ANTIBIOTICS AND ANALGESICS IN DENTISTRY

CONTENTS

Introduction

Classification of Antibiotics

Commonly used Antibiotics in Endodontics

Antibiotics prophylaxis

Conditions requiring dose modifications

Classification of Analgesics

Commonly used Analgesics in Endodontics

Points to remember while prescribing drugs

Clinical studies

Conclusion

References

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Introduction

Antibacterial agents, commonly called antibiotics, are very useful because they kill bacteria without

damage to the host. These drugs attack cell structure and metabolic paths unique to bacteria and not shared

with human cells. Systemic antibiotics are used frequently in the practice of medicine and dentistry. Some

say they are overused. Although this is probably true, it is also difficult to tell when an infection might

spread to cause life-threatening problems, such problems, such as cavernous sinus thrombosis, Ludwig's

angina, danger-space swelling reaching into the mediastinum, brain abscess, or endocarditis, all of which

have developed as sequelae of root canal therapy. It is probably wise to use systemic antibiotics when there

is a reasonable possibility of microorganisms beyond the rot canal, the immuno-logically compromised

patient should also be considered an indication for antibiotic therapy, regardless of the condition of the

canal.

Classification

Antibiotics may be classified into two main categories: those that kill bacteria rapidly and those that

kill more slowly by retarding bacterial protein synthesis. Generally speaking, the faster-killing antibacterial

agents are more desirable.

Types of Antibiotics Rapid-killing antibiotics

Penicillins and cephalosporins

Metronidazole (Flagyl®)

Fluoroquinolones

Antibiotics that slow protein synthesis

Erythromycins (macrolides)

Clindamycin (Cleocin®)

Tetracyclines

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Common Examples of Oral Penicillins and Cephalosporins

Penicillins

Penicillin V 500 mg qid

Ampicillin 500 mg qid

Amoxicillin 500 mg tid/qid

Augmentin 500 mg tid/qid

Cephalosporins

First generation

Cephalexin (Keflex®) 500 mg qid

Cefadroxil (Duricef®) 500 mg qid

Second generation

Cefuroxime (Ceftin®) 250 or 500 mg bid

Cefaclor (Ceclor®) 500 mg tid

Third generation

Cefixime (Suprax®) 400 mg daily

Dosages may vary with the specific situation.

Fast-killing antibacterial agents are often called bactericidal, meaning that they are observed to kill

quickly in the laboratory. Penicillins, Cephalosporins, and metronidazole are the bactericidal antibiotics

commonly used against endodontics pathogens. The first two kill by integrating into and weakening a newly

made cell wall, whereas the latter impedes DNA manufacture. Both require actively growing organisms to

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be effective, so antibiotics that fight bacteria by slowing their protein synthesis (bacteriostatic antibiotics)

are generally not given along with these bactericidal drugs.

Type of organisms against which primarily active

1. Antibacterial: Penicillins, Aminoglycosides, Erythromycin etc.

2. Antifungal: Griseofulvin, Amphotericin B, Ketoconazole etc.

3. Antiviral: Idoxuridine, Acyclovir, Amantadine, Zidovudine etc.

4. Antiprotozoal: Chloroquine, Pyrimethamine, Metronidazole, Diloxanide

5. Antihelminthic: Mebendazole, Piperazine, Pyrantel, Niclosamide etc.

PENICILLINS : a wide variety of this group is available and of all these the benzyl penicillin is the most

suited. The penicillin act by the inhibition of the cell wall. Benzyl penicillin

Antibacterial activity: this includes the

1. COCCI: streptococci (expect the group D) are highly sensitive, staph aureus although very

sensitive has acquired resistance. The gram negative cocci include the N. gonorrhoea, N.

meningitidis.

2. BACCILI: Grampositive bacilli this includes the C.diptheriae, clostridia group, listeria. treponema,

bacclius group. Actinomyces israelli is primarily moderately sensitive.

PENICIILIN RESISTANCE

The primary mechanism of the acquired resistance is by the production of the enzyme penicillinase.

Penicillinase: it is a narrow spectrum B - lactamase which opens up the ring and inactivates the penicillin.

Majority of the staph, B.subtilis and H. influenzae group produce this enzyme. This enzyme can be induced

and methicillin is an important inducer of this enzyme.

Absorption fate and excretion:

When given i.m it is quickly absorbed, the maximum concentration being achieved in about half an

hour. In order to maintain the cone, of this drug abut 500 mg of this drug needs to be given at least every 4-6

hr interval. Inflammation increases the penetration of this drug. The half life of this drug is less than half an

hour.

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SEMISYNTHET1C PENICILLIN:

Acid Resistant Penicillin: Penicillin V

Penicillinase resistant penicillin: Methicllin, Oxaciiiin, Cloxaciliin.

Extended spectrum penicillin: amDicillrn. bacampicillin. amoxicillin.

carbenicillin

piperacillin

B. lactamase inhibitor: clavulaunic acid.

Penicillin V: It is the penicillin which can be given orally, as it is acid stable.

Penicillinase resistant penicillin's: These have a side chain attached at their end terminal hence allowing

them to be resistant to the attack of the penicillinase producing staph. However these are not active against

the methicllm resistant staph (MRSA). It is generally given in cases of staphylococcal infection.

Extended spectrum infections:

AMPICILLIN : active against all the organisms sensitive to penicillin However

resistance has developed because of the misuse of this antibiotic. It is more active than penicillin against the

streptococcus vindans group. Staph are not affected Dosages : 500 mg six hourly.

Adverse effects are that diarrhea is quite common. Skin rashes are also quite common with the use of this

drug.

Bacampicillin : the only significant advantage is that it is completely absorbed. The incidence of diarrhoea

is lower than ampicillin

Amoxicillin : oral absorption is better and incidence of diarrhoea is lower

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Dosages : 500 mg every 8 hourly. For severe dental infections the course is extended for at least 5-10 days.

Beta lactamase Inhibitor:

Clavulanic Acid : obtained from streptomyces clavuligerus. It has no antibacterial activity of its own.

Uses : addition of the ciavulaunic acid reestablishes the activity of amoxicilim against the penicillinase

producing bacteria. Amoxicillin sensitive strains are not affected by the addition of this drug.

CEPHALOSPORINS:

These are a group of antibiotics that are derived from cephalosporin obtained from the fungus

cephalosporiium. They are chemically related to penicillin these drugs are divided into four groups. All the

ceph are bactericidal and theses have the same mechanism as that of the penicillin. However, they bind to

different proteins. This may explain the difference in the spectrum, and the lack of the development of the

cross resistance.

FIRST GENERATION :

These were developed in the 1960 and were active against the gram positive organisms.

SECOND GENERATION

These were developed as they were active against gram negative organism

1. Ceforoxime : it is resistant top the b lactamase organisms. Their uses lie however with the treatment

of the meningitis infection. Dosage: 250-750 mg

2. Cofactor : dosage 250 mg

THIRD GENERATION:

These compounds were developed in the 1980 and these were active against the gram negative

enterobacteriases. All were highly active against the b lactamase producing organisms.

1. Cefotaxime : Prototype of the third generation, has actions against both gram positive a well as the gram

negative. Dosage - 0.5-0.6 g per vial

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2. Ceftriaxone : distinguishing feature of the cephalosporin is the long duration of action. Dosage: 0.5-1.0

gm per vial.

3. Cefixime: orally active third generation, highly active against the H.influenzae. strepto and is resistant to

the b lactamase organism. Dosage 100-200 mg tab.

4. Cefdinir: againji an oraqlly active agents use is limited to much in the ent dosage. 300 mg tab.

ADVERSE EFFECTS:

1. Pain during the injection

2. Diarrhea

3. Hypersensitivity reaction

4. Nephrotoxicity

5. Bleeding

6. Neutropenia

AMINOGLYCOSIDES

This group includes the

1. Streptomycin

2. Gentamycin

3. Tobramycin

4. Amikacin

5. Kanamycin

6. Sisomycin

Due to there adverse effects these drugs are seldom used in dentistry expect for the gentamycin and

the amikacin. These drugs are used when the patient comes with severe infection with generalized

symptoms. In cases of the multisystem involvement these drugs are used as the last resort.

Gentamycin : dosag20, 60, 80, 240 mg per vial

Amikacin : dosage - 100, 200, 500 mg vial per

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ANTIAMOEBIC DRUGS:

These drugs include

1. Metronidazole

2. Secnidazole

3. Ornidazole

4. Satranidazole

Metronidazole : This drug has a wide variety of action. It has a broad spectrum of activity against he

protozoa, this activity includes many of the anaerobic bacteria too like the h. pylori. Metronidazole is

selectively toxic to the anaerobic bacteria.

Adverse effects

1. Anorexia

2. headache, glossitis, dizziness

3. peripheral neuropathy

4. threombophlebitis

Contraindication

1. in neurological disoders

2. first trimester of pregnancy

3. chronic alcoholisms

Dosage : 200-400 mg tds tab

Secnidazole : dosage 0.5-1.0 g tab

Ornidazole : dosage : 500 mg tab.

Satrindazole : dosage : 500mg BD

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ANTIFUNGALS:

Antibiotics

1. Nystatin, amphotericin, grisofulvin

AZOLES

1. Clotrimoxazole (topical)

2. econazole

3. miconazole ANTIBIOTICS

1. AMB : its antifungal activity includes the canmdida albicans, histoplasma crytococcus,

aspergillus.

Administered orall dosage : 50-100 QID

Adverse effects :

1. nephrotoxicity is the major dose limiting side effect.

2. NYSTATIN : similar to the AMB, however its usr is limited tro the oral route. It has been combined

with the tetracyclines for the prevention against the superainfection.

Dosage : 5 lacd U tab, 1 lac U tab.

KETOCONAZOLE : it is the first orally effective broad spectrum antifungal used in dermatophysis, deep

mycosis, dosage : 200 mg od

TETRACYCLINES

The tetracyclines comprise a group of closely related antibiotics that provide a broad spectrum of

activity against the organism. The activity includes the organisms that are insensitive to the penicillin as

well many gram negative organisms, these are generally bacteriotatic. These agents are administered orally

but can be given by the i.m or the iv route. These drugs are widely distributed in the boy tissues and reach

the CSF also. These chelate with the calcium ions present in the teeth and bones.

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UNWANTED EFFECTS OF TETRACYCLINES

Immediately after the absorption these drugs are built in the calcifying tissues and this becomes a

permanent feature in the teeth. There is a clear linear relationship between the number of courses of

treatment with tetracyclines and the discoloration of developing teeth. If at all possible then these drugs

should be avoided during the formative stages of the crowns of the teeth. If a tetracycline has to be used

then it has to be the oxytetracyclines, or doxycycline. As they produce the least objectionable amount of

staining.

Tetracycfine's produce a marked depression of the normal flora of the mouth, throat and colon.

Under some conditions these may lead to the development of an infection which may have grave

consequences. Staph infections which if occur might be very serious.

Candida albicans : overgrowth of which might be of concern to the dentist. The surface proliferation of

this organism which is a normal commensal of the mouth might then invade the tissue and cause infection.

This is especially likely to occur in patients with debilitating disease. (Antibiotic sore mouth). USES : in

dentistry the use of tetracycline remains restricted. It is used in cases where the penicillin hypersensitivity is

there. These drugs should never be used when they are being combined with a bactericidal drug. A

tetracycline mouth bath is effective in reliving the painful ulceration of the erosive lichen planus, severe

recurrent apthae ulcers.

DOSAGE : 250 mg every 6 hr.

MACROLIDE ANTIBIOTICS:

The group includes erythromycin, oleandomycin and spiramycin of which the first is of the interest

to the dentist. Erythromycin has an antibacterial spectrum that is quite similar to that of benzyl penicillin.

The drug acts by the inhibition of the protein synthesis.

UNWANTED EFFECTS:

All preparation can cause the gastrointestinal symptoms. Hypersentivity is rare but the estolate preparation

can cause the cholestatic hepatitis.

DOSAGE : This drug is administered orally and for most infections 500mg 6 hr for the course for 5 days

should suffice.

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Clindamycin : its mechanism of action is quite similar to that of the erythromycin. These are also primarily

static drugs. Its usage in dentistry is very much limited because of the serious side effects that it can cause -

pseudomembranous colitis which can be fatal.

AZITHROMYCIN: one of the best drugs in the class of macrolides. It has the best oral availability and has

the best spectrum of activity. However its use in dentistry is not widely accepted.

All drugs grouped in this class have analgesic, antipyretic and anti-inflammatory actions in different

measures.

Antibiotic Prophylaxis

The goal of antibiotic prophylaxis is to prevent clinical infection by helping destroy small numbers

of bacteria present before or introduced during treatment. Oral bacteria released during dental treatment

clearly can cause heart and artificial joint infections. Oral streptococci, in particular, have been indicted as

causative organisms for seeding heart and implanted joints, causing morbidity or even death.

Oral streptococci are weak pathogens know as "viridans strep". The long chains become seriously

pathogenic when "viridans" colonies form on heart valves, trapping blood cells and fibrin and thereby

reducing heart efficiency by hindering closure of the valves. Furthermore, portions of the sticky :

vegetations," as they are called, break of and lodge in small vessels at distant sites, causing ischemia with

possibly disastrous consequences.

CONDITIONS REQUIRING DOSE MODIFICATIONS

Patient Factors

1. Age may affect kinetics of many AMAs. Conjugation and excretion of chloramphenicol is

inefficient in the newborn: larger doses produce gray baby syndrome. Sulfonamides displace

bilirubin from protein binding sites — can cause kernicterus in the neonate because their blood brain

barrier is more permeable. The t 1/2 of amino-glycosides is prolonged in the elderly and they are

more prone to develop VIII nerve toxicity. Tetracyclines accumulate in the developing teeth and

bone — discolour and weaken them — are contraindicated below the age of 6 years.

2. Renal and hepatic function Cautious use and modification of the dose of an AMA (with low safety

margin) becomes necessary when the organ of its disposal is defective.

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Antimicrobials contraindicated or for whom dose modification is required in renal insufficieny are:

Dose reduction needed in renal failure Drugs to be avoided

Even in mild failure Only in moderate- Cephalothin

Aminoglycosides severe failure Cephaloridine

Cephalosporins Metronidazole Nalidixic acid

Vancomycin Cotrimoxazole Nitrofurantoin

Amphotericin B Carbenicillin Talampicillin

Ethambutol Fluoroquinolones Tetracyclines

Flucytosine (doxycycline)

Antimicrobials to be avoided or used at lower dose in liver disease are:

Drugs to be avoided Dose reduction needed

Erythromycin estolate Chloramphenicol

Pyrazinamide Metronidazole

Taiampicillin Clindamycin

Tetracyclines Isoniazid

Rifampin

3. Local factors: The conditions prevailing at the site of infection greatly affect the action of AM As.

a. Presence of pus and secretions decrease the efficacy of most AMAs, specially sulfonamides

and aminoglycosides.

Presence of necrotic material or foreign body makes eradication of infection practically impossible.

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b. Haematomas foster bacterial growth; tetracyclines, penicillins and cephalosporins get

bound to degraded haemoglobin in the haematoma.

c. Lowering of pH at site of infection reduces activity of macrolide and amino-glycoside

antibiotics.

d. Anaerobic environment in the centre of an abscess impairs bacterial transport processes

which concentrate aminoglycosides in the bacterial cell.

4. Drug allergy : History of previous exposure to an AMA should be obtained. If a drug has caused

allergic reaction — it should be avoided in that patient.

5. Impaired host defence: Integrity of host defence plays a crucial role in overcoming an infection. In an

individual with normal host defence, a bacteristatic AMA may achieve cure; while intensive therapy with

cidal drugs is imperative in those with impaired host defence (conditions given on p. 620) or when the

organisms are protected by a barrier — as in SABE.

6. Pregnancy All AMAs should be avoided in the pregnant because of risk to the foetus; contraindicated

drugs are:

Tetracyclines: teeth and bone discolouration and deformity in the offspring; risk of acute yellow atrophy

of liver, pancreatitis and kidney damage in the mother.

Aminoglycosides

Foetal abnormalities may be produced

Cotrimoxazole

POINTS TO REMEMBER WHILE PRESCRIBING DRUGS

1. Allergies

Serious anaphylactic allergic reactions are rare with oral penicillins and cephalosporins, although

they are possible. If allergic to one penicillin, the patient should be considered allergic to all penicillins and

possibly to cephalosporins as well.

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2. Resistance

The main biochemical structural similarity of penicillins and cephalosporins is the p-lactam ring.

Some bacteria can produce an enzyme, called p-tactamase or penicillinase, which cleaves this ring, thus

disabling the antibiotic. Potassium clavulanate has been added to amoxicillin, to make it stable in the

presence of p -lactamase. The combination is called Augmentin®.

3. A good specimen for culturing can often be obtained by needle aspiration from an abscess that has not

yet drained. A culture can be a bid advantage when a patient does not respond to the first antibiotic. The

practitioner can telephone the laboratory and quickly learn which drug to use next.

4. Suprainfection (Superinfection)

Use of most AMAs causes some alteration in the normal microbial flora of the body. Ordinarily, the

pathogen has to compete with the normal flora for nutrients etc. to establish itself. Lack of competition may

allow even a normally nonpathogenic component of the flora, which is not inhibited by the drug (e.g.

Candida), to predominate and invade. More complete the suppression of body flora, greater are the chances

of developing suprainfection. Thus, it is commonly associated with the use of broad/extended spectrum

antibiotics, such as tetracyclines, chloramphenicol, ampicillin, newer cephalosporins; specially when com-

binations of these are employed.

To minimize suprainfections:

(i) Use specific (narrow spectrum) AMA whenever possible.

(ii) Do not use antimicrobials to treat trivial, self limiting or unbeatable (viral) infections, (iii) Do not

unnecessarily prolong antimicrobial therapy.

5. Nutritional Deficiencies

Some of the B complex group of vitamins and vit K synthesized by the intestinal flora is utilized by

man. Prolonged use of antimicrobials which alter this flora may result in vitamin deficiencies.

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ANALGESICS

NON STEROIDAL ANTI INFLAMMATORY DRUGS CLASSIFICATION :

A. Nonselective COX inhibitors (conventional NSAIDs)3

1. Salicylates: Aspirin, Diflunisal

2. Pyrazolone derivatives: Phenylbutazone, Oxyphenbutazone.

3. Indole derivatives: Indomethacin, Sulindac

4. Propionic acid derivatives: Ibuprofen, Naproxen, Ketoprofen, Flurbiprofen.

5. Anthranilic acid derivative: Mephenamic acid

6. Aryl-acetic acid derivatives: Diclofenac

7. Oxicam derivatives: Piroxicam, Tenoxicam.

8. Pyrrolo-pyrrole derivative: Ketorolac.

B. Preferential COX-2 inhibitors

C. Selective COX - 2 inhibitors

Celecoxib, Rofecoxib, Valdecoxib

D. Analgesic- antipyretics with poor anti-inflammatory action

1. Paraaminophenol derivative : Paracetamol (Acetaminophen)

2. Pyrazolone derivatives: Metamizol (Dipyrone), Propiphenazone.

3. Benzoxazocine derivative : Nefopam

Beneficial actions due to PG synthesis inhibition

Analgesia : prevention of pain nerve ending sensitization

Antipyresis

Anti-inflammatory

Antithromobotic

Closure of ductus arteriosus

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Shared toxicities due to PG synthesis inhibition

Gastric mucosal damage

Bleeding : inhibition of platelet function

Limitation of renal blood flow : Na+ and water retention

Delay / prolongation of labour

Asthma and anaphylactoid reactions in susceptible individuals

Uses

1. As analgesic : For headache, backache, myalgia, joint pain, pulled muscle, toothache, neuralgias and

dysmenorrhoea; it is effective in low doses (0.3-0.6g 6-8 hourly)

2. As antipyretic : It is effective in fever of any origin; dose is same as for analgesia. However,

paracetamol, being safer, is generally preferred.

Aspirin has been a standard drug for dental pain for many years and is still useful. It, however,

prolongs bleeding, and for this reason is a poor presurgical drug. The anticoagulant effect comes from

interference with platelet formation. Aspirin irreversibly binds the enzyme cyclooxygenase, key to the

pathway from injury-induced arachidonic acid, that is released from the membranes of all cells, leading to

production of inflammation and pain-causing prostaglandins. Platelets in circulation do not have enough

protein synthesis reserves to replace the bound cyclooxygenase and are thus unable to participate in clotting

for the remainder of their cell life-around 11 days. Many patients are on routine, low-dosage aspirin therapy

for prophylaxis against stroke or heart attack. Prior to endodontic surgery, consultation with their physician

may be in order.

For patients with stomach problems, consider the use of coated aspirin, such as Ecotrin®. The

coating will not dissolve until reaching the alkaline conditions of the small intestine. This means that drug

action will be delayed for the usual 2-hour stomach transit time. Alternatively, aspirin buffered with

chemicals such as magnesium, calcium, or aluminium compounds to decrease stomach complaints

(Buffering®, Ascription®) can be considered for sensitive patients.

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INDOLE DERIVATIVES:

INDOMETHACIN: it is a potent pain killer and also is a strong antipyretic

Dosages: 25 - 50 mg qid,

Adverse Effects: leukopenia, rashes are also common.

PROPIONIC ACID DERIVATIVE: ibuprofen was the first member. It was better tolerated than aspirin.

The analgesic, antipyretic and antiinflammation property is somewhat lower than that of the aspirin. All the

members of this group inhibit the pg synthesis naproxen being the most potent.

ADVERSE EFFECTS: ibuprofen and its congers are all better tolerated than aspirin. These include some

gastric discomfort, gastric erosions, rashes; these are not to be prescribed to pregnant patients and should be

avoided.

PHARMOKOKINETICS: all of these are well absorbed, these erne the brain and the synovial fluid and

cross the placenta.

Recently ibuprofen was rated as the safest conventional NSAIDS in the UK.

The other members include the naproxen, ketopprofen, flubriprofen.

3. ANTHRANILIC ACID DERIVATIVE:

MEPHENEMIC ACID : an analgesic, antipyretic, anti-inflammatory drug which inhibits the COX

as well antagonizes the effect of PG.

ADVERSE EFFECT:

Diarrhoea is the most common side effect in this class.

Use: it is commonly indicated as an analgesic in the muscle and the soft tissue pain. DOSAGE: 250-50 mg

IDS.

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4. ARYL ACETIC ACID DERAVATIVE:

DICCLOFENAC SODIUM : an analgesic, antipyretic, anti-inflammatory drug which is similar in efficacy

as the naproxen. It is a potent analgesic.

CONTRAINDICATION : bronchial asthma, gastric bleeding and in patients bleeding disorders.

Dosage: 50 mg B.D, it is also available in the topical preparation as the voveran gel.

5. OXICAM DERAVTIVE

PIROXICAM: long acting potent NSAID with anti-inflammatory potency similar to indomethacin and

good analgesic antipyretic action. It is a reversible inhibitor of the COX. It inhibits the inflammation in

many ways.

ADVERSE EFFECTS: common side effects are heart effects, nausea and anorexia. It is less ulcerogenic

than indomethacin

6. PREFENTIAL COX-2 INHIBITOR:

1. NIMESULIDE: This newer NSAIDS is a relatively weak inhibitor. Of pg synthesis and there is some

evidence to indicate relatively COX - 2 selectively. The analgesic, antipyretic and anti-inflammatory

activity of nimesulide has been to other NSAID. It is has been used for short lasting inflammation

conditions.

ADVERSE EFFECTS : gastrointestinal, dermatological effects. Recent studies have shown that this drug

is causing fulminant hepatic failure. Advantage of this drug is that it doesn't aggravate the asthmatics and

bronchospasms.

DOSAGE: 100 mg B.D

MELOXICAM: this is a newer cogner of piroxicam has COX-2, COX-1. This drug has been labeled as the

preferential cox-2 inhibitor. Gastric side effects a are somewhat less than other NSAID. Dosage: 7.5-15 mg.

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SELECTIVE COX-2 INHIBITOR

Because of the theoretical advantage of inhibiting cox-2 without affecting cox-2 function, some

highly selective cox-1 functions.

1) The role of Cox 2 in acute pain and the use of selective cox-2 inhibitors for the acute pain relief (2004).

Lee Y et al the author reviewed the usefulness of the NSAIDS in the pain relief. The discovery of the

second COX-2 led to the hypothesis that NSAIDS side effect could be decreased, as the inhibition of cox-2

is more directly implicated in ameliorating inflammation while the inhibition of cox-1 is related to adverse

effects in the GI tract, this development of the cox-2 means that they are better tolerated than the

nonselective cox-2 but comparable in the analgesic efficiency.

CELECOXIB: The cox-2 selectively in different tests, it exerts anti inflammatory with low ulcerogenic

potential. DOSAGE -100-200 mg B.D

ROFECOX1B: it is the most selective cox-2 selective inhibitor. Dosage 12.5-25 mg O.D occurrence of the

gastric damage is much lower than others.

VALDECOXIB: similar to the rofecoxib activity. Dosage is the 10 mg. O.D. ETORICOXIB: similar to

rofecoxib. Dosage 60-120 mg O.D Topical NSAIDS:

Many have been marketed in topical formulations for application over painful muscles and joints.

Some of the topical preparations available are the:

1. diclofenac 1% gel

2. ibuprofen 10% gel

3. naproxen 10% ge!

4. ketoprofen 2.5% gel

5. flubiprofen 5% gel

6. nimuselide 1% gel

7. piroxicam 0.5% gel

Choice of non steroidal anti-inflammatory drugs

1. mild to moderate pain with inflammation- paracetamol or low dose ibuprofen

2. acute musculoskeletal - diclofenac or rofecoxib

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3. post operative or other acute but short lasting painful conditions- nefopam , ketorolac

4. Gastric intolerance to the NSAIDS- rofecoxibm, celocoxib.

5. Patients with history of asthmatic attacks or anaphylactic reactions: nimesulide.

6. Combinations of two or more drugs in this NSAIDS group are beneficial but should be restricted to a

short time.

BENZOXAZOCINE DERAVATIVE:

1. NEFOPAM: it is a nonopoid analgesic which does not inhibit the PG synthesis, in traumatic and

postoperative pain, it acts rapidly with an efficacy approaching morphine, yet no opoid action.

However this drug produces ant cholinergic actions, it is contraindicated in the epileptics. Dosage:

30-60 mg IDS oral.

PARAAMINOPHENOL DERIVATIVE:

Phenacitin : Has been banned due to its implicated ion analgesic abuse nephropathy.

Paracetamol (acetominiophen): Actions similar to the aspirin but its anti-inflammatory action is

much weaker than that of the aspirin.

Advantages:

1. no gastric stimulation

2. less mucosal erosions

3. does not affect the platelet function

4. non effect on the clotting factors

5. Does not stimulate the respiratory system.

Adverse effects:

1. Nausea or rashes

Analgesic nephropathy: occurs after years of heavy ingestion. Dosages: 0.5-1 .Og tab, 500mg tab.

Narcotics can cause addiction, with characteristics unique from other types of addiction. Both

physical and psychological addiction occur.

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Narcotics are central nervous system (CNS) depressants and work synergistically with all other CNS

depressants. Narcotics reduce reaction times, and narcotized patients must not drive or operate machinery.

Usually, narcotics are combined with acetaminophen or aspirin or an NSAID to make them more effective

without excessive narcotic side effects.

Proposyphene was originally introduced as a non-narcotic; however, it is now known as a rather

weak narcotic. It works for many patients, perhaps in part because its characteristic, dizziness, makes the

patient feel that it must be helping with the pain. Darvon® is available plain or with aspirin; with

acetaminophen, it is called Darvocdet-N®.

Codeine has been a standard drug in dentistry for many years because it is usually powerful enough

to control dental pain. It is irritating to the stomach in high doses, many patients with legitimate pain are

troubled with this gastrointestinal upset.

Occasionally, patients will experience sufficient pain from endodontic procedures to require high-

level narcotics, such as oxycodone or meperidine (Demerot®). Morphine is available orally as Oramorph®

for severe dental pain, such as when the bony cortical plates confine infection pressure, necessitating very

strong drug therapy, morphine remains a viable choice for the astute practitioner.

Tramadol (Ultram®) is a new, potent, synthetic pain reliever that has similarities and differences

with the classic opiates. Unlike other opiates, tramadol is not fully reversed by naloxone (Narcon®).

Further, it inhibits reuptake of serotonin and norepinephrine, a monoamine; hence, concomitant

administration with monoamine oxidase inhibitor drugs is not recommended. Tramadol is well absorbed

orally, and the usual adult does is 50 to 100 mg four times a day.

Acetaminophen (Tylenol) gives patients relief via its action directly on an unknown site in the brain.

It was popularized in the now unavailable "ARC" formulation of aspirin, phenacetin, and caffeine. Although

it is effective against pain and fever, inflammation remains unchanged by acetaminophen.

Acetaminophen is metabolized by the liver and should be used cautiously in patients with live

disease or chronic alcohol use.

Research data show that acetaminophen is better for elevation of the threshold for sharp pain, such

as with dental treatment, than other types of pain relievers.18

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CLINICAL STUDIES

Keenan JV et al (2006) The Cochrane Systematic Review promotes evidence-based outcomes

studies. The review summarized here was conducted in an attempt to achieve reliable evidence concerning

the effectiveness, or otherwise, of prescribing antibiotics for patients having irreversible pulpitis. Although

the selected study used a relatively small, low-powered sample, it did provide some evidence that there is no

significant difference in pain relief for patients with untreated irreversible pulpitis who received antibiotics

versus those who did not. These findings increase the rationale to investigate the teaching of safe and

effective antibiotic prescribing in endodontics and to advance the development of appropriate evidence-

based clinical guidelines.

Moore PA (1999) The use of erythromycine, a long-established macrolide antibiotic, may be limited

by gastrointestinal side effects. The newer long-acting macrolide antibiotics-azithromycin, clarithromycin,

and dirithromycin are some times used instead of erythromycin. The pharmacology, indications and

advantages of these newer drugs are reviewed. Clinical significance although, the newer macrolide

antibiotics clarithromycin, azithromycin, and dirithromycin are too costly for routine use in treating dental

infections, they do offer several advantages over erythromycin. Clarithromycin or azithromycin may be

used for bacterial endocarditis prophylaxis in patients allergic to peniclillin.

Doroschak AM et al (2000) : Endodontic pain continues to pose a challenge. They efficacy of a

non-steroidal anti-inflammatory drug (NSAID), flurbiprofen, and a new centrally acting analgesic tramadol,

was evaluated in a clinical study. Clinical significance For patients with endodontic pain, the combination of

tramadol and the NSAId flurbiprofen offered superior pain relief during the first 24 hours after endodontic

treatment.

Dental Abstract (Vol. 51 (3); 2006) Background: Clindamycin has proved extremely efficacious

for dental infections but is not recommended routinely because of its association with acute

pseudomembranous colitis (ARC). The pertinent facts concerning the use of clindamycin were reviewed.

Henry M et al (2001) : The effects of penicillin therapy in patients with continued symptoms after

emergency treatment for symptomatic necrotic teeth were assessed in a randomized trial. Postoperative

antibiotics may still be indicated for some patients with symptomatic, necrotic teeth, but this randomized,

placebo-controlled trial finds that postoperative penicillin does not reduce pain.

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Mellor AC et al (2005) AIM: To examine whether an intra-oral injection of a nonsteroidal anti-

inflammatory drug (ketorolac), in association with conventional local anaesthetic techniques, would

improve the pulp extirpation rate in teeth with irreversible pulpitis. An intra-oral injection of ketorolac did

not improve the pulp extirpation rate in a small group of patients with irreversible pulpitis compared with a

placebo. In addition, it was associated with such significant pain on injection that it cannot be recommended

as a treatment in this situation. Lindeboom JA et al (2005) AIM: To determine the value of clindamycin

prophylaxis in the prevention of postoperative wound infections in patients undergoing endodontic surgery.

No statistically significant difference was found between clindamycin prophylaxis and placebo with regard

to the prevention of postoperative infection in endodontic surgical procedures.

Farhad A (2005) : Calcium hydroxide is a multipurpose agent, and there have been an increasing

number of indication for its use. Some of its indications include direct and indirect pulp capping,

apexogenesis, apexification, treatment of; root resorption, iatrogenic root perforations, root fractures,

replanted teeth and interappointment intracanal dressing. The purpose of this paper is to review the

properties and various indications for the use of calcium hydroxide.

Modaresi J, et al (2006) The purpose of this study was to elucidate whether premedication therapy

with acetaminophen-codeine or ibuprofen is able to increase the depth of anesthesia in inflamed teeth. This

study reflected preoperative administration of ibuprofen, if not contraindicated, as a drug of choice 1 hour

before local anesthesia injection as an effective method for achieving a deep anesthesia during RCT of teeth

with irreversible pulpitis.

Conclusion

It is imperative that the dentist has a knowledge about the drugs that are available and the way they

work on the human system, also the dentist must keep his/her knowledge up to date regarding the newer

drugs that are being launched in the market.

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References

1. Text book of pharmacology: KD Tripathi

2. Text book of endodontics : Ingle

3. Text book of endodontics : Wein

4. Scientific foundation of Dentistry : Cohen

5. James V. et al 'A Cochrane systematic Review fluids no evidence to support the use of antibiotics

for pain relief in irreversible pulpits JOE -Vol. 32 No. 2 Feb 2006.

6. Dental abstracts clinical use of long-acting macrolide antibiotics. 1999

7. Dental abstracts NSAID / Opiate combination may be useful for managing pain in endodontic

emergency patients Vol. 45 issue 1, 2000.

8. Dental abstracts clindamyain for dental infections and prophylaxis Vol. 51 Issue 3, 2006.

9. Dental abstracts penicllin usefull for postoperative endodontic pain 2001.

10. Int endod J. 2006 Apr; Mellor AC et al the use of an intra-oral injection of Ketorolac in the

treatment of irreversible pulpits.

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