drugs used in endodontics

1. SUBMITTED BY:
ARTI
BDS – INTERN
BATCH – 2008 – 2013

3. Rx
Antiboitics
NSAIDS
GI relife eg. H2 blokers, proton pump
inhibitors

4.  Cardinal Rules:
1) Use the right drug.
2) Use the right dose.
3) Use the correct dosing schedule.
4) Correct duration.
 Avoid combinations of bacteriostatic and
bacteriocidal drugs.

5. Gram Positive?
Gram Negative?
Mixed Infection?
Anaerobes?

6. Narrow Spectrum?
Broad Spectrum?
Anaerobes? Consider if the infection is present > 3days
or if no improvement.

7. Specific for the pathogen.
Fewer disturbances of non-pathogenic bacteria.
Fewer side effects.
Rapid response for sensitive organisms.
Ex: Pen VK, Pen G, Erythromycin

8. Affects both Gram + and Gram – bacteria, better for
mixed infections.
May give up some effectiveness for Gram + to gain
effectiveness for Gram -.
Examples: Amoxicillin, Ampicillin

9. Necrotic pulp and apical abscesses
1. Obligate anaerobic bacteria
a. Gram negative rods
Prevotella & porphyomonas spp.
Fusobacterium spp.
Campylobacter rectus
b. Gram positive rods
Eubacterium spp.
Actinomycetes spp.
c. Gram positive cocci
Peptostreptococcus spp.
2. Facultative anaerobic bacteria
Gram positive cocci
Strep and Entercoccus spp.

11. 1. ß-Lactams
2. Cephalosporins
3. Lincosamides
4. Macrolides
5. Nitroimidazoles
6. Fluoroquinolones

12. Natural penicillins (Pen VK and Pen G)
MOA: Inhibit cell wall synthesis
Dose: 250-500 mg qid x 7-10 days
Contraindications:
Allergies
Poor renal fxn
 Adverse events: GI upset
Drug interactions: oral contraceptives
Pregnancy category B

13.  Bactericidal
 Spectrum:
 Strep, staph, enterococcus, neiseria, treponema, listeria
 Resistance:
 Mostly staph (>80%)

14. Amino-penicillins
Amoxicillin, ampicillin
MOA: Inhibit cell wall synthesis
Dose: 250-500 mg q 8 h x 7-10 days
Contraindications:
Allergies
Poor renal fxn
 Adverse events: GI upset
Drug interactions: oral contraceptives
Amoxicillin and clavulanic acid (Augmentin)

15. . Bactericidal
Spectrum:
 Strep, staph, enterococcus, neiseria, treponema, listeria, E.
coli, proteus, H. Flu, shigella, salmonella
Resistance:
 Entero, citro, serratia, proteus vulagris, provedincia,
morganella, pseudomonas aeriginosa, acinetobacter

16. Cephalexin (Keflex)
MOA: Inhibit cell wall synthesis
Dose: 250-1000mg q 6 h x 7-10 days
Contraindications:
Allergies
Poor renal fxn
Adverse events: mild GI
Drug interactions: probenecid
Pregnancy category B

17.  Cephalexin (Keflex)
 Bactericidal
 Spectrum:
 Gram +
 Resistance:
 Methicillin resistant gram +

18. Clindamycin (Cleocin)
MOA: binds to the 50S ribosomal subunit and inhibits
protein synthesis
Dose: 100-450mg q 6 h x 7-10 days
Precautions:
Poor hepatic fxn
Adverse events: GI upset, pseudomembraneous
colitis
Drug interactions: neuromuscular blocking agents
Pregnancy category B

19. Bactericidal or static depending on concentration
 Spectrum:
Gram +, anaerobes, parasites
Resistance
Enteroccocus
*Clostridium diff. pseudomembranous colitis!!

20. Azithromycin (Zithromax), clarithromycin (Biaxin)
MOA: bind to the 23S rRNA in the 50S subunit
ribosome
Dose: 250-500 mg/day x 5-10 days
Precautions :
Poor hepatic fxn
Adverse effects: GI
Drug interactions: Cytochrome P-450 (Remember
Seldane?)
Pregnancy category B

21.  Bactericidal
 Spectrum:
 Gram +, gram -, anaerobes
 Resistance:
 B. fragilis, and strep pneumo

22. Doxycycline (Vibramycin)
MOA: inhibit protein synthesis by preventing
aminoacyl transfer RNA from entering the acceptor
sites on the ribosome
Dose: 100mg qd-bid x 7-14 days
Contraindications:
pregnancy
Adverse events: GI
Drug interactions: anti-epileptics
Pregnancy category D

23. Doxycycline
Bacteriostatic
Spectrum:
Broad, Gram +, -, anaerobes, aerobes, and spirochetes
Resistance:
Widespread, cross resistance
PHOTO SENSITIVITY!!!

24. Metronidazole (Flagyl)
MOA: reduced intermediate interacts and breaks the
bacterial or parasitic DNA
Dose: 250-1000 mg q 6-8 h x 7-10 days
Precautions : poor hepatic fxn
Adverse events: HA, N/V/D
Drug interactions: EtOH, warfarin, Li+
Pregnancy category D

25.  Bactericidal
 Spectrum:
 Gram - anaerobes
 Resistance:
 Rare, H. Pylori?
 Unpleasant metallic taste

26. Ciprofloxacin (Cipro)
MOA: Inhibition of DNA gyrase, and Topo II
Dose: 250-500 mg qd x 7-10 days
Contraindications: <18 yrs old, pregnancy
Adverse events: spontaneous tendon rupture
Drug interactions: probenacid, warfarin
Pregnancy category C

27. Ciprofloxacin
Bactericidal
Spectrum:
Very broad except B. frag
Resistance:
MRSA, MRSE

28. Should be given to patients with a history of:
• Prosthetic cardiac valve
• Previous infective endocarditis
• Cardiac transplantation recipients, who develop
cardiac valvulopathy
• Congenital heart disease ( CHD)* including

29. Should not be given to patients with history of:
• Heart murmur (not as listed in 1.1)
• ‘Floppy valve’
• Hypertrophic cardiomyopathy
• Previous Rheumatic Fever
• Angina, Coronary disease, Previous MI
• Cardiac Failure
The following procedures and events do not need prophylaxis:
• Taking dental radiographs
• Dental impressions
• Routine dental anaesthetic injections through non-infected tissue
• Fissure sealants
• Supragingival restorations
• adjustment of orthodontic appliances
• root canal treatment, if not penetrating the apex

31. COX-2
(induced by inflammatory stimu

32. Ibuprofen
Naproxen
Fenoprofen
Ketoprofen
oxzprozin

33. Celecoxib
Valdecoxib
Rofecoxib
Naproxen, ibuprofen and diclofenac are frequently used as
comparators in RCTs on the safety and efficacy of COX-2
inhibitors.
BUT…
Different comparator doses may influence the results of RCTs.
It has been hypothesized that RCTs of COX-2 inhibitors where
different doses were administered resulted in different
conclusions about the cardiovascular safety of COX-2
inhibitors. High comparator doses may let COX-2 inhibitors
look better in terms of safety, while low comparator doses may
result in the opposite.

35. Dental Infection
Acute—Rapid growth
< 3 days
Chronic > 3 days
Pen VK 500mg q6h or
Amox 500mg q8h or
Cephalosporin
Allergic to PCN
Clindamycin 300mg q8h or
Cephalosporin (check allergic Rxn) or
Azith or Clarithromycin
Think Anaerobes
Add Metronidazole 250-500mg
To PCN, Amox, or Ceph
Clindamycin 300mg q8h