Dental phrmacology

Introduction To Pharmacology
Pharmacology is the science that deals with the study of
drugs and their interaction with the living systems.
The useful and toxic effects of many plant and animal
product were known to man in ancient time. The earliest writing on
drugs are the Egyptian Medical papyrus (1600 BC) . The largest
of them Ebers Papyrus lists some 800 preparations.
.
Dr. Firas Kassab 3

• Though medicine developed simultaneously in several countries the
spread of knowledge was limited because of poorly developed
communication across the world.
• India’s earliest pharmacological writing are form the ‘Vedas’. An ancient
Indian physician Charaka and then Sushuruta and Vagbhata, described
many herbal preparations included in Ayurveda (meaning the science of
life). Indians practiced vaccination as early as 550 BC.
• Various other traditional systems of
medicine were practiced in different
parts of the world- like
• Homeopathy ,
• Unani
• Siddh system
• Allopathy Dr. Firas Kassab 4

Thus several systems of medicine were introduced of which
only a few survived.
By the end of 17th century the importance of
experimentation, observation and scientific methods of study
became clear.
Francois Magendie and Claude Bernard popularized the
use of animal experiments to understand the effects of drugs.
simultaneous development of the other branches of science viz.
botany, zoology, chemistry and physiology helped in the better
understanding of pharmacology
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GENERAL DEFINITIONS
A. Pharmacology is the study of the interaction of chemicals with
living systems.
B. Drugs are chemicals that act on living systems at the chemical
(molecular) level.
C. Medical pharmacology is the study of drugs used for the
diagnosis, prevention, and treatment of disease.
D. Toxicology is the study of the untoward effects of chemical agents
on living systems. It is usually considered an area of pharmacology.
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E. Pharmacodynamic properties of a drug describe the action of
the drug on the body, including receptor interactions, dose-response
phenomena, and mechanisms of therapeutic and toxic action.
F. Pharmacokinetic properties describe the action of the body on the
drug, including absorption, distribution, metabolism, and excretion.
Elimination of a drug may be achieved by metabolism or by
excretion.
G. Chemotherapy is the use of chemicals for the treatment of
infections. The term now also includes the use of chemical compounds
to treat malignancies.
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INTRODUCTION TO PHARMACODYNAMICS
Concentration-Response.
A fundamental principle of pharmacology is that a
relationship exists between the concentration of a drug at its site of
action and its beneficial or toxic action.
The reliance of pharmacodynamic effects upon drug
concentration provides the key link between pharmacokinetics and
pharmacodynamics for it is the action of the body upon a drug that
determines its concentration at its site of action.
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Properties of Drug Receptors.
Most receptors are proteins (eg, enzymes, hormone and
neurotransmitter receptors); in addition, some DNA and RNA
molecules serve as drug binding targets.
A successful receptor must distinguish between different
ligands.
That is, it must bind selectively to certain ligands. In many
cases, drugs bind to a site on a protein that normally binds to an
endogenous small molecule or protein.
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Types of Drug-Receptor Interactions.
When a drug activates a receptor that it binds to, the drug is
an agonist.
Most agonists mimic the effects of small molecules or proteins
that serve as endogenous regulators of the receptor to which the drug
binds.
Pharmacologic antagonists have the opposite effect. That is,
they prevent the effect of endogenous agonists on the function of the
receptor. Most of the time, a pharmacologic antagonist binds to the
same site as an agonist and competes with the agonist for binding to
a critical site on the receptor. Pharmacologic antagonists have two
important properties.
1. In the absence of an agonist, they do not elicit a biologic response.
2. The effects of a competitive pharmacologic antagonist can be
overcome by adding more agonist.
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Graphical Representation of Concentration-Effect Relationships.
The relationship between drug concentration and receptor
binding, and drug concentration and pharmacodynamic effect can
best be understood through the use of graphical representations.
Dr. Firas Kassab 11

INTRODUCTION TO PHARMACOKINETICS
Pharmacokinetics concerns the effects of the body on the
administered drug. It can be pictured as the processes of absorption,
distribution, and elimination. Elimination includes both metabolism
and excretion. All of these processes involve movement of drug
molecules through various body compartments and across the barriers
separating those compartments.
:
Dr. Firas Kassab 12

Absorption of Drugs.
Drugs usually enter the body at sites remote from the target
tissue and are carried by the circulation to the intended site of action.
Before a drug can enter the bloodstream, it must be absorbed
from its site of administration. The rate and efficiency of absorption
differs depending on the route of administration.
Dr. Firas Kassab 13

Figure 1.1 Schematic representation of drug absorption, distribution, metabolism, and elimination.
Dr. Firas Kassab 14

1. Oral (swallowed).
Maximum convenience but may be slower and less complete
than parenteral routes.
Dissolution of solid formulations (eg, tablets) must occur first.
The drug must survive exposure to stomach acid.
This route of administration is subject to the first pass effect
(metabolism of a significant amount of drug in the gut wall and the
liver, before it reaches the systemic circulation).
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2. Sublingual (under the tongue)
Permits direct absorption into the systemic venous circulation
thus avoiding the first pass effect.
May be fast or slow depending on the physical formulation
of the product.
Nitroglycerin is administered by this route in the treatment of
angina.
3. Rectal (suppository)
Same advantage as sublingual route
larger amounts are feasible.
Useful for patients who cannot take oral medications
(eg, because of nausea and vomiting).
Dr. Firas Kassab 16

4. Intramuscular.
Absorption is sometimes faster and more complete than after oral
administration.
Large volumes (eg, 5 - 10 mL) may be given.
Requires an injection.
Generally more painful than subcutaneous injection.
Vaccines are usually administered by this route.
5. Subcutaneous.
Slower absorption than intramuscular.
Large volumes are not feasible.
Requires an injection.
Insulin is administered by this route.
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6. Inhalation.
For respiratory diseases, this route deposits drug close to the
target organ; when used for systemic administration (e.g., nicotine in
cigarettes, inhaled general anesthetics) it provides rapid absorption
because of the large surface area available in the lungs.
Dr. Firas Kassab 18

7. Topical.
Application to the skin or mucous membrane of the nose,
throat, airway, or vagina for a local effect.
It is important to note that topical drug administration can
result in significant absorption of drug into the systemic circulation.
Drugs used to treat asthma are usually administered this way.
Dr. Firas Kassab 19

8. Transdermal.
Application to the skin for systemic effect. Transdermal
preparations generally are patches that stick to the skin and are worn
for a number of hours or even days.
To be effective by the transdermal route, drugs need to be
quite lipophilic.
Nicotine is available as a transdermal patch for those who are
trying to stop cigarette smoking.
9. Intravenous.
Instantaneous and complete absorption (by definition, 100%);
potentially more dangerous because the systemic circulation is
transiently exposed to high drug concentrations
Dr. Firas Kassab 20

Distribution of Drugs.
The distribution of drugs from the site of absorption, through the
bloodstream and to the target tissue depends upon:
1. The blood flow to the tissue is important in the rate of uptake of
a drug.
Tissues that receive a high degree of blood flow (eg, brain, kidney)
have a fast rate of uptake whereas tissues with a low degree of
blood flow (eg, adipose tissue) accumulate drug more slowly.
2. Solubility of the drug in the tissue.
Some tissues, eg, brain, have a high lipid content and dissolve a
higher concentration of lipophilic agents
Dr. Firas Kassab 21

3. Binding of the drug to macromolecules in the blood or tissue limits
their distribution.
4. The ability to cross special barriers.
Many drugs are poorly distributed to the brain and the testis
because these tissues contain specialized capillaries (the smallest type
of blood vessel).
The endothelial cells that line these capillaries form a blood-
brain barrier and a blood-testis barrier by preventing the movement
of hydrophilic molecules out of the blood and into the tissue, and by
actively pumping lipophilic molecules out of the endothelial cell and
into the blood.
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Of special concern is the ability of drugs to distribute to
breast milk in lactating women, and the ability of drugs to cross the
placenta and affect the developing fetus.
A number of drugs are known to be teratogens (drugs that
cause abnormal fetal development) and should be avoided in
pregnancy.
Women taking drugs that are considered unsafe for infants
and that achieve appreciably high concentrations in breast milk
should not breast-feed their infants
Dr. Firas Kassab 23

Elimination of Drugs.
The rate of elimination (disappearance of active drug
molecules from the bloodstream or body) is almost always related to
termination of pharmacodynamic effect.
There are two major routes of elimination:
1. Excretion.
The most common route for drug excretion is through the kidney
and out of the body in the urine. To be excreted by the kidney, drugs
need to be reasonably hydrophilic so that they will remain in the fluid
that becomes the urine. Patients with impaired kidney function usually
have a reduced ability to eliminate hydrophilic drugs. To avoid
excessively high drug concentrations in these patients, we will need to
reduce their dosages or give dosages less frequently. A few drugs
enter the bile duct and are excreted in the feces.
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Metabolism.
The action of many drugs, especially lipophilic compounds, is
terminated by enzymatic conversion, or metabolism, to biologically
inactive derivatives.
In most cases, the enzymatic conversion forms a more
hydrophilic compound that can be more readily excreted in the urine.
Most of the enzymes that catalyze drug-metabolizing reactions
are located in the gastrointestinal tract and the liver.
Some drugs inhibit drug-metabolizing enzymes and thus cause
drug-drug interactions when co-administered with drugs that depend
upon metabolism for elimination.
Dr. Firas Kassab 25

Sources of Drugs :
Natural
Plant –
atropine , morphine
quinine , digoxin
Animal –
insulin , heparin , gonadotropin
Minerals-
magnesium sulphate , aluminium hydroxide ,
iron , sulphur
Micro organism –
obtain from sum bacteria or fungi we thus have
penicillin, chephalosporins , tetracycline's
(text book of pharmacology 2ed edition)
Dr. Firas Kassab 26

Humans :
 Immunoglobulin's from blood
 growth hormones from anterior pituitary
 chorionic gonadotropins from urine of pregnant women.
Synthetic :
 Quniolones
 omeprazole
 neostigmine
Dr. Firas Kassab 27

Dental Pharmacology INTRODUCTION
Rapid progress in dental pharmacotherapeutics requires
that clinicians constantly update their knowledge of new drugs,
drug interactions and useful therapeutic trends
These drugs play a useful role in the treatment of
ulcerations, inflammations, xerostomia and bleeding during
gingival retraction.
They also help in reducing dentinal hypersensitivity during
vital tooth preparation and increasing the gingival resistance
against infections.
Dr. Firas Kassab 28

LA are the drugs which upon topical application or local injection
cause reversible loss of sensory perception, especially of pain, in a restricted
area of the body.
These drugs act by excessive stimulation followed by depression
(Bennett, 1984a).
To work efficiently, the dental local anesthetics should have some
requirements (Haas, 2002) such as:
• High intrinsic activity, which ensures complete anesthesia for all dental
treatment
• Rapid onset
• Adequate duration of anesthesia (30 to 60 min for standard dental
treatment)
• Low systemic toxicity
• High efficacy-toxicity ratio
• Low overall incidence of serious adverse effects
Dr. Firas Kassab 30

Chemically local anesthetics are classified as
Esters
cocaine
procaine
tetracaine
benzocuaine
Amide types
lignocain
mepivacain
bupivacain
etidocaine
Dr. Firas Kassab 31

Local anesthetics containing vasoconstrictor agents are to be used with
caution in patients with
 Pheochromocytoma
 uncontrolled or unstable angina
 cardiac arrhythmias
 Congestive heart failure
 Hyperthyroidism
 diabetes.
 (Bennett, 1984c)
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The local adverse effects
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If allergic reactions occur,
The immediate treatment is
intravenous injection of 0.01 ml per kilogram body weight adrenaline,
supplemented by antihistamine agents such as 10 to 20 mg
chorpheniramine,
or 50 mg hydroxyzine or promethazine hydrochloride (Ball, 1999).
Dr. Firas Kassab 36

Topical anesthetics
are used in the oral cavity to provide pain relief at needle
insertion site and over ulcerations.
Topical anesthetic agents can also provide some
form of relief in patients exhibiting gagging during the
impression procedure.
Glycerine, lanolin, petrolatum, mineral oil, sodium
carboxymethylcellulose, propylene glycol and
polyethylene glycol are used as vehicles for topical
Anesthetics (Adriani and Zepernick, 1964).
Dr. Firas Kassab 37

Vasoconstrictors are used in dentistry either as components of
the local anesthetic syringe or for application with gingival retraction
cords.
These agents do not produce coagulation of blood but act by
constricting blood vessels.
Examples of vasoconstrictors accepted by the Council on Dental
Therapeutics include
Epinephrine (1:200,000/1:100,000/1:50,000),
Levonordefrine (1:20,000)
Norepinephrine (1:30,000).
Epinephrine is the vasoconstrictor of choice for use in dentistry (Felpel,
1999).
Dr. Firas Kassab 40

It restricts the blood supply to the area by decreasing the size
of blood capillaries thereby decreasing hemorrhage and fluid
seepage.
It is advisable to use low concentration epinephrine (0.01%) for
gingival retraction due to its superior effect in keeping the gingival
sulcus relatively dry during the impression procedure
(Csillag et al., 2007).
Dr. Firas Kassab 41

Antiseptics
Antiseptics are drugs that are applied on the body surfaces to
prevent infection by killing or inhibiting the growth of pathogenic
bacteria either by oxidation of bacterial protoplasm or
denaturation of bacterial proteins including enzymes
(Tripathi, 2008a).
Amongst the various types of antiseptics available,
chlorhexidine a biguanide, is one of the most commonly used.
Dr. Firas Kassab 43

First Generation
Phenols
Quaternary Ammonium compounds
Metallic ions
Sanguinaris
Second Generation
Bis biguanides
Third Generation
Delmopinol
Classification of Chemical Plaque Control agents
Dr. Firas Kassab 44

a) Phenols (Triclosan):
It’s a phenol derivative which is synthesized used as a topical antimicrobial
agent with a broad spectrum of action including against both gram -ve and
gram +ve bacteria.
It also has specific action against mycobacterium and candida species.
Mechanism of Action:
Triclosan acts on cytoplasmic membrane and induce leakage of cellular
contents which leads to bacteriolysis and Cell death.
Triclosan is induced in toothpaste to prevent plaque formation.
It is used along with zinc citrate or its polymer gantrez to enhance its
retention in the oral cavity.
It also inhibits prostaglandins and leukotriens thereby it reduces the
degree of inflammation. Dr. Firas Kassab 45

Metallic ions:
These are Zn -ions and Cu -ions.
It acts by reducing the glycolytic activity in bacteria and hence delays
bacterial growth.
Quaternary Ammonium Compounds:
These are Benzathonium Chloride, Benzallenium Chloride and
Cetylpyredinum. These are cationic antiseptics and surface active agents
which are effective against gram +ve organisms.
Mechanism of action:
Positively charged molecule reacts with negatively charged cell
membrane phosphates and thereby disrupting the bacterial cell wall
structure.
The side effects
• staining and enhanced calculus formation
• it also causes burning sensation and desquamation.Dr. Firas Kassab 46

Sanguinare:
 Sanguinare chloride is currently used in both mouth rinses and
toothpaste.
 It is an extract from blood root plant Sanguinare candensis.
 It is an benzophenanthredine alleloid.
 Mechanism of action is not known.
 It is most effective against gram positive organisms.
Dr. Firas Kassab 47

Second generation
Bisbiguanides:
isbiguanides posses anti plaque activity including Chlorhexidine,
Alexidine and Octenidine.
The antiplaque properties of chlorhexidine are unsurpassed by other
agents.
It has much greater and more prolonged effects than other
antiseptics.( Joyston-Bechal 1993)
The digluconate of chlorhexidine (1: 6 – Di 4 – chlorphenyl –
diguanidohexane) is a synthetic antimicrobial drug which is effective in vitro
against both gram positive and gram negative bacteria including aerobes,
anaerobes, yeast and fungi.
( Eley B. 1999)
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Mechanism of action:
Prevents pellicle formation by blocking acidic groups of salivary
glycoprotein’s thereby reducing glycoprotein adsorption on to tooth
surface. Prevents adsorption of bacterial cell wall on tooth surface.
Prevents binding of mature plaque
Antibacterial action of Chlorhexidineconsits of two actions, i.e.,
bacteriostatic at low concentration and bactericidal at high
concentration.
Bacteriostatic action at low concentration is mainly due to the negative
energy of the bacterial cell wall reacts with positive energy
chlorhexidine molecule. This alter the integrity of cell membrane and
Chlorhexidine binds to inner membrane phospholipids and increases
permeability. This leads to the vital elements leaks out resulting in
bacterial cell death. Dr. Firas Kassab 49

Bactericidal Action is due to the higher concentration of chlorhexidine.
This cause progressive greater damage of membrane and the larger
molecular weight compounds loss and coagulation and precipitation of
cytoplasm.
The Free CHX molecules enter the cell and coagulate proteins and vital
cell activity ceases and cause resultant cell death.
It has shown that 0.2% CHX mouth rinses will prevent development of
experimental gingivitis, it has been shown that Chlorhexidine is more
effective in preventing plaque accumulation on a clean tooth surface
than in reducing pre existing plaque deposits.( Joyston‐Bechal S,1993)
The adverse effects
brown staining of tooth and restoration
loss of taste sensation
stenosis of parotid duct. Dr. Firas Kassab 50

It affects the mucous membrane and tongue; and may be related to
the precipitation of chromogenic dietary factors on teeth and mucus
membrane. It is probable that one cationic group attaches
chlorhexidine to the tooth and mucosal surface, which the other cationic
group lyse the bacterial cell wall. Thus the cationic group can also
attach dietary factors such as gallic acid derivatives found in some
foods and beverages including tea, coffee and wines.
Dr. Firas Kassab 51

Essential oils (Listerine):
It’s a combination of phenol related essential oil, thymol and methyl
salicylate.
It has shown to have moderate plaque inhibitory effect and
antigingivitis effect.
It has poor oral retention and has burning and bitter taste. (Mandel
1988)
Mechanism of Action:
The action of phenol acid is cell wall disruption and inhibition
of bacterial enzyme.( McDonnell G 1999)
The phenolic compound are also known to act as scavengers of
oxygen free radical and hence has an effect on leucocyte activity
Dr. Firas Kassab 52

Third generation
Delmopinol : It’s a relatively new preparation which inhibits plaque
growth and gingivitis.
It interferes with plaque matrix formation and also reduces bacterial
adhesion and adherence.
It ceases binding of plaque to tooth, thus aiding the easy removal of
plaque by mechanical procedures.
It is indicated as a pre brushing mouth rinse.
Adverse effects
 staining of tooth and tongue
 taste disturbances
 mucosal soreness
 erosion Dr. Firas Kassab 53

Steroids
Steroids play a role in the modulation of the inflammatory reaction by
inhibitory activity affecting the production of mRNA and thus protein
synthesis. Application of topical steroid preparations provides
temporary relief of symptoms associated with inflammation and
ulcerated lesions in the oral cavity
such as recurrent apthous stomatitis.
These topical ointments include
Triamcinolone acetonide 0.1%
Kenalog in Orabase
Hydrocortisone acetate 1%
Betamethasone dipropionate 0.05%.
Dr. Firas Kassab 55

Topical use of steroids is usually well tolerated but some patients may
develop a secondary erythematous candidosis or pseudomembranous
candidosis (thrush) if predisposing conditions like
xerostomia,
Systemic and/or topical use of antibiotics
corticosteroid asthma inhalants
prostheses and cigarette smoking are present in them.
Even though clinical experience and laboratory studies have
shown systemic absorption of steroids to be insignificant through the
oral mucosa but caution should be exercised when used in patients with
• Diabetes
• Hypertension
• tuberculosis
(Savage and McCullough, 2005).
Dr. Firas Kassab 56

Analgesic agents are used for the management of pain
divided :
Nonopioid (non-narcotic)
Acetaminophen (Paracetamol)
Opioid (narcotic).
An important difference between the opioids and the
nonopioid analgesic agents is their mechanism of action.
The action of the nonopioid analgesic agents is related to their
ability to inhibit prostaglandin synthesis at the peripheral nerve
endings whereas the opioids affect the amount of pain by depressing
the central nervous system. Dr. Firas Kassab 58

Text book of pharmacology 2ed edition
Dr. Firas Kassab 59

Opioid Analgesics
Opioid analgesics used in dentistry for
oral administration are Codeine,
Hydrocodone, Oxycodone and
Pentazocaine whereas Morphine,
Meperidine and Fentanyl are used
parenterally .
Opioids are added to
nonopioids to manage pain that is
moderate to severe or that does not
respond to nonopioids alone. Opioids
differ from the nonopioids in that
they have no ceiling effect. The only
dosing limitation is based on side
effects (Felpel, 1997).
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The NSAIDs constitute a heterogeneous group of drugs with
clinically important analgesic, antipyretic and anti-inflammatory
properties that rank intermediately between corticoids with
anti-inflammatory properties on one hand, and major analgesics –
opioids on the other (Poveda-Roda et al., 2007).
These agents differ from opioid analgesics in the following ways:
(1) there is a ceiling effect to the analgesia
(2) they do not product tolerance or physical
Dependence
(3) they are antipyretic
(4) they possess both anti-inflammatory as well as analgesic properties
(Yagiela et al., 2004a).
Dr. Firas Kassab 64

Nonopioids are most effective in treating postprocedural pain
when given before the procedure (or immediately following a short
procedure), thus preventing the synthesis of prostaglandins that quickly
follow the surgical insult.
Dr. Firas Kassab 65

Text book of pharmacology 2ed edition
Dr. Firas Kassab 66

Physical, chemical or mechanical stimuli in the form of tissue
damage, hypoxia, immune processes, etc. induce arachidonic acid
release and metabolization.
NSAIDs inhibit cyclooxygenase (COX) – the enzyme
responsible for the transformation of arachidonic acid into
prostaglandins and thromboxanes, which are substances generically
referred to as eicosanoids.
These resulting metabolites (prostaglandins and thromboxanes)
exert potent vasodilating action, resulting in increased vascular
permeability, with the extravasation of fluids and white blood cells
therby contributing to inflammation.
Consequently, the inhibition of cyclooxygenase synthesis exerts
a clear anti-inflammatory effect (Poveda-Roda et al., 2007).Dr. Firas Kassab 68

Out of the two forms (isoenzymes) of cyclooxygenase namely
COX-1 and COX-2 the latter COX-2 appears to be more involved
with synthesis of prostaglandins at sites of inflammation, whereas
COX-1 is more involved at sites where adverse effects of NSAIDs are
expressed, such as the GIT.
Therefore NSAIDs that have more selective inhibitory activity
on COX-2 as opposed to COX- 1 would be expected to have a more
favorable therapeutic index (Waldman et al., 1982).
Celecoxib, Rofecoxib and Parecoxib are drugs showing selective COX-
2 inhibitory action but these should be avoided in patients with
moderate to severe hepatic damage.
Dr. Firas Kassab 69

Potential adverse effects of NSAIDs include
• peptic ulcer disease
• gastrointestinal (GI) bleeding,
• GI perforation
• impaired renal function
• inhibition of platelet function.
Salicylates should be avoided in patients suffering from
Ulcers, Asthma, Diabetes, Gout, Influenza and hypercoagulation
states.
Dr. Firas Kassab 70

Asprin and related salicylates are contraindicated for
treatment in children and teenagers with viral infections, as it has been
associated with hepatotoxicity and encephalopathy (Reye’s syndrome)
(Waldman et al., 1982).
Ibuprofen, naproxen sodium, ketoprofen and asprin are
currently approved by the food and drug administration for over
the counter (OTC) use.
These OTC drugs should not be used consecutively for over 10
days for pain and 3 days for fever (Yagiela et al., 2004b).
A 200 to 800 mg dose of ibuprofen should be considered as
the first choice for management of acute inflammatory pain
(Hargreaves and Abbott, 2005).
Dr. Firas Kassab 71

Acetaminophen (Paracetamol)
It has analgesic and anti-pyretic effects, and it is a weak
inhibitor of the cyclo-oxygenase sub-groups COX-1 and COX-2.
At therapeutic doses it does not inhibit prostaglandin in the
peripheral tissues so there is very little, if any, anti-inflammatory
action.
It is therefore not classified as an NSAID (Felpel, 1997).
Tolerance and dependence have not been reported, and
Paracetamol does not cause the same gastric irritation or the other
complications associated with aspirin and other NSAIDs (Seymour et al.,
1999).
The usual recommended adult dose of Paracetamol is 500-
1000mg every four to six hours (up to a maximum of 4000mg per
day) (Therapeutic guidelines, 2002). Dr. Firas Kassab 72

Combination drug therapy
The goal of combining analgesics with different mechanisms of
action is to use lower doses of the component drugs, thereby improving
analgesia without increasing adverse effects
(Mehlisch, 2002).
Patients with acute dental pain are best treated with NSAIDs or
acetaminophen as the primary analgesic and the addition of a narcotic
should be reserved for situations when additional analgesia is required.
Opioid and acetaminophen combination studies show that a
combination is better than opioids or acetaminophen alone (Moore et al., 1997).
Opioids such as codeine, hydrocodone and oxycodone combined
with ibuprofen are superior to manage acute dental pain than ibuprofen
alone (Po and Zhang, 1998).
Dr. Firas Kassab 73

The analgesic properties of aspirin, acetaminophen and ibuprofen
have been seen to increase when combined with 65 to 100 mg
caffeine.
Dr. Firas Kassab 74

Antibiotics are chemicals virtually always derived naturally
with the exception of ulfonamides, fluoroquinolones and
oxazolidinones.
These drugs act on the microorganisms to effect their
viability hence they can be either bactericidal (inducing cell death) or
bacteriostatic(preventing cell growth or replication) (Yagiela et al., 2004d).
Antibiotics with activity against a wide range of disease-
causing bacteria are termed as broad-spectrum antibiotics.
It also means that it acts against both Gram-positive and Gram-
negative bacteria.
This is in contrast to a narrow-spectrum antibiotic which is
effective against only specific families of bacteria.
Dr. Firas Kassab 76

tetracyclines and clindamycin are accepted by the Council on
Dental therapeutics, ADA.
Other antibiotics appropriate for use in Dentistry include
penicillin,
erythromycin
cephalosporins
bacitracin (Felpel, 1997).
Oral infections are usually caused by aerobic gram-positive cocci
(Staphylococcus aureus) and anaerobic microorganisms
(Peptostreptococcus) and the use of antibiotics in dentistry is to either
treat these or as a prophylaxis to prevent bacterial endocarditis that
is caused by α hemolytic streptococci
Dr. Firas Kassab 78

Most acute oral infections respond well to one of the oral
penicillin preparations.
adverse side effects, and allergic reactions.
A true allergic reaction usually manifests as an irritating rash.
Anaphylactoid reactions though rare, occur in
susceptible patients within 30 seconds of an im inj.
Signs and symptoms of anaphylaxis include
• oral paresthesia
• cold hands feet
• Bronchospasm
• wheezing,
• circulatory collapse
• unconsciousness Dr. Firas Kassab 79

Alternatives to penicillin include
 Erythromycin
 Cephalosporins
 Clindamycin,
 Tetracycline
but Cephalosporins should not be used in a person with a history of
anaphylaxis, angioedema or urticaria with penicillins or ampicillin.
Erythromycin estolate
Erythromycin ethylsuccinate
Contraindicated
liver dysfunction as they can cause cholestatic hepatitis.
Dr. Firas Kassab 80

Tetracyclines –
avoided during
Pregnancy
children below 8 years because permanent staining of deciduous and
permanent teeth and retardation of bone growth may occur.
gastrointestinal upset
Hepatotoxicity
Nephrotoxicity
photosensitivity
impaired calcium
absorption.
Similarly, quinolones should be avoided in children, pregnant or
nursing women, and in epileptics (Felpel, 1997).
Dr. Firas Kassab 81

Antibiotic prophylaxis is recommended for dental procedure
in patients with prosthetic cardiac valve, previous infective
endocarditis, cardiac transplantation recipients who develop cardiac
valvulopathy and during the first six months following any procedure
to treat congenital heart disease (Prevention of infectiveendocarditis,
2007).
Antibiotic coverage for invasive dental procedures is
recommended in patients with poorly controlled or uncontrolled
diabetes, infective endocarditis but not in those having orthopedic
prosthesis placed over 2 years prior to the dental procedure.
Prophylactic use of antibiotics in conjunction with dental
treatment should be avoided unless there is a clear indication since
unwarranted overuse of antibiotics can lead to development of
resistant strains of microorganisms (Barker, 1999).
Dr. Firas Kassab 82

Antibiotic prophylactic regimen for dental procedures in
high risk patients
Dr. Firas Kassab 83

Oral moniliasis (thrush) is a fungal infection of the oral cavity caused
by Candida albicans.
C albicans can also colonize prosthetic devices like dentures.
Atleast 2 weeks of therapy are required for treating oral candidiasis.
Nystatin (Mycostatin) is the most common drug used in dentistry and it
can have a fungistatic or fungicidal effect depending on its dose.
A 2-3 ml (100,000 units/ ml) suspension or
1-2 lozenges (200,000 units each)
may be used four to five times per day.
Colonized dentures can be treated by soaking them in a nystatin
solution
or applying an ointment (100,000/g) of nystatin to the tissue surface.
Dr. Firas Kassab 87

Clotrimazole (Mycelex), a fungistatic can be used in a dose of 10 mg
troches dissolved in the mouth five times a day
Since Nystatin and Clotrimazole are not appreciably absorbed from
the gastrointestinal tract, the topical route is preferred for their
administration.
Oral Fluconazole (Diflucan) in a dose of 50 to 100 mg/day and
Itraconazole (Sporanox) 200mg/day are broad-spectrum antifungal
agents that are effective in treating oropharyngeal and esophageal
candidiasis (Yagiela et al., 2004e).
Dr. Firas Kassab 88

Antianxiety agents are used in clinical dentistry for premedication in an
apprehensive patients pending operative procedure like Implant surgery.
Antianxiety agents are known to summate with
Anesthetics
opioid analgesics
Antidepressants
sedative-hypnotics
alcohol to cause excessive CNS depression (Yagiela et al, 2004f)
hence should be prescribed with caution.
Benzodiazepines such as
Diazepam (Valium),
Lorazepam (Ativan)
and Alprazolam (Xanax)
Antihistamines such as
Hydroxyzine (Vistaril)
Promethazine (Phenergan)
are the preferred anxiolytics for use in dentistry.
Dr. Firas Kassab 90

They should preferably have a rapid onset and a short duration of
action.
Diazepam (2-10mg),
Lorazepam (2-6 mg)
Alprazolam (0.25-1.5mg) have a 12-24 hour duration of action
whereas antihistamines in a dose of 25-100mg have a 4-6 hour
duration of action.
The use of Benzodiazepines is contraindicated in patients with
psychosis,
acute narrow-angle glaucoma
liver disease.
Dr. Firas Kassab 91

These are drugs that reduce skeletal muscle tone without altering
consciousness.
They are used in chronic spastic conditions and acute muscle spasms of
the temporomandibular joint.
These drugs usually cause slight sedation hence caution is to be
exercised regarding operation of motor vehicles.
These drugs have a potential for abuse and dependence hence
prolonged administration and abrupt stoppage is to be avoided
(Stanko, 1990).
Dr. Firas Kassab 93

Definition
According To ADA council on dental “a dentifrice is a substance use
with a toothbrush for the purpose of cleaning the accessible surfaces
of the teeth”.
Webster described the term dentifrice as derived from (Latin)
dens (tooth)
fricare (to rub)
Came into English in 1558.
Dorland described it as a preparation for cleaning and polishing the
teeth.
Dr. Firas Kassab 96

Functions of a toothpaste (in conjunction with toothbrush):
• Minimizing build up of plaque.
• Strengthening teeth against caries.
• Cleaning teeth by removing stains.
• Removing tooth debris.
• Freshening the mouth.
• Composition:
Dentifrices have been prepared in several physical forms
- Pastes
- Powder
- Liquid
- gel
Dr. Firas Kassab 97

Powder dentifrices :
abrasive,
detergents,
Flavoring
sweetening agents.
Paste dentifrices: contain the above plus
binders,
preservative ,
humectant,
water
Dr. Firas Kassab 98

• Composition
Dr. Firas Kassab 99

The polishing or abrasive agent(25-50 %):
• An ideal abrasive is one that cleans well with no damage to the
tooth surface and provides a high polish that can prevent or delay
the reaccumalation of stains and deposits.
• Abrasives by volume are the single largest components of a
dentifrice.
Abrasive agent has two purposes:
• Firstly, its mild abrasive action helps to eliminate plaque from the
teeth, hence reducing plaque build up.
• Secondly, the abrasive agent removes stained pellicle from the
teeth, polishes the surfaces, restores the natural luster and enhances
enamel whiteness
Dr. Firas Kassab 100

• Abrasive agent must be chosen very carefully, so that there is no
scratching or damaging the enamel or the much softer underlying
dentine.
• In particular attention is paid to the size of the particles and their
shape and hardness.
• The abrasive system should be insoluble, inert nontoxic and
preferably white.
• Commonly used abrasive materials include calcium carbonate,
dicalciurn phosphate dihydrate, alumina and silicas.
• In gel toothpaste, the abrasive system is usually a special porous
silica that becomes transparent when blended into the gel system.

The binder or thickener(1-2%):
• The binder or thickener controls the stability and consistency of a
toothpaste, and also affects the ease of dispersion of the paste in
the mouth.
• Choice of the correct binder and concentration is critical to ensure
that the product can be readily squeezed from the tube and yet
have a good appearance when it is on the toothbrush.
Commonly used thickeners can be divided into two classes –
• Water soluble- carrageenates, alginates and sodium
carboxymethylcellulose.
• Water insoluble - magnesium aluminum silicate, sodium magnesium
silicate and colloidal silica.

The surfactant agent /detergent (1-3%):
Purposes:
1. To Lower surface tension.
2. Penetrate and loosen surface deposits and stains.
3. Emulsify debris for easy removal by toothbrush.
• The surfactant agent provides the foam that causes the removal of
food debris and aids dispersion of the product in the mouth.
• Early dentifrices actually used soap, but mild synthetic detergents
are now universally used to give better taste, foam and product
stability.

• The detergent used most widely by all major manufacturers is
sodium lauryl sulfate.
• Sodium lauryl sulfate also has anti microbial properties and thus
helps to preserve the toothpaste during manufacture and use.
• It also has a rapid antimicrobial effect on oral flora, which adds to
the overall plaque-inhibiting properties of the toothpaste.
• Another positive role sodium lauryl sulfate has is to help to
solubilize key ingredients such as flavors and certain anti-microbial
agents.

Surfactant used should fulfill the following criteria:
• Non toxic
• Neutral in reaction
• Active in acid or alkaline media.
• Stable
• Compatible with other dentifrice ingredients.
• No distinctive flavor
• Have foaming characteristics.
Examples :
1. Synthetic detergents
2. Sodium lauryl sulfate
3. Sodium and lauryl sarcosinate

The humectant :
• A humectant is a material that helps to reduce the loss of moisture
from a preparation.
• In toothpaste, the humectant minimizes plug formation in tube
nozzles and improves the texture and feel of the product in the
mouth.
• It can also act as a sweetening agent.
• Examples are: glycerin, sorbitol and polyethylene glycol. Glycerin
and sorbitol are the humectants used most often .

The flavoring agents
• The choice of flavor is very important.
• It renders the product pleasant to use and should leave a fresh
taste in the mouth after use.
• Types of flavor : peppermint oil, spearmint oil and wintergreen
(methyl salicylate).
• Others - wintergreen, aniseed, lemon oil and eucalyptus are also
usually added to improve the acceptability of the flavor and to
add individual notes to the flavors - important in medicinal
formulations
Uses of flavor:
1. To make dentifrice desirable
2. To make other ingredients that may have a less pleasant flavor

Water (20-30%):
• Most important of the remaining ingredients.
• Serves as vehicle to deliver ingredients of toothpaste.
• Deionized or distilled water is utilized

Preservatives (0.05-0.5%):
Most dentifrice humectants and some organic binders are
susceptible to attack by microorganisms or molds.
Hence preservatives such as dichlorophene benzoate, p-
hydroxy benzoate, formaldehyde or paraben
Others:
Titanium dioxide to whiten the preparation

Therapeutic agents (0.4 – 1.0 %)
Toothpaste is an excellent vehicle for delivering oral health
benefits and hence many therapeutic agents are added.
These include
Anti caries agents
Anti plaque agents
Anti tartar agents
Anti sensitivity agents.
Therapeutic agents and their mechanism of action:

ANTI-CARIES AGENTS
1. Fluoride:
Fluoride is considered to be the most effective caries-inhibiting agent, and
almost all toothpastes today contain fluoride in one form or the other.
Most common form
- sodium fluoride(NaF).
Mono-fluoro-phosphate (MFP)
Stannous fluoride (SnF) are also used.
The fluoride amount in toothpaste is usually between 0.10-0.15 %.
Toothpastes are the main vehicle for fluoride.

Three main theories considering the positive action of fluoride in the
prevention Of caries:
1. It is claimed that fluoride, incorporated into the enamel during
tooth development in the form of fluorhydroxyapatite (FAP),
reduces the solubility of the apatite .
2. It is also suggested that fluoride has antibacterial actions. In
an acidic environment, if fluoride is present, hydrogen fluoride
(HF) is formed .
3. Today the most important anti-caries effect is claimed to be
due to the formation of calcium fluoride (CaF2) in plaque and on
the enamel surface during and after rinsing or brushing with
fluoride. CaF2 serves as a fluoride reservoir .

2. XYLITOL
Xylitol is a sugar alcohol that cannot be fermented by oral microorganisms.
It is considered to be a cariostatic agent since it can inhibit the
carbohydrate metabolism in different oral microorganisms .
The inhibitory effect on glycolysis has been related to the
uptake of xylitol via a constitutive fructose specific PTS system and
subsequent intracellular accumulation of xylitol-5-phosphate. Such a
mechanism leads to reduced acid formation from glucose, and a
reduction in the streptococcus mutans content in both plaque and
saliva

3. Calcium/Phosphate:
Calcium and phosphate supplementation in a toothpaste will
increase the concentration of these ions in the oral cavity.
This has been reported to improve remineralization and
increase fluoride uptake.
4.Sodium Bicarbonate:
Several studies have shown that bicarbonate is one of the
salivary components that potentially modifies the formation of caries.
It increases the pH in saliva, and in this way creates a hostile
environment for the growth of aciduric bacteria.
Sodium bicarbonate can also change the virulence of the
bacteria that cause tooth decay

ANTI-CALCULUS AGENTS
• Of the anti-calculus agents, the crystal growth inhibitors have
been most extensively tested clinically. These agents act by
delaying dental plaque calcification, thereby promoting plaque
removal with normal tooth brushing
1.Pyrophosphate:
• Inhibit the formation of supragingival dental calculus.
• Added as tetrasodium pyrophosphate, tetrapotassium
pyrophosphate or disodium pyrophosphate.
• It has been shown that pyrophosphate has high affinity to
hydroxyapatite (HA) surfaces, probably by an interaction with Ca+
in the hydration layer, reduces their protein-binding capacity.Dr. Firas Kassab 115

It also has the ability to inhibit calcium phosphate formation. It
is therefore conceivable that pyrophosphate introduced in the oral
cavity through dentifrices may affect pellicle formation.
P-O-P bond of pyrophosphate is susceptible to enzymatic hydrolysis by
plaque and salivary phosphatases, and the effect may thus be of limited
duration in the oral cavity .
Tartar control dentifrices that contain pyrophosphate incorporate
phosphates inhibitors that prolong the activity of pyrophosphate in the mouth.

. Zinc:
• Zinc has anti-calculus effect due to its anti-plaque properties, but in
addition it is thought to influence calculus formation by inhibiting
crystal growth

ANTI-DENTINE HYPERSENSITIVITY AGENTS
Although the condition is referred to as "dentine
hypersensitivity" it isn't really the dentine that is sensitive. The
sensitivity of dentine is caused by fluid-filled tubules in communication
with the pulp.
Potassium salts:
Potassium ions are thought to act by blocking action potential
generation in intradental nerves.
It is claimed that potassium salts increase the concentration of
potassium ions around the pulpal nerves, and thereby depolarizes the
nerve. This can inhibit a nerve response from different stimuli .
The exact mechanism by how potassium desensitises dentine is
yet to be elucidated.

ANTI-APHTOUS AGENTS
Aminoglucosidase and Glucose oxidase:
Enzymatic toothpastes do not contain detergents like SLS because
the detergent can denaturate the enzymes.
SLS may induce adverse effects in oral soft tissues and increases the
frequency of ulcers in patients suffering from recurrent aphthous ulcers
(RAU). Enzyme toothpastes can therefore be an alternative for patients
suffering from RAU .
Use of a dentifrice containing the combination of the enzymes
aminoglucosidase and glucose oxidase has a positive, inhibiting effect on
RAU.
The ulcers were generally reported to be smaller and less painful,
to have a shorter healing time and the frequencies of aphthous ulcers
episodes were decreased.

WHITENING AGENTS
• Whitening toothpastes do not lighten the colour of the tooth
structure; they simply remove surface stains with abrasives or
special chemical or polishing agents, or prevent stain formation.
1. Abrasives:
• An abrasive is required for the effective removal of a
discoloured pellicle.
• Abrasives provide a significant whitening benefit, particularly on
smooth surfaces.
• limited use for areas along the gum line and interproximally .
• Coarse abrasives in toothpates can damage the dental tissue.

2.Dimethicones:
Dimethicones are versatile substances that ranges from low
molecular weight polydimethylsiloxane fluids to high molecular weight
polymers that are gum-like in nature. They cause a smooth surface on
the tooth that prevents stain formation.
3. Papain:
Papain is a sulfahydryl protease consisting of a single
polypeptide chain, extracted from the Carica papaya plant. It is able
to hydrolyse peptide bonds, and can also catalyse the transfer of an
acyl group. It is used in toothpastes as an non-abrasive whitening
agent
4. Sodium bicarbonate:
Dentifrices containing high concentrations of sodium
bicarbonate are more effective in removing intrinsic tooth stain than
those not containing sodium bicarbonateDr. Firas Kassab 121

ANTI-HALITOSIS AGENTS
Zinc:
Halitosis originates mainly from the oral cavity and is due to
the retention of anaerobic, Gram-negative bacteria.
These bacteria use sulphur containing amino acids as
substrates in their production of volatile sulphur-containing compounds
(VSC).
VSC have a distinctly unpleasant odour even in low
concentrations Zinc inhibits the production of VSC in the oral cavity by
interacting with sulphur in the amino acids or their metabolism.
Zinc can be retained in the oral cavity for approximately 2-3
hours after tooth brushing by binding to acidic substances on the oral
mucosa, in the saliva or on bacterial surfaces.

Astringents
Astringents are the substances that precipitate proteins, but do
not penetrate cells, thus affecting the superficial layer of mucosa only.
They toughen the surface by making it mechanically stronger
and decrease exudation.
Astringents may be administered by retraction cords already
impregnated with the agent or by applying them to cotton pellets.
Examples
• Alum
• aluminum chloride
• zinc chloride (8-20%)
• tannic acid Dr. Firas Kassab 123

Styptics are the concentrated form of astringents.
They cause superficial and local coagulation.
Some of the examples are ferric chloride and ferric sulfate.
Aluminum chloride and Ferrous sulfate are preferred astringents
amongst prosthodontists because they cause minimum tissue damage
(Rosenstiel, 2006a).

Hemostatic Agents
Hemostatic agents are used in dentistry for hemorrhage control and wound
protection (Mc Bee and Koerner, 2005).
These are drugs which arrest more serious bleeding from cut or
lacerated capillaries and arterioles.
Some of the examples are:
I. Thrombin- It is prepared from mammalian pro-thrombin, acts by
accelerating the clotting of blood.
It is available in powder form and mixed with saline.
It should be applied locally and never injected.
II. Gel Foam- It is also known as gelatin sponge and is available as a
powder or porous sheet.
The hemostatic properties of absorbable gelatin sponge can be
improved by soaking it in a thrombin solution before application
(Felpel, 1999).

Xerostomia may result from disease states (Sjogren's syndrome,
rheumatoid arthritis, diabetes insipidus, pernicious anemia), from
radiation, as a side effect of a wide variety of
drugs, or from natural aging.
Sialogogues are the agents which activate muscarinic
cholinergic receptors of the parasympathetic nervous system to
increase salivary flow in patients with xerostomia (Tripathi, 2008b).
All commercially available preparations have a limited
duration of action, making frequent application necessary.
Agents such as sugar free gum or candies and lozenges
containing citric acid sorbitol, mannitol or xylitol may be
recommended.

According to Boucher, making a conscious effort of consuming at least
eight glasses of water, juice or milk daily is the most important
measure to relieve dry mouth
(Zarb and Bolender, 2004a).
Pilocarpine have been reported as potentially effective sialogogues
for xerostomic patients in a study on patients with dry mouth following
cancer therapy
(Gorsky et al., 2004).
Carboxy methyl cellulose based artificial saliva demonstrated
moderate effects in reducing dry mouth related symptoms with more
significant effects appearing in patients whose residual
secretory potency was severely compromised
(Oh et al., 2008).

These agents are used to decrease salivary secretion by cholinergic
antagonist action.
They decrease salivary secretion by inhibiting the action of myo-
epithelial cells in the salivary glands thus producing a dry field.
examples of anti-sialogouges,
Methantheline
Propantheline (synthetic atropine derivatives)
with Propantheline being 5 times more potent.
Clonidine (0.2mg) an antihypertensive drug has been found to be as
effective as methantheline (50 mg) in reducing salivary flow (Wilson et al.,
1984).
For the desired reduction in salivary flow, the oral administration of atropine,
scopolamine, or methantheline and propantheline should precede the clinical
procedure by 1to 2 h, half to 1 h, or one-half
an hour, respectively.

Medications with anti sialogogic effect include
(Rosenstiel et al., 2006b);
• probanthine (7.5 to 15 mg),
• robinul (1 to 2 mg),
• saltropine (0.4 mg) and
• antipasbentyl (10 to 20 mg).
Anticholinergic drugs are contraindicated in patients with
glaucoma, prostatic hypertrophy, severe gastrointestinal disorders
(ulcerative colitis, obstructive disease, intestinal atony), and myasthenia
gravis (Felpel, 1999).

Gum Paints
Gum paints are the combination of antiseptics and tanning agents
which precipitate proteins but do not penetrate cells thereby affecting only
the superficial layer making it mechanically stronger and decreases
exudation.
They have germicidal, fungicidal, anesthetic and healing properties.
When applied, they provide a soothing, cooling and an astringent effect.
All these preparations contain
• Choline salicylate
• Tannic acid
• Cetrimide,
• Thymol
• Camphor,
• Cinnamon oil
• Iodine
• Alum (hydrated potassium aluminumsulfate).

‘Zingisol’ containing 2% Zinc Sulfate is used to control bleeding gums.
The patient is advised to apply 3-4 drops on finger and massage 3-4
times a day.
‘Sensoform’ gum paint (Warren) contains tannic acid, glycerine and
potassium iodide and is applied on affected area several times with the cotton
applicator for the treatment of stomatitis, inflammation and bleeding gums.
It also decreases sensitivity and increases gingival resistance against
infections.
‘Stolin’ gum paint (dr. reddy’s)15ml contains
cetrimide 0.1 % w/v
tannic acid 2 % w/v
zinc chloride 1 % w/v.
‘Sensorok’ gum astringent with zinc sulfate is used for gum massage 2-3
times daily

It must be emphasized that improper care of dentures can
have detrimental effects on the health of the denture supporting
tissues. Maintenance of adequate denture hygiene is essential to
minimize and eliminate adverse tissue reactions.
It must be an integral component of post insertion patient care
(Zarb and Bolender, 2004b).
Following are the requirements of an ideal denture cleanser:
- Should be non toxic
- Easy to remove and harmless to the patient
- Be able to dissolve the denture deposits such as calculus
- Exhibit bacteriocidal and fungicidal effect
- Should have long shelf life and inexpensive
- Harmless to the denture base materials, denture teeth as well as soft
liners

Commonly available denture cleansers are available in powder and
tablet form and include:
a) Oxygenating cleansers- overnight immersion of dentures in alkaline
peroxide solution is a safe and effective method.
b) Hypochlorite cleansers- immersion of the dentures in a solution of one part
of 5% sodium hypochlorite in three parts of water followed by light brushing
is advisable.
c) Dilute mineral acids.
d) Abrasive powders and pastes.
e) Enzyme containing minerals (proteases).
Commercially available denture cleansers include
Kleenex, Stain Away, Polident, Triclean, Efferdent

Denture adhesives augment the same retentive mechanisms already
operating when a denture is worn.
They consist of keraya gum,
tragacanth,
sodium carboxyl methyl cellulose,
polyethylene oxide,
flavouring agents,
antimicrobial agents
plasticizers
They enhance retention through optimizing interfacial forces by
increasing the adhesive and cohesive properties and viscosity of the medium
lying between the denture and the basal seat and eliminating voids between
the denture base and the basal seat
(Zarb and Bolender, 2004c).

These agents are finely powdered, inert and insoluble.
They afford physical protection to the mucous membrane thus are used
for apthous ulcers and gingival inflammation.
All these gel preparations should be applied 2-3 times daily.
The Lignocaine based preparations contain
Lignocaine hydrochloride, Benzalkonium and Choline salicylate.
Examples are Dentogel, Dologel and Emergel.
Dentasep, Dentonex-M, Maghex-M and Metrogyl DG gel are
examples of metronidazole and chlorhexidine preparations.
Oraguard B and Mucopain are gels containing Benzocaine as the
active ingredient. Petroleum jelly is also used successfully as an oral
protective agent

Demulcents
These are inert substances which sooth the inflamed and denuded
mucosa by preventing contact with air or irritants in the surrounding.
They can be applied as thick colloidal and viscid solutions in water.
Commonly used agents are
Gum Acacia
Gum Tragacanth.
These are used as suspending agents for indiffusible powders,
emulsifying agents for oils and in lozenges.
Glycerin (50-75%) in water acts as a popular vehicle for gum paint
(Tripathi, 2008c).

CONCLUSION
All the pharmacological agents mentioned
are used either before commencement of the
treatment, during the treatment or at the post
treatment duration.
Therefore, a dentist should have sound
knowledge of the benefits and drawbacks of these
agents in achieving the desired results

Dental phrmacology

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