ENDODONTIC PHARMACOLOGY

ASHA REDDY

Introduction Antibiotic therapy in ana!e ent o" in"ection# a$ de"inition b$ princip%e# o" therapy c$ princip%e# o" antibiotic #e%ection d$ princip%e# o" antibiotic ad ini#tration C%a##i"ication a$ ba#ed on che ica% #ructure b$ type o" or!ani# # on &hich it act# c$ bacteri#tatic' bacteriocida% d$ che otherapeutic #pectra Mechani# o" action Antibiotics commonly used in endodontics Penici%%in# Cepha%o#porin# (uino%one# Tetracyc%ine# Macro%ide# Anti"un!a% a!ent# Anti)ira% a!ent# Antibiotic Prophy%a*i# "or Heart and Arti"icia% +oint Patient# Analgesics used in endodontics Introduction De"inition Propertie# C%a##i"ication o" Pain Pain Path&ay# Mana!e ent o" pain Opioid Non$opioid a$ c%a##i"ication b$ echani# o" action Anti$an*iety Dru!# Other dru!# Root$cana% Irri!ant# Intra$cana% edica ent# Mu y"in! a!ent# Styptic# Re"erence#

CONTENTS

PHARMACOLOGY, #cience o" dru!# and their interaction &ith the %i)in! #y#te # DR-G .De"/ .0HO/ $ a dru! i# de"ined a# any #ub#tance or product that i# u#ed or intended to be u#ed to odi"y or e*p%ore phy#io%o!ica% #y#te # or patho%o!ica% #tate# "or the bene"it o" the recipient Dru!# are i portant in Endodontic# to "i!ht a!ain#t 12 in"ection# 32 pain 42an*iety

5acteria% path&ay# to the pu%p, 12 carie# 32 periodonta% di#ea#e 42 "racture# 72 dentina% tubu%e# not co)ered 82 Anachore#i# Pu%pa% in)a#ion be!in# &ith a i*ed in"ection o" aerobe# and anaerobe# A# o*y!en i# dep%eted ob%i!ate anaerobic bacteria and "acu%tati)e bacteria predo inate2 Pri ary !oa% o" endodontic treat ent i# to e%i inate a ho#pitab%e p%ace "or icroor!ani# # to !ro&2 12 debride ent o" cana% #hou%d be a# thorou!h a# po##ib%e 32tota% obturation o" the #pace to c%o#e o"" the path "or ora% bacteria to reach beyond the ape* 42 u#e o" #teri%e techni9ue to a)oid introducin! any ne& icrobe# 5ut in #ituation# &here in"ection# e*i#t beyond the root cana% it i# ad)i#ab%e to u#e #y#te ic antibiotic#2 Che otherapy$ i# de"ined a# the u#e o" #ynthetic: #e i#ynthetic: and natura%%y occurin! che ica%# that #e%ecti)e%y inhibit #peci"ic or!ani# # cau#in! di#ea#e2

ANTI5IOTIC THERAPY IN MANAGEMENT O6 IN6ECTIONS

ANTI5IOTICS are antibacteria% a!ent# &hich are u#ed to ;i%% bacteria &ithout da a!e to the ho#t2 12 ore appropriate ter i# anti icrobia% a!ent# 32they are obtained natura%%y a# &e%% a# #ynthetica%%y

Definitions

Anti icrobia%# < are #ub#tance# that ;i%% or #uppre## the !ro&th or u%tip%ication o" icroor!ani# #: either bacteria: )iru#e#: "un!i: or para#ite#2 Antibiotic# < #ub#tance# produced by icroor!ani# # or by #ynthetic che ica% ethod# that ha)e the capabi%ity to produce an antibacteria% action2

Principles of therapy

Pre#ence o" in"ection State o" ho#t de"en#e# Sur!ica% draina!e and inci#ion Pre#ence o" in"ection, < Loca% Si!n# o" in"ection, pain: #&e%%in!: erythe a: pu# "or ation: and %i itation o" otion #hou%d be noted2 < Sy#te ic #i!n# , "e)er: %y phadenopathy: a%ai#e: to*ic appearance: and %eucocyto#i#2 Non$in"ectiou# condition#, < Re o)a% o" third o%ar: a=or #ur!erie# o" the a*i%%o"acia% re!ion < %ead to #&e%%in! and pain2 In the abo)e condition# proper dia!no#i# p%ay# a )ery

i portant ro%e State o" ho#t de"en#e#,

< Ho#t de"en#e echani# # are the o#t i portant "actor in the "ina% outco e o" bacteria% in#u%t2 < It i# pro)ided by the &hite b%ood ce%%# and antibodie# produced2 < It i# nece##ary to e)a%uate the #tate o" ho#t de"en#e echani# 2 < In"ection# are u%ti ate%y cured by ho#t than antibiotic# i# critica%2 < Antibiotic# he%p in condition# &here the ho#t ha# been o)er&he% ed by bacteria2 Sur!ica% draina!e and inci#ion ,

< It i# an e#tab%i#hed princip%e o" treat ent o" deep ti##ue in"ection#2 < The ob=ecti)e i# to drain pu# "ro ti##ue #pace# and to in#ert drain# #o that no pu# accu u%ate# in the#e #pace#2 < In odonto!enic in"ection# < re o)a% o" tooth: openin! o" the pu%p cha ber2 < Sur!ica% inci#ion < in ce%%u%iti# &ithout pu# "or ation2 < < < < < < < < Identi"ication o" the cau#ati)e or!ani# 2 Deter ination o" antibiotic #en#iti)ity2 -#e a #peci"ic: narro& #pectru antibiotic -#e the %ea#t to*ic dru!2 5acterio#tatic )# 5actericida%2 -#e o" antibiotic &ith a pro)en hi#tory o" #ucce##2 Co#t o" the antibiotic2 Encoura!e patient co p%iance2 Identi"ication o" the cau#ati)e or!ani# , Can be done by i#o%atin! the or!ani# "ro pu#: b%ood: or ti##ue2 Antibiotic therapy i# then either initia% or de"initi)e2 Initia% e pirica% therapy ay be #tarted i" the "o%%o&in! criteria are et, < Site and "eature# o" in"ection are &e%% de"ined2 < The circu #tance# %eadin! to in"ection are ;no&n2 < the or!ani# '# cau#in! the di#ea#e are ;no&n2 The typica% odonto!enic in"ection < aerobic and anaerobic bacteria2 < Appro* >?@ $ i*ed "%ora < 38@ $ pure anaerobic < 8@ $aerobic2 It ha# been reported that the bacteria "ound in ce%%u%iti# type o" in"ection# < aerobic bacteria2 Chronic non$ad)ancin! ab#ce## < anaerobic bacteria2 A# the in"ection beco e# #e)ere$ i*ed "%ora

Principles of antibiotic selection

Odontogenic infections Aerobic Anaerobic

Gram positive S.Milleri S. Salivarius S.Sanguis S. mutans.

Gram positive cocci-30% Gram negativerods-70% peptosreptococci Bacteroids streptococci fusobacterium

P .gingivalis P .denticola P.asaccharolytics

Bacteroids Porphyromonas

More common . P .melanogenica P .denticola P. Intermedia P .buccae

Provetella

Princip%e# o" antibiotic ad ini#tration

Proper do#e Proper ti e inter)a% Proper route o" ad ini#tration Con#i#tency in route o" ad ini#tration Co bination o" antibiotic therapy Proper do#e Mini u inhibitory concentration .MIC/ o" the dru! #hou%d be ;no&n2 6or therapeutic purpo#e# the pea; concentration o" the

dru! at the #ite o" in"ection i# 4$7ti e# MIC2

Therapeutic %e)e%# !reater than 4$7ti e# the MIC do not i pro)e the re#u%t#2 Lead# to to*icity and i# &a#te"u%2 Increa#ed do#e# are =u#ti"ied &hen the #ite i# i#o%ated "ro b%ood #upp%y: %i;e abce## or non)ita% ti##ue2

the

 Su""icient antibiotic u#t be !i)en to reach the therapeutic %e)e%#2 Sub therapeutic do#e# ay a#; the in"ection and #uppre## the c%inica% #y pto # 2 May cau#e recurrence o" in"ection2 Proper ti e inter)a%, Ano&%ed!e o" the phar aco;inetic# o" the dru! #hou%d be ;no&n2 The u#ua% do#a!e inter)a% "or therapeutic u#e o" antibiotic# i# < 7ti e# the tB .p%a# a ha%" %i"e/ Patient #hou%d be e)a%uated "or h'o rena% di#ea#e#2 They ha)e reduced rena% c%earance and ay re9uire %on!er ti e inter)a% bet&een do#e#2
Proper route o" ad ini#tration Seriou#: e#tab%i#hed in"ection < parentera% route2 A"ter initia% re#pon#e i# achie)ed: the route o" ad ini#tration #hou%d not be chan!ed i ediate%y2 The in"ection ay recur becau#e the b%ood %e)e%# o" the dru! ay be reduced2 5acteria are not eradicated unti% the antibiotic ha# been

!i)en "or 8 or C day#2

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Co bination o" antibiotic# Co bination #hou%d be a)oided &hen not indicated2 The re#u%t o" co bination, 5road #pectru e*po#ure that %ead# to depre##ion o" the nor a% ho#t "%ora and increa#ed opportunity "or re#i#tant bacteria to e er!e2 Indication# , < Nece##ity to increa#e the antibacteria% #pectru : in patient# &ith %i"e threatenin! condition#2 < 0hen increa#ed bactericida% e""ect a!ain#t a #peci"ic or!ani# i# re9uired2 < Pre)ention o" e er!ence o" re#i#tant bacteria

 Patient onitorin! Re#pon#e to treat ent, < Patient# rare%y ha)e a noticeab%e re#pon#e < 37$7Dhr#2 < The re#pon#e be!in# the #econd day2 < Eradication o" in"ection i# !enera%%y achie)ed by the third day2 < -#ua%%y > $ day cour#e i# indicated2 < I" no i pro)e ent i# #een on 4rd or 7thday$ the patient #hou%d be care"u%%y re$e)a%uated2 < The antibiotic ha# to be ree)a%uated
CLASSI6ICATION O6 ANTI5IOTICS 5a#ed on che ica% #tructure Type o" or!ani# # on &hich it act# 5acterio#tatic'5acteriocida% Che otherapeutic #pectra C%a##i"ication o" anti icrobia%# Che ica% #tructure Su%"ona ide# and re%ated dru!# Su%"adiaEine and other# Su%"one# < Dap#one .DDS/: Paraa ino#a%icy%ic acid .PAS/2 Dia inopyri idine# Tri ethopri Pyri etha ine (uino%one# Na%idi*ic acid Nor"%o*acin Cipro"%o*acin etc $%acta antibiotic# Penici%%in# Cepha%o#porin# Monobacta # Carbapene #

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Tetracyc%ine# O*ytetracyc%ine Do*ycyc%ine etc NitrobenEene deri)ati)e Ch%ora phenico% A ino!%yco#ide# Strepto ycin Genta icin Neo ycin etc Macro%ide antibiotic# Erythro ycin Ro*ithro ycin AEithro ycin etc Po%ypeptide antibiotic# Po%y y*in$5 Co%i#tin 5acitracin Type of organisms against which primarily active Antibacteria% Penici%%in# A ino!%yco#ide# Erythro ycin etc Anti"un!a% Gri#eo"u%)in A photericin 5 AetoconaEo%e Anti)ira% Ido*uridine Acyc%o)ir A antadine Fido)udine etc AntiprotoEoa% Ch%oro9uine

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Pyri etha ine MetronidaEo%e Di%o*anide etc Anthe% intic MebendaEo%e Pyrante% Nic%o#a ide Diethy% carba aEine etc

5actericida%$ the abi%ity to ;i%% the bacteria 5acterio#tatic$ the abi%ity to inhibit or retard the !ro&th o" bacteria Bacteriostatic vs Bactericidal Ch%ora phenico% A ino!%yco#ide# C%inda ycin 5acitracin erythro ycin Cepha%o#porin# #u%"ona ide# MetronidiaEo%e Tetracyc%ine# )anco ycin Tri ethopri Penici%%in# cipro"%o*acin #trepto ycin cotri o*aEo%e

E""ecti)e a!ain#t on%y a "e& icroor!ani# # &ith a )ery #peci"ic etabo%ic path&ay or enEy e2

Narrow spectrum

!hemotherapeutic "pectra

-#e"u% in treatin! a &ide )ariety o" in"ection#

Penici%%in G: #trepto ycin: erythro ycin Broad spectrum

Ex: tetracycline, chloramphenical, cephalosporins

Mechanism of action

Antibiotics commonly used in #ndodontics

Penici%%in# Cepha%o#porin# (uino%one# Tetracyc%ine# Macro%ide# Anti"un!a% a!ent#

Anti$)ira% a!ent#

PENICILLINS
These drugs act on the bacterial cell wall by: Interfere with synthesis of peptidoglycan layer in cell wall bind to and inhibit activity of en ymes transpeptidases, so that cross!lin"ing does not ta"e place These en ymes and related proteins!#penicillin!binding proteins$ 0hen bacteria di)ide in the pre#ence o" G$%acta antibiotic#$ ce%% &a%% de"icient "or # are produced2 The interior o" the bacteria i# hypero# otic: e)entua%%y cau#e ce%% %y#i#

Penici%%in

B#$%&' P#$I!I''I$ (P#$!I''I$ )* PnG i# a narro& #pectru antibioticH acti)ity i# %i ited pri ari%y to !ra po#iti)e bacteria
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Antibacterial activity Mo#t potent AMA: inhibit# the !ro&th o" #u#ceptib%e or!ani# 2 Main%y !ra I)e: !ra <)e cocci and #o e !ra I)e baci%%i &ith e*ception o" enterococci2 < Cocci < Hi!h%y #en#iti)e < Streptococci: Pneu ococci: Staph2 aureu#: N2 !onorrhoeae: N2 enin!iti# < 5aci%%i < 52 anthraci#: Corynebacteriu diphtheriae: c%o#tridiu tetany and #pirochete# < Actino yce# i#rae%ii i# oderate%y #en#iti)e SEMI SYNTHETIC PENICILLINS The a=or dra&bac;# o" benEy% penici%%in are , < Inacti)ation by the !a#tric hydroch%oric acid < Short duration o" action < Poor penetration into CS6 < Acti)ity ain%y a!ain#t !ra I)e or!ani# < Po##ibi%ity o" anaphy%a*i# Atte pt# there"ore ha)e been ade to #ynthe#iEe penici%%in "ree "ro #uch dra&bac;#2 P2chry#o!enu produce# natura% penici%%in# &hich produce the C a ino$ penici%%anic acid .C$APA/ nuc%eu#2 The attach ent o" #ide chain# are inhibited and in#tead )ariou# or!anic radica%# &ere #ub#tituted2 Thu# a )ariety o" #e i #ynthetic dru!# are produced2
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CLASSI6ICATION Acid re#i#tant a%ternati)e to penici%%in G .Pheno*y ethy% penici%%in/ Penici%%ina#e re#i#tant penici%%in#2 .Methici%%in:C%o*aci%%in/ E*tended #pectru penici%%in#.a pici%%in: a o*ici%%in/

Acid re#i#tant penci%%in# +

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Si i%ar antibacteria% #pectru

Pota##iu

pheno*y ethy% penici%%in (penicillin ,*

%i;e benEy%penici%%in2

More acti)e a!ain#t re#i#tant #taphy%ococci Le## inacti)ated by the !a#tric acid2 P%a# a %e)e%# achie)ed i# 3 to 8 ti e# hi!her than benEy%penici%%in2 < 8?$>?@ i# bound to p%a# a protein#2 < 38@ o" dru! i# e%i inated in urine < Ad ini#tered in the do#e o" 38? <8?? ! at 7$D hour# inter)a%#: at%ea#t 4? in be"ore "ood2 < Thi# can be u#ed in %e## #eriou# in"ection# .pneu occi and #treptococci/ < Do#e <penici%%in J 8?? ! 9id2
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E*tended #pectru A ino penici%%in# ,

penici%%in#

A pici%%in < Antibacteria% acti)ity i# #i i%ar to that o" PnG but i# ore e""ecti)e than PnG a!ain#t a )ariety o" !ra $)e bacteria < Dru! i# e""ecti)e a!ain#t H2in"%uenEae #trep2)iridan#: N2!onorrhea: Sa% one%%a: #hi!e%%ae: A%eb#i%%a and enterococci2 Ab#orption: "ate and e*cretion , < Ora% ab#orption i# inco p%ete but ade9uate2 < Not de!raded by !a#tric acid2 < 6ood inter"ere# &ith ab#orption < Part%y e*creted in bi%e and part%y by ;idney < ?28$3 ! ora%'IM or IJ dependin! on #e)erity o" in"ection e)ery C hour# < Chi%dren , 38$8? !';!'day < AMPILIN: ROSCILLIAN: 5IOCILIN < 38?: 8?? ! cap 1?? !' % ped drop#: 38? !' % dry #yr: 1 ! ')ia% in=

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AMOKICILLIN +

Thi# i# a #e i$#ynthetic penici%%in .a ino$p$hydro*y$benEy%penci%%in/ < Antibacteria% #pectru i# #i i%ar to A pici%%in but %e## e""ecti)e than A pici%%in 2 < Ora% ab#orption i# betterH "ood doe# not inter"ereH hi!her and ore #u#tained b%ood %e)e%# are produced2

< It i# %e## protein bond and urinary e*cretion i# hi!her than that o" a pici%%in2 < Incidence o" diarrhea i# %e##

Do#e + < 8?? ! tid'9id < AMOKYLIN: NOJAMOK: SYNAMOK: MOK: AMOKIL 38?: 8?? ! cap: 138 !'8 % dry #yr: 8?? !')ia% in=2

."#" + Typhoid 5ronchiti# -rinary in"ection S5E Gonorrhoea 5ETA LACTAMASE INHI5ITORS CLAJ-LANIC ACID Obtained "ro STREPTOMYCES CLAJ-LIGER-S It ha# a 5eta %acta rin! < no antibacteria% acti)ity Ca%%ed a# Suicide inhibitor <inacti)ated a"ter bindin! to enEy e Per eate# the outer %ayer# o" ce%% &a%% o" !ra $)e bacteria Phar aco;inetic# , Ora% ab#orption$ rapid 5ioa)ai%abi%ity$C?@ Di#tribution #i i%ar that o" a o*ici%%in E*cretion$tubu%ar #ecretion -#e# + Staph aureu#:H in"%uenEa: !onorrhoea and E co%i Adverse effects + Poor !2i2 to%erance Hepatoto*icity A.)M#$TI$/ AMO$AT#/ #$0A$!I$ DOSE$A o* 38? !Ic%a)u%anic acid 138 ! tab:1$3 tab TDS: #e)ere in"ection 7 tab# C hour%y

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!#P0A'O"PO1I$"
Cepha%o#poriu acre oniu &a# the "ir#t #ource2 They contain > a ino cepha%o#poronic acid nuc%eu#2 Structura%%y they contain G$%acta and dihydro thiaEine rin!#2 Mechani# o" action + < Act by inhibitin! bacteria% ce%% &a# #ynthe#i# and are bactericida%2 < Ne& deri)ati)e# are uch ore re#i#tant than the o%der cepha%o#porin# C%a##i"ication 6ir#t !eneration cepha%o#porin

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Good acti)ity a!ain#t !ra I)e bacteria2 .e*cept enterococci/2 Mo#t ora% ca)ity anaerobe# are #en#iti)e2 Parenta% Ora% CEPHALOTHIN CEPHALEKIN CE6AFOLIN CEPHRADINE CE6ADROKIL

!ephala2in and !ephadro2il + -#e"u% in treatin! co unity ac9uired: re#piratory and urinary tract in"ection# and in #ur!ica% prophy%a*i#2 Not choice "or #y#te ic in"ection#2 Do#e, 38?:8?? ! cap .C$D hour%y/ !efa3olin + 6or anti icrobia% prophy%a*i# in o#t #ur!ica% procedure#2 Gi)en on%y IM ' IJ2 Do#e , < IM < ?238! D hr%y . i%d ca#e#/ 1! C hr%y .#e)ere ca#e#/2

SPORIDEK: CEPHAKIN: CEPHACILLIN: CE6ADROK: DROKYL

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Increa#ed acti)ity a!ain#t !ra

"econd generation !ephalosporins

<)e or!ani# 2

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More acti)e a!ain#t anaerobe#2 Parentera% Ora% CE6-ROKIME CE6ACLOR CE6OKITIN CE6-ROKIME

Ce"ac%or, i# hi!h%y e""ecti)e by ora% route2 More acti)e a!ain#t H2 in"%uenEae: E co%i2 Do#e , 8?? ! tid AE6LOR: CE6T-M: CE6OGEN: 6-ROKIL Third !eneration cepha%o#porin They hi!h%y au! ented a!ain#t !ra <)e enterobacter and p#eudo ona#2 Hi!h%y re#i#tant to $%acta a#e "ro !ra <)e bacteria2 Le## acti)e on !ra I)e cocci < Parentera% Ora% < CE6OTAKIME CE6IKIME < CE6TIFOKIME CE6DINIR < CE6TRIAKONE CE6TI5-TEN < CE6TAFIDIME < CE6OPERAFONE Do#e , < 7?? ! dai%y < 3??$7?? ! tab: bid2 < CESPAN: CE6OPROK: PROCADAK: CEPODEM: OR6IK 6ourth !eneration cepha%o#porin# De)e%oped in 1LL? #i i%ar to that o" 4rd !eneration2 Hi!h%y re#i#tant to $%acta a#e#2 Acti)e a!ain#t any bacteria re#i#tant to ear%ier dru!#2 It ha# hi!h potency and e*tended #pectru 2 E""ecti)e in any #eriou# in"ection#2 Parenteral < CE6EPINE: CE6PIROME ."#" + < Seriou# and re#i#tant ho#pita% ac9uired in"ection#2 < Septice ia: < Lo&er re#piratory tract in"ection2 Do#e , 1$3! IM ' IJ 13 hr%y2

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CE6ROM: CE6ORTH < 1! in=2 -#e#$ A%ternati)e# to penici%%in#2 RTI: -TI and #o"t ti##ue in"ection Penici%%ina#e producin! #taph in"ection2 Septice ia#2 Sur!ica% prophy%a*i# Menin!iti#: !onorrhea Typhoid Mi*ed aerobic and anaerobic in"ection# In"ection by odd or!ani# or ho#pita% in"ection# Prophy%actic treat ent in neutropenic patient#

4.I$O'O$#"
Entire%y #ynthetic anti icrobia%#2 Are acti)e pri ari%y a!ain#t !ra <)e bacteria2 Na%idi*ic acid$ %o& potency: ode#t b%ood and ti##ue %e)e%#: %i ited #pectru : hi!h re#i#tance

6%uoro9uino%one# <.1 or ore "%ourine #ub#tituition / hi!h potency: e*panded #pectru : better ti##ue penetrance: #%o& re#i#tance2 They inhibit the enEy e bacteria% DNA !yra#e2

CIPRO6LOKACIN 6ir#t !eneration 6( acti)e a!ain#t a broad ran!e o" bacteria e#pecia%%y !ra <)e aerobic baci%%i2 Hi!h%y #u#ceptib%e + < E co%i: #hi!e%%a: N enin!iti#: A pneu oniae: Proteu#: H in"%uenEa: Enterobacter: J2 cho%erae: S2 typhi: N !onorrhoea2 Moderate%y #u#ceptib%e + < Staph aureu#: bruce%%a: M2 tubercu%o#i# Microbio%o!ica% "eature# ,Rapid bactericida% acti)ity and hi!h potency2 Re%ati)e%y %on! po#t antibiotic e""ect on enterobacteria: p#eudo ona# and #taph2 Lo& "re9uency o" utationa% re#i#tance2 protecti)e inte#tina% #treptococci and anaerobe# are #pared2

Acti)e a!ain#t any %acta bacteria2 Le## acti)e at acidic pH

and a ino !%yco#ide re#i#tant

GIT < Nau#ea: )o itin!: bad ta#te: anore*ia: diarrhoea i# in"re9uent2 CNS$ DiEEine##: headache: re#t%e##ne##: an*iety: in#o nia and #eiEure# are rare2 S;in'hyper#en#iti)ity < ra#he#: pruriti#: urticaria2 Tendoniti# and tendon rupture !I51A$/ !IP'O6/ !IP1OBID/ !IP1O'#T Do#e , < 38?: 8??:>8? ! tab: 3?? !'1?? % IJ in"u#ion: 4 !' % eye drop#.

Ad)er#e e""ect

NOR6LOKACIN
It i# %e## potent than cipro It attain# %o&er concentration in ti##ue#2 It i# etabo%iEed a# &e%% a# e*creted unchan!ed in urine2 ."#" -TI and Genita% in"ection#2 5acteria% diarrhea2 NOR5ACTIN: NOR6LOK: -RO6LOK Do#e , 3??: 7??: D?? ! tab: 4 !' % eyedrop# O6LOKACIN Inter ediate bet&een Cipro and Nor"%o*acin in acti)ity a!ain#t Gr$)e bacteria More potent "or Gr I)e or!ani# # and anaerobe# Good acti)ity a!ain#t ch%a ydia: a%ternati)e dru! "or non#peci"ic urethriti# and atypica% pneu onia2 Inhibit# M tubercu%o#i#H acti)e a!ain#t M2 %eprae2 -#ed in u%tidru! re!i en#

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Do#e$ 1??:3?? ! tab

T#T1A!&!'I$#"

Ha)e a nuc%eu# o" "our cyc%ic rin!#2 Obtained "ro #oi% actino ycete#2 6ir#t to be introduced < ch%ortetracyc%ine.1L7D/ Then o*ytetracyc%ine "o%%o&ed2 Tetracyc%ine# are bacterio#tatic2.inhibit protein #ynthe#i# by bindin! to 4?# ribo#o e#/

5road #pectru

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Anti icrobia% acti)ity Gra I)e and <)e cocci are #en#iti)e Gra I)e baci%%i are inhibited Entero bacteria are hi!h%y re#i#tant Spirochete# are 9uite #en#iti)e A%% ric;ett#iae and Ch%a ydia are hi!h%y #en#iti)e Mechani# o" action, Inhibit protein #ynthe#i# by bindin! to 4?# ribo#o e#

antibiotic#

Ab#orption and e*cretion, Tetracyc%ine# ha)e che%atin! property < "or in#o%ub%e co p%e*e# &ith ca%ciu and other eta%#2 Inco p%ete%y ab#orbed "ro !i tract2 Ab#orbtion i# better i" ta;en on e pty #to ach2 Mi%;: iron preparation#: and antacid#$reduce their ab#orption2 Do*ycyc%ine and inocyc%ine < co p%ete%y ab#orbed: irre#pecti)e o" "ood2 They are concentrated in %i)er: #p%een: bone and teeth2 E*creted by urine

Ad)er#e e""ect# ,

GIT$ epi!a#tric burnin!: nau#ea: )o itin!: diarrhea Li)er da a!e Rena% "ai%ure E""ect# on teeth M bone#$ Ca tetracyc%ine che%ate Mid pre!nancy$8 onth# deciduou# teeth$ bro&n: i%% "or edH 4 onth#$Cyr#$ per anent anterior teeth and o%ar#H %ate pre!nancy or chi%dhood$ #uppre##ion o" bone !ro&th2 Hyper#en#iti)ity Reaction# Super in"ectionH Anti$anabo%ic e""ect

DOSE Tetracyc%ine < 38?$8?? ! td# in adu%t# Chi%dren o)er Dyr# $38 to 8? ! ';! dai%y in 3 to 7 di)ided do#e Do*ycyc%ine < 3?? ! initia%%y: 1??$3?? ! od2 Leder ycin 18?:4?? ! cap'tab RAMYCIN:RESTECLIN$38?:8?? !cap:8? !' % in1? % )ia% in= DOKT: NOJADOK: TETRADOK$1?? ! cap2 Cyano ycin 8?:1?? ! cap

Precaution Not to be u#ed in pre!nancy: %actation and in chi%dren A)oided in patient# on diuretic# -#ed cautiou#%y in rena% and hepatic in#u""iciency 5eyond e*piry date #hou%d not be u#ed Do not i* in=ectab%e Tc &ith Pn$ inacti)ation occur#

Antibiotic# ha)in! acrocyc%ic %actone rin!$ ERYTHROMYCIN$ I#o%ated "ro Strepto yce# erythreu# .1L83/ A%ternati)e to penici%%in 5acterio#tatic$%o& conc2 5acteriocida%$ hi!h conc 0ater #o%ubi%ity i# %i ited2#o%ution re ain# #tab%e on%y &hen ;ept co%d2 Act# by inhibitin! protein #ynthe#i#2 Co bine# &ith 8?# ribo#o e# and intere"ere# &ith tran#%ocation Antibacteria% acti)ity Narro& #pectru antibiotic a!ain#t penici%%in re#i#tant #taphy%ococci2 Acti)e a!ain#t !ra I)e

MA!1O'ID#"

Pharmaco7inetics + < Erythro ycin ba#e $ acid %abi%e < To protect it "ro !a#tric acid $Gi)en &ith enteric coated $ inco p%ete ab#orption < It# acid #tab%e e#ter# are better ab#orbed < 0ide%y di#tributed in body < E*creted throu!h bi%e Do#e , Adu%t# 38? $ 8?? ! Chr%y Chi%dren 4? < C? !';!'day Erythro ycin ba#e $ ERYSA6E 38? ! tab Erythro ycin #tearate $ERYTHROCIN < 38?:8?? ! tab

Ad)er#e e""ect# + GIT < epi!a#tric pain On hi!h do#e# < hearin! i pair ent Hyper#en#iti)ity reaction# < rare
< < < <

.ses + Sub#titute "or penici%%in: penci%%in re#i#tant Ora% ad : #a"e and e""ecti)e Perio'periapica%'N-G'e*traction Prophy%actic u#e

in"ection#

< < < <

1O6IT01OM&!I$ Se i #ynthetic $ %on! actin!: acid #tab%e acro%ide Antibacteria% #pectru #i i%ar to erythro ycin Dose $ 18?$4?? ! 5D 4? in be"ore "ood Chi%dren $ 328$8 !';! 5D ROKID: ROKI5ID 18?:4?? ! tab 8? ! ;id tab:18? ! tab !'I$DAM&!I$ It i# %inco#a ide antibiotic ha)in! #i i%ar action . acro%ide 8?#/ 5acterio#tatic < %o& concH5acteriocida% < hi!h conc Mo#t acti)e a!ain#t !ra I)e cocci: C2diphtheriae: Actino yce# Hi!h%y acti)e a!ain#t < anaerobe# .5 "ra!i%i#/ Pharmaco7inetics +

Ora% ab#orption < !ood Di#tribution < #;e%eta% and #o"t ti##ue# E*creted in urine Adverse effects + < Ra#he# :-rticaria < Abdo ina% pain < Superin"ection $Enteroco%iti# MDiarrhoea .ses + < Anaerobic and i*ed in"ection#$ a%ternati)e to Pn M acro < Ab#ce## and bone in"ection#$#taphy and bacteroid# < In"ecti)e endocarditi# Dose + < 18?$4?? ! (ID ora% H 3??$C?? ! I2)2 D hour%y < DALCAP: CLINCIN: DALCIN: 18?: 4?? ! cap: 4?? !'3 % and C?? !'7 % in=
< < <

Antifungal agents

A photericin 5 < obtained "ro $ Strepto yce# nodu#u# < Ha# a Macrocyc%ic rin! < 5ind# to er!o#tero% pre#ent in the "un!a% ce%% !enerate# pore# < -#ed in #eriou# #y#te ic "un!a% in"ection#
<

e brane and

Anti"un!a% acti)ity , "un!icida% at hi!h conc$#tatic at %o& conc2 Acti)e a!ain#t$ candida a%bican#: hi#top%a# a: cryptococcu# neo"or an#: a#per!i%%u# Not ab#orbed ora%%y Do#e , < Ad ini#tered i) a# #u#pen#ion DOC < Ora%%y 8?$1?? ! (ID < MYCOL 8? ! )ia% Ad)er#e e""ect#$ < acute reaction#: %on! ter to*icity -#e# , topica%%y < ora%:)a!ina% and cutaneou# candidia#i#2

$&"TATI$ A po%yene deri)ed "ro Streptomyces noursei

 5ind# to #tero%# o" "un!a% ce%% e brane 5ecau#e o" hi!h #y#te ic to*icity u#ed a# Topica% anti"un!a% a!ent2 3nd choice to c%otri aEo%e 1 %ac unit#$7 ti e# a day: 1?$17 day# Myco#tatin 8 %ac - tab
!'OT1IMA%O'# E""ecti)e in the topica% treat ent$ E#p2 ath%ete# "oot: oto yco#i# and ora%: cutaneou# candidia#i#2 &e%% to%erated a%thou!h Loca% irritation and burnin! No #y#te ic to*icity i# #een a"ter topica% u#e2 Do#e ,oropharyn!ea% candidia#i#$ 1? ! troche $4 to 7 ti e# day2 S-R6AF: CLOTRIN: CLODERM: 1@ %otion: crea : po&der 1?? ! tab2 Candid 1@ crea : !e%: po&der2
<
< < <

8#TA!O$A%O'# 6ir#t ora% e""ecti)e broad #pectru anti"un!a% dru!2 The ora% ab#orption o" ATF i# "aci%itated by !a#tric acidity Hepatic etabo%i# i# e*ten#i)e etabo%ite# are e*creted in

urine2
< <

The u#ua% do#e i# 3?? ! OD or 5D 6-NAFOLE: AETOJATE: 6-NGICIDE: 3?? ! tab: 3@ oint: crea : #ha poo2 Adverse effects + < Nau#ea and )o itin! < %o## o" appetite: headache: pare#the#ia: ra#he#: hair %o##2

Indications+ Herpe# #i p%e* )iru# .HSJ/ 1 and 3 in"ection#H #e)ere !enita% HSJ in"ection#H HSJ encepha%iti#H #hin!%e# and chic;enpo*H oint ent "or !enita% herpe# in"ection#H crea "or co%d #ore# < Actions+ Inhibit# )ira% DNA rep%ication
<

Acyclovir

A$TI9,I1A' D1.)"2

Indications+ Prophy%a*i# and treat ent o" i%%ne## cau#ed by in"%uenEa A )iru# in adu%t#H prophy%a*i# a!ain#t in"%uenEa A )iru# in chi%dren < Actions+ Inhibit# )ira% rep%ication: po##ib%y by pre)entin! the uncoatin! o" the )iru#
<

1imantadine

A$TIBIOTI! P1OP0&'A6I" 5O1 0#A1T A$D A1TI5I!IA' :OI$T PATI#$T"

Antibiotic# are u#ed "or t&o ain rea#on#, To treat in"ection# To pre)ent in"ection# Antibiotic prophy%a*i# i# !i)en in patient# &ho are i unoco pro i#ed: patient# &ith heart ai% ent# and patient# &ith hip and =oint pro#the#i#

Jiriden# #treptococci are the cau#ati)e or!ani# # "or #eedin! heart and i p%anted =oint# cau#in! orbidity and death
The#e #2)iriden# "or co%onie# on heart )a%)e# trappin! b%ood ce%%# and "ibrin and thereby reducin! heart e""iciency by hinderin! c%o#ure o" the )a%)e# The#e #tic;y )e!etation# brea; o"" and %od!e in # a%% )e##e%# at di#tant #ite# cau#in! i#che ia The !oa% o" antibiotic prophy%a*i# i# to pre)ent c%inica% in"ection# by he%pin! de#troy # a%% nu ber o" bacteria pre#ent be"ore or introduced durin! treat ent2

Oral procedures re;uiring prophyla2is

Requiring antibiotic prop !la"is #ot requiring prop !la"is

Extractions Periodontal procedures Implant placement Tooth reimplantation Placement of orthodontic bands Endodontic instrumentation (beyond root apex) Periapical surgery Intraligamentary injection Prophylactic cleaning and procedures in which significant bleeding is anticipated %mo"icillin

Operative and prosthodontic procedures with or without retraction cord ! injection Intracanal endodontic procedures Placement of removable appliances Impression ta"ing $"foliation of primar! toot Oral radiography #luoride Post operative suture removal

Standard general prop !la"is

%dults & 'g ( ildren -)0mg*+g , r before procedure. -ts unable to %mpicillin %dults & 'g ta+e oral ( ildren -)0mg*+g medications .M*./ 30mins before procedure -enicillin allergic (lindam!cin %dults -100mg2c ildpts (ep ale"in*cefadro"il '0mg*+g. %0it rom!cin* %dults -'g2 c ildclindam!cin )0mg*+g %dults-)00mg2 c ild,)mg*+g. , r before t e procedure -ts unable to (lindam!cin %dults-100mg2 c ildta+e oral cefa0olin '0mg*+g../ medications %dults-,g 2 c ild')mg*+g .M*./. 30mins before procedure.

In the ca#e o" de%ayed hea%in! or o" a procedure that in)o%)e# in"ected ti##ue#: additiona% do#e# o" antibiotic# ay be needed: e)en thou!h the bactere ia ay %a#t# "or no %on!er than 18 in# a"ter the procedure2 A o*ici%%in i# the pre"erred ora% antibiotic2 I" the pt i# ta;in! a o*ici%%in on a %on! ter ba#i# "or #o e rea#on: a di""erent c%a## o" antibiotic #hou%d be u#ed2 I" a hi!h ri#; pt .pro#thetic )a%)e/ ha# aintained a hi!h %e)e% o" ora% hea%th: ora% antibiotic prophy%a*i# ay be u#ed "or #i p%e denta% procedure# rather than parenta% re!i en2

Additional guidelines for antibiotic prophyla2is

A$A')#"I!" ."#D I$ #$DODO$TI!"

Introduction : Pain is the number one reason people seek health care & has been deemed the fifth vital sign. The study of pain has in recent years diverged into many different fields from pharmacology to psychology & neurobiology.

efinition of pain: an unpleasant sensory or emotional e!perience associated "ith actual or potential tissue damage or described in terms of such damage

a disagreeable sensation produced by the action of stimuli of harmful nature macbryde#$%&'

(n unpleasant sensation occuring in varying degrees of severity as a conse)uence of in*ury +disease or emotional disorder.

,edical thesaurus Properties of pain $- Threshold & intensity If intensity is lo"er than the threshold . pain is not felt /eber 01echners la": $22 fold increase in intensity 34 fold increase in pain '-(daptation Pain receptors sho" no adaptation+pain continues as long as receptors are stimulated. 4- 5ocalisation of pain Superficial pain is comparatively better localised than deep pain. 6isceral pain is usually referred 7-8motional accompaniment: associated emotions are unpleasant &- Influence of the rate of damage on the intensity of pain : If the rate of in*ury is high intensity of pain is also high ( very slo"ly gro"ing tissue damaging agent eg: cancer at an early stage may not produce pain at all. 9- ouble pain: ue to the initial action on a.delta fibres#follo"ed by c.fibres.fast pain is better localised than slo" pain. :iochemical basis of pain: neurotransmitters neuromodulators ;eurotransmitters: are substances that are synthesi<ed & stored in the neuron for release during neural activity. ;euromodulators are substances that modify the release of neurotransmitters from pre.synaptic terminals

;eurotransmitters are classified into: $- 8!citatory agents: (ch + norepinephrine+ glutamate+ substanceP+ histamine '- Inhibitory agents: serotonine+ =(:(+ endorphins+ glycine+ somatostatin+ dopamine. 4- Inflammatory agents: prostaglandins+ bradykinin =lutamate: (mino acid secreted by pre.synaptic terminals 1ound in the spinal cord dorsal horn & is associated "ith no!ious input. Substance P : Polypeptide+composed of $$ amino acids >eleased at the terminals of primary nociceptive neurons (lso released from spinal cord by stimulation "ith (.delta & ?.fibres Serotonin: Secreted in the brain stem & pro*ect do"n to the spinal cord Imp. Inhibitory neurotransmitter in the ?.;.S ?entral serotoninis thought to potentiate endorphin analgesia Prostaglandins: P=8' metabolised from arachidionic acid Sensiti<e nerve endings to nociceptive stimuli :radykinin: >eleased as part of the inflammatory reaction (cts as an allogenic agent that e!cites all kinds of receptors (lso sensiti<es some high threshold receptors >e)uires the presence of P=s to act.

?lassification of pain Primary 0in*ury +neuropathic pain

Secondary.referred pain (cute ?hronic Primary pain: inflammatory : follo"ing in*ury pain sets in & persists until healing # characteristically produces hyperalgesia & allodynia @yperalgesia : an increased response to a stimulus that is normally painful (llodynia : pain due to a stimulus that does not normally provoke pain. >eferred pain: pain in a part of body that is fairly remote from the site of origin

(?AT8 P(I; Sharp+fast +pricking type Bccurs in 2.$ secs of stimulus ?arried by large caliber myelinated (.delta fibers Speed of travel.9.42 mCsec

CHRONIC PAIN S%o&:burnin!:achin! !radua%%y increa#e# a"ter 1 #ec o" #ti u%u# # a%% ca%iber un ye%inated C$"iber# Speed o" tra)e% ?28$3 '#ec

Mechanism of oro facial pain

Impulses from the face and mouth enter the brainstem via the trigeminal nerve.the cell bodies of the trigeminal afferent neurons are located in the =asserian ganglion.

 The central a!on synapses at the trigeminal spinal tract nucleus of the pons. Peripheral mechanisms 1ollo"ing neurogenic inflammation & local tissue in*ury .activation of inflammatory mediators Sensiti<e peripheral nociceptors

The #en#ory input "ro the "ace and the outh i# carried by &ay o" the "i"th crania% ner)e HT@8 T>I=8,I;(5 ;8>68. The ce%% bodie# o" the tri!e ina% a""erent neuron# are %ocated in the 5arge =asserian =anglion I pu%#e# carried by the tri!e ina% ner)e enter direct%y into the brain #te in the re!ion o" the Pons to #ynap#e in the trigeminal spinal tract nucleus. Thi# re!ion i# )ery #i i%ar to the dor#a% horn o" the #pina% cord and i# #o eti e# re"erred to a# the edu%%ary dor#a% horn

The brain #te $ tri!e ina% nuc%eu# co p%e* con#i#t# o" the ain #en#ory tri!e ina% nuc%eu# &hich i# ro#tra%%y %ocated and recei)e# periodonta% and #o e pu%pa% a""erent#H and the #pina% tract o" the tri!e ina% nuc%eu# &hich i# ore cauda%%y %ocated

Subnuc%eu# ora%i# appear# to be a #i!ni"icant area in thi# tri!e ina% brain #te co p%e* "or ora% pain echani# #2 Subnuc%eu# cauda%i# ha# e#pecia%%y been i p%icated in tri!e ina% nocicepti)e echani# # on the ba#i# o" e%ectrophy#io%o!ica% ob#er)ation# o" nocicepti)e neuron#2 S2cauda%i# i# ho o%o!ou# to the substantia gelatinosa o" the #pina% dor#a% horn The ar!ina% ri o" the nuc%eu# corre#pond# to %a ina I o" the dor#a% horn

Motor nuc%eu# Another co ponent o" the tri!e ina% brain #te co p%e* i# the motor nucleus of the 6th nerve. Thi# area i# in)o%)ed interpretation o" i pu%#e# that re9uire otor re#pon#e# or re"%e*e#2

The path&ay Second order tri!e ina% neuron# pro=ect to the tha%a u# "ro #ynaptic =unction# &ith pri ary a""erent# in the #ubnuc%eu# cauda%i# A# in the dor#a% horn the#e interneuron# repre#ent three type# o" Transmission Cells or T cells2 They are N 0ide dyna ic ran!e neuron# .0DR/ N Nocicepti)e #peci"ic neuron# .NS/ N Lo& thre#ho%d echanorecepti)e .LTM/ a""erent#

The 0DR and NS neuron# do inate in %a ina I:II:IJ and co pri#e the tri!e ina% nocicepti)e path&ay2 They a%% recei)e input "ro cutaneou# #tructure# and at %ea#t ha%" o" the recei)e input "ro deep #tructure# o" the outh and "ace2

The de!ree to &hich a per#on react# to pain )arie# tre endou#%y2 Thi# re#u%t# part%y "ro a capabi%ity o" the brain it#e%" to #uppre## input o" pain #i!na%# to the ner)ou# #y#te by acti)atin! a pain contro% #y#te : ca%%ed an analgesia system.

The endogenous pain inhibiting mechanism

Se)era% tran# itter #ub#tance# are in)o%)ed in the ana%!e#ia #y#te H e#pecia%%y in)o%)ed are 8nkephalin or Serotonin+ #ecreted by any ner)e "iber# .en;epha%iner!ic or #eroto!enic neuron#/ deri)ed "ro the Peri)entricu%ar nuc%ei and "ro the Peria9ueducta% !ray area

The#e neuron# #ynap#e &ith the A and C "iber ter ina%# at the #ub#tantia !e%atino#a ro%andi .SGR /&hich brin! pain "ro the periphery in the po#terior horn o" the #pina% cord2 The#e "iber# &hen #ti u%ated re%ea#e en;epha%in or #erotonin an endo!enou# opiod peptide &hich inhibit# the pain2

The pain phenomenon :

Pain i# a%&ay# #ub=ecti)e due to odu%ation and cro## o)er in the CNS The proce## be!in# in the periphery &here #pecia%iEed ner)e "iber# recei)e a pain"u% #ti u%u#2

Thi# in"or ation pa##e# throu!h the Spina% cord to reach the brain and the brain interpret# the in"or ation a# pain The #pina% tract nuc%eu# STN i# di)ided into three re!ion# 1/ Subnucleus Bralis 3/ Subnucleus Interpolaris 4/ Subnucleus ?audalis: &hich corre#pond# to the edu%%ary dor#a% horn Tooth pu%p a""erent "iber# !o to a%% three #ubnuc%ei

Odonto!enic pain tran# i##ion i# ediated pri ari%y by the periphera% #en#ory neuron# o" the tri!e ina% ner)e2The periphera% ter ina%# o" the#e ner)e# inner)ate the denta% pu%p and other ora% ti##ue#: &herea# the centra% ter ina%# re%ea#e neurotran# itter# #uch a# #ub#tance P: &hich are in)o%)ed in the initiation o" pain The#e tri!e ina% #en#ory a""erent neuron# a%on! &ith the #y pathetic branche# o" the #uperior cer)ica% !an!%ion and b%ood )e##e%#: enter throu!h the apica% "ora en o" a tooth2 to!ether: the#e ner)e# and b%ood )e##e%# "or the neuro)a#cu%ar bund%e2 The#e ner)e "iber# are ,
! fibers ( alpha $ beta$ gamma % delta) ' ( )(*+ dia$ +,(-, m.sec vel 3 ( *(0 microns dia$ 0(*0m.sec vel

Detection of Odontogenic pain

Mye%inated

-n ye%inated

& fibers ,/0(*1 dia$ ,/0(2 m.s vel

Pu%pa% #en#ory ner)e acti)ity, Main%y there are three type# o" "iber# are "ound in the pu%p,

A%"a and 5eta 6iber# O 6a#t conductin! O Ro%e not ;no&n

Mo#t co on in denta% pu%p They are re"erred to a# NOCICEPTIJE 6I5ERS Once beneath the odontob%a#tic %ayer they %oo#e their ye%in #heath ana#to o#e and "or the PLEK-S O6 RASHAO0 The "ree ner)e endin!# e*tend 3??P into the dentina% tubu%e# . pu%po dentina% co p%e*/ Produce# o entary 9uic; #harp pain

A Delta fibers

Hi!h thre#ho%d un ye%inated "iber# Run #ub=acent to de%ta "iber# Not direct%y in)o%)ed in the pu%podentina% co p%e* and %e## ea#i%y pro)o;ed Du%% poor%y %oca%iEed pain Acti)ate by inten#e heatin! or coo%in! Once acti)ated the pain can radiate any&here in the ip#i%atera% "ace and =a&# Sti u%ated C "iber# re%ea#e in"%a atory odu%ator# #uch a# #ub#tance P and ca%citonin !ene re%ated peptide .CGRP/ More re#i#tant to co pro i#ed b%ood "%o& than A de%ta "iber# Processing The input "ro the teeth and periradicu%ar re!ion i# tran# itted by the a*i%%ary and andibu%ar branche# o" tri!e ina% ner)e to the CNS The pri ary a""erent neuron# enter# the brain #te at the %e)e% o" the pon#2 The pri ary neuron #ynap#e# &ith a #econd order neuron in the #ub nuc%eu# cauda%i# re!ion o" the tri!e ina% #pina% tract nuc%eu# 6ro here the i pu%#e i# carried to the tha%a u#2 The #econd order neuron cro##e# the brain #te to the oppo#ite #ide o" the brain and a#cend# to the hi!her center#

C nerve fibers

A de%ta "iber# "ro the pu%p #ynap#e in the %a ina I area o" the #ubnuc%eu# cauda%i# and c "iber# #ynap#e in the %a ina II and III area# 2 A de%ta neuron# pa## to the tha%a u# direct%y by the &ay o" the neo#pinotha%a ic tract2 The path&ay a#cend# to the tha%a u# direct%y and i# #aid to carry fast pain.its sharp and easy to locali<e The #econd order C "iber# neuron carrie# i pu%#e# )ia the the pa%eo#pinotha%a ic tract

Thi# pa##e# throu!h the reticu%ar "or ation : &here the i pu%#e# are in"%uenced by any odu%atin! proce##e# be"ore they reach the tha%a u#: #ince the#e i pu%#e# ta;e %on!er to reach the tha%a u# the pain i# ca%%ed slo" pain.D dull aching Once the nocicepti)e input reache# the #en#ory corte* in the parieta% %obe pain reco!nition occur#2 The corte* ay re%y on e ory o" pre)iou# e*perience o" denta% pain to reco!niEe the input a# pain2 In addition to the tri!e ina% path pain i# a%#o ediated by #y pathetic and #o e para#y pathetic a""erent ner)e "iber# and > th: Lth and 1?th crania% ner)e# &hich #upp%y the ora% re!ion2

Perception The "ina% #tep in the #ub=ecti)e proce## i# perception : thi# happen# &hen the input reache# the corte*2 And perception di""er# "ro patient to patient dependin! on pa#t e*perience: e otiona% #tate:cu%tura% "actor# etc2 Oro"acia% pain ay produce unrea#onab%e an*iety in the patient and thi# i# &hy it# i portant "or the c%inician to identi"y the #ource o" the pain22

Mana!e ent o" pain

Anae%!e#ic# are dru!# &hich re%ie)e pain &ithout %o## o" con#ciou#ne##2 They o""er #y pto atic re%ie" "ro pain &ithout a""ectin! it# cau#e They are o" t&o c%a##e# Opoid or orphine type o" ana%!e#ic# Non$opiod or a#pirin type o" ana%!e#ic#

Opiu i# in u#e #ince 7??? 5C Opioid i# a ter u#ed "or dru!# &ith orphine %i;e action# Ear%ier ca%%ed a# Narcotic ana%!e#ic# C%a##i"ication, A!oni#t# , $natura% opiu a%;a%oid#:e! orphine:codeine $#ynthetic opiod#:e!2 Pethidine: ethadone 32 Anta!oni#t# , Na%o*one: Na%tre*one2

Opioid ana%!e#ic#,

42 Mi*ed a!oni#t$anta!oni#t# , PentaEocine: Na%buphine: Morphine +

Mechani# o" action$ act on #peci"ic opiod receptor#2 $ The opiod receptor# are u: ;appa: de%ta $ Endo!enou# opiod peptide# re%ea#ed in re#pon#e to pain are en;epha%ine#: the endorphin#: and dynorphin#

Re%ie)e# pain &ithout %o## o" con#ciou#ne## It a%ter# perception and reaction to pain Rai#e# pain thre#ho%d and increa#e# capacity to to%erate pain

Euphoria and #edation add to it# ana%!e#ic e""ect# 5ioa)ai%abi%ity$ 3?$7? @:on#et o" action i# 18$3? in: duration o" action$ 4$8 hr Morphine produce# ad)er#e e""ect# %i;e nau#ea: )o itin! :diEEine##: hypoten#ion Morphine i# Hi#ta ine %iberator and thi# action i# re#pon#ib%e "or a%%er!ic e""ect#

Do#e, 1?$3? ! IM'SC: 3? ! tab a)ai%ab%e . ethy% orphine/ Acute orphine poi#onin! ay be accidenta%: #uicida% or ho icida% Letha% do#e$ 38? ! :co a and death occur due to re#2 "ai%ure and pu% onary oede a Ga#tric %a)a!e &ith pota##iu per an!anate to re o)e unab#orbed dru! Speci"ic antidote i# na%o*one$ ?27 $?2D ! i) repeated e)ery 1?$ 18 in# Codeine and pethidine are other opiod ana%!e#ic# u#ed in 38$ 4? ! do#a!e# They are %e## potent than orphine Their duration o" action i# uch #horter and on#et o" action i# ore rapid than orphine

$O$9"T#1OIDA' A$TI9I$5'AMMATO1& D1.)" ( $"AID" /

A#pirin type or non opioid ana%!e#ic# They ha)e anti in"%a atory : antipyretic and urico#uric propertie# &ithout addiction %iabi%ity The acti)e princip%e Q#a%icinR &a# i#o%ated "ro bar; o" &i%%o& tree and i# con)erted into !%uco#e and #a%icy%ic acid in the body

CLASSI6ICATION Sa%icy%ic acid deri)ati)e < A#pirin:Sodiu #a%icy%ate: Para a ino pheno% deri)ati)e#$ paraceta o% PyraEo%one deri)ati)e#$ pheny% butaEone: AEapropaEone Indo%e acetic acid deri)ati)e#$ indo ethacin:#u%indac

Ary% acetic acid deri)ati)e#$ Dic%o"enac:Aetora%ac: To% etin Propionic acid deri)ati)e#$ Ibupro"en: 6enopro"en Anthrani%ic acid$ 6%u"ena ic acid:Me"ena ic acid O*Ica #$ Piro*ica : Teno*ica A%;anone#$ nabu etone: Su%"onani%ide deri)ati)e#$ ni u#e%ide: ce%eco*ib

Mechani#i o" action Arachidonic acid %iberated "ro e brane pho#pho%ipid# durin! in"%a ation i# con)erted to pro#ta!%andin# cata%yEed by the enEy e cyc%o$o*y!ena#e The#e pro#to!%andin# produce hypera%!e#ia &hich #en#itiEe ner)e endin!# to pain and other ediator# o" in"%a ation %i;e brady;inin and hi#ta in The#e NSAID# inhibit the PG #ynthe#i# by inhibitin! the enEy e cyc%o$o*y!ena#e
Are #a%t# o" #a%icy%ic acid e!, ethy% #a%icy%ate: #odiu #a%icy%ate: acety% #a%icy%ic acid.A#pirin/ -#ed a# anae%!e#ic:antipyretic and anti in"%a atory action# Ga#tric irritation i# #e)ere and %ead# to epi!a#tric #tre##:nau#ea and )o itin! PA1A AMI$O P0#$O' D#1I,ATI,#" Paraceta o% .aceta inophen/ It i# a etabo%ite o" phenacetin Ha# !ood ana%!e#ic:antipyretic but poor anti in"%a atory propertie# 0e%% ab#orbed ora%%y Acute paraceta o% poi#onin! occur# in chi%dren

"alicylates

Ni e#u%ide , i# a &ea; inhibitor o" PG #ynthe#i# &ith a hi!her a""inity "or COK$3 than COK$1 It inhibit# %eu;ocyte "unction: pre)ent# the re%ea#e o" ediator# and in addition ha# antihi#ta inic and anti a%%er!ic propertie# Do#e, 8?$1?? ! 5D Lon! ter u#e can cau#e hepato to*icity Co%eco*ib and Ro"ece*ib are other hi!h%y #e%ecti)e COK$3 inhibitor#

S-L6ONANILIDE DERIJATIJES

DR-G

A#pirin Sa%icy%ic acid deri)ati)e

DOS PROPE ADJANT RTIES AGES Ana% Good Po&er"u% !e#ic ana%!e#ic : anti$ AGE

-SES

$4??$ anti$pyretic: C?? !'C$ anti$ Dhr# in"%a atory Anti$ Ga#tric in"%a ator irritant y 7$ C! 'day

in"%a atory and anti$ p%ate%et acti)ity

ache:

Pyre*ia: headache:bac; Rheu atic

"e)er

Aceta in ophen .Ty%eno%/ Para$ a inopheno% deri)ati)e

?28$ Good Le## A# ana%!e#ic 1! .4$C ana%!e#ic: anti !a#tric irritation Anti pyretic: ti e# dai%y/ pyretic: poor chronic pu%piti#: anti$ peridonta% ab#ce## Ma*$7! in"%a atory Good concentration in #yno)ia% "%uid: ad)er#e e""ect# i%d

Dic%o"ena 8? Ana%!e c $Indo%e acetic ! 5D'TDS #ic: anti$ acid deri)ati)e pyretic: anti$ in"%a atory Ge% "or topica% app%ication Piro*ica O*ica deri)ati)e

Chronic in"%a atory condition#: rheu atoid arthriti#: o#teoarthriti#: acute pu%piti#: periapica% ab#ce##

! OD

3?

Ana%!e #ic: anti$ pyretic: anti$ in"%a atory

actin!

Lon!

5etter to%erated

Arthriti#: u#cu%o#;e%eta% pain : po#t$operati)e pain

4567

4O8E

P5OPE5TIE8 !49!:T!7E8 68E8 5heumatoid and osteoarthritis$ gout$ an"ylosing spondilitis

Phenylbuta;one *,,( 7ood anti( Powerful anti Pyra;olone 2,,mg$ <4 inflammatory$ inflammatory derivative poor analgesic$anti( pyretic$ water retention causes oedema

Indomethacin 20(0,mg$ !nalgesic$ anti( Potent anti Indole acetic +(0 pyretic$ anti( inflammatory acid derivative times.day inflammatory and analgesic Toxicity is high

5heumatoid$ psoriatic and osteoarthritis$ gout$ an"ylosing spondilitis$ closure of P4!

&elecoxib 5ofecoxib &ox(2 inhibitors Ibuprofen Propionic acid derivative

*,,(2,,mg Effective anti twice daily inflammatory 0,mg.day agent &ox2 inhibitor =,,(>,,mg !nalgesic$ anti( T48 pyretic$ anti( inflammatory ?ilder than aspirin

ess side effects 5heumatoid and less and ulcerogenic osteoarthritis !dverse effects !nalgesic$ anti milder$ better pyretic$ soft tolerated tissue injuries$ fractures$ chronic pulpitis$ periodontal and gingival abscess

&orticosteroids
6sed in cases of post endodontic flareups Inflammatory mediators are released into the tissues causing vascular dilatation 7lucocorticoids are used to reduce the acute inflammatory response

by suppressing vasodilatation$ migration of P?: leucocytes$ and phagocytosis and by inhibiting the formation of arachidonic acid from neutrophil and macrophage cell membrane phospholipids thus bloc"ing cyclooxygenase and lipooxygenase pathways and respective synthesis of prostaglandins and leu"otrienes 7lucocorticoids are secreted by adrenal gland in response to ultradian and circadian rhythms and to stress They are available as systemic as well as topical forms &ommonly used are cortisone(2,(+,, mg.day hydrocortisone(2,(2=,mg.day prednisone(0(),mg.day

6LEKI5LE PRESCRIPTION PLAN

A "%e*ib%e pre#cription p%an

e""ect# 2 The "o%%o&in! !oa%# are achie)ed by thi# p%an, A a*i a%%y e""ecti)e do#e o" the non$narcotic ana%!e#ic In rare ca#e# in &hich patient# #ti%% ha)e oderate to #e)ere pain: to con#ider addin! dru!# that increa#e the NSAIDRS ana%!e#ia

ini i#e# both po#t$ operati)e pain and #ide

ANTI ANKIETY DR-GS.ANKIOLYTICS/ An*iety i# ten#ion or apprehen#ion &hich i# a nor a% re#pon#e to certain #ituation# in %i"e2 -ni)er#a% hu an e otion 5ut &hen e*ce##i)e and di#proportionate to the #ituation it beco e# di#ab%in! and need# treat en

C%a##i"ication , 5enEodiaEepine# < DiaEepa : Ch%ordiaEepo*ide: LoraEepa : A%praEo%a 8$HT a!oni#t$anta!oni#t# < 5u#pirone: Gepirone: Ip#apirone G$ 5%oc;er#$ Proprano%o% Other#$ Meproba ate: Hydro*yEine

Lon! actin!$ DiaEepa :6%uraEepa Short actin!$ Ti aEepa : LoraEepa : TriaEo%a I portant action on CNS and inc%ude 1$ #edation M hypno#i# 3$ reduction in an*iety 4$ u#c%e re%a*ation 7$ anti con)u%#ant e""ect# Ad)er#e e""ect#, 1$ dro&#ine##: con"u#ion: a ne#ia: %ethar!y and i paired coordination 3$ in #o e it cau#e# parado*ica% irritaba%ity and an*iety Do#a!e, 8 ! diaEepa : 238 ! triaEo%a !i)en 1hr prior Anta!oni#t, 6%u aEeni%

5enEodiaEepine,

otor

G$b%oc;er#,

-#ed in pt# &ith pro inent autono ic #y pto # o" an*iety %i;e tre or#: pa%pitation and hyperten#ion Proprano%o% i# co on%y u#ed Can be u#ed a# ad=u)ant# to benEodiaEepine Do#a!e, 7?$37? !. C$13hr#/

Other drugs used in dentistry

Root cana% irri!ant#
The "our !oa%# o" irri!ation are, La)a!e o" debri# Ti##ue di##o%ution Antibacteria% action Lubrication Idea% re9uire ent# o" a root cana% irri!ant, )ross debridement with dissolution of the organic debris. "hould effectively flush out inorganic debris and dentinal shavings. 'ubricating action. #liminate the microorganisms. $on to2ic. #conomical. !apable of removal of the smear layer.(<<<<*

TYPES O6 ENDODONTIC IRRIGANTS, "odium hypochlorite. 0ydrogen pero2ide. !helating Agents+ = #DTA = 1! Preparation. = #DTA! = 1#DTA = "alvi3ol Acid cleansers+

= >? potentiated acid. = Phosphoric acid. = 'actic acid. = !itric acid. = Tannic acid. "aline @ater. Anesthetic solution. )lyo2ide. !hlorhe2idine gluconate INTRACANAL MEDICAMENTS Intracana% edica ent# are an inte!ra% part o" treat ent and i portant to #ucce## in endodontic#2 To achie)e de#ired out co e in rc treat ent dr2%oui# I !ro## an de#cribed three pha#e# 5 p:che ica%:#ter%iEation -SES E%i ination o" icroor!ani# :To #teri%iEe <de#troy a%% )iab%e icroor!ani# # :to di#in"ect$de#troy a%% patho!en# Renderin! content# o" cana% inert:byche ica% ean#$to u i"y:to"i*:toneutra%iEe Pre)ention 'contro% o" po#t treat ent pain:to a%ter the in"%a atory re#pon#e either by anti icrobia% action or phar aco%o!ica% action Pheno%ic# Naoc%

Type# o"

edica ent#

CMCP

Ha%ide# Eu!eno%

Parach%oropheno% Ca phorated parach%oropheno% .CPC/ Metacre#y%acetate Cre#o%

Creo#ote .beech &ood/

Thy o% A%dehyde#, 6or acre#o% G%utara%dehyde

Antibiotic#

ch%ora ine#$T #teroid# Hea)y eta% #a%t# Ca.OH/3 Co bination# $

pota##iu

iodine

M-MMI6YING AGENTS

 A!ent# u#ed to harden and dry the ti##ue# o" the pu%p #o a# to a;e the re#i#tant to in"ection Li9uid "or a%dehyde, u#ed &ith Einc o*ide and !%ycerine to harden ti##ue# Iodo"or and tannic acid are a%#o u#ed in co bn &ith eu!eno%:pheno% and !%ycero% ANTICOAG-LANTS The#e are dru!# u#ed to reduce the coa!u%abi%ity o" b%ood2 Coa!u%ant# u#ed in )i)o are Heparin: %o& o%2&t heparin heparinoid#$ Heparan #u%phate: de*tran #u%phate Ora% anticoa!u%ant# a2 cou arin deri)ati)e#, 5i#hydro*ycou arin.dicu aro%/ 0ar"arin #od b2 Indandione deri)ati)e, Phenindione
HEPARIN, $It i# na ed QheparinR beco# it i# obtained "ro %i)er2 $it i# a %ar!e : hi!h%y ioniEed o%ecu%e: there"ore not ab#orbed ora%%y $it doe# not cro## b%ood brain barrier or p%acenta $it i# etabo%iEed in %i)er by heparina#e and i# e*creted in urine it i# re%ea#ed "ro a#t ce%%# and it# riche#t #ource# are %un!:%i)er and inte#tina% uco#a Do#a!e , 8???$1?:??? - e)ery 7$C hr# and i# "o%%o&ed by continuo# in"u#ion o" >8?$1??? -'hr ti%% b%eedin! i# contro%%ed

Ora% anti coa!u%ant#, 5i#hydro*y cou arin.Dicu aro%/$3?? - "or 3 day#2 Side e""ect# < !2i2t di#turbance# 0ar"arin #od2$1?$18 - "or 4$C day#2 The ain u#e o" anticoa!u%ant# i# to pre)ent thro bu# and e bo%i co p%ication# by reducin! the rate o" "ibrin "or ation in di#ea#e# %i;e MI: deep )ein thro bo#i# and pu% onary e bo%i# :RHD
Are %oca% he o#tatic#

STYPTICS

 -#ed to arre#t %oca% b%eedin! "o%%o&in! e*traction and other denta%

procedure# N Adrena%ine$ 1,1?:??? #o%n o" adrena%ine S#oa;ed cottonT 32 Thro bin po&der 42 6ibrin 72 Ge%atin "oa 82 Tannic acid

A!ent# A""ectin! Sa%i)ation

Anti$cho%iner!ic Dru!#$.cho%iner!ic$ anta!oni#t#:anti
u#carine a!ent# or para#y patho%ytic#/ Co on%y u#ed i# Atropine Su%"ate.be%%adona a%;a%oid/ !i)en ora%%y ?24$123 !'7$C hour%y Other dru!# are, 12 G%ycopyrro%ate !i)en ora%%y 1$3 ! upto D !' day 32 Propathe%ine bro ide ora%%y >28$4? ! upto 4? !'day 42 Scopo%a ine 5uty%bro ide ora%%y 1?$3? ! 72 Scopo%a ine Hydrobro ide ora%%y ?27$?2D ! Anticho%iner!ic dru!# b%oc; the e""ect# o" ach and cho%iner!ic dru!# at u#carinic receptor #ite#2 Ad)er#e e""ect# , inhibition o" )ariou# phy#io%o!ica% action# o" ACH Con#tipation: nau#ea and )o itin! Kero#to ia Dryne## o" re#piratory tree -rinary retention

(345.#$RG.( 6R7GS
Produce e""ect# that i ic ACH -#ed in the ana!e ent o" *ero#to ia Pi%ocarpine i# u#ed "or the re%ie" o" *ero#to ia cau#ed by radiation therapy and in S=o!ren# #yndro e Do#a!e < 8 ! tid.tab%et#/ Other dru! i# Ce)i e%ine hydroch%oride Do#a!e$4? ! tid.cap#u%e#/

Re"erence# Path&ay# o" the pu%p: Lth edition: Stephen Cohen2 5oo; o" Endodontic#: 8th edition: In!%e Endodontic Therapy: Cth edition: S2 0eine E##entia%# o" Medica% Phar aco%o!y: 7TH Edition:A2D2Thripathi The Denta% C%inic# o" North A erica: 3??3 The Denta% C%inic# o" North A erica: 3??>