therapeutic agent [drugs] in edndodontic
TRANSCRIPT
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
1/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
2/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
3/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
4/34
Management of anxiety
Patientreassurance
Chemical drugs
Nitrous oxide
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
5/34
-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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
6/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
7/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
8/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
9/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
10/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
11/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
12/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
13/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
14/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
15/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
16/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
17/34
Analgesic
Narcotic opioidanalgesics morphine- like Non narcotics
2-Non anti inflammatory analgesics antipyretic
1-Non steroid anti inflammatory drugs
Non Narcotics
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
18/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
19/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
20/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
21/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
22/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
23/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
24/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
25/34
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 ?
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
26/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
27/34
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 ]
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
28/34
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 ?
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
29/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
30/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
31/34
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 ]
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
32/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
33/34
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
-
7/28/2019 Therapeutic Agent [Drugs] in Edndodontic
34/34
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