulfonanilides Etodolac Rofecoxib

Nimesulide

COMMON PROPERTIES OF ALL NSAIDS

Analgesia Anaphylactoid reactions

Antipyresis Antiinflammatory

Renal effects

Dysmenorrhoea

Gastric mucosal damage Parturition Ductus arteriosus closure

Antiplatelet aggregatory

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

iagnosis efinitive Rx rugs Drug : Pretreat with NSAIDs Prescribe by clock Long acting LA Flexible prescription plan

Definitive treatment : Pulpotomy, pulpectomy, Root Canal Treatment

Extraction
Incision & drainage

Flexible analgesic prescription plan

Aspirin like drugs indicated Ibuprofen 200 mg NSAIDs (alone max.effective dose) OR NSAID + acetaminophen Ibuprofen 400 mg/4 hrly and equivalent of acetaminophen 600 mg / codine 60 mg 4 hrly Aspirin like drugs contra indicated

Mild pain

Acetaminophen 600-1000mg
Acetaminophen 600-1000 mg + codine 60 mg

Moderate pain

Severe pain

NSAID (max. dose) & acetaminophen / oxycodone 10 mg combination

Acetaminophen 1000 mg with equivalent of oxycodone 10 mg

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 Appointment

Oxazepam - 10-30 Mg Capsules And Tablets -1 Tablet At Bed Time And 1 Tablet 1-2 Hour Before Appointment

ANTIBIOTICS

CLASSIFICATION
CHEMICAL 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, Tinidazole Quinolones- Nalidixic Acid, Norfloxacin, Ciprofloxacin Nicotonic 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 - Streptomycin - Erythromycin

- Tetracyclines -Chloramphenicol

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: Malnutrition, Cancer & Leukemia

Defective immune system: Agammaglobulinaemia

Multiple Myeloma

Drugs:

Cytotoxic drugs Glucocorticoids Azathioprine Cyclosporine

Total body radiation

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

Establish a clear indication
Malaise,Fever,Chills,Trismus,Rapid Respiration,Lymphadenopathy,Swelling,A bscess & Cellulitis

Determine patients health status

Systemic considerations Polypharmacy History of adverse drug reactions

 Selection of appropriate agent , with:

Narrow spectrum Low toxicity Empirical therapy
History Clinical criteria

Definitive therapy
Grams smear Culture & Sensitivity

Dosage regimen

Duration of therapy
Patient compliance

THE RATIONAL APPROACH

Reversible Pulpitis Irreversible Pulpitis Acute Apical/Perio./Ging. Abscess ANUG Pericoronitis Cellulitis
Precludes any benefit from Antibiotics Elimination of source of infection/inflammation without concurrent,routine use of Antibiotics Empirical antibiotic therapy based on signs& symptoms 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 -Dont prolong the antibiotic therapy unnecessarily -In cases of chronic infections like Tuberculosis, Leprosy, etc employ multiple drug regime.

TIME TO WAKE UP

ANY QUESTIONS???