SPECIAL DENTAL PHARMACOLOGY: ANTIPLAQUE AGENTS ANTIGINGIVITIS AGENTS DISCLOSING AGENTS DENTIFRICES STYPTICS ANTICARIES DRUGS DESENSITIZING AGENTS OBTUNDENTS MUMMIFYING AGENTS BLEACHING AGENTS ANTIBIOTICS IN PERIODONTAL DISEASE

1. DR. BUSHRA HASAN KHAN
ASSISTANT PROFESSOR
DEPARTMENT OF PHARMACOLOGY
JN MEDICAL COLLEGE, AMU, ALIGARH

2. 2
ANTIPLAQUE AGENTS
ANTIGINGIVITIS AGENTS
DISCLOSING AGENTS
DENTIFRICES
STYPTICS
ANTICARIES DRUGS
DESENSITIZING AGENTS
OBTUNDENTS
MUMMIFYING AGENTS
BLEACHING AGENTS
ANTIBIOTICS IN PERIODONTAL DISEASE

3. 3
ANTIPLAQUE AGENTS
AND
ANTIGINGIVITIS AGENTS

4. 4
Dental plaque: soft deposit on the tooth surface
Bacteria + Polysaccharides + Glycoproteins
Resists removal by ordinary brushing and rinsing
Bacterial Lactic acid, Ammonia, Hydrogen sulfide 
Gingivitis
Gums  Edematous, swollen; Subgingival pockets
Hyaluronidase and collagenase  spongy gums
Periodontal disease develops
Prevented and treated by inhibiting plaque formation

5. 5
• Streptococcus sanguis often appears first followed by
Streptococcus mutans
• Both depend on a sheltered environment for growth
presence of extracellular carbohydrate (sucrose)
• Sucrose is used to synthesize intracellular
polysaccharides that serve as an internal source of
energy, as well as external polysaccharide coats

6. 6
Mouth Rinse, Gels, Toothpaste
Chlorhexidine
Povidone iodine
Quaternary ammonium antiseptics  Cetylpyridinium chloride,
Benzalkonium chloride
Phenols  Triclosan, Listerine
Oxygenating agents  Hydrogen peroxide, Sodium perborate
Zinc citrate
Stannous fluoride
Sanguinarine
ANTIPLAQUE AGENTS

7. 7
Chlorhexidine
• BD Mouth rinsing for 1-3 min with 10–15 ml
of 0.12–0.2% solution for 5 days

8. 8
• Chlorhexidine gluconate is a cationic (positively
charged) molecule
• After rinsing, chlorhexidine is attracted to and
attaches to the negatively charged bacterial cell
walls, causing lysis or breakage of the cell wall
• The contents of the cells leak out
• Chlorhexidine enters the cell through the
opening, resulting in death of the bacteria

9. 9
• By binding to the pellicle on the tooth surface,
chlorhexidine inhibits plaque attachment
• Chlorhexidine exhibits substantivity, with
approximately 30% of the drug binding to oral
tissues and the plaque on the teeth, and showing
antimicrobial activity for 8–12 hours afterward

10. 10
• It is recommended to rinse twice a day for 30
seconds
• The positive charge of chlorhexidine causes it to bind
to the negatively charged molecules in toothpastes
such as fluorides and sodium lauryl sulfate (a
detergent), and thus inactivates them
• Therefore, it is best to rinse either 30 minutes before
or after toothbrushing or rinse very well with water
after toothbrushing

11. 11
• Because of this inactivation of anionic
compounds, chlorhexidine is not available in
toothpaste
• Chlorhexidine can be used as an irrigant, but it is
usually diluted with water to reduce the
incidence of staining

12. 12
Chlorhexidine
• Antibacterial and antiseptic
• Prevention and treatment of surface infections
• Combined with hydrogen peroxide as a subgingival
irrigant for reduction of gram-negative
microorganisms
• Iodine can stain teeth, clothing, skin, and restorations

13. 13
Quaternary ammonium antiseptics
• Cetrimide: 0.1% in STOLIN gum paint
• Benzalkonium chloride: 0.02% in ZYTEE gel;
0.01% in DENTOGEL gel

14. 14
Phenols  Triclosan, Listerine
• Nonstaining
• Nonirritating
• Do not impart bad taste or odour

15. 15
• Listerine is a combination of phenolic compounds or
essential oils, including thymol, eucalyptol, menthol,
and methyl salicylate, in an alcohol vehicle
• MOA: cell wall disruption, resulting in leakage of
intracellular components and lysis of the cell
• The original-formula Listerine contains 26.9% alcohol,
whereas the Cool Mint, Fresh Burst Listerine, and
Natural Citrus contain 21.6% alcohol

16. 16
• Rinse for 30 seconds with 2/3 ounces, once in the
morning and once at night
• Possible adverse side effects include a burning
sensation and bitter taste

17. 17
• Alcohol-containing mouthrinses should not be
used in a patient taking metronidazole
• A severe disulfiram-like reaction occurs with
nausea, vomiting, flushing, and faintness

18. 18
Alcohol-free mouthrinses include:
• GUM® Chlorhexidine 0.12% alcohol-free rinse
• Crest Pro-Health Rinse
• Rembrandt
• Listerine Zero
• Oral B Plaque Rinse
• Listermint
• BreathRX

19. 19
Oxygenating agent  Hydrogen peroxide
• Release molecular oxygen
• Regular rinsing may reduce plaque scores

20. 20
• Since hydrogen peroxide liberates gaseous
oxygen, it provides a cleansing action and gentle
effervescence for oral wounds
• However, peroxide has minimal antimicrobial
action against anaerobic microorganisms

21. 21
Zinc citrate, Zinc chloride, Zinc sulphate
• Decrease plaque formation
• Astringent action on gums

22. 22
Stannous fluoride
• Stannous ions reduce the adhesion of GPB to
tooth surface
• Fluoride ions inhibit bacterial glycolytic
enzymes and glucose transport

23. 23
Sanguinarine
• Alkaloid from the blood-root plant
• Inhibits sulfhydryl enzymes of bacteria
• Requires low pH (below 5.5) to transform into
the active quaternary imminium configuration

24. Disadvantages
Chlorhexidine  Brown staining of teeth and tongue
Burning sensation in the mouth
Bad taste
Oral ulcers
24

25. Controlled-Release Antimicrobial
Drugs Used in Dentistry
• Microspheres of minocycline HCl
• 10% doxycycline hyclate
• 2.5 mg chlorhexidine gluconate perio chip

26. 26
• Dyes used to facilitate clear visualization of dental
plaque
• Dyes used as disclosing agent are:
 Erythrosine
 Fluorescein: Yellow dye which fluoresces under UV
light
 Two-tone dye
 Newer plaque (< 3 days) stains red
DISCLOSING AGENTS

27. 27
• Tablets
• Mouth Rinses
• Pre Loaded Pellets
Disclosing agents are available as

28. 28
• Compatible in taste
• Good flavour
• Intensity of colour: Contrast between early and mature
biofilm
• Should come out easily during procedure
• Not irritating to the gingiva, non-allergic
BASIC PROPERTIES

29. 29
• Visualizing the dental biofilm
• The color guides the biofilm removal
• Calculus is easier to detect
• Faster, more efficient and minimally invasive
• For calculating Plaque indices
Advantages of Disclosing agents

30. 30

32. 32

33. 33
A dentifrice is a substance (powder or paste) used with a
toothbrush for the purpose of cleaning the accessible
surfaces of the teeth
 Hygiene aids
 Facilitates cleaning of teeth and gums
 Improves appearance of teeth and gums
 Controls bad breath (halitosis)
 Medicated or non-medicated
DENTIFRICE

34. 34
• Abrasives
• Detergents
• Humectants and binding agents
• Sweetening agents
• Flavouring agents
• Colouring agents
INGREDIENTS OF DENTIFRICE

35. 35
Abrasives used in dentifrices:
• Calcium carbonate
• Silicates
• Calcium phosphate
• Magnesium carbonate
• Aluminium oxide
• Magnesium oxide

36. 36
• Sodium bicarbonate  mild abrasive  on
reacting with slightly acidic saliva releases some
CO2 that facilitates foaming during brushing 
Reduces oral bacteria that thrive in the acidic
medium
• Toothpastes are less abrasive than tooth powders

37. 37
• Dentifrice containing papain, alumina, and citrate
 reduces discoloration

38. 38
Detergents:
• Sodium lauryl sulfate
• Lauryl sarcosinate
• Dioctyl sodium sulfosuccinate
• Ammonium lauryl sulfate
• Dodecyl benzene sulfonate

39. 39
Sodium lauryl sulfate
 Reduces surface tension of stain molecules and
prevent binding of these molecules to enamel
 Promotes penetration of fluoride into dentine,
loosens plaque and has antibacterial action

40. 40
Humectants retain moisture, prevent drying
• Glycerine
• Sorbitol
• Propylene glycol

41. 41
Binding agents swell in water and hold together
solid and liquid phases, give thick consistency to the
paste
• Methyl cellulose
• Bentonite
• Mucilage of tragacanth

42. 42
Sweetening agents mask blandness and improve
taste
• Saccharine Sorbitol
• Glycerol

43. 43
Flavouring agents improve acceptability and counteract
halitosis (bad breath)
• Menthol  produces a cooling sensation in the mouth
and imparts a feeling of freshness
• Thymol
• Eugenol
• Camphor
• Clove oil

44. 44
Colouring agents
• Methylene blue
• Chlorophyll
• Liquor rubri

45. 45
Whitening dentifrices contain:
• Hydrogen peroxide
• Calcium peroxide
• Sodium citrate
• Sodium pyrophosphate
• Sodium chlorite

46. 46
• Triclosan and methyl paraben are the most
commonly used antimicrobial agents in whitening
dentifrices
• Micro charcoal in dentifrices is claimed to absorb
dirt and clean gaps between teeth

47. 47
• Fluoride: Sodium monofluorophosphate Or Sodium
fluoride for prevention of caries
• Antiseptics: Chlorhexidine, Triclosan Or
Benzalkonium chloride for prevention and
treatment of dental plaque
MEDICATED DENTIFRICE

48. 48
• Desensitizing agents: Potassium nitrate or Strontium
chloride are mostly added to treat dentine sensitivity
• Bleaching agents: Carbamide peroxide is the
commonest bleaching agent added to stain-removing
dentifrices
MEDICATED DENTIFRICE

49. 49
• Local Haemostatics (styptics) are substances used to stop
bleeding from a local and approachable site
• Effective on oozing surfaces, e.g. tooth socket, abrasions
STYPTICS

50. 50
Normally haemostasis occurs by
• Contraction of injured vessel wall (lasting few
minutes)
• Adhesion and aggregation of platelets to form a
plug
• Formation of a blood clot
• Dissolution of the clot by fibrinolysis

51. 51
Absorbable materials
• Fibrin (prepared from human plasma and dried as
sheet or foam)
• Gelatin foam
• Oxidized cellulose (as strips which can be cut and
placed in the socket) provide a meshwork 
activates the clotting mechanism  checks bleeding
 Left in situ  absorbed in 1–4 weeks  no foreign
body reaction

52. 52
• Thrombin obtained from bovine plasma may be
applied as dry powder or freshly prepared
solution to the bleeding surface in haemophiliacs
• Vasoconstrictors like 1% Adrenaline solution may
be soaked in sterile cotton-gauze and packed in
the bleeding socket (or nose in case of epistaxis)
to check bleeding when vasoconstriction is
inadequate

53. 53
• Astringents such as tannic acid or metallic salts
(e.g. alum, ferric chloride) are occasionally
applied for bleeding gums, bleeding piles, etc.

54. 54
• Many diseases and drugs can affect the vascular
response to injury, platelet function or
coagulation to create haemostatic problems

55. 55
• Vitamin C deficiency impairs collagen synthesis
and causes bleeding gums, excessive post
extraction blood loss
• Long-term corticosteroid therapy can also
compromise haemostasis by impairing vessel
retraction as well as by reducing platelet count

56. 56
• Platelet function may be deficient due to
thrombocytopenia (count<100,000/mL) or use of
drugs which inhibit platelet aggregation 
Transfusion of platelet-rich plasma is indicated
• Aspirin and other NSAIDs are the most important
drugs that inhibit platelet aggregation

57. 57
• A large number of older individuals now receive
long-term low dose aspirin prophylaxis for
ischaemic heart disease or stroke
• Many others receive long term clopidogrel for a
variety of thromboembolic disorders
• Several patients of arthritis regularly take NSAIDs

58. 58
• Discontinuation of aspirin for 5 days before dental
surgery should be considered
• Proper packing and use of local haemostatics is
needed to prevent excess bleeding

59. 59
• Monitoring of INR prior to dental surgery is essential
• INR > 3.5  stop the anticoagulant for 2–3 days or
temporarily switch over to heparin
• In case of emergency dental bleed  give i.v.
infusion of FFP (fresh frozen plasma : containing all
coagulation factors)
• Vit. K may be injected
• Adequate packing and local measures

60. 60
• The heparin antagonist protamine may be given
i.v. in case of emergency bleed during surgery in
patients who are taking heparin therapy

61. 61
• Dental caries is localized loss of tooth tissue due to
bacterial action resulting in formation of cavity in tooth
• Streptococcus mutans, Lactobacilli break dietary sugars
sugars to produce lactic acid on the tooth surface
• Sucrose is most easily converted into acids by plaque
bacteria and is the most cariogenic sugar
ANTICARIES DRUGS

62. 62
• The acid remaining in contact with tooth enamel
for sufficient time destroys hydroxyapatite
crystals causing demineralization and loss of tooth
substance
• Anticaries drugs help only to prevent dental
caries, since no drug can restore already formed
caries cavity

63. 63
Anticaries drugs
• Fluoride makes tooth more resistant to caries and
has weak antibacterial action
• Antiplaque agents (mainly chlorhexidine and
triclosan) reduce the population of cariogenic
bacteria

64. 64
Preventive measures for caries
• Restriction of sugar containing food
• Frequent brushing of teeth
• Prevention of xerostomia by hydration, since
dryness of mouth promotes caries

65. Fluoride
• Hardness of tooth enamel is primarily due to its
hydroxyapatite crystals  Dissolved by the action of
acid over a period of time
• Fluoride radical being highly reactive exchanges
with hydroxyl radical forming fluorapatite
65

66. 66
• Fluorapatite is a more compact, harder and less
acid labile substance than hydroxyapatite
• As a result teeth become less prone to caries
• Fluoride enhances remineralization of enamel
that has been attacked by acid

67. 67
• Free fluoride ions released from fluorapatite by
action of acid raise local fluoride ion conc. and
facilitate remineralization of damaged enamel

68. 68
• Plaque bacteria bind fluoride with high affinity, so
that fluoride concentration in plaque is several
times higher than its salivary concentration:
significant intraplaque bacteriostasis may be
exerted
• Fluoride ions inhibit acid forming enzyme of
plaque bacteria

69. 69
Fluoride therapy
• Prevention of dental caries by reducing
demineralization and enhancing remineralization

70. 70
Systemic fluoride
• Indicated in areas with fluoride deficient water
supply
• 0.5–1.0 p.p.m. fluoride is optimum for health
• Both low as well as high fluoride content of
drinking water is harmful

71. 71
Fluoridation of water supply
• 0.5–1.0 p.p.m.
• Failure to adjust the fluoride content to the
optimum level can expose the population to the
risk of fluorosis

72. 72
Fluoridation of common salt
• Sodium fluoride
 Tablets (0.55 and 1.1 mg)
 Lozenges (2.2 mg)
 Drops (0.55 and 1.1 mg per drop)
Daily till the age of 16 years

73. 73
Topical fluoride
• Fluoride enhances resistance to caries even when
applied directly to the tooth surface
• Risk of systemic as well as dental fluorosis

74. 74
Fluoride toothpastes
• Sodium monofluorophosphate (MFP) 0.76 %
• Calcium salts included as abrasives in certain
dentifrices inactivate sodium fluoride
• Thorough rinsing of the mouth is advised after
brushing with fluoridated toothpaste

75. 75

76. 76
Fluoride mouth rinse Sodium fluoride (0.055%) or
stannous fluoride (0.1%) solution  Daily mouth
rinse to prevent caries

77. 77
• Rinse solution is held in the mouth for 1–3 min
and swished around
• It is then discarded and food/ drink are avoided
for the next 30 min to minimise washing away of
fluoride that is in contact with the teeth
• Stannous fluoride can stain the teeth

78. 78
Acidulated Phosphate Fluoride (APF)
• Specifically developed to achieve high fluoride
permeation into the enamel
• Prolonged caries protection
• Formulated as a solution or gel
• Contains 1.23% fluoride and 0.1M orthophosphoric acid
• pH is adjusted to about 3.0

79. 79
• Acidic medium enhances fluoride diffusion into
the enamel
• Orthophosphoric acid prevents enamel dissolution
• Applications are generally repeated at 6 month
intervals
• Optimal duration of each application is 4 min

80. 80
• Nausea, vomiting and acute fluoride toxicity if
swallowed

81. 81
Precautions
• Use of disposable tray applicator
• Upright position during application
• Instruction not to swallow the solution/gel
• Constant suction of saliva during application
• Wiping the teeth and gums dry after the
application

82. 82
Fluoride varnishes
• Nonaqueous preparations which are not washed
off by saliva
• Retained on the teeth for longer period
• A 2% sodium fluoride lacquer in resin base or a
polyurethane varnish containing 0.7% fluoride is
painted over the teeth or applied to the cavity

83. 83

84. 84
Fluoride toxicity
Chronic fluoride toxicity
• Fluorosis occurs due to excess fluoride content of
drinking water
• Occasionally due to industrial exposure or
ingestion of fluoride supplements/ Use of
toothpastes, etc. over a period of time

85. 85
• Low levels of excess fluoride (>2 p.p.m.) in
drinking water produce dental fluorosis in
children
• Higher levels (>8 p.p.m.) produce skeletal
fluorosis in children as well as in adults

86. 86
Dental fluorosis
• It occurs in children due to relatively low excess
fluoride exposure from birth to 14 years of age
when teeth are developing and erupting
• There is hypomineralization of enamel while its
protein content increases
• White flecks appear on the teeth

87. 87
• Later there is brown discolouration, pitting,
hypoplasia and deformity of dentition

88. 88
Skeletal fluorosis
• Crippling disorder producing rigidity of spine,
kyphosis, thoracic and pelvic deformity
• Limb bones become thick but brittle
• Spontaneous fractures occur
• Ligaments calcify

89. 89
• Fluorosis can be prevented by changing the source
of drinking water or defluoridation of water by
adsorption on activated alumina/charcoal, or by
avoiding other sources of excess fluoride
• Once fluorosis has developed, it can only be
halted but not reversed

90. 90
Acute fluoride toxicity
• Ingestion of gross overdose of fluoride causes
acute toxicity; especially in children
• > 5 mg/kg sodium fluoride is considered lethal

91. 91
Acute fluoride toxicity
• Nausea, Vomiting, Abdominal pain, gastric
erosion,
• Muscle weakness, Spasms and tetany due to
hypocalcaemia
• Acidosis
• Hypotension and cardiac arrhythmia

92. 92
Treatment
• Gastric lavage
• Calcium gluconate infusion (i.v.) to precipitate
excess fluoride and to counteract hypocalcaemia
• Correction of acidosis and fluid/electrolyte
imbalance
• Other supportive measures

93. Antiplaque agents for caries
• Use of orally applied germicides can clearly reduce
the incidence of caries and add to the protection
afforded by fluoride
• The two most commonly used agents are:
Chlorhexidine
Triclosan
93

94. 94
• Desensitizing agents mitigate dentine sensitivity
i.e., shooting pain triggered from sensitive tooth
by thermal (hot and cold), mechanical (touch,
chewing, blast of air) or chemical (sour and sweet
food) stimuli
• Dentine may get exposed to external stimuli due
to enamel damage
DESENSITIZING AGENTS

95. 95
Enamel damage may occur due to
• Chewing hard substances
• Age related tooth attrition
• Erosion by acidic food at the crown
• Denudation of root as a result of gingival
recession of old age, faulty brushing, periodontal
disease, etc.

96. 96
• Dentine is traversed by numerous fine fluid filled
dentinal tubules
• When these tubules are exposed, mechanical and
thermal stimuli cause abnormal perturbations of
the fluid in the tubules and activate the nerve
endings at their inner mouth or in the pulp

97. 97
• Soluble chemicals (acids/sugars in food) diffuse
through the tubules and act on the sensory
nerves—all producing sharp pain

98. 98
The desensitizing agents aim to interrupt this pain-
inducing process by:
• Creating a plug in the dentinal tubules
• Sealing their mouth at the tooth surface
• Modulating the generation of painful nerve
impulses

99. 99
• Most desensitizing agents are self applied by the
patient 1–3 times daily, while some are applied by
the dentist once a while

100. Commonly used desensitizing agents
100

101. 101
Potassium nitrate 5% in desensitizing toothpastes
• Paste is to be applied on the sensitive teeth and
left in place for ~ 5 minutes before brushing
lightly and then rinsing it off
• Repeated 2–3 times daily
• Obliterates dentinal tubules by precipitation
• Dampens the pain inducing nerve impulses

102. 102
Strontium chloride
• It is an alkali-earth metal salt that precipitates
proteins in the dentinal tubular fluid and thus
tends to limit/obstruct the easy displacement of
fluid by the pain inducing stimuli
• Calcification of the bony component of tooth is
believed to be hastened by strontium ions
• Toothpastes and gels  10% strontium chloride

103. 103
Potassium oxalate
• It diffuses into the dentinal tubules, reacts with
ionic calcium in the fluid to produce calcium
oxalate which deposits as crystals
• Crystals hinder fluid movement in the tubules
induced by external stimuli, thereby decrease the
pain

104. 104
Fluoride
• Fluoride compounds like sodium
monofluorophosphate, sodium/stannous fluoride
may react with calcium and produce calcium
fluoride crystals in the dentinal tubules

105. 105
• Stannous fluoride may deposit fine layers of tin
particles in the tubules creating partial
obstruction
• Fluoride ion accelerates secondary dentine
formation which may reinforce the tubules and
reduce dentine sensitivity

106. 106
Fluoride iontophoresis
• Quick diffusion of fluoride ions into the dentinal
tubules is obtained by applying electrical current
through 2% sodium fluoride solution
• Rapid desensitization of sensitive tooth
• Special equipment and expert application
• Expensive

107. 107
Formaldehyde 1-1.5%
• Weak desensitizing agent
• Denaturation and precipitation of proteins
• Disagreeable taste and smell

108. 108
Dentine bonding agents
• Hydroxyethyl methacrylate, resins, composites,
varnishes
• After suitable preparation of the sensitive tooth and
use of primers, the bonding agent is applied and
allowed to dry
• A long lasting bonding with dentine occurs rapidly—so
that painful stimuli are blocked from reaching the
pulpal nerve endings

109. 109
• Obsolete drugs
• When applied to teeth and gums produce
numbness that dampens toothache due to cavity
formation and other causes, as well as pain of
excavation
• Penetrate poorly and do not relieve deep seated
or sharp pain
OBTUNDENTS

110. 110
Obtundents act by:
• Stimulation followed by desensitization of nerve
endings: Clove oil, Thymol, Menthol, Camphor,
Phenol
• A characteristic pleasant smell
• Irritate sensory nerve-endings

111. 111
• Counter-irritant property
• Produce relative numbness due to desensitization
of sensory nerves lasting one to few hours
• Clove oil has been used as a household remedy for
tooth ache, but can stain the tooth

112. 112
• Astringent action: Stannous chloride, Zinc
chloride, Paraformaldehyde
• Precipitate surface proteins and may interfere
with the function of pain receptors
• The pain relieving action is mild

113. 113
• When astringents and antiseptics are used to harden and
dry tissues of the pulp and root canal so that the tissues
are resistant to infection, they are termed as
mummifying agents
• Used in certain dental procedures when it is not possible
to completely remove the pulp and contents of root
canal
• A combination of agents are used in the form of paste or
semi-liquid preparation like tannic acid glycerine
MUMMIFYING AGENTS

114. 114
Formaldehyde or Paraformaldehyde (Paraform) mixed
with zinc oxide or zinc sulfate + creosote
• Made into a paste for filling in the root canal
• Paraformaldehyde releases formaldehyde slowly
which destroys all living tissue in the pulp, hardens it
and makes it resistant to infection
• A local anaesthetic like lidocaine or benzocaine may
be included, to prevent pain caused by the filling

115. 115
Iodoform + Phenol
• Made into a paste with glycerine
• Eugenol and cinnamon oil  improve the smell of
the paste
• Liberated iodine as well as phenol act as
antiseptic

116. 116
Tannic acid
• It is an astringent and precipitates proteins
• The tissues are hardened and become resistant to
bacterial infection
• It may be used alone or in combination with
iodoform or eugenol and glycerine

117. 117
• Root canal therapy  pulpectomy, tissue free dry
canal  pack with gutta-percha (a tough material
made from latex) points, silver points or epoxy
resin canal sealant

118. 118
• Inert, impervious, nonirritant
• Preclude risk of reinfection
• Minimum complications

119. 119
• These are agents used to remove stains from teeth
• Improve whiteness
• Most of the bleaching agents act by oxidizing the
stain/yellowish coating on the enamel
• Few reducing agents also have stain removing action
BLEACHING AGENTS

120. 120
Oxygen releasing agents
• They release oxygen which reacts with the
organic pigment to decolourise it and loosen it
from tooth surface
• It is then washed off to expose the white enamel

121. 121
Hydrogen peroxide
• Concentrated solution (20–30%) in water (called
perhydrol) or ether (named pyrozone) applied to
the stained teeth and wiped off for cosmetic
whitening
• CAUTION Burning sensation, erythema,
inflammation and sloughing may occur if it comes
in contact with gingival/oral mucosa

122. 122
Carbamide peroxide
• Equimolar complex of hydrogen peroxide with
urea which acts as a carrier and releases
hydrogen peroxide on reacting with water
• Some tooth whiteners contain 10% carbamide
peroxide

123. 123
Sodium peroxide
• Water soluble, releases oxygen in solution and
may be used for bleaching teeth
Sodium perborate
• Insoluble but slowly releases oxygen on coming in
contact with water
• It is present in some tooth powders

124. 124
Chlorine releasing agent
Bleaching powder (chlorinated lime)
• Slowly releases chlorine which acts as an oxidizing
agent and decolourises many dyes
• Addition of acetic acid to bleaching powder
immediately before application accelerates its
decomposition and hastens stain removal

125. 125
• May damage tooth enamel and dentine
• Tooth sensitivity and weakening of crown
• Oral microbial flora may be disturbed

126. 126
Reducing agent Sodium thiosulfate
• Used for removing certain stains, e.g. iodine stain
• Sequential application of an oxidizing agent
followed by a reducing agent may be needed for
silver stain

127. 127
Silica
• It is a nonabrasive adsorbant which is included in
some whitening toothpastes and tooth powders

128. 128
• Use of laser for whitening the teeth is increasing

129. 129
In dental practice, antibiotics are indicated for
1. T/t of acute odontogenic/orofacial infections
2. Prophylaxis against infective endocarditis
3. Prophylaxis for patients at risk for infection
because of compromised host defense
mechanisms
ANTIBIOTICS IN
PERIODONTAL DISEASE

130. 130
• Choice of antimicrobial therapy is based on
morphology and growth of bacteria
• Bacteria are classified according to shape
(morphology) (e.g., cocci, bacilli) and growth
patterns (e.g., aerobic—oxygen; anaerobic—without
oxygen)
• Bacteria are also classified according to ability to
retain a certain stain (gram-positive or gram-
negative)

131. 131
• Samples of dental subgingival biofilms may be
sent for culture and sensitivity
• Topical antimicrobial agents (e.g., Doxycycline,
Minocycline) are used in patients with localized
chronic periodontitis
PLACEMENT OF MINOCYCLINE MICROSPHERES

132. 132
• Systemic antibiotics are usually used in patients
with aggressive periodontitis because the bacteria
with this periodontal disease invade the soft
tissue and elude mechanical debridement

133. 133
• Systemic antibiotics are indicated in:
 An endodontic lesion with soft tissue swelling that is not
draining
 Systemic involvement
 Spread of the infection
• The drug of choice is penicillin VK

134. 134
• A systemic antibiotic as well as an antimicrobial
oral rinse may be indicated for implant surgery
• Postoperative infections, are treated with
drainage and systemic antibiotics such as
penicillin VK
• Antibiotics are indicated in the treatment of peri-
implant infections, which are associated with
bone loss, suppuration, and increased pocket

135. 135
Patients Taking Penicillin VK or Amoxicillin
• Instruct patients to take the entire prescribed
antibiotic even if they feel better
• Take on an empty stomach (1 hour before or 2
hours after meals); amoxicillin can be taken
without regard to meals
• Monitor for superinfections

136. Common orodental infections
• Alveolar abscess
• Periodontal abscess
• Dental pulp infections
• Chronic periodontitis
• ANUG
136

137. 137
• Streptococci
• Obligate anaerobes gram-positive cocci (e.g.,
Peptostreptococcus)
• Obligate anaerobic gram-negative (e.g.,
Porphyromonas or Prevotella sp.)

138. 138
• Anaerobes predominate, in abscesses and
cellulitis
• Orodental infections are often mixed bacterial
infections

139. 139
• Penicillin/amoxicillin (with/without clavulanic
acid)
• Cephalosporins like cefuroxime or cefaclor which
are active on anaerobes
• Erythromycin
• Azithromycin
• Clindamycin

140. 140
• Vancomycin
• Doxycycline
• Ofloxacin
• Metronidazole/tinidazole

141. 141
• Empirical therapy with amoxicillin +
metronidazole can be initiated
• In a few situations the clinical diagnosis itself
indicates the infecting organism and directs the
choice of drug

142. 142
• Penicillin/Doxycycline + Metronidazole for ANUG
• Nystatin/Clotrimazole for oral thrush

143. 143
• Tetracycline (1 g/day)/doxycycline (200 mg/day)

144. 144
Tetracyclines as a group are:
• Bacteriostatic
• Broad spectrum
• Inhibit bacterial growth and multiplication by
inhibiting protein synthesis at the 30S ribosomal
subunit

145. 145
Two semisynthetic analogues of tetracycline
• Doxycycline hyclate
• Minocycline HCl
Broad-spectrum antibiotics
Affect both gram-positive and gram-negative
microorganisms

146. 146
Anticollagenase Feature of Tetracyclines
• Affect the host response by inhibiting the production
and secretion of collagenase by polymorphonuclear
leukocytes (PMNs)
• Collagenase is an enzyme responsible for the
destruction of collagen, which makes up the
connective tissue of the periodontium
• This anticollagenase property does not depend on the
drug’s antibacterial actions

147. 147
• Doxycycline 20 mg is indicated for generalized
chronic periodontitis
• The use of doxycycline in 20 mg sub-antimicrobial
doses is also called enzyme-suppression or host
modulatory therapy

148. 148
Concentration in Gingival Crevicular Fluid
• Tetracyclines, Doxycycline and Minocycline
concentrate in gingival crevicular fluid (GCF) at 2
to 4 times blood levels following multiple doses
• Tetracyclines exhibit higher substantivity than
other antibiotics, which allows binding to root
surfaces with a slow release into the GCF

149. 149
• Binding of tetracyclines to calcium ions in GCF
enhances substantivity
• These properties allow the drug to maintain high
therapeutic levels in GCF
• GCF bathes the subgingival pocket area where
periodontal pathogens live

150. 150
• Metronidazole + chlorhexidine (gel)  treatment
of ANUG

151. 151
If patient is unable to take oral medications,
parenteral options are
• Ampicillin
• Cefazolin
• Ceftriaxone

152. 152
• Cephalosporins are avoided in patients with a
history of anaphylaxis, angioedema, or urticaria
with penicillins or ampicillin
• Allergic to penicillin and unable to take oral
medications  Give IM / IV Clindamycin

153. 153
Tetracycline (1 g/day):
• Halts periodontal connective tissue breakdown by
inhibition of Ca2+ dependent collagenases
• Free radical scavenging

154. 154
Doxycycline (200 mg/day) therapy
• Specific activity against anaerobic pathogens
Oral metronidazole
• ANUG