1. DRUGS IN PROSTHODONTICS
Guided by:
Dr. S M Gundawar Dr. U M Radke Dr. N A Pande
Professor & Guide HOD & Professor Professor
Dr. S P Deshmukh Dr. T.K. Mowade Dr. Rajlakshmi Banerjee
Reader Reader Reader
Presented by:-
Dr. Richa Sahai
I MDS
2. CONTENTS
• Introduction
• Definitions
• Classification:
1. Drugs used directly for therapeutic purpose.
a. Drugs causing localized effect in the oral cavity.
- Local Anesthetics
- Agents for Gingival displacement & astringents
- Hemostatic agents
- Sialogogues
- Antisialogogues
- Mouth rinses containing local anti-infective agents
- Topical fluorides
- Styptics
3. b. Drugs used for Systemic Pharmacological Effects
-Analgesics
- Steroids
- Antibiotics
- Antianxiety drugs
- Centrally acting muscle relaxants
- Vitamins and minerals
2. Drugs which influence the success of prosthodontic treatment :
- Drugs causing Xerostomia(Dry mouth)
- Drugs which cause changes in oral flora
- Drugs affecting gingiva & oral mucosa
- Drugs causing sialorrhoea
- Drugs affecting bones or residual ridge
4. - Drugs causing dysphagia
- Drugs causing orthostatic hypotension
- Drugs causing bronchospasm, bradycardia & dyspnea
- Drugs causing hypoglycemic shock
- Drug induction of Parkinson- like syndrome & other Bizarre
muscle Movement, including Facial Muscles.
• Drugs used in emergency
• Drugs In Prosthodontics
• Conclusion
• References
5. Introduction
• Pharmacology is concerned with the study of drug action.
• The two main aspects of concern are the –
Effects of drugs on biological systems and
Effect of biological systems on efficacy and metabolism of drugs.
• Prosthodontics deals with patients of all ages, hence making it more
important to know about the local and systemic effects of drugs and their
side effects.
• Drugs play an important role in improving the response of the patient in
both pre-treatment and post-treatment phases.
• Drugs in dentistry act as a primary treatment modality as well as
facilitator of dental procedures.
6. DEFINITIONS
• PHARMACOLOGY
- Greek: Pharmacon - Drug
- Logos: Discourse in
Pharmacology is the science of drugs.
In broad sense, it deals with interaction of exogenously
administered chemical molecules (drugs ) with living systems.
• DRUG
- French: Drogue - A dry herb
Drug is any substance or product that is used or is indented to be
used to modify or explore physiological systems or pathological
states for the benefit of the recipient.
7. 1. Drugs causing localized effect in the oral cavity:-
a. Local anesthetics
b. Agents for Gingival Retraction & astringents
c. Hemostatic agents
d. Sialagogues
e. Anti- sialogogues
f. Mouth rinses containing local anti-infective agents
g. Topical fluorides
CLASSIFICATION
8. a. LOCAL ANAESTHETICS
• They are drugs that will temporarily interrupt conduction when absorbed
into the nerve.
CLASSIFICATION:-
Injectable:-
1. Lower potency, short duration:
-PROCAINE
-CHLOROPROCAINE 3.High potency, long duration:
-TETRACAINE
-BUPIVACAINE
-RUPIVACAINE
-DIBUCAINE
2. Intermediate potency, duration:
-LIDOCAINE(Lignocaine)
-PRILOCAINE
10. PROPERTIES OF AN IDEAL ANAESTHETIC:-
1. Action must be reversible.
2. Non-irritating to tissues & produce no secondary local reaction.
3. Should have low degree of systemic toxicity.
4. Should have rapid onset & be of sufficient duration to be advantageous.
5. Should have sufficient penetrating properties to be an effective topical
anesthetic.
6. Relatively free from producing allergic reaction .
7. Stable in solution and undergo biotransformation readily within the body.
11. PRECAUTIONS:-
• Care should be taken with the use of amides in patients with Hepatic
Disorders.
• Care should be taken with use of ester group in any suspected genetic
based plasma pseudo cholinesterase deficiencies.
• Allergy to methyl paraben, which is used as a preservative should be kept
in mind.
• Least possible volume should be used.
• Solution should be deposited slowly.
• Aspiration must be done before injection.
12. COMPLICATIONS:-
• Resulting from absorption of anesthetic solution:-
1. Toxicity
2. Idiosyncrasy
3. Allergy
4. Anaphylactic Reaction
5. Infections caused by contaminated solutions
6. Local irritation or tissue reaction.
13. Resulting from insertion of the needle:-
1. Syncope
2. Muscle Trismus
3. Pain or hyperalgesia
4. Edema
5. Infection
6. Broken needle
7. Prolonged anesthesia
8. Hematoma
9. Sloughing
10. Bizarre neurological symptoms.
14. VASOCONSTRICTING AGENTS:-
They are an integral and necessary part of most local
anesthetics.
Can be grouped into 3 categories:-
1. Pyro-catechin derivatives- Epinephrine
- Nor epinephrine
2. Benzol derivatives- Levonordefrin
3. Phenol derivatives- Phenylephrine
16. Uses :
Vasoconstrictor is added
e.g. Adrenaline ( 1:50,000 to 1:200,000 )
or
Phenylephrine( 1:2,000 )
1. Prolongs duration of action of LAs by decreasing their rate
of removal from the local site into the circulation
2. Reduces systemic toxicity of LAs : rate of absorption is
reduced & metabolism keeps the plasma concentration
lower.
17. AGENTS FOR GINGIVAL DISPLACEMENT &
ASTRINGENT
• By combining chemical action with pressure packing,
enlargement of the gingival sulcus as well as control of fluids
seeping from the walls of the gingival sulcus can be
accomplished.
• Cotton cords impregnated with racemic epinephrine or
aqueous solutions of metal salts have been used for gingival
retraction.
18. • The criteria for selection of gingival displacement materials
are :-
1. Effectiveness in gingival displacement & hemostasis.
2. Absence of irreversible damage to the gingiva.
3. Paucity of untoward systemic effects.
• Racemic epinephrine is approximately half as potent as L-epinephrine,
the form that accounts for most of the pharmacologic activity of drugs.
• All the precautions for epinephrine as used in LAs apply to its use in
retraction cords because systemic absorption is nearly as rapid as
19. ASTRINGENTS:-
• Are metal salts that cause gingival retraction by precipitating
protein or in some cases by a desiccant effect.
• Precipitated protein - physically obstructs hemorrhaging, thus
making astringents used as hemostatic.
• Administration -
1. By retraction cords already impregnated with the agent.
2. Applying them to cotton pellets.
• Aluminium chloride - is the most widely used agent - it is irritating
& may cause local tissue damage in conc. <1%.
• Zinc chloride - causes tissue damage at higher conc. (20%)
• Ferrous sulfate - is the only astringent accepted by Council on
Dental Therapeutics but it is irritating & causes staining.
20. Agents for gingival retraction and astringents
Drug
Official or
trade name
Manufacturer Conce-ntration
Preparation
form
Aluminium
acetate
Aluminium
chloride
Aluminium
sulfate
Epinephrine
Ferrous
sulfate
Zinc chloride
Burrow’s
solution
Hemodent*
Pascord
Gingibraid
Gingi-Pak
Astringedent*
-
-
Premier Dental
Products
Pascal
Van R Dental
Products
Surgident
Ultradent
Products
-
5%
0.9-1.8mg/"
0.48-1.45mg/"
1.0mg/"
0.5mg/"
15.5%
8-20%
Solution
Retraction cord
Retraction cord
Retraction cord
Retraction cord
Solution
Retraction cord
21. HEMOSTATIC AGENTS
• They are agents that reduce or control blood flow.
• Epinephrine may be applied topically as a local hemostatic agent.
• It is most effective in the control of superficial capillary bleeding
but will not control bleeding from larger vessels.
• Absorption is rapid from sites of trauma & the usual precautions
must be observed in patients.
22. Thrombin:-
• Is a blood clotting factor that maybe applied as a powder or a liquid on sites
that are free of clotted blood.
• Must not be injected because of extensive intravascular clotting that may result
in death.
• The hemostatic properties of absorbable gelatin sponge are improved by
soaking it in a thrombin solution before application.
• Astringents produce hemostasis by causing tissue contraction followed by
coagulation of blood in the local area. e.g. styptics.
• Ferric sub-sulfate solution ( Monsel’s solution ) is a hemostatic agent but causes
a black stain on teeth.
24. SIALOGOGUES
• Xerostomia may result from disease states like Sjogrens syndrome,
rheumatoid arthritis, diabetes insipidus, pernicious anemia, from
radiation, as a side effect of a wide variety of drugs, or from natural
aging.
• leading to complications that reduce denture wearing time &
cause difficulty in swallowing, loss of taste, difficulty in speaking,
stomatitis, burning tongue, rampant caries & periodontal disease.
• The treatment rationale for xerostomia is- to activate muscarinic
cholinergic receptors of the parasympathetic nervous system to
increase salivary flow.
25. • Pilocarpine, a naturally occurring cholinergic agonist, produce a short
duration increase in salivary flow without any side effects, suggesting
that it may possess some degree of selectivity as salivary gland
cholinergic receptors.
• Use of pilocarpine limited to- Sjogren’s syndrome & radiation.
• Not used in patients with drug induced xerostomia & patients with
uncontrolled asthma.
• It causes mild to moderate sweating .
• Treatment of chronic xerostomia limited to oral rinses & saliva
substitutes.
26. SALIVA SUBSTITUTES
• Most saliva substitutes contain either carboxymethyl cellulose or
hydroxyethyl cellulose as lubricant & a variety of artificial
sweeteners, preservatives & chloride or fluoride salts.
• Mucin containing preparations have better wetting & lubricating
properties than the other two cellulose preparations , have a
limited duration of action, making frequent applications
necessary.
28. MOUTH RINSES CONTAINING FLUORIDE:-
• Useful in
- controlling plaque formation
- reducing caries formation, especially in patients with xerostomia, part
of the anticaries activity of fluoride is from an antibacterial effect.
• Mechanism of antibacterial effect is complex but is, in part, caused by the
suppression of enzymatic pathways involved with bacterial glycolysis.
• Fluorides become more effective in acid medium, as occurs in vicinity of
cariogenic plaque.
29. Mouth rinses containing fluoride
Trade name Manufacturer OTC Ethanol
(%)
Fluorid
e (%)
ACT*
Fluorigard*
Oral-B Fluorinse*
MouthKote F/RT+
Oral-B Anticavity
Rinse*
Point-Two
Prevident*
Reach*
Johnson & Johnson
Colgate-Palmolive
Oral-B lab
Parnell
Orachem Pharmaceuticals
Oral-B lab
Colgate Oral Pharm
Colgate Oral Pharm
Johnson & Johnson
Yes
Yes
No
Yes
No
Yes
No
No
Yes
7
6
0
0
0
0
6
6
7
0.02
0.02
0.2
0.04
0.05,0.2
0.05
0.09
0.2
0.02
30. ANTISIALOGOGUES
• Agents used to decrease salivary secretion .
• They are cholinergic antagonists & thus block the same receptors that are
activated by the sialogogues or cholinergic agonists.
• For reduction in salivary flow
• oral administration of Atropine, Scopolamine, or Methantheline &
Propantheline should precede the clinical procedure by 1 to 2 hours, one-half
to 1 hour, or one- half hour respectively.
• Atropine - is prototype anticholinergic drug.
• A reduction in salivary flow for 4-6 hours after oral administration.
• Atropine differs from scopolamine in that, at high doses it causes CNS
stimulation, whereas scopolamine causes sedation.
31. • The sedative and slight amnesic effect of scopolamine is the basis
for its clinical use; it is usually combined with meperidine and
promethazine as a preanesthetic medication.
• Methantheline and propantheline are pharmacologically identical
except propantheline is approximately five times more potent.
Neither drug offers any particular advantages over atropine.
33. CONTRAINDICATIONS:-
• In patients with glaucoma
• Prostatic hypertrophy
• Severe gastrointestinal disorders like ulcerative colitis
• Obstructive diseases
• Intestinal atony
• Myasthenia gravis.
34. INTERACTIONS:-
• Drugs such as tricyclic antidepressants and antihistamines, which
have anticholinergic activity, can have an additive effect.
• Centrally acting anticholinergic drugs, used to treat Parkinson's
disease, would interact with antisialogogues.
• Also anticholinergic blockade of the vagal action on the heart could
antagonize the desired therapeutic effect of b-blockers such as
propranolol.
36. Styptics
• Thrombin : obtained from bovine plasma, As dry powder or freshly
prepared solution
• Fibrin : prepared from human plasma, As sheets or foams, left in situ,
gets absorbed
• Gelatin foam: spongy gelatin, gets absorbed in 1-2 months
• Russel's vipor venom: used in Hemophiliacs
• Vasoconstrictors : 1% adrenaline
• Astringent : tannic acid (20% in glycerin)
37. -Analgesics
- Steroids
- Antibiotics
- Antianxiety drugs
- Centrally acting muscle relaxants
- Vitamins and minerals
DRUGS USED FOR SYSTEMIC PHARMACOLOGICAL
EFFECTS :
38. 1. ANALGESICS
• Algesia or pain is an ill defined, unpleasant sensation, usually evoked by
an external or internal noxious stimulus.
• Analgesic is a drug that selectively relieves pain by acting on the CNS or
on the peripheral pain mechanisms, without significantly altering
consciousness.
• Classification:-
1. Opioid/ Narcotic/ Morphine like analgesics.
2. Non opioid / Non-narcotic / Aspirin like / Non steroidal anti-
inflammatory analgesics.
39. OPIOID ANALGESICS
Classification:-
1. Natural opium alkaloids – e.g. Morphine and cocaine.
2. Semisynthetic opiates – e.g. Diacetylmorphine, Ethyl morphine,
Pholcodeine.
3. Synthetic opioids – E.g. Pethidine (Meperidine), Fentanyl, Methadone.
Morphine - is the prototype or standard opioid to which all other drugs are
compared. It is rarely used in dentistry, because it undergoes significant first-pass
metabolism and is therefore usually parenterally administered.
Codeine - First-pass metabolism of codeine results in formation of small amounts of
morphine.It is frequently used in dentistry as an analgesic, particularly in
combination with aspirin or acetaminophen. It is an excellent antitussive at doses
less than those used for analgesia.
40. Side effects of all opiate analgesics :
i) Respiratory depression.
ii) CNS depression.
iii) Nausea and vomiting
iv) Release histamine which can cause bronchospasm.
v) Cause spasm of gastrointestinal smooth muscle.
vi) Spasm of biliary tract musculature consisting of severe pain.
vii) Spasm of bladder sphincter causing urinary retention.
viii) Induce hyperglycemia.
41. Contraindications:
1. In patients with any condition in which respiration is compromised.
2. In patients on CNS depressants.
3. In epilepsy.
4. In asthma.
5. In diabetics.
*Individuals receiving opioids who are not in severe pain frequently experience
dysphagia rather than euphoria*
42. NON STEROIDAL ANTI-INFLAMMATORY ANALGESICS
Classification:
1. Analgesic and anti-inflammatory.
2. Analgesic but poor anti-inflammatory.
1. Analgesic and anti-inflammatory:
a. Salicylates- e.g. Aspirin, salicylamide.
b. Pyrazolone derivatives – e.g. Phenylbutazone, oxyphenbutazone.
c. Indole derivatives – e.g. Etodolac, indomethacin.
d. Propionic acid derivatives– Ibuprofen, naproxen, ketoprofen, fenoprofen.
e. Anthranilic acid derivatives – e.g. Mephenamic acid, enfenamic acid.
43. f. Aryl-acetic acid derivatives – e.g. diclofenac.
g. Oxicam derivatives – e.g. piroxicam.
h. Pyrrolo-pyrrole derivatives – e.g. ketorolac.
2. Analgesic but poor anti-inflammatory:
a. Para aminophenol derivatives – e.g. Paracetamol (Acetaminophen).
b. Pyrazolone derivatives – E.g. Metamizol, Propiphenazone.
c. Benzoxazocine derivatives – E.g. Nefopam.
44. SIDE EFFECTS:
1. Gastric irritation; if severe gastric ulceration & occult blood loss iron
deficiency anemia
2. NSAID’s prolong bleeding time because of the inhibition of cyclooxygenase
results in decrease formation of thromboxane A2, a compound that causes
platelet aggregation.
3. Hypersensitivity to aspirin is common and manifests as rhinitis, urticaria,
bronchoconstriction, and laryngeal edema.
4. Aspirin causes a dose dependent hepatotoxicity.
5. Salicylism is a toxic reaction to long-term use of high doses of aspirin. This
reaction might occur during the treatment of arthritis or a result of drug
overdose.
45. CONTRAINDICATIONS:
1. Peptic ulcers.
2. Bleeding tendencies or disorders.
3. Asthma (Arachidonic acid gets biosynthesized by the lipoxygenase pathway
resulting in leukotrienes which are Broncho constrictors).
4. Children with chickenpox or influenza.
5. Patients on phenytoin, penicillin, anticoagulants, and oral hypoglycemic.
6. Diabetics.
7. Alcoholics.
46. 2. STEROIDS
The adrenal cortex secretes steroidal hormones like glucocorticoids from the
zona fasciculate, mineralocorticoids
Glucocorticoids are:
47. Mineralocorticoids are:
a. Deoxy-corticosterone acetate.
b. Fludrocortisone.
c. Aldosterone.
Mechanism of Action:
• Corticosteroids inhibit phospholipase A2 ( an enzyme involved in the
formation of arachidonic acid )
• As a result the formation of both prostaglandins and leukotrienes is
inhibited by corticosteroids, which may account for their greater anti-
inflammatory effect compared to the NSAID’s.
51. 3. ANTIBIOTICS
CLASSIFICATION:
1. Bacteriostatic
2. Bactericidal
1. Bacteriostatic agents - interfere with the synthesis of cellular
components and inhibit bacterial growth.
2. Bactericidal agents - inhibit synthesis of the cell wall or membrane
and kill the bacteria.
• Also used as:
a. Antibacterial. b. Antifungal. c. Antiviral.
d. Antiprotozoal. e. Anthelmintic.
1. Systemic antibiotics
2. Topical antibiotics
52. Adverse Effects:
1. Toxicity.
2. Hypersensitivity reactions.
3. Drug resistance.
4. Supra or superinfection.
5. Nutritional deficiencies.
53. Prophylactic regimen for dental procedures
in patients who are at risk
Drug standard
regimen
Dosing regimen
Amoxicillin
Patients allergic to
amoxicillin/penicillin
Erythromycin
Clindamycin
3.0gm orally 1 hr. before procedure;
then 1.5gm 6hr after initial dose
Erythromycin ethyl succinate 800mg
or erythromycin stearate 1.0gm
orally 2hr before procedure; then
half the dose 6 hr. after initial dose
300mg orally 1hr before procedure
and 150mg 6hr after initial dose
54. Alternate prophylactic regimens for dental procedures
in patients who are at risk
Drug During regimen
Patients unable to
take oral medications
Ampicillin
Patients allergic to
ampicillin/
amoxicillin/ penicillin
and unable to take
oral medications
Clindamycin
Intravenous or intramuscular administration
of ampicillin, 2.0gm, 30 min before
procedure; then intravenous or
intramuscular administration of ampicillin
1.0gm or oral administration of amoxicillin
1.5gm 6 hr after initial dose
Intravenous administration of 300mg 30 min
before procedure and an intravenous or oral
administration 150mg 6hr after initial dose
55. Patients considered
high risk and not
candidates for
standard regimen
Ampicillin,
gentamicin
Patients allergic to
ampicillin/amoxicillin
/ penicillin and
considered high risk
Vancomycin
Intravenous or intramuscular
administration of amoxicillin and ampicillin
2.0gm plus gentamicin 1.5mg/kg (not to
exceed 80mg) 30 min before procedure,
followed by amoxicillin 1.5gm orally 6hr
after initial dose alternatively, the
parenteral regimen may be repeated 8 hr
after initial dose
Intravenous administration of 1.0gm over a
1hr period, starting 1hr before procedure;
no repeated dose necessary
57. • Most common drugs used in dentistry to treat fungal infections of the oral
cavity are nystatin (mycostatin) and amphotericin B.
• They have a dose-dependent fungi-static or fungicidal effect on several fungi,
including candida albicans.
• Nystatin is not absorbed, tablets are usually held in the mouth for several
minutes until they dissolve, colonized dentures can be treated by soaking
them in a solution of nystatin.
• Nystatin tablet may be crushed and suspended in glycerin for application in
mouth.
• Fluconazole - is rapidly absorbed into body fluids, including saliva and
cerebrospinal fluid, after oral administration.
• Side Effects - nausea and vomiting.
58. 4. ANTIANXIETY AGENTS
• These are an ill-defined group of mild CNS depressants which are aimed
to control the symptoms of anxiety, produce a restful state of mind
without interfering with normal mental or physical function
CLASSIFICATION:
1. Benzodiazepines – E.g. Diazepam,
Alprazolam.
2. Others – E.g. Antihistamines like
promethazine and hydroxyzine,
b-blockers like propranolol.
59. • Antianxiety agents are perhaps most appropriately used in clinical dentistry
for patients who become usually apprehensive to the stress.
• The safest and most popular drugs for such clinical situations are the
benzodiazepines.
• Dentists require an anxiolytic effect that is rapid in onset and short in
duration .
• Diazepam is one of the most popular of the benzodiazepines for clinical
dentistry and serves as a prototype for the class.
60. Adverse effect:-
• little effect on cardiovascular function or respiration.
• Because they are CNS depressants, they can cause drowsiness and
impaired motor function.
Interactions:-
1. Benzodiazepines, in combination with some CNS depressant drugs,
can be lethal.
2. Alcohol causes potentiation of the CNS depressant effect of
benzodiazepines rather than an additive effect.
Flumazenil is a benzodiazepine antagonist available for the treatment of
benzodiazepine overdose and should be available as an emergency drug
if benzodiazepines are used clinically.
61. 5. CENTRALLY ACTING MUSCLE RELAXANTS
CLASSIFICATION:
1. Mephenesin group – E.g. Chlorzoxazone, Methocarbamol, Mephenesin.
2. Benzodiazepines – E.g. Diazepam.
3. GABA derivative – E.g. Baclofen.
• These are drugs which reduce skeletal muscle tone by selective action in
the CNS, without altering consciousness.
• They selectively depress spinal and supraspinal polysynaptic reflex
involved in the regulation of muscle tone without significantly affecting
monosynaptically mediated stretch reflex.
62. • They cause slight sedation that may contribute to their muscle relaxant
effect.
• These drugs are sometimes used in treating TMJ disorders.
• They are also used for acute muscle spasms, relieving anxiety and tension,
tetany etc.
• Padministration should be avoided and doses should be tapered off to
avoid withdrawal symptoms in a patient who is dependent.
63. 6. VITAMINS & MINERALS
• 2 types:
- Fat soluble – Vitamin A, D, E & K.
- Water soluble – B complex and C
• Vitamin A – Maintenance of normal mucosa, keratinization of
mucosal tissue including oral mucosa. (Dose 800 – 1000 (RE))
• Vitamin D – 2 forms
- D2 or Ergocalciferol
- D3 or Cholecalciferol
- Vitamin D increases absorption of calcium from the intestinal tract
and promotes the deposition of calcium and phosphate by specifically
acting on bone cells.
64. - Over doses results in bone resorption including loss of alveolar bone
(Dose 0.1mg)
• Vitamin B complex –
- Niacin causes pellagra characterized by stomatitis, glossitis.
Desquamative lesions reported in gingiva including ulceration interdental
papilla. ( Dose 6.6mg/kcal )
• Vitamin B6 – deficiency causes cheilosis, glossitis, stomatitis. ( Dose 2mg )
• Vitamin B2 – deficiency causes cheilosis, angular stomatitis, glossitis, sore
throat & anemia. ( Dose 0.6mg/1000 kcal )
65. • Vitamin B1 – deficiency causes pernicious anemia. ( Dose 0.003mg )
• Vitamin C – deficiency causes scurvy ( Dose 6mg/day )
MINERALS
• Sodium and potassium - help to maintain water and electrolyte
balance. ( Dose 5g & 1g respectively )
• Calcium and phosphorous - Dose 1.7 & 1.2 mg respectively.
66. Drugs influencing the success of prosthodontic treatment:-
1. Drugs causing Xerostomia (Dry mouth)
2. Drugs which cause changes in oral flora
3. Drugs affecting gingiva & oral mucosa
4. Drugs causing sialorrhoea
5. Drugs affecting bones or residual ridge
6. Drugs causing dysphagia
7. Drugs causing orthostatic hypotension
8. Drugs causing bronchospasm, bradycardia & dyspnea
9. Drugs causing hypoglycemic shock
10.Drug induction of Parkinson-like syndrome & other Bizarre Muscle Movement,
including Facial Muscles
67. ANTIHISTAMINES
• Drugs - Diphenhydramine(benedryl)
Promethazine (Phenergan)
Pheniramine (avil)
• Indications:-
1. Allergic disorders
2. pruritus
3. Common cold
4. Motion sickness
5. Parkinsonism- Promethazine in early cases
68. Adverse affects:-
1. Sedation
2. Diminished alertness & concentration
3. Light headedness
4. Motor incoordination
5. Fatigue
6. Restlessness & nervousness
Oral side effects:-
• Dryness of mouth
• H1 blockers in addition antagonize muscarinic actions of acetylcholine
69. The anticholinergic action can be graded as :-
High:- Promethazine
Diphenhydramine
Dimenhydrinate
Low:- Chlorpheniramine
Antazoline
Hydroxyzine
Cyclizine
Minimal/ Absent:- Cetrizine
Loratidine
71. • After prolonged therapy:-
- Abnormal movements
- Behavioral effects
• Oral side effects:-
- Alteration in taste sensation
- Reduction in salivary secretion
These are the drugs having a higher central and peripheral anticholinergic
action-
• ANTIPSYCHOTIC DRUGS
• TRICYCLIC ANTIDEPRESSANTS
72. • Drugs -- Quinidine, procainamide, disopyramide
• Adverse effects – Nausea, vomiting, diarrhea, fever, angioedema.
• Oral side effects – Dry mouth.
ANTIHYPERTENSIVE DRUGS
• Used to lower blood pressure in hypertension.
• Drugs – ACE inhibitors – Enalapril
- Ca channel blockers – Verapamil
- a adrenergic blockers – Prazosin
- b adrenergic blockers – Propranolol
• Adverse effects – Dry persistent cough (ACE inhibitors) ,Headache,
drowsiness, blurred vision and dry mouth (Prazosin).
ANTIARRHYTHMIC DRUGS
73. ANTIBIOTICS
• Use of most antimicrobial agents causes some alteration in normal
microbial flora of the body.
• Suprainfection is commonly associated with broad /extended spectrum
antibiotics such as tetracycline, chloramphenicol, ampicillin and newer
cephalosporin's.
• Suprainfection are most common when the host defense is compromised.
- Corticosteroid therapy, Leukemia's, AIDS, Diabetes
• Sites – Oropharynx, respiratory tract.
DRUGS CAUSING CHANGES IN ORAL FLORA
74. DRUGS AFFECTING GINGIVA & ORAL MUCOSA
• GINGIVAL HYPERPLASIA – refers to an increase in size of a tissue or
an organ produced by an increase in the number of its component
cells.
Drugs - Phenytoin – Antiepileptic
- Nifedipine – Ca channel blockers
- Cyclosporine – immunosuppressive agent
• TRANQUILIZERS – leads to agranulocytosis. Anemia in any form leads
to lowered tissue tolerance.
75. • NSAID’s – Chemical burns of the oral tissues are common occurrences
that may be accidental or from misuse of products that are being used
for self medication.
-- The ‘aspirin burn’ represents the typical example. Aspirin is
detrimental to dentures. Agranulocytosis caused by its prolonged
consumption can account for low tissue tolerance and subsequent ‘sore
spots’ under dentures.
• LICHENOID DRUG ERUPTIONS – Lichen Planus occurs on the oral
mucosa.
Prosthodontists are likely to encounter patients with this disorder,
particularly if it causes any discomfort or concern.
77. ANTICANCER DRUGS
- Drugs - Alkylating agents – Mechlorethamine
- Dacarbazine
- Antimetabolites - Methotrexate
- Side effects – - Loss of hair
- Xerostomia
- Brownish discoloration of teeth & tongue
- Burning sensation of oral mucosa
- Erythematous areas
- Local ulcerations
- Increased tooth mobility
78. DRUGS CAUSING SIALORRHOEA
• Excessive salivation causes difficulty in impression making and can affect
retention of dentures.
CHOLINERGIC DRUGS
Classified as :
– Direct acting drugs - includes derivatives of choline and pilocarpine. They
produce their effect by acting like acetylcholine.
- Indirect acting drugs - Physostigmine
- Neostigmine
- They produce their effect by inhibiting the enzyme cholinesterase.
- Adverse effects – Salivation, Lacrimation, Urination, Confusion.
79. DRUGS AFFECTING BONE
• CORTICOSTEROIDS
- Drugs - Hydrocortisone
- Cortisone
- Prednisolone
- Uses - Acute adrenal insufficiency
- Addison‘s disease
• HEPARIN
- Used as an anticoagulant
- These drugs manifest osteoporosis but their role in resorption of
alveolar bone is not known.
• VITAMIN D
- Influences the absorption of Ca from gastrointestinal tract & its
subsequent deposition in bone. It leads to bone loss including alveolar bone.
80. DRUGS CAUSING DYSPHAGIA
• Difficulty in swallowing, gagging, could cause difficulty during
the making of an impression.
a. Phenothiazine derivatives (Thorazine, Sparine, Prolixin)
b. All agents that produce xerostomia could lead to dysphagia.
81. DRUG CAUSING ORTHOSTATIC HYPOTENSION
• Drugs - Phenothiazine derivatives
- Tricyclic anti depressants
- Antihypertensives
- Glyceryl trinitrite (Anti anginal)
GLYCERYL TRINITRITE (Anti anginal)
- Uses - Angina pectoris
- CHF & acute LVF
- MI
- Adverse effects - Fullness in head, throbbing headache, flushing, dizziness
and fainting.
Postural hypotension is a common side effect of these drugs, raising the
patient suddenly from the supine position causes loss of consciousness.
Therefore abrupt movements of the patient should be avoided.
82. DRUGS CAUSING BRONCHOSPASM,
BRADY CARDIA & DYSPNOEA
Propranolol - is a b blocker.
• Uses - Arrhythmias
- Angina
- Hypertension
- Migraine headache
• Adverse effects - Depresses heart
- Produces broncho-constriction
- Causes hypoglycemia
Bronchospasm or dyspnoea can cause difficulty in managing the patient
during any dental procedure
83. DRUGS CAUSING HYPOGLYCEMIC SHOCK
• Insulin – is used therapeutically to treat diabetes mellitus.
• In diabetics taking insulin, hypoglycemic reactions may result from failure to
eat, stress or inadvertent administration of too large a dose of insulin.
• The other symptoms include sweating, weakness, hunger, tachycardia,
mental confusion, headache.
• Dental appointments for patients taking insulin should not interfere with
meals, stressful situations should be minimized.
84. DRUG INTERACTION OF PARKINSON- LIKE
SYNDROME & OTHER BIZARRE MUSCLE
MOVEMENTS INCLUDING FACIAL MUSCLES
• ANTIPSYCHOTIC DRUGS
Drugs - Chlorpromazine, Thiothixene, Haloperidol
Uses - Psychoses, Anxiety, Antiemetic
Adverse effects – Drowsiness, lethargy, mental confusion, postural
hypotension (a adrenergic blockade), dry mouth (anticholinergic).
85. TRICYCLIC ANTIDEPRESSANTS
Drugs – Imipramine, desipramine, trazodone.
Adverse effect – Dry mouth (anticholinergic), mental confusion,
postural hypotension (specially in older patients), fine tremors are
relatively common.
Uses – Endogenous depression, peptic ulcer, migraine.
These movements can cause difficulty in establishing &
recording jaw relations.
86.
87. Drugs Implicated in Removable, Complete and
Partial Prosthesis
• Placement of removable prosthesis in the oral cavity produces profound
changes of the oral environment that may have an adverse effect on the
integrity of the oral tissues.
• Some of the direct sequelae caused by wearing removable complete or
partial dentures are :
mucosal reactions, oral galvanic currents, burning mouth syndrome,
gagging, residual ridge reduction, periodontal disease, and caries of the
abutments.
88. • Oral moniliasis (thrush) – Anti Fungal Drugs Local therapy with
nystatin, amphotericin B, miconazole, or clotrimazole preferred to systemic
therapy with ketoconazole or fluconazole because resistance
of Candida species occurs with them regularly.
Treatment should continue for a minimum of 4 weeks along with meticulous
oral hygiene maintenance.
• Xerostomia -- muscarinic cholinergic receptors Pilocarpine hydrochloride
(Salagen) and Cevimeline hydrochloride (Evoxac) produce a short-duration (3
h) increase in salivary flow
-- Salivary substitutes contain either carboxymethylcellulose or
hydroxyethylcellulose as lubricants and a variety of artificial sweeteners,
preservatives, and chloride or fluoride salts. A few over-the-counter substitutes
are Orex, Salivart, Xero-lube, etc .
89. • Traumatic ulcers -- Discontinuation in wearing dentures and
-- Application of topical benzoczine 20% and benzakonium
hexachloride, available as mucopain or dologel (also contains salicylates for
antibacterial action).
--In cases of severe inflammation, kenacort gel (containing
triamcinolone acetonide 0.1%)
• Antisialogogues are the agents used to control hyper salivation. Atropine and
its synthetic derivatives are used such as methantheline, propantheline, and
scopolamine.
• Gagging or hyperactive gag reflex --Peripherally acting drugs such as local
anesthetics and centrally acting drugs such as antihistamines, sedatives,
tranquilizers, parasympatholytics, and CNS depressants are indicated if other
non-pharmacological methods fail in controlling the hyperactive gag reflex.
90. Drugs Implicated in Implant Prosthesis
• The implant therapy is usually a two-stage procedure which involves :
- The surgical and
- Prosthetic phase.
• The success of the therapy involves the prevention of the infection in
and around the implants.
91. Surgical Phase of Implant Therapy
Antibiotics –
- Standard regimen: Amoxicillin 3.0 g orally 1 h before procedure; then 1.5 g
6 h after the initial dose.
-Patients allergic to amoxicillin/penicillin: Erythromycin ethyl succinate 800
mg or erythromycin stearate 1.0 g orally 2 h before the procedure; then half
the dose 6 h after the initial dose.
-Clindamycin 300 mg orally 1 h before the procedure and 150 mg 6 h after
the initial dose.
92. • Analgesics –
• The nonsteroidal anti-inflammatory drugs (NSAIDs) play a main role in the
pain management during the surgical phase of the implant placement.
• The most commonly used NSAIDs are ibuprofen combined with
paracetamol, or diclofenac with paracetamol, or aceclofenac with
paracetamol combination. Opioids are not generally used .
• Steroids –
• Only two steroid preparations are accepted by the Council on Dental
Therapeutics, and both are limited to topical application for inflammation:
• Hydrocortisone and Triamcinolone. Dexamethasone has been used by
some practitioners to reduce the postoperative swelling after the implant
placement.
93. • Antianxiety agents -- Diazepam and alprazolam are generally given the
night before the procedure.
2. Maintenance phase
• Chlorhexidine digluconate, at concentrations of 0.12%, has been approved
for the treatment of gingivitis and suppression of the formation of plaque.
• Chlorhexidine-containing mouth rinses are useful adjuncts that may
facilitate healing after insertion of the implant dentures.
94. Drugs Implicated in Fixed Dental Prosthesis
Gingival retraction --
• Epinephrine, aluminum potassium sulfate, aluminum sulfate and aluminum
chloride, ferrous sulfate, and zinc chloride. They aid in hemostasis and control
the level of gingival crevicular fluid.
• There are certain issues pertaining to the use of epinephrine as a
vasoconstrictor agent, which indicate that the operator should take proper
medical history of the patient before using epinephrine.
Local anesthetics –
• amides and esters. Sodium bisulfate and meta-bisulfite are the antioxidants that
are used as preservatives in preparations that contain vasoconstrictor agents
and may cause allergic reactions.
• Methylparaben, an antibacterial preservative, is allergenic but is now available
in multiple-dose vials of local anesthetics.
95. CONCLUSION
• Understanding the role of pharmacology in prosthodontics is
imperative because this is one of the most neglected parts of
research even though there are a large number of dental
patients suffering from systemic diseases which have to be taken
care of before the commencement of dental treatment.
• Another main reason is that the prosthodontist may have to deal
with a medical emergency arising on the dental chair.
96. REFERENCES
1. Ciancio G. Sebastian – Clinical pharmacology for dental
professionals 2nd Edition – 1984.
2. Felpel P. Leslie – A review of pharmacotherapeutics for prosthetic
dentistry, Part I, JPD, 77(3); 1997.
3. Felpel P. Leslie - A review of pharmacotherapeutics for prosthetic
dentistry, Part II, JPD, 77(3); 1997.
4. Heartwell M. Charles, Rahn O. Arthur – Syllabus of complete
dentures, 4th Edition – 1992.
5. Joglekar P. Anil – Biologic approach to complete dentures, JPD,
30(4); 1973.
6. Jones M. Philip – Complete dentures and the associated soft
tissues, JPD, 36(2); 1976.
97. 7. Moore A. Paul – The Dental Clinics of North America, 46(4); 2002.
8. Rutkauskas S. John – The Dental Clinics of North America, 41(4); 1997.
9. Tripathi D.K. – Essentials of medical pharmacology, 4th Edition – 1999.
10. Felpel LP. A review of pharmacotherapeutics for prosthetic dentistry: Part
I. J Prosthet Dent. 1997;77:285–92. [PubMed]
11. Felpel LP. A review of pharmacotherapeutics for prosthetic dentistry: Part
II. J Prosthet Dent. 1997;77:293–305. [PubMed]
