Therapeutics in Endodontics

Dr Mohamed Rabie
BDS, MSc, PhD
 Learning objectives
▪ 1- Identify the cases in need for therapeutic treatment in dentistry.
▪ 2- Determine drugs employed for treatment of anxiety.
▪ 3- Determine the therapeutic treatment of pain.
▪ 4- Determine non-steroidal anti-infalmmatory agents.
▪ 5- Differentiate non-narcotic from narcotic analgesics.
▪ 6- Describe mechanism of antibiotic action.
▪ 7- Describe mechanism of bacterial resistance to antibiotics.
▪ 8- Recognize antibiotic toxic and allergic effect.
▪ 9- Identify different types of antibiotics.
▪ 10- Recognize different types of penicillin.
▪ 11- Illustrate the structure, spectrum, effects, adverse effects,
administration and does of cephalosporin, erythromycin, clindamycin,
tetracycline, and metronidazole.
 Cases requiring therapeutic
treatment in endodontics:

• Anxiety ( true fear )

• Pain
• Infection
Control of Anxiety (true fear)

▪ Can be treated by antianxiety which control stress and fear during

dental treatment and modifies behavior and cooperation of the
patient.

▪ 1. Benzodiazepines (Tranquilizers).

▪ 2. Sedative – Hypnotics.

▪ 3. Antihistamines.

✓ All three groups in suitable doses, produce CNS effect with ;

➢Sedation (calming)
➢Hypnosis (sleep producing)
1. Benzodiazepines

✓Pharmacologic effects
– Antianxiety
– Anticonvulsant
– Sedative-nonhypnotic
– Skeletal muscle relaxant
– Amnesic

✓Properties
• Well absorbed from GIT
• Peak blood levels after 1-2 hours
Adverse effects
▪ Drowsiness and Ataxia
▪ Motor impairments
▪ CNS depression
▪ Chronic drug dependence
Contraindications
▪ Allergy to the drug
▪ Glaucoma
▪ Porphyria
▪ 1st trimester of pregnancy
▪ Dosage
2-10 mg (adult oral dose)
Examples ;
– Diazepam (Valium)
– Chlordiazepoxide (Librium)
– Lorazepam (Ativan)
 Sedative - Hypnotics

▪1. Barbiturates
▪2. Non barbiturates
 Barbiturates

▪ A drug that acts as a CNS depressant and can produce a wide

spectrum of effects from mild sedation to death.

▪ Pharmacological effects
– Sedation
– Hypnosis
– Anesthesia, or
– Death >> according to the dose because of
respiratory depression
– Normal hypnotic dose >>> slight fall in heart rate & blood
pressure
 Barbiturates

▪ Adverse effects
– Respiratory depression
– CNS ,,
– Psychological and physical dependence
▪ Routes of administration
– Orally
– Rectally
– IM or IV.
▪ metabolized In liver
 Barbiturates

▪Contraindications
– Liver impairment
– Respiratory distress
– Allergy to the drug
– Porphyria
Dosage (adult)
▪ 100 mg Pentobarbital (Nembutal) 1 hour preoperative
▪ 100 – 200 mg of Secobarbital (Seconal) 1 hour preoperative
 Nonbarbiturates (antihistamines)

▪ Drugs that are not chemically related to barbiturates and have a

sedative- hypnotic properties.
▪ Differ from barbiturates in two aspects:

▪ 1- Less potent than barbiturates

▪ 2- Not cross – allergenic with barbiturates
▪ May have similar adverse effects of barbiturates If taken in
efficacious doses e. g.;
dizziness, drowsiness, motor incoordination, blurred vision,
euphoria, nervousness and insomnia.
Ex; Atarax, Phenergan, Telfast, tandryle.
Nitrous oxide – oxygen pharmacosedation
 Nitrous oxide – oxygen pharmaco-sedation

Nitrous oxide is a colorless inorganic gas that is compressed

into liquid, having sweet odor
▪ Advantages
– Rapid onset of action and rapid recovery (saturation of
blood and brain occurs within 3-5 minutes)
– Ease of administration
– Reasonable lack of adverse effects
– Ease of dose control
– Nonirritating to respiratory mucosa
Subjective symptoms
▪ Mental and physical relaxation
▪ Indifference to the surroundings and passage of time
▪ Lessened pain awareness
▪ Euphoria
▪ Drowsiness
▪ Dreaming
▪ Feelings of warmth over the entire body
▪ Tingling sensation in the extremities, tongue and lips
▪ Heaviness of chest
▪ Vibrating sensation
▪ Distortion of sounds (sounds seem distant)
▪ adverse effects
– Nausea and vomiting
– Perspiration
– Behavioral alterations
▪ contraindications
– acute anxiety
– migraine and headaches
– drug abuse
– history of psychosis
 Control of Pain

It is an unpleasant sensory or emotional experience associated

with actual tissue damage.
Algesia : It is defined as an ill defined, unpleasant
sensation, usually evoked by an external or internal
stimuli.

Analgesic : A drug that selectively relieves pain by

acting in the CNS or peripheral pain mechanism,
without loss of consciousness.
▪ How the pain occurs
Injury
• Mechanical injuries, such as punctures and cuts or chemical (burn)will
release chemicals from the injured tissues.

Reception
• A specialized nerve cell called a nociceptor will be sensitized by the
stimulus and the chemicals released from injured tissues.

Transmission
• The nociceptor sends signals to the brain through several neurons
within the central nervous system.
• The signals travel up the spinal cord to the brain through a "neural
freeway" called the spinothalamic tract.
Pain center reception
• Within the brain, a relay station called the thalamus distributes the
signals to various parts of the brain; there is no single pain center.
• Areas like the somatosensory cortex process the information and you
feel pain.

Pain suppression or relief (analgesia)

• prevent inflammation and block
release of chemicals that
stimulate nociceptors.
 Control of Pain
NSAIDs – Narcotics - Local Anesthesia
▪ Definition of analgesics:
any drug which has the ability to relieve pain by acting in the
CNS or peripheral pain mechanism, without loss of
consciousness.
Classification
– 1. Non narcotics
• NSAIDs (aspirin, ibuprofen)
• Antipyretic analgesics (acetaminophen [Tylenol]

– 2. Narcotics
 NSAIDS
▪Group of drugs differ in chemical structure and sharing the
pharmacological & toxicological properties known as non-
narcotic analgesics.
Advantages

– Highly effective for pain of inflammatory origin

– Do not cause sedation or respiratory depression (Do not
depress the CNS)
– Not produce physical dependence.
– They act primarily on peripheral pain mechanisms.

Disadvantages
▪ May mask fever
▪ Not effective for sever pain
▪ GIT irritation
▪ Damage of platelets
Mechanism Of Action of NSAIDs
 Mechanism of NSAIDs
❖Most NSAIDs inhibit COX-1 and COX-2
nonselectively .
❖But some newer NSAIDs; like: celecoxib and
rofecoxib are selective inhibitors of COX-2.

• Theoretically, COX-2 inhibitors have less

adverse effects but have caused death in
cardiac patients and have been banned in
many countries.
 Classification 2

Ibuprofen
Non selective NSAIDS Naproxen
Diclofenac
ketoprofen

Selective NSAIDS Celecoxib

meloxicam
 Celecoxib(celebrex)

• Selective COX-2 inhibitors

• Food decrease its absorption

• Highly bound to plasma proteins

• Celecoxib (Celebrex) 200 mg

once/day
 NSAIDS
(for mild to moderate pain)
Nonsteriodal anti-inflammatory drugs (NSAIDs)
▪ Pharmacologic effects
– analgesic
– antipyretic
– anti-inflammatory
– anti-rheumatic
▪ Toxicological properties
– GIT irritation (prostaglandin)
– Bleeding (platelets damage)
– allergy
– liver damage
– Renal failure
 Indications of NSAIDS in Endodontics

▪1- Irreversible pulpitis

▪2- Apical periodontitis
▪3- Acute alveolar abscess
▪4- Infected cyst
 Classification of NSAIDs

▪ 1. Salicylic Acids
– Acetylsalicylic acid (aspirin).
– Non-acetylated salicylates (Diflunisal).

▪ 2. Propionic Acids
– Ibuprofen, 200-800 mg / 4-6hrs.
– Ketoprofen, 75 mg / 4-6hrs.

▪ 3. Acetic Acids
– Indomethacin, 50 mg / 8hrs.
– Diclofenac, 50-75 mg / 12hrs.
 Aspirin

▪ Aspirin (acetylsalicylic) acid is the most useful salicylate for treating

pain.
▪ It sends signals to hypothalamus to decrease the synthesis of
prostaglandin which possess the pain sensitizing effect and release
of inflammatory mediators.
▪ It primarily inhibits the enzyme cyclooxygenase (COX).

▪ * well absorbed from the stomach and small intestine.

▪ * metabolized in liver, food slows its rate of absorption.
▪
 Aspirin
• Uses
Adverse effects

➢Mild to moderate pain ➢Gastric irritation

➢Fever ➢Prolonged bleeding time
➢Inflammation ➢ Nausea
➢Prevention of stroke or ➢ Vomiting
heart attack ➢ Epigastric pain
➢Antiplatelet effects ➢ Constipation
 Dose of Aspirin

• Usual adult dose for treatment of pain or fever is 325-

650 mg every 4 hours

• For prevention of myocardial infarction, the dose is 75-

325 mg/day

• Children’s dose is 10-15 mg/kg every 4-6 hours

• Enteric coated aspirin: a coating that dissolves in the

intestine rather than the stomach
 Diflunisal (dolobid)

▪ A derivative of salicylic a. and have the same

pharmacological and toxicological properties of NSAID

▪ Properties:
▪ Long-term duration ( 8-12 hr. ), however has a slow onset of
action ( 3 hrs. ).
▪ Contraindicated in patients with aspirin intolerance , in the
last trimester of pregnancy.
 Propionic Acids ( Ibuprofen )

▪ The oldest member of the NSAIDs

▪ Ibuprofen was derived from propionic acid

▪ The drug of choice for dental pain when an NSAID is

indicated

▪ Usual dose is 400-800 mg every 4-6 hours

 Propionic Acids ( Ibuprofen )

▪ Pharmacological properties:
▪ - Analgesic -antipyretic
▪ - Anti-inflammatory - anti-rheumatic
▪ well absorbed orally , excreted in kidney.
▪ Adverse effect:
▪ - G I T irritation - epigastric pain - Anorexia - nausea
▪ - vomiting - dizziness - vertigo
▪ Contraindications:
▪ - Allergy - peptic ulcer
 Drug interactions
• Antihypertensive medications

• Aspirin

• Lithium

• Warfarin
 Acetic Acids Diclofinac ( voltaren, cataflam )

▪ Diclofenac is a Nonsteroidal anti-inflammatory drug taken to reduce

inflammation and pain

Diclofenac exists in two forms :

1. diclofenac sodium
2. diclofenac potassium

▪ Administration : orally or parenterally.

▪ The effect and adverse effect like other NSAID

▪ Dose: 50-100 mg / 8 hr.

 Diclofenac
• USES ADVERSE DRUG REACTIONS
• Pain associated with dental • Liver damage
surgery • Nausea
• post traumatic and post • Dizziness
operative inflammatory • Headache
conditions • Abdominal Pain
• Peptic Ulceration Hypertension
• Oseto-arthritis
• GI Bleeding
• Skin Rashes
 Antipyretic analgesics

▪ e.g. Acetaminophen

▪ A substitute drug of choice for aspirin allergic patients, with only analgesic
and antipyretic effect
▪ Pharmacological properties:

▪ Analgesic and antipyretic effects.

– No anti-inflammatory property, and no effect on platelet aggregation.

▪ Therapeutic doses have no effect on the cardiovascular and respiratory

system.
▪ It does not have any real gastrointestinal effects.

▪ Introduced as a an aspirin substitute.

▪ the most common one Tylenol, Panadol.
▪
 Acetaminophen

▪ It is rapidly and completely absorbed from the gastrointestinal tract.

▪ It achieves peak levels in 1-3 hours.
▪ Acetaminophen is metabolized by the liver.
 Acetaminophen
Mechanism:
inhibits prostaglandin synthesis via CNS inhibition of
COX (not peripheral)-
*doesn’t promote ulcers, bleeding or renal failure;
*peripherally blocks generation of pain impulses,
*inhibits hypothalamic heat-regulation center
 Acetaminophen

Dose :
Adults : 0.5-1 g every 4-6 hours
6-12 year..250-500 mg every 4-6 h
1-5 years .. 120-250 mg every 4-6 hours

Daily doses should be limited to 4 g / day

 Acetaminophen

• Tablets
• Suppositories
• Syrups
• Soluble tablets
• Capsules
 Acetaminophen
• Adverse Effects
– Hepatotoxicity
• Can occur after the ingestion of a single toxic dose (20-25
gm) or after long term use of therapeutic doses.

• Chronic large doses of alcohol can increase the risk for

hepatotoxicity.

• Children are at high risk for hepatotoxicity because they

are often given doses that are not age- and weight-
appropriate.
• Signs and symptoms include nausea, vomiting, abdominal
pain, anorexia.
– Nephrotoxicity
• It has been associated with long-term use.
 Narcotic Analgesics
(for moderate to sever pain)

▪ These drugs work on the necrotic receptors in the C N S.

▪ Narcotic  Opioid
▪ These drugs are used for moderate to severe pain.
▪ Not of much use for dental pain.

▪ Common opioid drugs used are:

1. Morphine
2. Codeine
3. Tramadol (50-100mg every 4-6 hours)
 Morphine

▪ It is a natural constituent of opium along with narcotine and codeine.

▪ Well absorbed parenterally, but poorly orally.

▪ adult dose: 5-20 mg.

▪ It is the drug of choice in severe pain e.g.

▪ traumatic pain , accidental pain, and neoplastic pain.
▪ Pharmacological effect:
▪ 1- analgesic 2- sedation 3- euphoria
▪ 4- convulsions 5- cough suppression
▪ Adverse effect:
▪ Respiratory depression Dependence Nausea
▪ Constipation Dizziness Insomnia Hallucination
▪ Contraindications:
▪ – Head injuries - Asthmatic patients
 Codeine

▪ Commercially synthetic from morphine.

▪ The pharmacological effect is similar, but quantitavely less

than
▪ Morphine.

▪ Well absorbed orally and parenterally.

▪ Drug of choice for cough suppression.

▪ Dose: 15-60 mg
 Tramadol

▪ It is an opioid pain medication used to treat moderate to

severe pain.
▪ Used for short lasting as well as chronic pain.
▪ can be used orally and parenterally.
▪ Dose: 50-100mg every 4-6 hours

▪ 100 mg Tramadol = 10 mg morphine.

Differences between Opioids(narcotic) and Non
Opioids
• Opioid Analgesics Non Opioid Analgesics
• Act centrally • Act peripherally

• Do not cause addiction

• Cause addiction
• No CNS depression
• Produce CNS depression

• Produce gastric irritation

• Do not produce gastric
irritation
• Do not provide anti • Provide anti inflammatory
effect
inflammatory effect
 Goals of Combination Therapy
• To use lower doses of the component drugs.
• Increasing range of action by combining a fast-onset,
short acting analgesic for milder pain, and a slower-
onset, longer-duration analgesic.
• They allow in a significant dose reduction of opioids
and help in minimizing opioid side effects.

• E.g.
• Ibuprofen 400 mg and codeine 60 mg
• Ibuprofen 400 mg and oxycodone 10 mg.
• Tramadol and Ibuprofen
 Antibiotics
▪
▪ Drugs used for treatment of established infections and as a prophylactic
agent in medically compromised patient.

▪ The use of antibiotics in treatment of endodontic conditions is limited, usually

the analgesics are sufficient for managing most of the symptomatic
endodontic cases.
▪ According to the A A E, antibiotic prescription in medically healthy patient is
indicated when systemic manifestations ( fever, malaise, lymphadenopathy )
and diffuse swelling are present.
▪ An endodontic infections are usually poly-microbial involving a combination of
gm +ve and gm –ve facultative aerobes and strict anaerobes. Broad
spectrum antibiotics are usually prescribed.
▪ N.B : Improper dosing and duration of therapy may lead to development of
antibiotic resistant microorganisms.
 Antibiotics

▪ Mechanism of action of antibiotics

▪ - Suppression of bacterial protein synthesis.

▪ - Inhibition of cell wall formation & induction of autolysis.

▪ Mechanism of bacterial resistance to antibiotics

▪ Natural: spontaneous mutation of bacterial genes independent of
▪ contact to A. B.
▪ Acquired in presence of contact to A. B.
▪ Some bacteria secrete enzymes to destroy A. B.
▪ e. g B- Lactamase enzyme.
 Conditions requiring prophylactic antibiotics

▪ 1-Uncontrolled diabetes
▪ 2- Rheumatic or congenital heart disease
▪ 3- Prosthetic cardiac valves
▪ 4- Mitral valve prolapse with regurgitation
▪ 5- SBE
▪ 6- Immunosuppressive drugs ( chemotherapy, prolonged corticosteroids.
▪ 7- Immunological diseases that reduce the patient defensive mechanism
e. g. H I V , AIDS infections
 Antibiotics in Endodontics

▪Penicillin
▪ A generic name for closely related A. B. that differ in:
▪ * antibacterial spectrum.
▪ * resistance to gastric acidity .
▪ * destruction by beta-lactamase enzyme.

▪ Classified into : 1- Natural penicillin G.

▪ 2- Semi-synthetic penicillin V.
 Penicillin G

▪ - The only completely natural penicillin used clinically.

▪ - Spectrum: Gm +ve & Gm –ve cocci, most anaerobic microorganisms.
▪ - Resistant organisms ; enterococci, most gram – rods, and most
staphylococci
▪ - Absorption ; 2/3 to ¾ of oral dose is destroyed in stomach or inactivated
by bacteria in GIT
▪ Adverse reaction
▪ The most commonly allergic of all drugs.
Allergic Reactions (according to the time of onset)
– Immediate (within 20 minutes) e. g. urticaria, anaphylactic shock
– Accelerated (2 + 48 hours) e. g. urticaria , fever , laryngeal edema.
– Late (3 days or longer) e. g anemia , Erythema multiform, arthralgia
▪Penicillin V
▪ - Semisynthetic penicillin similar to penicillin G
▪ - Stable and resistant to gastric a.
▪ - 65% of the drug is absorbed when taken orally.

▪Ampicillin and Amoxicillin

▪ Both have similar A. B. spectrum against most gm +ve and gm –ve
aerobic & anaerobic bacteria.
▪ Amoxicillin is generally the penicillin of choice because of its somewhat
better absorption from the GIT
 Augmantin ( amoxicillin+ clavulanic a. )

▪ It is a combination of amoxicillin and potassium clavulanate. The

potassium clavulante is a B- lactamase inhibitor which increase the
spectrum of augmantin.

▪ Spectrum : gm +ve aerobes and anaerobes.

▪ gm -ve aerobes and anaerobes.
▪ better effect : clavulanic a. effective against B- lactamase enzyme.
▪
▪ Adult dose: 500 – 1000 mg / 12 hrs.
▪ Syrup and I. M. injection s also available
 Unasyn(sultamicillin)

▪ It is an combination of ampicillin and sulbactam ( B-lactamase inhibitor).

▪ Spectrum: broad penicillin and B- lactamase inhibitor
▪ Used for skin and intra-abdominal infections as well as dental infections.
▪ Adult dose: tablets 375-750 mg / 12hrs.
▪ Also I.V. injection is available.

▪ Excreted unchanged in urine.

 Cephalosporins

▪ Broad spectrum bactericidal antibiotics

▪ Sensitive to beta-lactamase enzymes like penicillin
▪ Effective against;
– Streptococcus pyogenes, viridans & pneumoniae
– Non-haemolytic streptococci
– Staphylococcus aureus.
– Actinomyces Israeli and Neisseria

– Most anaerobic species.

▪ Excretion ; unchanged by kidney within 6 hrs
▪ Availability ; parenteral and oral use
▪ E. g. Cephalexin (Keflex) , Cefadroxil
▪ adult dose : 250 - 500 mg / 6-8 hrs.
▪ Children : 125 mg syrup.
▪ Adverse effects ;
– Allergy in form of skin rash, fever, serum sickness, and
eosinophilia.
– Cross allergy with penicillin is anticipated (10%)
Many generations are available
▪ 1st, 2nd, 3rd, 4th, and 5th generations.
 Clindamycin, Lincomycin
( clindam, lincocin, and Dalacin-c)

▪ They are classified as lincosamide antibiotics

▪ Effect : Anaerobic bacteria
– Streptococcus (pyogenes and viridans)
– Pneumococci and many staphylococci
▪ Resistance
– All gram – rods (esp. Clostridium)
– Enterococci
– Neisseria
– Administration: well absorbed orally.
– Adult dose : 150 – 300 mg / 6-8 hrs.
 Clindamycin, Lincomycin
( clindam, lincocin, and Dalacin-c)
▪ Adverse effects:
– Abdominal pain
– Nausea and vomiting
– Diarrhea
– Allergy in 10 % of pts in form of urticaria and skin rash
▪ - - Dangerous Pseudomembranous colitis
▪ pseudo membrane consist of : fibrin, mucous,
inflammatory cells,
▪ and epithelial debris  necrotizing inflammation of the
bowl.
▪ this membrane peels off  bleeding  death.
 Erythromycins

▪ Large molecule antibiotics

▪ Effective against nearly the same bacteria as penicillin, so it can be used
in patients allergic to penicillin
– Effective against gm +ve & gm –ve streptococci and some
staphylococci but not gram –ve aerobic bacilli
▪ Side effects
– GIT & Stomach irritation, and epigastric pain
– Nausea, vomiting, and diarrhea
– Transient deafness in high doses
– allergy is extremely rare
– Administration : oral 250 - 500 mg / 6-8 hrs.
▪ New generations
– Azithromycin -- Clarithromycin
▪ Less stomach irritation
▪ More useful in dental infections
 Tetracyclines

▪ Broad spectrum antibiotics

▪ it exerts a bacteriostatic effect
– Against Staphylococcus aureus, Streptococcous (pyogens, viridans &
pneumonia), Neisseria, Shigella, Actinomyces and Bacteroids.
– Incompletely absorbed from GIT
▪ Administration: oral 1- 2 gm / day divided into 2 to 4 doses.
▪ Adverse effects
– GIT (epigastric pain, nausea and vomiting)
– The most directly toxic antibiotic.
– Moderately allergic
– Liver damage in high doses ( in form of jaundice, acidosis and shock)
– Staining of developing dentition
– Contraindicated in renal failure and liver damage
– Rarely used in oral and dental infection used to treat acne, cholera,
and malaria.
▪ Ex; Vibramycin, Achromycin…….
 Metronidazole (flagyl)
▪ It is an antibiotic used to treat a wide variety of infections.
▪ Spectrum : bactericidal against most of anaerobic bacteria.
▪ Is used in combination with another antibiotic, usually penicillin in
sever infections
▪ Helpful in periodontal infections.
▪ Administration: oral & I.V. injection.
▪ Detoxified in liver and excreted in urine.
▪ Side effects :
▪ unpleasant metallic taste, gastritis, and brown discoloration of
urine, and xerostomia.
▪ Due its effect on DNA synthesis, it has a mutagenic and
carcinogenic potential. So better to avoid long term treatment.
▪ Adult dose: 250 – 500 mg / 6-8 hrs.
▪Antibiotic prophylactic regimens for oral and
dental procedures
situation agent regimen

Standard general Amoxicillin Adults: 2.0 g

prophylaxis Childen: 50 mg/kg orally 1 hour
before procedure

Unable to take oral Ampicillin Adults: 2.0 g IM or IV

medications
Allergic to penicillin
Children: 50 mg/kg IM or IV
within 30 min before
procedure
Clindamycin Adults: 600 mg Children: 20
mg/kg orally 1 hr before
procedure

OR cephalexin Adults: 2.0 g 1 hour .

Children: 50 mg/kg orally 1
OR cefadroxil hour before procedure

OR azithromycin Adults: 500 mg

Children: 15 mg/kg orally
Clarithromycin
1 hour before procedure

Allergic to penicillin unable Clindamycin Adults: 600 mg

to take oral medications Children: 20 mg/kg and IV
within 30 min before procedure

OR cefazolin Adults: 1.0 gChildren: 25 mg/kg

IM or IV within 30 min before
✓ CORTICOSTEROIDS
Not exactly pain
killing medicines
but they are anti-
inflammatory.

But due to their

inflammatory
processes, they
can reduce pain.

For example, a patient with

arthritis may be relieved
from injections of steroids
into the inflamed joint.
Thank You

75