importance of pharmacology in endodontics.

1. ENDODONTIC PHARMACOLOGY

2. CONTENTS
• Introduction
• Importance of medical history
• Considerations for effective pain control
• Local anaesthesia
• NSAIDs
• Opiod analgesics
• Corticosteroids
• Antibiotics
• Enzymes
• Management of pregnant patients
• Conclusion

3. INTRODUCTION
Pharmacology is the science of drugs.
In greek, Pharmacon - drug and logos- discourse in
Deals with interaction of exogenously administered chemical
molecules with living systems.
WHO(1966)- defined Drug as “any substance or product that is used or
intended to be used to modify or explore physiological systems or
pathological states for the benefit of recipient”
In context of dental practice a broad understanding of pharmacology
is imperative to prescribe/use drugs specially in systematically
compromised patients.

4. Even today, endodontic treatment and pain are considered
synonymous which is a misconception.
•Achieving successful endodontic pain control in a predictable and
efficient manner requires working knowledge of the underlying
pathology , adequate skill and efficient pharmacotherapy.
According to a February 2015 AAE online survey, root canal treatment is the dental
procedure that makes Americans most apprehensive. Fifty-six percent said root canal
treatment would cause anxiety, followed by tooth extraction and placement of a
dental implant . Women are more likely than men to say dental procedures make
them anxious, including root canal treatment (62% vs. 48%), tooth extraction (54% vs.
39%) and dental implant placement (49% vs. 35%). However, a 2008 AAE consumer
awareness survey found that patients who have experienced root canal treatment
are six times more likely to describe it as “painless” than patients who have not had
root canal treatment.

5. IMPORTANCE OF MEDICAL HISTORY
•vital role in the diagnosis, treatment planning and prescribing
drugs.
•Virtually no systemic contraindications to endodontic therapy
but still, a recent medical history is mandatory
•Some medical conditions can have clinical presentations that
mimic oral pathologic lesions.
•also include family history, because it will be helpful in focusing
on relevant inherited diseases, such as hemophilia, thallesemia,
malignant hyperthermia susceptibility etc.
•Provides awareness regarding drug allergies or allergies to
dental products.

6. MEDICAL CONDITIONS THAT WARRANT
MODIFICATION OF DENTAL CARE OR TREATMENT

7. CONSIDERATIONS FOR EFFECTIVE “ THREE D”
PAIN CONTROL
• DIAGNOSIS
• DEFINITIVE DENTAL TREATMENT
• DRUGS
Diagnose the pain condition, then deliver appropriate Dental
treatment and finally administer effective Drugs.

8. • Management of endodontic pain-multifactorial –reduction in
peripheral+central components of hyperalgesia through
combined endodontic procedures and pharmacotherapy.
• Pharmacotherapy in endodontics mainly involves-
LOCAL ANAESTHESIA
NON-NARCOTIC ANALGESICS : NSAIDS
OPIOD ANALGESICS
CORTICOSTEROIDS
ANTIBIOTICS

10. Effective local anaesthesia is the bedrock of pain control in endodontics.
CLINICAL FACTORS TO BE CONSIDERED FOR INCOMPLETE ANAESTHESIA BEFORE
REVIEWING THE LITERATURE
First, subjective approaches for assessing depth of anaesthesia(are you numb?) lack
sensitivity & specificity. Instead testing for pulpal responses should de done.
Second, prior history of incomplete anaesthesia often predicts subsequent problems
with obtaining complete anaesthesia.
Third, pre-operative pain is a risk factor with eight fold increase in prevalence of
incomplete anaesthesia in patients with irreversible pulpitis.
Fourth, preoperative apprehension, possibly due to previous dental procedures

11. •LA are drugs which upon topical application or local injection cause reversible
loss of sensory perception, especially of pain, in a restricted area of body
without loss of conciousness.
The sequence in which sensations are lost
CLASSIFICATION
• Depending on the route of administration
•Depending on duration and mode of action
•Depending on chemistry
PAIN COLD WARMTH TOUCH MOTORPRESSURE

12. DEPENDING ON ROUTE OF ADMINISTRATION AND DURATION OF ACTION
INJECTABLE
Low potency, short duration
Procaine
Chloroprocaine
Intermediate potency, duration
Lignocaine (Lidocaine)
Mepivacaine
Articaine
High potency, long duration
Tetracaine
Bupivacaine
Dibucaine
SURFACE ANESTHETICS
Soluble
Cocaine
Lidocaine
Tetracaine
Benoxinate
Cyclomethycaine
Insoluble
Benzocaine
Butylaminobenzoate (Butamben)
Oxethazaine

13. DEPENDING UPON CHEMISTRY
FEATURES OF AMIDE LAS
•Produce more intense and longer lasting anaesthesia
•Not hydrolysed by plasma esterases
•Rarely cause hypersensitivity reactions
Articaine

14. MECHANISM OF ACTION

15. LIGNOCAINE
Introduced in 1948
Metabolism : liver
Vasodilation properties <procain but > prilocain
Onset of action : rapid (2-3 min’s)
Effective dental concentration :2%
Topical anesthetic action : present , availabe as 10% spray formulation
Action: ( 2% lidocain + 1: 100000 epinephrine) CONSIDERED STANDERED
40- 60 mins pulpal anesthesia
2-3 hrs – soft tissue anesthesia
Less bleeding in the area of injection

16. MEPIVACAINE
• Introduced in: 1960, 2% with vasoconstrictor
• 1961, 3% without vasoconstrictors.
• Potency: same as cocain
• Vasodilation property: Slight
• Onset of action: rapid (1 ½ - 2 min’s)
• Effective dental concentration: 3% without vasoconstrictors
• 2% with vasoconstrictors
• Topical anesthetic concentration: not in clinically acceptable
concentrations.
• Action: Mepivacain plain is most often administered in paediatric
dentistry and is very appropiate in management of geriatric patients

17. BUPIVACAINE
•Produce very long acting anesthetic effect upto 8 hours to delay the post
operative pain from the surgery for as long as possible
• 0.5% solution with vasoconstrictor(1:200000)
• less frequently used in dentistry
• Onset time is longer than other drugs because most of the radicals (about
80%) bind to sodium channel proteins effectively
• most toxic local anesthetic drug

18. PRILOCAINE (CITANEST)
• Identical pKa and same conc. with lidocaine
• Almost same duration as lidocaine
• Less toxic in higher doses than lidocaine because small vasodilatory activity
ARTICAINE (SEPTOCAINE)
• newest local anesthetic drug approved by FDA in 2000
• Same pKa and toxicity as lidocaine, but its half life is less than about ¼ of
lidocaine
• available in combintion of artcaine 4% and epinephirine 1:100000
•Not contraindicated in patients with sulfa allergies.

19. MANDIBULAR ANAESTHESIA
Involves conventional IAN block using 1.8 ml of 2% lignocaine with 1:100000
epinephrine.
Anaesthetic success- defined as percentage of subjects who achieve two
consecutive 80 readings on EPT within 15 mins and lack of responsiveness for
60 mins. This end point is benchmark for clinically significant information.
Obtained in 35 to 60% of patients
Anaesthetic failure- defined as percentage of subjects who never achieved two
consecutive 80 readings on EPT at any time during 60 min period.
Obtained in 11% to 32% of patients
Slow Onset- normally within 10-15 mins. Defined as percentage of subjects
who achieved an 80 EPT reading after 15 min.
Occurs in 19 to 17% of cases.
Duration- persists for approximately 2.5 hours

20. ALTERNATIVE INJECTION SITES AND TECHNIQUE
•Gow-gates and Vazirani-akinosi
•Incisive nerve block at mental foramen
•Mandibular first molar infiltration injection of an articaine solution following
IAN block
ALTERNATIVE ANAESTHETIC SOLUTIONS
•3% Mepivacaine (carbocaine polocaine and scandonest) and 4% prilocaine
(citanest plain)
•Articaine with 1:100000 epinephrine(septocaine)
•4% prilocaine 1: 200000 epinephrine ( citanest forte)

21. MAXILLARY ANESTHESIA
•More easily obtained than mandibular anesthesia
•Infiltration most commonly used technique with 1.8 ml of 2% lidocaine
(1:100000 epinephrine).
•Anaesthetic Success – infiltration anesthesia results in 90% to 95% of
succesful pulpal anesthesia
•Anesthetic failure- occurs about 5% to 10%.
•Onset of anesthesia- occurs within 5 to 7 mins
•Duration of anesthesia- in anterior teeth starts to decline after about 20 to
30 mins.
In molar teeth, declines after 30 to 45 mins.

22. ALTERNATIVE INJECTION TECHNIQUE
•Posterior superior alveolar nerve block
•Infraorbital nerve block
•Palatal-Anterior superior alveolar nerve block
•Anterior middle superior alveolar nerve block
ALTERNATIVE ANAESTHETIC SOLUTIONS
•3% Mepivacaine (carbocaine polocaine and scandonest) and 4% prilocaine
(citanest plain)
•Articaine with 1:100000 epinephrine(septocaine)
•4% prilocaine 1: 200000 epinephrine ( citanest forte)
•0.5% Bupivacaine wuth 1:200000 epineprine(Marcaine)

23. SUPPLEMENTAL ANAESTHESIA
When anesthesia from conventional injections is inadequate and pain too
severe for practitioner to proceed.
Three such techniques include:
Intraligamentary anesthesia
Intraosseous anesthesia
Intrapulpal injection

24. INTRAOSSEUOS ANESTHESIA
•LA delivered directly into cancellous bone adjacent to tooth 3mm to 7mm
apical to mucogingival junction
•Two intraosseuos systems available-
Stabident system
X-tip system
•Anesthetic success- 82% success rate in absence of back flow into oral cavity
•Concerns-
 Perforation pain- 48% patients with irreversible pulpitis had moderate to
severe pain with stabident system
Perforator separation
•Drawback
invasive procedures and require greater technical skill.
•Advantage- LA reach the bloodstream quickly and
without loss during the absorption process.

25. INTRALIGAMENTARY ANESTHESIA
ONSET- Immediate with no waiting period
Duration- 10 to 20 mins when given as primary injection
approximately 23 mins when given as supplemental to IAN block.
Anesthetic success- reported to be 60% to 96% for endodontic procedures
when used as supplemental injection
Technique- needle is placed in the gingival sulcus on the mesial surface and
advanced along the root surface until resistance is met. Approximately 0.2ml
of anesthetic is injected under strong back pressure.
Drawback- possibility of tissue damage
-technique sensitive

26. INTRAPULPAL INJECTION
INDICATION- even when repeated supplemental injections given, pain persists
when pulp is entered
DRAWBACK-
•Moderately to severely painful: needle placed directly into vital pulp
•Short duration(15 to 20 mins) hence bulk of pulpal tissue must be removed
quickly at correct WL
•Pulp must be exposed which is difficult as anesthetic problems occur before
exposure while still working in dentin
ADVANTAGE-
•Profound anesthesia only if given under back
pressure
•Immediate onset

27. PRECAUTIONS AND INTERACTIONS
•Aspirate lightly to avoid intravascular injection.
•Inject LA slowly and take care not to exceed the maximum safe dose.
•Vasoconstrictor containing LA should be avoided for patients with
ischaemic heart disease
cardiac arrhythmia
Thyrotoxicosis
uncontrolled hypertension
those receiving beta blockers.
•Propranolol reduce metabolism of lignocaine

29. •Major class of drugs for managing endodontic pain.
•NSAIDS offer antiinflammatory, analgesic and antipyretic effects.
•In 1971,Vane & coworkers observed that aspirin & other nsaids
blocked prostaglandin production.

31. COX-1
•ubiquitous form
•produced in normal condition
•serves physiological house
keeping functions
•regulate cellular homeostasis,
such as renal blood flow, and in
circumstances where
prostaglandins have a protective
function, such as gastric mucus
production.
COX-2
•the inducible form of the
enzyme
•Present in minute quantities
•expressed in endothelial
cells, macrophages, synovial
fibroblasts, mast cells, and
osteoblasts after tissue
trauma, and therefore plays
an important role in
inflammation.

32. •Analgesia: prevention of pain
nerve ending sensitization
•Antipyresis
•Anti-inflammatory
•Antithrombotic
•Closure of ductus arteriosus
•Gastric mucosal damage
•Bleeding: inhibition of
platelet function
•Limitation of renal blood
flow: sodium & water
retention
•Asthma & anaphylactoid
reactions in susceptible
individual
BENEFICIAL ACTIONS SHARED TOXICITY
ACTIONS DUE TO PROSTAGLANDIN SYNTHESIS INHIBITION

33. CLASSIFICATION

34. NONSELECTIVE COX INHIBITORS( MIXED COX)
Pyrazolone derivatives
Salicylates
Indole derivatives
Propionic acid derivatives
Anthranilic acid derivatives
Aryl-acetic acid derivatives
Oxicam derivatives
Pyrrolo-pyrrole derivatives
Aspirin, Diflunisal
Phenylbutazone, Oxyphenbutazone
Indomethacin, Sulindac
Ibuprofen, Naproxen, Ketoprofen, Flurbiprofen
Mephenamic Acid
Diclofenac
Piroxicam, Tenoxicam
Ketorolac

35. PREFENTIAL COX-2 INHIBITORS
Nimesulide, Meloxicam, Nabumetone
Celecoxib,Rofecoxib,Valdecoxib
SELECTIVE COX-2 INHIBITORS
ANALGESIC-ANTIPYRETICS WITH POOR ANTIINFLAMMATORY
ACTIONS
• Paracetamol (Acetaminophen)Paraaminophenol derivatives
• Metamizol (Dipyrone), PropiphenazonePyrazolone derivatives
• NefopamBenzoxazocine derivatives

36. SALICYLATES- ASPRIN
• Is Acetylsalicylic acid
• Rapidly converted in body to salicylic acid, responsible for most of its
action.
PHARMACOLOGICAL ACTIONS
• Analgesic, Antipyretic, Anti-inflammatory actions
• Metabolic effects: cellular metabolism is increased specially in skeletal
muscles
• Effect on cardiovascular system
• Effect on GIT
• Effect on blood & platelets

37. ADVERSE EFFECTS
At analgesic dose(0.3-1.5 g/day)
• Nausea,vomiting,epigastric distress,increased occult blood loss
in stools.Most important is gastric mucosal damage & peptic
ulceration.
At Anti-inflammatory doses(3-5 g/day)
Produces syndrome called salicylism- causing dizziness, tinnitus,
vertigo, reversible impairment of hearing and vision, excitement &
mental confusion, hyperventilation, and electrolyte imbalance
An association between salicylate therapy and reye’s syndrome
has been noted

38. •Acute salicylate poisoning
More common in children
Fatal dose in adult is 15-30g, but lower in children
Manifestations include Vomiting, dehydration, electrolytic
imbalance, acidotic breathing, hyper/hypoglycaemia, petechial
haemorrhages, restlessness, delirium, hallucinations,
hyperpyrexia, convulsions, coma & death due to respiratory
failure& cardiovascular collapse
T/T- symtomatic and supportive
•Hypersensitivity & idiosyncrasy
rashes, fixed drug eruption, urticaria, rhinorrhoea,
angioedema, asthma & anaphylactoid reactions

39. PRECAUTIONS & CONTRAINDICATIONS
Given during
pregnancy- low birth
weight babies
Should be stopped 1
week before elective
surgery
Bleeding tendencies
Should be avoided by
breast feeding
mothers
In chronic liver
disease: hepatic
necrosis
Avoid in diabetics & in
juvenile rheumatoid
arthritis
Avoid in G-6PD
deficient individuals-
haemolysis can occur
Patients sensitive to it
& in peptic ulcer

40. PROPIONIC ACID DERIVATIVES
•Includes ibuprofen, naproxen, flurbiprofen and ketoprofen
•Ibuprofen – first member of class (1969)
•Ibuprofen considered prototype and has well documented
efficacy and safety profile.
•Multiple randomized, placebo-controlled clinical studies have
shown that NSAIDs such as ibuprofen, in doses ranging from 400-
600 mg, provide profound analgesia for inflammatory pain due to
endodontic infection.

41. ADVERSE EFFFECTS
•gastric discomfort, nausea
and vomiting.
•CNS effects including
headache, dizziness,
blurring of vision and
tinnitus
•Avoid in peptic ulcer
patient
•Contraindicated in
pregnancy
THERAPEUTIC USES
•rheumatoid arthritis,
osteoarthritis and other
musculoskeletal disorders
where pain is more
prominent than
inflammation
• soft tissue injuries,
fractures, tooth extraction
and post operatively
suppresses swelling and
inflammation.

42. DOSAGE AND PREPARATIONS OF PROPRIONIC ACID
DERIVATIVE

43. SELECTIVE COX-2 INHIBITORS
•Includes celecoxib, rofecoxib and valdecoxib.
•Offered potential for both analgesic and antiinflammatory
benefits with reduced GI irritation.
•Moreover COX-2 levels are increased in inflammed human dental
pulp.
BENEFICIAL EFFECTS OVER CONVENTIONAL NSAIDS
•Reduced GI damage and occurrence of peptic ulcers.
•Do not depress TXA2 production by platelets.
•Do not inhibit platelet aggregation or prolong bleeding time.

44. ROFECOXIB
 selectivity of 36-800 fold.
-avoided in presence of
severe renal/ hepatic
diseases.
plasma t1/2 - 17 hours.
 Dosage-12.5-25 mg OD.
CELECOXIB
COX-2 selectivity 6-375 fold.
even at maximal doses does
not affect the gastroduodenal
mucosa.
plasma t1/2 - 11 hours.
 Dosage: 100-200 mg BD.

45. CONCERNS
Rofecoxib-Introduced in 1999-Became very popular for osteo
and rheumatoid arthritis as well as for dental and musculoskelal
pain but withdrawn in september 2004 due to high risk of MI and
stroke.
Two metaanalysis conducteetd by Kearny et al and Mcgettigan
estimated a relative risk for CV events associated with COX-2
inhibitors to be 1.42. Naproxen was found to have no significant
adverse effect on CV system.
As of December 2011, only celecoxib is still available for
purchase.
Given this situation and reasonable alternative NSAIDS COX-2
inhibitors not recommended for treating routine endodontic pain
patients.

46. ARYL ACETIC ACID DERIVATIVE
•Diclofenac sodium
•Analgesic-antipyretic-antiinflammatory
•Inhibits PG synthesis with short lasting antiplatelet action
•Adverse effects- mild epigastric pain, nausea,headache,
dizziness
•Dosage- 50mg T.D.S, B.D.
75mg B.D
•Often used in combination with paracetamol
Diclofenac (50 mg) + Paracetamol (500 mg)

47. PYRROLO -PYRROLE DERIVATIVES
•Includes Ketorolac
•potent analgesic, modest anti inflammatory and antipyretic
activity.
•equalled the efficacy of morphin in post operative pain ,but does
not interact with opioid receptors and is free of opiod side effects.
•rapidly absorbed after oral and im administration
•USES-
 Post operative, dental and acute musculoskeletal pain.
 Migraine `
 Pain due to bony metastasis.

48. •ADVERSE EFFECTS-
Nausea, abdominal pain ulceration, loose stools, drowsiness,
nervousness and fluid retention have been noted.
•DOSAGE- Orally 10-20 mg 6hrly for short term management
of moderate pain.
•Acute pain : 20- 30 mg im/iv every 6 hr
•2-16 years- 0.5 mg/kg IV/IM q6hr; not to exceed 5 days
•In postoperative dental pain ketoralc rated superior to
aspirin 650 mg, paracetamol 600mg and equivalent to
ibuprofen 400 mg.

49. DRUG INTERACTIIONS OF NSAIDS

50. PARA AMINO PHENOL DERIVATIVES
•Paracetamol Introduced in 1950 - a de-ethylated active
metabolite of phenacetin
•Good antipyretic and raises pain threshold, but has weak
peripheral antiinflammatory component
•No significant drug interactions.
•Dosage- 10-15 mg/kg
Adults- 0.5-1 g TDS
Infants-50 mg
Children- 1-3 years- 80-160 mg
4-8 years – 240-320 mg
9-12 years – 300-600 mg

51. USES
•over the counter drug,in head
ache, musculoskeletal
pain,dysmenorrhea.
•First choice analgesic for
osteoarthritis.
• Best drug to be used as
antipyretic.
•Can be used in all age groups
as well as in pregnant and
lactating mothers
ADVERSE EFFECTS
•Analgesic nephropathy -
occurs after years of heavy
ingestion
•Acute paracetamol
poisning

52. ACUTE PARACETAMOL TOXICITY
•Occurs in children with low hepatic glucuronide conjugating
ability.
•If a large dose (>150mg/kg) is taken serious toxicity can occur
•Healthy adults- not > 4000mg
•Early manifestations- nausea, vomiting, abdominal pain and liver
tenderness
•Lately, hepatic necrosis accompanied by renal tubular necrosis
and hypoglycemia progressing to coma.

53. TREATMENT
•Gastric lavage done
•Activated charcoal given to prevent further absorption.
•N-acetylcysteine 150mg/kg should be infused i.v over 15 mins,
followed by the same dose i.v over next 2 hrs.
•Alternatively 75mg/kg may be given orally every 4-6 hours for 2-3
days.

54. •Mild to moderate pain : paracetamol or low dose aspirin
•Post-extraction or acute pain : Ketorolac, propionic acid derivative,
diclofenac, nimesulide or aspirin
•Gastric intolerance to NSAIDS : selective COX-2 inhibitor, celecoxib.
•Patient with history of asthma or anaphylactoid reactions to
aspirin/ other NSAIDS : nimesulide
•Postoperative or other acute but short lasting painful condition
with minimal inflammation – Ketorolac
•Paediatric patients- paracetamol, ibuprofen and naproxen have
been adequately evaluated.
NSAIDS IN DENTISTRY

55. COMORBID CONDITIONS AGGRAVETED BY NSAIDS
•Peptic ulcer
•Hypertension
•Congestive heart failure
•Renal insufficiency
•Haemostatic disorder

56. AHA 2007 RECOMMENDATIONS FOR PATIENTS WITH
CARDIOVASCULAR DISEASE
•Acetaminophen and opioid analgesics preferred for short-term
pain management
•If NSAID is needed, naproxen “appears to be the preferred
choice”
•Prescribe them at lowest effective doses for shortest possible
period of time
•Diclofenac not recommended as NSAID in this group of patients
•Ibuprofen should be given 30 mins AFTER low-dose aspirin or 8
hrs before
Use of NSAIDs. An update for clinicians. A Scientific Statement from the American Heart
Association Antman, E. M. et al. February 26, 2007

57. DO NSAID DRUGS “MASK” SYMPTOMS IN THE ODONTOGENIC PAIN
PATIENT?
•Many patients will self-medicate with over-the-counter
ibuprofen before coming to the dental office.
•In a study it was demonstrated that 800 mg ibuprofen reduced
palpation pain by 40%, percussion pain by 25% and cold pain
by 25% on teeth with a diagnosis of symptomatic irreversible
pulpitis and symptomatic apical periodontits .
•Thus, clinicians should ask which analgesics were taken in the
4-6 hours prior to clinical evaluation
Read JK, McClanahan SB, Khan AA, Lunos S, Bowles WR. Effect of Ibuprofen on masking endodontic diagnosis.
J Endod. 2014;40(8):1058-62.

58. OPIOD ANALGESICS

59. •Potent analgesics for moderate to severe pain
•produce majority of their therapeutic and adverse effects by acting as
agonists at mu and/or kappa opioid recepters in brain
• inhibits transmission of nociceptive signals from trigeminal nucleus to higher
brain regions.
•Codiene considered the protoype for orally available combinations.

60. Analgesic efficacy is unlimited, side effects often prevent the
use of doses adequate to completely relieve severe pain.
ANALGESIC DOSES OF OPIODS

61. ADVERSE EFFECTS
•Nausea, emesis, dizziness, drowsiness
•GI distresss- Constipation
•Potential for respiratory depression
•Chronic use-dependence and tolerance
As dosage is limited by side effects- combination
formulation preffered mostly with acetaminophen,
aspirin or ibuprofen.

62. COMMONLY PRESCRIBED OPIOD ANALGESICS FOR TREATING
DENTAL PAIN

63. ANTIBIOTICS

64. •Odontogenic infections, including endodontic infections, are
polymicrobial, and in most cases, the prescription of
antibiotics is empirical.
•Led to the increasing use of broadspectrum antibiotics even in
cases where antibiotics are not indicated, such as symptomatic
irreversible pulpitis, necrotic pulps and localized acute apical
abscesses
•International concern about the overuse of antibiotics and
the emergence of antibiotic-resistant bacterial
strains(American Association of Endodontists 1999)
•As dentists prescribe approximately 10% of antibiotics
dispensed in primary care.

65. CLASSIFICATION
Based on mechanism of action -
• Inhibit cells wall synthesis: Penicillin, Cephalosporins, Vancomycin,
Bacitracin etc.
• Damage membrane: (Causing leakage of cell contents) :
Amophotericin and Nystatin.
• Bind to ribosmes and inhibit protein synthesis: Chloramphenicol,
Tetracycline, Erythromycin, Aminoglycosides, Clindamycin.
• Inhibit DNA gyrase : Floroquinolones like ciprofloxacin, Norfloxancin.
• Inhibit DNA functions: Rifampicin.
• Inhibit DNA synthesis: Acyclovir, Zidovudine.
• Interfere with metabolic steps: Sulphonamide

67. PENICILLIN V
•Narrow-spectrum antibiotic for infections caused by aerobic
gram-negative cocci, facultative and anaerobic
microorganisms
•Exerts its antibacterial effect by the inhibition of cell wall
production in bacteria.
•Not well absorbed from the intestinal tract, meaning that at
least 70% of an oral dose is wasted, with diarrhoea as a
frequent side effect.

68. • Dosage-
•Adults- loading dose of 1000 mg of penicillin v should be
administered orally followed by 500 mg every 6-8 h
• Children < 12- 25-50 mg/kg/day in 3-4 divided doses
Testing antibiotic susceptibility on a panel of bacteria
isolated from endodontic infections, the percentages of
susceptibility for the 98 species analysed were 85% for
penicillin v, 91% for amoxicillin, 100% for
amoxicillin/clavulanic acid, 96% for clindamycin and 45% for
metronidazole (baumgartner & xia 2003).

69. AMOXILLIN
• Alone or in combination with clavulanic acid, is the preferred
prescribed antibiotic in endodontic infections.
•Represents a synthetic improvement upon the original
penicillin molecule.
•Moderate-spectrum, bacteriolytic, b-lactam antibiotic

70. Demonstrates greater efficacy and therapeutic value
• broader spectrum and is more effective than penicillin V
against certain gram-negative anaerobes due to better microbial
penetration
•absorption not impaired by food ,reaching peak plasma levels
within 2 hours of ingestion
• Only approximately 20% of absorbed amoxicillin is protein-
bound in the plasma, being more readily available
•
5. significantly greater half-life requiring doses to be taken 2-3
times a day as opposed to 4 times daily for penicillin V
AAE Guidance on the Use of Systemic Antibiotics in Endodontics 2007

71. •Dosage `1000 mg loading dose followed by 500 mg every 8 h
250 mg amox/125-mg clavulanate Tablets
500 mg amox/125-mg clavulanate Tablets
Paediatric patients- 30 mg/kg/day divided every 12 hours
Oral suspensions-
125 mg/31.25 mg per 5 mL
200 mg/28.5 mg per 5 mL
250 mg/62.5 mg per 5 mL
•Has been argued that it has a broader spectrum than is
required for endodontic needs and, therefore, its use in a
healthy individual could contribute to the global problem of
antibiotic resistance (American Association of Endodontists
1999)

72. ANTIBIOTIC RESISTANCE
indiscriminate antibiotic use has selected strains that possess
many resistance mechanisms against beta-lactam antibiotics.
These include:
1. constitutive expression of high molecular weight
penicillin-binding proteins (PBP) that have lower affinity
to beta-lactam antibiotics;
2. expression of beta-lactamase (also known as penicillinase)
enzymes and
3. drug efflux pumps, particularly in certain gram-positive
strains
AAE Guidance on the Use of Systemic Antibiotics in Endodontics 2007

73. CEPHALOSPORIN
•Semisynthetic B-lactams
•Generally more resistant to B-lactamases.
CLASSIFICATION

74. ORAL FIRST GENERATION CEPHALOSPORINS
• Cephalexin Monohydrate
Adult- 0.25-1 g 6-8 hourly
Children- 25-100mg/kg/day
Uses- active against strains of gonococci, meningococci,
actinomyces, C. diptheria,and other anaerobes
Finds place in dentistry as alternative to amoxicillin
• Cefadroxil
Adult-0.5-1 g BD
Children- 25-100mg/kg/day
Uses- similar to cephalexin, frequently used in dentistry

75. ORAL SECOND GENERATION CEPHALOSPORINS
• Cefaclor
Adults- 125 - 250 mg capsules BD
Children-20-40 mg/kg/day
Uses- against H. influenzae, E. coli
• Cefuroxime axetil
Adults-250-500 mg BD
Children- 125-250 BD, 125mg/ml suspension BD
Uses-meningitis,
-Action against anaerobes, frequently chosen for
dental infections

76. Cefprozil
250,500 mg tablets
125,250/5cc susp
250-500 mg q 12 h
Children: 7.5 - 10 mg/kg q 12 h

77. THIRD GENERATION
• Spectrum: gram negative > gram positive.
• Cefotaxime
Adult- 1-2 gm im/iv 6- 12 h
Children- 50 -100 mg/kg/day 12 h
Uses- meningitis, septicemia, infections in immunocompromised
patients
• Ceftriaxone
uses-
Meningitis 4 gm followed by 2 gm iv
( children 75-100 mg/kg) once daily for 7 -10 days
Typhoid 4 gm iv daily x 2 days followed by
2 gm/day ( children 75mg/kg) till 2 days after fever subsides

78. •Cefixime- orally active
Adults- 200-400mg BD
children-100 mg/5ml
Uses- respiratory, urinary and biliary infections

79. METRONIDAZOLE
•used either as an antiprotozoal agent or an antibiotic against
anaerobic bacteria
•suggested as a supplemental medication for amoxicillin
because of its excellent activity against anaerobes (American
Association of Endodontists (AAE) 1999)
•used in combination with penicillin V or amoxicillin increased
the susceptibility to 93% and 99% of bacteria, respectively
•DOSAGE - 1000 mg loading dose followed by 500 mg every 8 h
•Paediatric patients15-30 mg/kg/day PO/IV divided q6h

80. MACROLIDES
•Comprises of Erythromycin, Clarithromycin and Azithromycin
•effective against a variety of aerobic and anaerobic gram-
positive bacteria.
•Valuable in patients allergic to penicillin or those with penicillin
resistant infections.

81. •DOSAGE FOR CLARITHROMYCIN- 500-mg loading dose
followed by 250 mg every 12 h
Children 6 months-12 years - 7.5 mg/kg twice a day.
DOSAGE FOR AZITHROMYCIN - a loading dose of 500 mg on
the first day and then 250 mg on days 2 to 5.
• chidren-10 mg/kg on the first day, followed by doses of 5
mg/kg per day for the following 4 days
•ADVERSE EFFECTS-
•Jaundice
•Ototoxic (high doses)
•GI distress

82. CLINDAMYCIN
•belongs to the lincosamide class of antibiotics
•effective against most gram-positive aerobes and both gram-
positive and gram-negative facultative bacteria and
anaerobes
Uses
•first drug of choice for patients with a history of
hypersensitivity to penicillin drugs.
•Because of good bone penetration- particularly suited for
dentoalveolar abscess.

83. Dosage - 600 mg loading dose followed by 300 mg every 6 h
for adults
Children: 10-20mg/Kg divided into 4 equal doses.
Adverse Effects
•Pseudomembranous colitis – clindamycin > cephalosporins
> aminopenicillins.
Clostridium difficile infection was responsible for almost half
a million infections and was associated with approximately
29,000 deaths in 2011
•Abdominal pain, fever, leukocytosis, bloody stool…
•Diarrhea commonly develops on days 4-9 of treatment.
Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, et al. Burden of
Clostridium difficile infection in the United States. N Engl J Med 2015;372:825-34.

84. INDICATIONS FOR ANTIBIOTICS AS AN ADJUNCT DURING
ENDODONTIC THERAPIES
The most important initial decision is not which antibiotic to prescribe but whether to
use one at all !

85. Can Systemically Administered Antibiotic Reach Pulpal And
Periradicular Tissues In Therapeutic Concentrations?
If antibiotic are to be effective in managing endodontic symptoms, they must reach
the target tissue in therapeutic concentrations.
This is especially a concern in pathological conditions, when the tissue may have
reduced blood flow or may even become necrotic.
In a study conducted on the vital dental pulp from patients with impacted third molar
or partially erupted mandibular third molars, it was shown that level of an ampicillin
analog peaked in the pulp in about 90 min. the mean ratio of antibiotic in the pulp to
that in serum at peak value was 0.61 with a range of 0.01-0.99.
Various studies have been done which conclude that antibiotic can permeate vital
pulpal and periradicular tissue within the hours in level that can reach the MIC for
some pathogens, but that permeation of empty space may take days, and is
presumably by diffusion.

86. DURATION OF ANTIBIOTIC THERAPY
•In endodontic infections has not been defined precisely
•General tendency to administer an antibiotic for 5–7 days
•Fazakerley et al. (1993) and Martin et al. (1997) compared
three antibiotics and duration of usage (2, 3 and 10 days).
They reported that the majority of the patients were
asymptomatic after 2 days.
•Despite the fact that antibiotics - useful tools in cases posing
risk for the patient, they are not substitutes for endodontic
treatment. The key to obtaining a successful result in an
endodontic infection is the chemomechanical removal of the
infecting agent from the root canal system as well as drainage
of pus.

87. ANTIBIOTIC PROPHYLAXIS
Defined as the administration of antibiotics to patients
without evidence of infection to prevent bacterial colonization
and reduce subsequent postoperative or post-treatment
complications.
Indication for antibiotic prophylaxis for dental patients
-prevention of infective endocarditis in patients with specific
medical conditions or previous IE
-impaired host defenses (chemotherapy, organ transplant or
tissue graft recipient, insulin-dependent diabetes, alcoholics)
-patients with indwelling catheters (hemodialysis)

88. ENDOCARDITIS PROPHYLAXIS RECOMMENDATIONS
Prophylaxis against infective endocarditis is reasonable before
dental procedures that involve
-manipulation of gingival tissues
- manipulation of the periapical region of teeth
-perforation of the oral mucosa in patients

89. In 2017, the AHA and American College of Cardiology (ACC)
published a focused update to their previous guidelines for
patients at increased risk of developing IE and at high risk of
experiencing adverse outcomes from IE and their key
recommendations were-
1. Prosthetic cardiac valves, including transcatheter-implanted prostheses and
homografts.
2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings
and chords.
3. Previous IE.
4. Unrepaired cyanotic congenital heart disease or repaired congenital heart
disease, with residual shunts or valvular regurgitation at the site of or adjacent
to the site of a prosthetic patch or prosthetic device.
5. Cardiac transplant with valve regurgitation due to a structurally abnormal
valve

90. AHA/ADA GUIDELINES FOR PROPHYLAXIS FOR
MEDICALLY COMPROMISED PATIENTS

91. GROSSMAN PASTE (PBSC)
•proposed in 1951
•firstly reported local use of an antibiotic in endodontics
•combination of penicillin, bacitracin, streptomycin and caprylate
sodium suspended in a silicone vehicle
•ineffectiveness against anaerobic species and allergic reactions,
FDA prohibited in 1975.
•Later, an antifungal version of PBSC named with PBSN, in which
Nystatin substituted caprylate sodium, was released.

92. LESION STERILIZATION AND TISSUE REPAIR (LSTR)
• technique allowing disinfection of dentinal, pulpal, and
periradicular lesions using a combination of antibacterial drugs.
• concept was developed in Niigata University, Japan, 1988
•Ciprofloxacin (200mg), Metronidazole (500mg),
Minocycline(100 mg), Propylene glycol/ macrogol, Normal saline
as carrier.
•ratio of 1:1:1 for the 3Mix formulation
•disadvantage -tooth discoloration to a bluish-grey hue,
contributed to tetracycline family

93. USES OF LSTR
•Periradicular pathosis of permanent tooth with mature apices
•Periradicular pathosis of permanent tooth with immature
apices
•Endodontic Regenerative Procedure
minimal or no instrumentation followed by placement of TAP
and later bleeding is induced from periapical region. The
bleeding from periapex would lead a matrix for movement &
growth of new vital tissue in root canal spaces
•Periradicular pathosis of primary tooth

94. MTAD
was introduced by Torabinejad and Johnson in 2003.
Part A is a liquid containing 4.25% citric acid and 0.5% polysorbate
80 detergent (Tween 80) + Part B is a powder containing 3%
doxycycline hyclate
ADVANTAGES-
reasonable antimicrobial property
better smear layer removal
● lesser adverse effects on dentinal structure
● good biocompatibility
DISADVANTAGES
● less than optimal antimicrobial activity
● high cost
•reduced shelf life

95. CORTICOSTEROIDS

96. Potent antiinflammatory properties of glucocorticoids first utilized as an
adjunct to endodontic therapy more than 50 years ago.
Mechanism of action-
pain after endodontic therapy attributed to inflammation, infection or both in
periradicular tissues
Establishing patency, BMP introduce bacteria and its products, necrotic pulp tissue
or caustic irrigating solution in periradicular tissue
Inflammatory mediators released into this region
Vasodilation and permeability increased resulting in edema and high tissue
pressure
Pain fibres directly sensitized or stimulated
Supress vasodilation, migration of PMNLs and phagocytosis
Also inhibits archidonic acid formation from PMNLs cell membrane phospholipids
thus blocking COX pathways
CORTICOSTEROIDS

97. INTRACANAL ADMINISTRATION
In a study by Chance et al, intracanal placement of a 2.5% steroid
solution or saline placebo on completion of intrumentation
resulted in significant reduction of incidence of post operative
pain.
Another study found no significant difference in flare up rate
when either formocresol , Ledermix or calcium hydroxide was
placed into the canals.
LEDERMIX is corticosteroid + antibiotic paste containig 1%
triamcinolone acitonide and demeclocycline
(demethylchlorotetracycline , a tetracycline analog).
•corticosteroids control pain and inflammation and antibiotic is
added to compensate for the perceived corticoid-induced
reduction in the host immune response.

98. SYSTEMIC ADMINISTRATION
•Kaufman et al. were the first to evaluate the effect of an intraligamentary
delivery of corticosteroids on endodontic post endodontic pain. The results
showed a significant decrease in post operative pain in methylprednislone
group compare to the active and palacebo group
•In another placebo controlled study, patients with irreversible pulpitis were
given 4mg of dexamethasone or placebo by supraperiosteal injection and
found reduction in post treatment pain during the first 24 hours.
•Other studies evaluated efficacy of oral administration of 0.75 mg
dexamethasone on incidence and severity of post treatment endodontic pain.
It was found that pain significantly reduced after 8 and 24 hours .

99. DEXAMETHASONE
Adult:0.75-9mg qd in divided dose
Paediatric dosage - 0.02 to 0.3 mg/kg/day in three or four divided
doses
PREDNISOLONE-
Adult- 10-20 mg
Paediatric dosage - 0.05-2 mg/kg/day PO in three or four divided
doses

100. •A small, but significant portion of patients, have fears so great
that it impedes their ability to properly receive oral heath care
•majority of these fearful patients can be easily and safely
treated with oral sedatives
•oral route is widely accepted, easy, convenient, painless, and
inexpensive
•BENZODIAZEPINES and their newer derivatives are the most
widely used class of drugs for anxiolysis and sedation.
ANTIANXIETY DRUGS

101. WHY BENZODIAZEPINES ARE THE DRUGS OF CHOICE?
•High therapeutic index
•They have few peripheral effects
•Slow development of tolerance
•Lower incidence of physical dependence
•Fewer drug interactions
• Not respiratory depressants

102. MECHANISM OF ACTION
enhances the effect of the neurotransmitter gamma-
aminobutyric acid (GABA) at the GABAA receptor, do not
directly activate GABA-A receptors and require endogenous
GABA to express their effects.
EFFECTS ON CNS
•Sedation
•Hypnosis
•Decreased Anxiety
•Muscle Relaxation
•Anticonvulsant effects (status epilepticus)
•Antidepressant effects

103. COMMOMLY PRESCRIBED BENZODAZAPINES
LORAZEPAM
•intermediate-acting benzodiazepine
•Adult dose range-2 - 4 mg 1 hr before appointment
•Pediatric dose- 0.05 mg/kg
•Onset: 1 hr (peak levels in 2 hrs)
•Duration: 2 - 4 hrs (used for longer procedures)
•Children: 0.05 mg/kg/dose PO q4-8hr
ALPRAZOLAM
•Adult dose range - 0.25 – 1 mg 1 hr before appointment
•Onset- 1 hr (peak levels in 1 – 2 hrs)
•Duration- 1 – 2 hrs
•<18 years old: Not recommended

104. DIAZEPAM
 Adult dose range: 2 - 10 mg, 1 h before appointment
 Onset: 1 hr (peak levels in 2 hrs)
 Duration: 1 - 3 hrs
 Pediatric- 0.2-0.3 mg/kg 90 minutes prior to procedure

105. ADVERSE EFFECTS
•Drowsiness & Confusion
•Sedation
•Memory impairment
•Improper body balance
•Increase or decrease in
appetite
•Nausea & Vomiting
•Dependence and abuse
•Withdrawal symptoms

106. •combat inflammation and inflammatory disorders
•a protein (proteolytic) enzyme isolated from the non-
pathogenic enterobacteria Serratia E15 found in silkworms.
•preferred over other proteolytic enzymes such as trypsin and
chymotrypsin as it has high potency with negligible side effects.
SERRATIOPEPTIDASES

107. MODE OF ACTION
•has anti-inflammatory, anti-edemic, fibrinolytic activity.
•decreases the amount of fluid in the tissues, and facilitates the
drainage of the fluid, thereby reduces swelling. This also
enhances tissue repair and reduces pain.
•dissolves the dead tissue surrounding the injured area without
harming living tissue, thereby accelerating healing.
•hydrolyses bradykinin, histamine, and serotonin thereby
reduces inflammation and improves microcirculation.
• Kumar S The Emerging Role Of Serratiopeptidase In Oral Surgery: Literature Update. Asian J
Pharm Clin Res, Vol 11, Issue 3, 2018, 19-23

108. DOSAGE-
•Adult- 10-15 mg 3 times a day
•available as a sole drug or in combination with with non-
steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac,
aceclofenac, ibuprofen, tramadol, and paracetamol.
Aceclofenac 500+ Paracetamol/Acetaminophen 325 +
Serratiopeptidase 15 mg

109. CONTRA-INDICATIONS
• pregnancy & lactation
• hemophiliacs
•liver damage
•renal dysfunction
•patients taking antiplatelet drugs (aspirin and clopidogrel),
anticoagulants (warfarin)

110. CHYMOPTRYPSIN / TRYPSIN
THERUPATIC USES
•Reduce redness and swelling associated with pockets of
infection ,surgery
•Traumatic injuries
•Bronchitis lung diseases
•Sinus infections
CONTRAINDICATIONS
•Pregnancy and lactations
•Hypersenstivity reactions
COMBINATION DOSAGES
•Diclofenac 50mg+chymotrypsin 50000 AU

111. MANAGEMENT OF PREGNANT
PATIENTS

112. PREGNANT PATIENT MANAGEMENT
GUIDELINES
•comprehensive review of the patient’s medical and surgical history
•supine position should be avoided to avoid the development of the supine
hypotensive syndrome.
•ideal position in the dental chair is the left lateral decubitus position with
the right buttock and hip elevated by15°.
•All elective surgical procedures should be postponed until postpartum.
•Avoid dental radiographs unless information about the tooth roots or bone is
necessary for proper dental care. If radiograph must be taken, use proper
shielding

113. FDA HAS PROVIDED THE DEFINITIVE GUIDELINES FOR
PRESCRIBING DRUGS DURING PREGNANCY.

115. THE FDA HAS CATEGORIZED TERATOGENIC DRUGS WHICH CAUSE BIRTH
DEFECTS AS FOLLOWS

116. Dose reduction in liver diseases
Chlorophenical
Isoniazides
Rifampin
Clindamycin
Metronidazole
Drugs to be avoided in liver diseases
Erythromycin estolate
Pyreizinamide
Tetracycline
Nalidixic acid
Pefloxacine
Tolampicillin
Medical condition and their impact on dental care. DCNA oct 2006
PROPOSED BY DCNA IN 2006

117. Drugs contraindicated in cardiac disorders
LA with adrenaline
Na+ containing drugs
Streptomycin
Gentamycin
Lignocaine
Vasodilators like Hydralazine
Skeletal muscle relaxants
ciprofloxacin
Clofazamine
Medical condition and their impact on dental care. DCNA oct 2006

118. Drugs contraindicated in Diabetes
Tetracycline
Furosemide
Β blockers
Phenothiazines
Alcohol
Pentamidine(anti kala-azar)
Drugs contraindicated in respiratory disorders
Aspirin + salicylate
Β blockers
Skeletal muscle relaxants
Quinolones
Nalidixic acid
Medical condition and their impact on dental care. DCNA oct 2006

119. HIV POST EXPOSURE PROPHYLAXIS
Risk of infection
Through blood contaminated needle prick is 1:200 to 1: 300.
Investigations
•HIV Elisa testing in exposed victim immediately to know baseline
status and if negative repeat after 6 months.
•HIV-DNA by PCR (after 72 Hrs) in blood of the victim, if possible.
•HIV1 & 2RNA copies by PCR of the patient, if possible to know
the viral load
Medical condition and their impact on dental care. DCNA oct 2006

120. MANAGEMENT
Local measures like through cleaning with cetrimide.
Councelling regarding modes of transmission of HIV and taking
care till HIV –ve satus is confirmed
To start with antiretroviral drug combination as early as possible
zidovudine 300mg BD PO
lamivudine 150mg BD PO
Medical condition and their impact on dental care. DCNA oct 2006

121. HEPATITIS B- PROPHYLAXIS
Local measures are same as HIV
It is ideal that all the medical and paramedical personnel are
completely vaccinated with Hepatitis B vaccine as soon as they join
the training/profession
Hepatitis B vaccine (DNA recombinant)
a. Infant - 10 micogram or 0.5ml
b. Children adults -20 micrograms or 1 ml
c. Immunocompromised - 40 microgram or 2ml
vaccination given on 0,30,180 days( 3 dose regimen) or on
0,30,60 and 365 days (4 dosage)
Medical condition and their impact on dental care. DCNA oct 2006

122. Post exposure prophylaxis
1. Person is not vaccinated-
one dose of hepatitis B Immuneglobin (HBIG). 0.06ml/kg
intramuscularly.
Start Hepatitis vaccination as above
2. Person is vaccinated , antibody titer not known-
estimate anti HBsAG titer- if adequate(>10mlU/ml) no
treatment
If inadequate one dose of HBIG as above and one dose of
Hepatitis B vaccine booster dose
Medical condition and their impact on dental care. DCNA oct 2006

123. CONCLUSION
Despite the fact that drugs are effective tools for managing
endodontic infection , they are not substitutes for endodontic
treatment. The key to obtaining a successful result in an
endodontic infection demands working knowledge of the
underlying pathology ,chemomechanical removal of the
infecting agent from the root canal system followed by
obturation with thorough individualized clinical assessment.
Endodontic pharmacotherapy can only be used as an
adjunct to endodontic treatment.