Endodontic pharmacology

1. ENDODONTIC
PHARMACOLOGY
Dr. Shivani Parmar

2. CLASSIFICATION
• Based on when the drug isadministered-
• Pre treatment- analgesics, antibiotics, anti-anxiety
• Treatment- corticosteroids, antibiotics, anti-microbials, local anaesthesia
• Post treatment- antibiotics, corticosteroids, analgesics
• Based on route of administration-
• Local- topical antibiotics, anti-microbials, topical anaesthetics
• Systemic- oral- antibiotics, analgesics, anti anxiety
• injectable- im/iv- antibiotics, analgesics, sedatives
• Inhalation- sedatives, anaesthesia

3. DRUGS IN ENDODONTICS IS BROADLY CATEGORISED AS:
• MANAGEMENT OF FEAR AND ANXIETY
• EFFECTIVE PAIN CONTROL
• MANAGEMENT OF INFECTION
• MISCELLANEOUS

4. MANAGEMENT OF FEAR AND ANXIETY
REASONS FOR FEAR IN DENTAL CLINIC:
• FEAR OF PAIN
• BELONEPHOBIA
• UNPLEASANT PAST EXPERIENCE OF SELF AND PEER GROUPS

5. • Initial management – psychosedation (verbal and non verbal)
• Anxiolytic sedative hypnotic drugs can be prescribed in routine
• Rarely anaesthesia is required

6. Sedative- Hypnotic drugs

7. Barbiturates :
• Produces different levels of CNS Depression: relaxation and
drowsiness
• Enhances the activity of neurotransmitter that inhibits activity of
nerve cells in brain.
• At higher doses can produceGA and even coma
• Mainly used as minor tranquilizers to reduce anxiety levels and mental
acuity
• Was initially used in OS for third molar extraction, however their
tendency to cause respiratory depression leads to its limited use in
dental clinics
• 100-200mg secobarbital and 15-30mg pentobarbital thrice daily are
effective sedative hypnotic drugs

8. Benzodiazepines:
•Less potent
•Decreased occurrence of hangover effect that often
accompanies barbiturates
•Commonly used are:
• Diazepam (valium) – 5-10 mg orally and 2.5 -5.0 mg IV
• Midazolam (versed)- 0.5-1.0 mg/kg orally and 0.05-0.15 mg/kg
IV
• Trizolam (halcion)-0.25-0.50 mg orally 1 hour prior is effective
• Lorazepam (atvian)- 0.5-4.0 mg

9. Non – benzodiazepines:
•Zolpidem
•Zaleplon
•Zopiclone
Antihistamines: causes sedation as a side effect (Benadryl
for allergic cough)
Anticholinergics (glycopyrrolate , atropine, scopolamine)
Miscellaneous : opioids , propofol

10. ANESTHETIC AGENTS
Injectable
• Short duration (30 minutes of pulpal anesthesia)-Procaine
• Intermediate duration (60 minutes of pulpal anesthesia)-
Lignocaine, prilocaine
• Long duration (over 90 minutes of pulpal anesthesia)-Tetracaine,
bupivacaine, ropivacaine, dibucaine
Surface anesthetic
Soluble
Cocaine Lignocaine Tetracaine
Benoxinate
Insoluble
Benzocaine
Butylaminobenzoate ( Butamben)

11. Anesthesia delivery systems
Computer controlled technology
o Wand system
o Comfort control syringe
Intraosseous delivery system
o Stabident system
o X-tip system
o Intraflow system

12. • Wand system utilizes computer microprocessor to control the flow rate and
also the fluid pressure. An electronically controlled motor delivers the
anesthetic solution at a slow rate.The delivery of anesthetic solution into
any injection site is carried out at a rate below the threshold of pain.The
small diameter of the syringe/handpiece facilitates stable grip, subsequently
less pain to the patient.
• The Comfort Control Syringe is an electronic, computer-controlled
anesthetic delivery system.The Syringe houses the anesthetic cartridge
directly behind the needle, just as in a conventional syringe; facilitating
finger tips to control the delivery. It has five pre-programmed speeds for
different injection techniques and can be used for all injection techniques.

13. • Intraosseous delivery system
The technique of delivering local anesthetics directly into alveolar bone
(intraosseous) in close proximity to root apices is not new; however, electronic
delivery methods have greatly improved the convenience of intraosseous
injections.The intraosseous technique is quite reliable for pulpal anesthesia for one
or two teeth and is particularly useful to anesthetize the 'hot tooth'.The systems
used are:
• The Stabident system is a two-part system with a separate perforated needle.
A bur is first used to penetrate the house using a slow speed handpiece after
which the anesthetic injection needle is passed through the perforation directly
into the cancellous bone.

14. • The X-Tip system is also a two-part system; in place of the perforated needle, a
cannular guide is used for insertion of the anesthetic injection needle into the cancellous
bone.
• The Intraflow system is a one-step technique utilizes a low-speed handpiece with a
foot-pedal control system that permits perforation and injection into the site
immediately.
• As the intraosseous injections are delivered into the highly vascular cancellous bone
tissue; use of vasoconstrictor in anesthetic agents is not advised due to rapid uptake of
the agent into the circulatory system, subsequently increasing patient's heart rate.

15. Techniques of anaesthesia
Inhalation sedation-
• N20-O2, rapid onset of action, level of CNS depression that can
be rapidly increased if necessary, level of CNS depression that
can be rapidly decreased if necessary, complete recovery
following the delivery of 100%O2 at the completion of
procedure- permits the patient to leave the clinic unescorted, no
other route of drug administration offers this advantage.
• Because of rapid onset, it can be titrated, which increases both
the safety and success of the technique.
• Only disadvantage for endodontists is the nasal hood on the way
which is not a problem once experienced

16. Oral conscious sedation-
• Least controllable route
• Slow onset of action usually
• Erratic absorption of the drug from the GIT
• Only advantage is easy for dentist and patient
• CNS depressants given night prior to planned appointment, in
the morning 1 hr prior to the scheduled dental visit, to assist them
in overcoming any last minute increase in their anxiety.

17. IV CONSCIOUS SEDATION
• Rapid onset, titration possible to desired level, more safer than oral
• Requires fasting prior to procedure
• Inability to quickly lessen the level of CNS depression
• Inability to reverse the action of some drugs (barbiturates)
• Prolonged clinical recovery
• Benzodiazepines, midazolam, diazepam
• Venipuncture skillrequired

18. INTRAMUSCULAR
• Drug by passes the GI tract, being absorbed directly into the system
• Hepatic first pass effect neglected, leading to more reliable
absorption and more rapid onset of action
• Titration not possible
• Doses decided by weight (mg/kg)
• Reversal done with iv flumazenil or naloxone
• Im not controllable like iv so sedation limited to moderate level,
doctor should be trained to recognize and manage the patient
entering deep sedation

19. INTRANASAL
• Newer technique in dentistry
• More rapid absorption since nasal mucosa is highly vascular
• No injection needed
• Cannot be titrated
• Dosage based on weight
• Sedation limited to moderate, not controllable
• IN midazolam commonly used
GENERAL ANAESTHESIA : Provided by an anesthetologist

20. EFFECTIVE PAIN CONTROL
• Management of endodontic pain is multifactorial and
directed at reducing the peripheral and central
components of hyperalgesia through combined
endodontic procedures and pharmacotherapy.
• Effective management depends on
• Diagnosing cause of pain
• Use of analgesic as premedication along with sedative drugs
• Use of anesthesia when required
• Acupunture/laser acupuncture as per need

21. • Types of analgesics used in endodontics are:
1. Non- narcotic/ non-opioid analgesics
2. Opioid analgesics
3. Corticosteroids
4. Alternative analgesics (acupuncture)

22. Non-narcotic/non-opioids
• Function by inhibiting cyclooxygenase enzymes ( COX 1 , COX2) which
produces prostaglandins which is responsible for inflammation and pain.

24. Commonly prescribed analgesics in
endodontics
• Ibuprofen -200 mg , 400 mg , 600 mg
• Paracetamol -650 mg
• Diclofenac -50 mg , 100 mg
• Aceclofenac- 250 mg
• Tramadol -50 mg
• Ketorol DT -10 mg
• Nimesulide- 100 mg

25. Opioid analgesics
• potent analgesics
• Used in dentistry in combination with acetaminophen, aspirin, or
ibuprofen
• activate opioid receptors located at several important sites in the brain
• Activationof these receptors inhibits the transmission of nociceptive signals
from the trigeminal nucleus to higher brain regions
• opioids also activate peripheral opioid receptors located in dental pulp
• Intraligamentary injection of morphine has been shown to significantly reduce
pain in endodontic patients and other inflammatory pain states
• Adverse side effects, which can include nausea, emesis,dizziness,drowsiness,
and the potential for respiratory depression and constipation

26. • Commonly used are
• Morphine
• Tramadol
• Pentazocaine (fortwin)
• Butorphanol (butrum)
• Combination of drugs
• Ibuprofen + opioid= considered effective and safe
• Diclofenac + vitamin B- more effective in pain relief
• Acetaminophen/NSAID+ opioid = increased analgesia
• Aspirin-opioid combination NOT PREFERRED because of potential interactions

27. CORTICOSTEROIDS
• Not used in endodontics because of its immunosuppressive effect
• Single dose or local intracanal medicaments might not have any specific
harmful effects
• Two classes of enzymes: phospholipase and cyclooxygenase are the basic
target site with the intake of analgesics and anti-inflammatory drugs
• Phospholipase synthesizes – arachidonic acid from phospholipids
• Cyclooxygenase synthesizes – prostaglandins
• Steroids functions by inhibiting phospholipase A2 which reduces the
production and contration of prostaglandins and leukotrienes

29. • Glucocorticoids are frequently used to reduce or to eradicate inflammation
• Should be used with caution in patients with ulcerative colitis, peptic ulcers,
diabetes, pregnancy and pyogenic infections
• Contraindicated in pts with systemic fungal infections and those
hypersensitive to the drug
• May lead to psycgological disturbances which can be mild and reversible pr
pronounced. Severity depends on duration and dose.
• Intaligamentary/ intraosseous, IM and oral administration of steroids have
effectively reduced the postendontic pain
• Effective in reducing pain associated with irreversible pulpitis and chronic
inflammatory diseases

30. • Used systemically to shorten the course of nerve parasthesia due to
endodontic procedures
• IM inj are prescribed for treatment of sodium hypochlorides accidents
• Corticosteroids cause the adrenal glands to slow down or stop production of
cortisol. Hence ,can’t be discontinued abruptly. Adrenal gland take some
time to start producing cortisol again.

31. Local application of steroids
• As Intracanal medicaments
• Hydrocortisone alone and in combination with antibiotics-
favourable results
• Most commonly used steroid –antibiotic combinations are:
1. Ledermix: 1% triamcinolone and 3% demeclocycline (tetracycline eith
polyethanol glycol base)
2. Ledermix paste (1%T +3%D-Calcium) and Ledermix cement (0.7%T
+3%D with calcium salts)
3. Ledermix and calcium hydroxide (50:50 mixture)
4. Septomixine forte paste ( steroid + neomycin and polymixin B sulphate)

32. Acupunture and laser acupunture
• A study wherein a laser acupuncture involving a beam from 2.8-6 mW
Helium- Neon laser was delivered and focused on selected skin point of the
pt.
• No other sedative or analgesic was administered before or during the
procedure
• Out of 610 patients studied, no one complained of any side effects.

33. MANAGEMENT OF INFECTION
• Odontogenic infection including endodontic infection are
polymicrobial involving combination of gram –ve , +ve
,facultative anaerobes and strict anaerobic bacteria
• Microbial resistance to antibiotics is increasing at an alarming
rate due to inappropriate use
• Endodontic sensitivity to endodontic bacteria is gradually
decreasing with growing number of resistant strains
(porphyromonas and prevotella spp.)
• Antibiotics should only be employed for management of active
infectious diseases or prevention of metastatic infection such as
IE in medically high risk patients.

35. Myths of using antibiotics
• Antibiotics cure patients
• Antibiotics are substitutes for surgical intervention
• When and which antibiotic to be used
• Antibiotics increase the host defence
• Multiple antibiotics are superior to a single antibiotic
• Bactericidal agents are always superior to bacteriostatic agents
• Antibiotic dose and duration of therapy for endodontic infections
• All type of infections require a complete course of antibiotic therapy

39. Antibiotic prophylaxis
• Systemic diseases compromising the immune system – main call for
consideration
• Oral bac. specially streptococci can cause heart and artificial joint infections.
• Protocol proposed byAmerican heart association states that antibiotics
must be administered one hour (oral route) or 30 minutes (iv route) before
the procedure.
• Antibiotics of choice are:
• Amoxicillin 2 g
• Clindamycin 600mg is preferred for pts allergic to penicillin

41. Procedures for which antibiotics are
recommended are:
• Periodontal procedures
• Implant surgery
• Difficult extractions
• Replantation of avulsed tooth
• Endodontic surgery
• Intraligamentary/intraosseous injections
• Postoperative suture removal (selected cases)
• Prophylactic cleaning of teeth where bleeding is anticipated

43. Antibiotic use : risk and precautions
• Pregnancy
• Kidney failure
• Liver failure

44. Miscellaneous drugs
• Antiemetic drugs
• Anticholinergics- hyoscine, dicyclomine
• Antihistaminic – chlorpromazine, prochlorperazine
• Prokinetic drugs- domperidone, metoclopramide
• Adjuvant antiemetics- dexamethasone, benzodiazepines
• Newer drugs- ondonsetron, bolasterone
• Vitamin and mineral supplements

45. Thank you