therapeutic agent [drugs] in edndodontic

7/28/2019 Therapeutic Agent [Drugs] in Edndodontic

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Therapeutic agent [drugs] in edndodontic

Endodontic treatment is the most clinicalsituation amenable to drug therapy indentistry

Why the therapeutic agent to describe topatient?

To decrease fear and anxiety of the-1patient

To control the pain-2

To control the infection-3


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Management of anxiety

What is meaning anxiety ?Irrational anxiety and rational fear of the

patient toward dental treatment are majorfactors limiting access to dental care

many patient having a dental problemN Bbut he did not go to dental clinical SICKELtreatment just fear just anxiety

This fear may be improper handling fromanother doctors

Or may be history he tell from another one


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Why are have control anxiety of pt before start treat?

is very importantTo cooperation of patient-1for successful any dental treatment

to make dentalThrough control anxiety of pt-2treatment is very easy for pt or practitioner aslike

Through control anxiety providing excellent-3dental treatment for patient

So dentist provide optimal dental care


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Management of anxiety

Patientreassurance

Chemical drugs

Nitrous oxide


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-Patient reassurance-1Dentist explain the steps ofDentist smile

procedure for patient [explain every steps] as whatis caries what are you going to-do?If patient need endotreatment and any problem intooth the dentist explain the steps of this procedure

Chemical drug-2

Sedative

Benzodiazepam-ASedative hypnotic-B

Antihistaminic-C


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BenzodiazepineGroup of the drugs have sedative effect and calming effect on the pt

Benzodiazepine according to duration divided into

as valium LibriumLong acting-1

Medium or short acting-2

The pharmacological effect

1- Antianexiety

2-Sedative and hypnotic [small dose it is sedative and calmingbut increasing dose leading to sleeping effect drug for sleep]

3- Anticonvulsant

4-Skeletal Ms relaxation5-Hallucination

6-Addiction


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Side effect

Drowsiness-1

Ataxia and lethargy-2

Visual motor impairment co ordination-3Behaviour changes and daytime sedation-4

Chronic drug dependence-5

C N S depression-6


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Classification of hypnotics

1-Urea derivativesA-Diureides barbiturates B Related ureides glutethimide

2-Benzodiazepines

3-Alcohols chloral hydrate

4-Aldehydes-paraldhyde5-Acetylated carbinols- ethinamate

6-Imidazopyridine - zolpidem

7-Miscellaneous

antihistaminic scopolamine Meprobamate

8-Drugs like morphine and pethidine besides acting as analgesic also possesshypnotic


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2-Sedative and hypnotic drugs

Barbiturates Non barbiturategroup dividing according to duration intoBarbiturate

intermedium actingshort actingUltra short actinglong acting

The effect of barbiturate depend on the dose if given inNBthe dose of 15mg 3 to 4 times day acts as daytime sedative[large dose produce sleep The hypnotic effect appear within15 to 30 min and maintained for 4 to 5 hours ]

Anesthetic effect short acting thiobarbiturates IV producegeneral anesthesia

Side effect1-physical dependence

2-Respiratory depression and death


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Nonbarbiturate

have different chemical structureNonbarbituratethan barbiturate so no cross allergy and it havesimilar pharmacological effect

Less potent than barbiturate

Side effectAtaxia euphoria neurological insomnia visual

motor in coordinationhypotension dyspnearespiratory depression nervousness buellered visioninsomnia

Types of nonbarbiturate as

chloral hydrateethyl alcoholBenzodiazepineantihistaminic


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Nitrous oxide inhalationIt is inorganic gas compressed into liquid [ laughing gas]

It is wide used in dental clinic used for uncooperative patient to controlanxiety

It is neither inflammable nor explosive colorless sweet smellingIt is not irritated to respiratory tract

Why using it ? Advantage1-Rapid onset and recovery [ onset within 3- 5 min ] and no need

recovery room as general anesthesia2- Easy administration[ minimum side effect

Effect on patient [reasonable reverse side effect]Mental and physical relaxation-1

Indifference in surrounding-2Elevation in pain perception-3

Euphoria drowsiness floating drink-4Side effect minimum side effect [behavior alteration as euphoria

]assume shockContraindicate

1-Acaustic anxiety 2- history of pschycosis 3-migrain neurologicaldamage with prolonged abuse


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2-Pain control

It is one of the most challenge aspect of the clinicalpractice of endodontic and one by which the skillfulendodontic called be a major

Your skill in patient judged by pain control [ proper

control of pain of patient you will good doctor]What's the pain ?

Unpleasant physical and emotional experience trigged bynoxious stimulus which transmitted and received in

higher brain center along special pathwayNB stimulus of the pain transited by pathway to higher

brain center which receive this signal


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How can management the endodontic pain ?

Preoperative-1 -Accurate diagnosis [before starting your treatment making

proper diagnosis]

- Anxiety reduction

- What's the relation of the anxiety to pain ?

- If proper control to anxiety of the patient that postoperative painwill decrease as the case report

-Operative-2- -Effective local anesthesia

- -Operative technique endodontic treatment

-Postoperative control pain through using the drugs-3


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Pain management strategiesThe [ 3 Ds ]

it is a critical initial step in mange painDiagnosisbecause some condition have referred pain which not

odontogenic relation as sinusitis so proper diagnosisto prevent misdiagnosis

Definitive treatment

According to condition to make pulpotomy or

pulpectomyWhy the definitive treat is important to reduce pain?

In emergency condition of endodontic as

Definitive treatment DrugsDiagnosis

Acute pulpitis Acute apical abscess Acute peri apical periodontitis


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Why decreasing the pain by pulpotomy or pulpectomy anddrainage ?

which cause interpulpal pressureRemoving pulp tissue-1

from pressing on nerve fiber[pus drainage leading to remove the present pressure sopain relief

of theRemoving or reducing inflammatory mediator-2

disease which stimulate nerve fiberDefinitive treatment reduce or eliminate peripheralNBcausative factors cause hyperemia

[\\arePredictable pain reduction strategies in emergencypulpotomy or pulpectomy as in case of Acute pulpitis and

secondly canal depridment and occlusal reduction ]treat by pusIn case of acute per apical periodontitis

drainageis drainage pusDefinitive treat in per apical abscess

through tooth and incision and drainage

i h i f l i ibl l i i i ff i


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When make pulpotomy or pulpectomy ?If you haven't enough time and in multirootedcanal so removing pulp tissue in pulp chamber[ pulpotomy]

But if you have time pulpectomy is indicated

that optimum mange of painThe final conclusionof odontogenic origin should be focus on two

issue is removing etiologicalDefinitive treatmentsource of infection at primary site with

[ analgesic topharmacological mange if needed

control pain]

NB IF patient have painful irreversible pulpitis is effectiveto management pulpectomy or pulpotomy


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Analgesic

Narcotic opioidanalgesics morphine- like Non narcotics

2-Non anti inflammatory analgesics antipyretic

1-Non steroid anti inflammatory drugs

Non Narcotics


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Analgesics

The drug that has the ability to raise visceral threshold to sub

cortical levelDrug used to decrease or eliminate pain without

unconsciousness but GA with unconsciousness

Non steroid anti inflammatory drugs-1

It is first strategies for management the endodontic pain1. Acetyl salicylic acid [ aspirin ]

2. -Prop ionic acid [Ibrufen Advil ]

3. -Ketoprofen ibuprofen

4. -Mefenmic acid ponstan

5. -Piroxicam folden

6. -Zomax

M d f ti f NSAD


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Mod of action of NSADsIt inhibit synthesis of prostaglandin from arachonic acid [one of the

inflammatory mediators]So they available to managing of pain and inflammation

most of the pulp diseases are inflammatory disease so it need this drugN Bfor treatNSADs have the same of pharmacological effect but different in chemicalNB

structures

Pharmacological effect1-Anagisic2-antipyritic

3- Anti inflammatory4-Antireheumtic

-Gastric ulcer gastric acidity ulceration G IT disturbance- Blood reaggregation bleeding

-Nephrotoxicty if it is used in large dose it have side effect on kidney-Allergic

we must start definitive treatment and used drugs if needed at theNBlast

-In 90% the conditions of endo dontic pain reliefing after pulpotomy orpulpectomy whatever you using analgesic or not

C t i di ti f NSAD


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Contraindications of NSADs1-Sensitivity to drug2-G I T disturbance peptic ulcer3- Bleeding disorder renal disease

4-Chronic liver diseases5-Pregnancy and nursing may be responsible for low birthweight babies

Non anti inflammatory analgesic antipyreticAcetaminophen [ paracetamol]Indication-Save in using during pregnancy-In case of G i T disturbance-No effect on bleeding time

Contraindication of acetaminophenNo absolute conaindication unless use in large dose1- Allergy2-Hepatic toxic and renal failure

NBthis drug is the second choice as less effective and not have anti inflammatory effect


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Opioid [ Narcotic ] analgesic

It is natural or synthetic drug that bind specifically to opioid brain receptor andproduce some or all pharmacological effect of morphine

Mode of actionOpioid means that drug make activation to opioid receptor in the brain whichblock to pathway of signal transmission from trigeminal neuralgia

Opioid work in high brain center so it is very effective but N S A D workNBperipherally

Pharmacological effect1-Analgesic 2-Hypontosis 3-Euphoria 4-Musle relaxation

so it used only in sever orofacial painwide adverse side effectNB it have

Dyesnae Drowsiness constipation Cough suppression Respiratorydepression

Physical dependence and addiction

Indication

1-In moderate to sever pain

opioid are frequently used in combination with other drugs because theNB

combination permit lower dose of the opioid that can reduce the side effect[ Oxycodone + Acetaminophen ]

A l i t t


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Analgesic strategy

Flexible prescription strategy has been purposed to maximize

analgesic benefit with minimal exposure with side effectto optimize dose of Narcotic-1Analgesic strategies

before enter in Narcoticif pain not responded for routine treatment you can usedNB

combination of Narcotic plus N S A DS to decreasing thedose of Narcotic and simultaneously decreasing its sideeffect2-Make balance between patient need for analgesic andpotential averse side effect

Long acting anesthesia to control pain

Duration is 8 -10 hours


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3- Infection control

Optimum management of endodontic infection involveddefinite treatment and pharmacological adjunct whenindicated

Management of infection

1-Definitive treatment 2- Pharmacological adjunct

Definitive treatment

How to control the infection in root canal system?

-Clean and shaping [instrumentation combined with irrigationwith intracanal medicament

Irrigation solution act as antimicrobial activity which irrigateinaccessible area [lateral canal and some area in pulpchamber ]that difficult for entering by file

-It is flushing agent for debris

Irrigation solution as sodium hypo chloride antibacterial


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Secondly use may be need antibacterial [antibiotics ]

are natural compound that possesAntibioticsantimicrobial effect and are use as holding adjunct to

control of infection [ just helping ]if patient have periapical abscess you have startingNB

endodontic treatment and finally descriptionantibiotics if needed [antibiotic is consider to be help

for agentManagement of infection

The simple most important decision in antibiotictreatment is not so much which antibiotic should be

use but which antibiotic used at tour1- Before prescribed antibiotic you must known ifvirtually need antibiotic2-Which types of antibiotic you can to use


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When prescription antibiotic to patient ?There are must be clear evidence of bacterial invasion that isgreater than host defense capability

-There are must be clear evidence that invasion ofmicroorganism above limit of immune system-In some cases virulence of microorganism is very highabove immune system so described antibiotic

For treatment infection-1

-Acute infection and patient have systemic manifestation[hotness redness lymphoadenopathy ]NB antibiotic described in acute infection not in chronicinfection

Diffuse swelling-Virulence of microorganism is very high and immune systemcannot localize infection so you must help itTo localized infection

As prophylaxis before infection-2-in immunocopromised patient -bacterial endocarditis

When antibiotic are not indicated ?


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When antibiotic are not indicated? When not useantibiotic?

Irrevesible pulpitis-1

Acute apical periodontitis-2-Complete pulpectomy and reduction occlusion to relief

pain and infection

[chronic periapical abscess]Drainging localized swelling-3

-In localized swelling or sinus tract drainage the immunesystem is very good because it is tried to confined theinfection and it need only removing irritant from root canal

Endo surgery-4

-If site is clean and aseptic condition as body will healwithout antibiotic

antibiotic indicated in surgery in cases of implant orNBprosthesis as plates


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Why not to prescribe antibiotics ?

1-Antibiotic are harm and not save as all lit cause GITdisturbance nepherotoxicity

2-Antibiotic are used as prophylaxis isn't commonly useful

3- Bacteria may achieve antibiotic resistance [ patient notrespond to antibiotic ]

Antibiotic divided according to the potent into

1- Bacteriostatic suppress growth of microorganism stop growth lead to

immune system control organism 2-Bacteriocidial direct killing

-Antibiotic divided according to coverage into

1-Narrow spectrum work on single species

2-Extended spectrum worked on gram +ve plus some of gramve

3-Broad spectrum work against both species Antibiotic dividing according to mode of action into

1-Ihibation of cell wall synthesis

2-Alteration of cell membrane integrity

3-Ihibation of R NA synthesis and suppress of nucleic acid

R d [b f i ti tibi ti ]


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Road map [before prescription antibiotic]

1-Whate is the appropriate antibiotic ?

2- What is the dose and what's duration ?

3-When will are going to selected antibiotic ?

Sensitivity test \\

Most endodontic infection are facultative anaerobic microorganism so wedont work sensitivity test

NB Sensitivity test need 4 days to one week to performed so in endodonticinfection dont depend on it but the choice is empirical

Dose depended on age weight Adult in case acute infection \\ first give high loading dose [ 2 capsules 1000

mg at first time to high serum level ]

Maintenance dose 500 mg every 6 hours

Duration \\

how you known the proper selection to anti biotic ?

After 24- 48 hours patient follow up if sign and symptom of acute infection[decrease swelling and redness hotness ] relief or patient good response andprognosis to antibiotic

Duration after sign and s relief extended your time for using antibiotic twodays to three days to prevent microorganism resistance [mutation ofmicroorganism ]

All duration is 6 -10 days [2-3 days plus 2-3 days after s s relief]

What's antibiotic ?


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What s antibiotic ? Penicillin It has spectrum of microbial activity including both facultative and anaerobic

microorganismPenicillin Vk oral rout 500 mg \ 6 h

Penicillin G I m injection Mod of action bactericidal Why penicillin is first choice in used ? -It is very save -Mode of action against antibacterial [facultative anaerobic microorganism ] Adverse side effect

1-Allergy All penicillin have up to 10% allergy G I T disturbance or anaphylactic shock To prevent allergy taking history from the patient if have allergy to one

product he allergic to all types of penicillin -After 24 h follow up and take history of patient as[ diarrhea GiTdisturbancance

-You can management anaphylactic shock 2- Gastro intestinal disturbance 3-Bacterial resistance [ develop pencillinase enzyme that destruction ring

structure of penicillin Broad spectrum penicillin as amoxicillin cloxacillin dycloxaciillin NB To overcome problem of resistance of microorganism adding Kgluconate

to amoxicillin prevent ring destruction as augmentin Neocene amoxicillin kgluconate

Treatment of anaphylactic shock


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Treatment of anaphylactic shock

It is medical emergency and need immediate treat of laryngeal edema bronchospasma

and hypotension

Acute allergic reaction occurs within 1\2 h after administration penicillin

Smooth ms contraction urticaria caused by release of histamine and bradykinin

If treat does not begin immediately death can result

1-Lay patient flat and raise his legs

2-Attend air way

3- Administration of adrenalin

Adult 0.5ml of 1: 1000 solution i. m or 3-5 ml of 1: 10.000 solution I m or slowly I v [the

drug may be repeated after 15

20 min ] if patient sever ill and there is doubt aboutadequancy of circulation use adrenaline i. v ]

NB iv injection of adrenaline 1 :1000 solution can be hazardous and can induce lethal

cardiac arrhythmias and in patient on non-selective beta blocker sever anaphylaxis may

not responded to adrenaline and addition of I. v salbutamol

Administration of I v fluid hypotetion corrected by i. v fluid [ colloids]

Corticosteroids hydrocortisone hemisuccinate 100mg I .v followed by oral prednisolone

Antihistaminic drugs chlorpheniramin I. v slowly in dose 10 -20 mg over one min andrepeated for 24 -48 h to prevent late manifestations of allergy it must be given after

adrenaline

Bronchodilators I. v aminophylline or nubulised salbutamol to resist bronchospasm

Supportive measures oxygen and assisted ventilation

0.01ml of 1 : 1000 solution per kg

i. m or 1 : 10.000 per kg slowly i.v

in children

Cephalosporin


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Cephalosporin It is the second choice but the third generation is very expensive ;100pound]

Indication use alternative to penicillin in cases resist to penicillin

Side effect 1- Allergy 2- G I T disturbance 3- Anti vit K bleeding

Erythromycin 500 mg \ 6-8 h

If patient allergy to penicillin you will go to use erythromycin

NB\\ it is not very effective

Adverse side effect

Nausea vomiting hepatomegally and blocking metabolism of certain drugtoxicity

Metronidazole or flagel 500 mg \ 6- 8 h Mode of action Bacteriocidial effective against anaerobic bacteria and

protozoa but ineffective against facultative bacteria

Adverse side effect 1-G I T disturbance 2- Unpleasant metallic taste 3- brown discoloration

Contraindication in alcoholic patient

Use it can be used in combination with penicillin helping in sever dental

infection [specially in periodontal infection ]


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Clindamycin [Dalacin 150- 300 mg\ 6h]

Mode of action Bacteriostatic and effective against

facultative strict anaerobic bacteria Side effect

1-Sever G I T disturbance [ulceration in GIT

Sometimes need to emergency in hospital if abuse

of dalacin 2-Pseudomembranous enterocolitis

NB\\ it is the last choice [ penicillin is more save ]

used in serious anaerobic infection

Tetracycline Used in periodontal infection not used in endodontic


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Antibiotic prophylaxis for medically compromised patient1-Cardiac patient [ bacterial endocarditis caused by streptococci ]2- Patient with total joint placement

streptococci seeding in defect in heart or joint artificial or natural\\NB3-Incidnous dependant diabetic patient uncontrolled [ 60 80 mg \ dl normal bloodglucose]

4- malnutrition patient5- Patient with hemophilia and immune suppressed patient

When use antibiotic as prophylaxis

1- Intra alignment injection anesthesia2- Root canal treatment3- Endosurgery

What antibiotic used ?Amoxicillin and ampicillin-1

It is effective against facultative anaerobicIt dont develop penecillinase resistance organism

Finally rapidly absorbed led to high serum level so it effective duringwork

capsule orally one hour4min before procedure [ or30gm2\\Dosebefore procedure ]

If allergy to penicillin can used Erythromycin or clindmycin cephalixin


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Before start to drug selection you have known

1-The efficiency of the drug

2-Adverse side effect 3-Medical history of the patient

NB\\Dont forget antibiotic are not substitute for

proper local treatment before you selectantibiotic there must be clear evidence ofbacterial invasion that is greater than the hostdefense capability

NB\\All antibiotics are allergic nepherotxicity andhepatotoxicity

It can produce ulcer pseudomembrane entercolitis

therapeutic agent [drugs] in edndodontic

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