ANTIBIOTICS AND ANALGESICS IN DENTISTRY

CONTENTS
Introduction
Classification of Antibiotics
Commonly used Antibiotics in Endodontics
Antibiotics prophylaxis
Conditions requiring dose modifications
Classification of Analgesics
Commonly used Analgesics in Endodontics
Points to remember while prescribing drugs
Clinical studies
Conclusion
References
1
Introduction
Antibacterial agents, commonly called antibiotics, are ery useful because they !ill bacteria without
damage to the host" #hese drugs attac! cell structure and metabolic paths unique to bacteria and not shared
with human cells" $ystemic antibiotics are used frequently in the practice of medicine and dentistry" $ome
say they are oerused" Although this is probably true, it is also difficult to tell when an infection might
spread to cause life%threatening problems, such problems, such as caernous sinus thrombosis, &udwig's
angina, danger%space swelling reaching into the mediastinum, brain abscess, or endocarditis, all of which
hae deeloped as sequelae of root canal therapy" It is probably wise to use systemic antibiotics when there
is a reasonable possibility of microorganisms beyond the rot canal, the immuno%logically compromised
patient should also be considered an indication for antibiotic therapy, regardless of the condition of the
canal"
Classification
Antibiotics may be classified into two main categories( those that !ill bacteria rapidly and those that
!ill more slowly by retarding bacterial protein synthesis" )enerally spea!ing, the faster%!illing antibacterial
agents are more desirable"
Types of Antibiotics Rapid!illin" antibiotics
Penicillins and cephalosporins
*etronida+ole ,-lagyl./
-luoroquinolones
Antibiotics t#at slo$ protein synt#esis
Erythromycins ,macrolides/
Clindamycin ,Cleocin./
#etracyclines
0
Co%%on E&a%ples of Oral 'enicillins and Cep#alosporins
'enicillins
Penicillin 1 233 mg qid
Ampicillin 233 mg qid
Amoxicillin 233 mg tid4qid
Augmentin 233 mg tid4qid
Cep#alosporins
-irst generation
Cephalexin ,5eflex./ 233 mg qid
Cefadroxil ,6uricef./ 233 mg qid
$econd generation
Cefuroxime ,Ceftin./ 023 or 233 mg bid
Cefaclor ,Ceclor./ 233 mg tid
#hird generation
Cefixime ,$uprax./ 733 mg daily
6osages may ary with the specific situation"
-ast%!illing antibacterial agents are often called bactericidal, meaning that they are obsered to !ill
quic!ly in the laboratory" Penicillins, Cephalosporins, and metronida+ole are the bactericidal antibiotics
commonly used against endodontics pathogens" #he first two !ill by integrating into and wea!ening a newly
made cell wall, whereas the latter impedes 68A manufacture" 9oth require actiely growing organisms to
:
be effectie, so antibiotics that fight bacteria by slowing their protein synthesis ,bacteriostatic antibiotics/
are generally not gien along with these bactericidal drugs"
Type of or"anis%s a"ainst $#ic# pri%arily acti(e
1" Antibacterial( Penicillins, Aminoglycosides, Erythromycin etc"
0" Antifungal( )riseofulin, Amphotericin 9, 5etocona+ole etc"
:" Antiiral( Idoxuridine, Acycloir, Amantadine, ;idoudine etc"
7" Antiproto+oal( Chloroquine, Pyrimethamine, *etronida+ole, 6iloxanide
2" Antihelminthic( *ebenda+ole, Pipera+ine, Pyrantel, 8iclosamide etc"
'ENICILLINS ) a wide ariety of this group is aailable and of all these the ben+yl penicillin is the most
suited" #he penicillin act by the inhibition of the cell wall" Ben*yl penicillin
Antibacterial actiity( this includes the
1" COCCI) streptococci ,expect the group 6/ are highly sensitie, staph aureus although ery
sensitie has acquired resistance" #he gram negatie cocci include the 8" gonorrhoea, 8"
meningitidis"
0" BACCILI( )rampositie bacilli this includes the C"diptheriae, clostridia group, listeria" treponema,
bacclius group" Actinomyces israelli is primarily moderately sensitie"
'ENICIILIN RESISTANCE
#he primary mechanism of the acquired resistance is by the production of the en+yme penicillinase"
'enicillinase) it is a narrow spectrum 9 % lactamase which opens up the ring and inactiates the penicillin"
*a<ority of the staph, 9"subtilis and =" influen+ae group produce this en+yme" #his en+yme can be induced
and methicillin is an important inducer of this en+yme"
Absorption fate and e&cretion)
>hen gien i"m it is quic!ly absorbed, the maximum concentration being achieed in about half an
hour" In order to maintain the cone, of this drug abut 233 mg of this drug needs to be gien at least eery 7%?
hr interal" Inflammation increases the penetration of this drug" #he half life of this drug is less than half an
hour"
7
SE+ISYNT,ET-C 'ENICILLIN)
Acid Resistant 'enicillin) Penicillin 1
'enicillinase resistant penicillin) *ethicllin, @xaciiiin, Cloxaciliin"
E&tended spectru% penicillin) am6icillrn" bacampicillin" amoxicillin"
carbenicillin
piperacillin
B. lacta%ase in#ibitor) claulaunic acid"
'enicillin /) It is the penicillin which can be gien orally, as it is acid stable"
'enicillinase resistant penicillin0s) #hese hae a side chain attached at their end terminal hence allowing
them to be resistant to the attac! of the penicillinase producing staph" =oweer these are not actie against
the methicllm resistant staph ,*R$A/" It is generally gien in cases of staphylococcal infection"
E&tended spectru% infections)
A+'ICILLIN ) actie against all the organisms sensitie to penicillin =oweer
resistance has deeloped because of the misuse of this antibiotic" It is more actie than penicillin against the
streptococcus indans group" $taph are not affected 6osages ( 233 mg six hourly"
Ad(erse effects are that diarrhea is quite common" $!in rashes are also quite common with the use of this
drug"
Baca%picillin ) the only significant adantage is that it is completely absorbed" #he incidence of diarrhoea
is lower than ampicillin
A%o&icillin ) oral absorption is better and incidence of diarrhoea is lower
2
Dosa"es ) 233 mg eery A hourly" -or seere dental infections the course is extended for at least 2%13 days"
Beta lacta%ase In#ibitor)
Cla(ulanic Acid ) obtained from streptomyces clauligerus" It has no antibacterial actiity of its own"
1ses ) addition of the ciaulaunic acid reestablishes the actiity of amoxicilim against the penicillinase
producing bacteria" Amoxicillin sensitie strains are not affected by the addition of this drug"
CE',ALOS'ORINS)
#hese are a group of antibiotics that are deried from cephalosporin obtained from the fungus
cephalosporiium" #hey are chemically related to penicillin these drugs are diided into four groups" All the
ceph are bactericidal and theses hae the same mechanism as that of the penicillin" =oweer, they bind to
different proteins" #his may explain the difference in the spectrum, and the lac! of the deelopment of the
cross resistance"
2IRST GENERATION )
#hese were deeloped in the 1B?3 and were actie against the gram positie organisms"
SECOND GENERATION
#hese were deeloped as they were actie against gram negatie organism
1" Ceforoxime ( it is resistant top the b lactamase organisms" #heir uses lie howeer with the treatment
of the meningitis infection" 6osage( 023%C23 mg
0" Cofactor ( dosage 023 mg
T,IRD GENERATION)
#hese compounds were deeloped in the 1BA3 and these were actie against the gram negatie
enterobacteriases" All were highly actie against the b lactamase producing organisms"
1" Cefotaxime ( Prototype of the third generation, has actions against both gram positie a well as the gram
negatie" 6osage % 3"2%3"? g per ial
?
0" Ceftriaxone ( distinguishing feature of the cephalosporin is the long duration of action" 6osage( 3"2%1"3
gm per ial"
:" Cefixime( orally actie third generation, highly actie against the ="influen+ae" strepto and is resistant to
the b lactamase organism" 6osage 133%033 mg tab"
7" Cefdinir( again<i an oraqlly actie agents use is limited to much in the ent dosage" :33 mg tab"
AD/ERSE E22ECTS)
1" Pain during the in<ection
0" 6iarrhea
:" =ypersensitiity reaction
7" 8ephrotoxicity
2" 9leeding
?" 8eutropenia
A+INOGLYCOSIDES
#his group includes the
1" $treptomycin
0" )entamycin
:" #obramycin
7" Ami!acin
2" 5anamycin
?" $isomycin
6ue to there aderse effects these drugs are seldom used in dentistry expect for the gentamycin and
the ami!acin" #hese drugs are used when the patient comes with seere infection with generali+ed
symptoms" In cases of the multisystem inolement these drugs are used as the last resort"
Genta%ycin ) dosag03, ?3, A3, 073 mg per ial
A%i!acin ) dosage % 133, 033, 233 mg ial per
C
ANTIA+OEBIC DR1GS)
#hese drugs include
1" *etronida+ole
0" $ecnida+ole
:" @rnida+ole
7" $atranida+ole
+etronida*ole ) #his drug has a wide ariety of action" It has a broad spectrum of actiity against he
proto+oa, this actiity includes many of the anaerobic bacteria too li!e the h" pylori" *etronida+ole is
selectiely toxic to the anaerobic bacteria"
Aderse effects
1" Anorexia
0" headache, glossitis, di++iness
:" peripheral neuropathy
7" threombophlebitis
Contraindication
1" in neurological disoders
0" first trimester of pregnancy
:" chronic alcoholisms
6osage ( 033%733 mg tds tab
$ecnida+ole ( dosage 3"2%1"3 g tab
@rnida+ole ( dosage ( 233 mg tab"
$atrinda+ole ( dosage ( 233mg 96
A
ANTI21NGALS)
Antibiotics
1" 8ystatin, amphotericin, grisofulin
A3OLES
1" Clotrimoxa+ole ,topical/
0" econa+ole
:" micona+ole A8#I9I@#IC$
1" A+B ) its antifungal actiity includes the canmdida albicans, histoplasma crytococcus,
aspergillus"
Administered orall dosage ( 23%133 DI6
Aderse effects (
1" nephrotoxicity is the ma<or dose limiting side effect"
0" NYSTATIN ) similar to the A*9, howeer its usr is limited tro the oral route" It has been combined
with the tetracyclines for the preention against the superainfection"
6osage ( 2 lacd E tab, 1 lac E tab"
4ETOCONA3OLE ) it is the first orally effectie broad spectrum antifungal used in dermatophysis, deep
mycosis, dosage ( 033 mg od
TETRACYCLINES
#he tetracyclines comprise a group of closely related antibiotics that proide a broad spectrum of
actiity against the organism" #he actiity includes the organisms that are insensitie to the penicillin as
well many gram negatie organisms, these are generally bacteriotatic" #hese agents are administered orally
but can be gien by the i"m or the i route" #hese drugs are widely distributed in the boy tissues and reach
the C$- also" #hese chelate with the calcium ions present in the teeth and bones"
B
1N5ANTED E22ECTS O2 TETRACYCLINES
Immediately after the absorption these drugs are built in the calcifying tissues and this becomes a
permanent feature in the teeth" #here is a clear linear relationship between the number of courses of
treatment with tetracyclines and the discoloration of deeloping teeth" If at all possible then these drugs
should be aoided during the formatie stages of the crowns of the teeth" If a tetracycline has to be used
then it has to be the oxytetracyclines, or doxycycline" As they produce the least ob<ectionable amount of
staining"
#etracycfine's produce a mar!ed depression of the normal flora of the mouth, throat and colon"
Ender some conditions these may lead to the deelopment of an infection which may hae grae
consequences" $taph infections which if occur might be ery serious"
Candida albicans ) oergrowth of which might be of concern to the dentist" #he surface proliferation of
this organism which is a normal commensal of the mouth might then inade the tissue and cause infection"
#his is especially li!ely to occur in patients with debilitating disease" ,Antibiotic sore mouth/" E$E$ ( in
dentistry the use of tetracycline remains restricted" It is used in cases where the penicillin hypersensitiity is
there" #hese drugs should neer be used when they are being combined with a bactericidal drug" A
tetracycline mouth bath is effectie in reliing the painful ulceration of the erosie lichen planus, seere
recurrent apthae ulcers"
6@$A)E ( 023 mg eery ? hr"
+ACROLIDE ANTIBIOTICS)
#he group includes erythromycin, oleandomycin and spiramycin of which the first is of the interest
to the dentist" Erythromycin has an antibacterial spectrum that is quite similar to that of ben+yl penicillin"
#he drug acts by the inhibition of the protein synthesis"
1N5ANTED E22ECTS)
All preparation can cause the gastrointestinal symptoms" =ypersentiity is rare but the estolate preparation
can cause the cholestatic hepatitis"
DOSAGE ) #his drug is administered orally and for most infections 233mg ? hr for the course for 2 days
should suffice"
13
Clinda%ycin ) its mechanism of action is quite similar to that of the erythromycin" #hese are also primarily
static drugs" Its usage in dentistry is ery much limited because of the serious side effects that it can cause %
pseudomembranous colitis which can be fatal"
A3IT,RO+YCIN) one of the best drugs in the class of macrolides" It has the best oral aailability and has
the best spectrum of actiity" =oweer its use in dentistry is not widely accepted"
All drugs grouped in this class hae analgesic, antipyretic and anti%inflammatory actions in different
measures"
Antibiotic 'rop#yla&is
#he goal of antibiotic prophylaxis is to preent clinical infection by helping destroy small numbers
of bacteria present before or introduced during treatment" @ral bacteria released during dental treatment
clearly can cause heart and artificial <oint infections" @ral streptococci, in particular, hae been indicted as
causatie organisms for seeding heart and implanted <oints, causing morbidity or een death"
@ral streptococci are wea! pathogens !now as Firidans strepF" #he long chains become seriously
pathogenic when FiridansF colonies form on heart ales, trapping blood cells and fibrin and thereby
reducing heart efficiency by hindering closure of the ales" -urthermore, portions of the stic!y (
egetations,F as they are called, brea! of and lodge in small essels at distant sites, causing ischemia with
possibly disastrous consequences"
CONDITIONS RE61IRING DOSE +ODI2ICATIONS
'atient 2actors
1" Age may affect !inetics of many A*As" Con<ugation and excretion of chloramphenicol is
inefficient in the newborn( larger doses produce gray baby syndrome. $ulfonamides displace
bilirubin from protein binding sites G can cause !ernicterus in the neonate because their blood brain
barrier is more permeable" #he t
1
4
0
of amino%glycosides is prolonged in the elderly and they are
more prone to deelop 1III nere toxicity" #etracyclines accumulate in the deeloping teeth and
bone G discolour and wea!en them G are contraindicated below the age of ? years"
0" Renal and hepatic function Cautious use and modification of the dose of an A*A ,with low safety
margin/ becomes necessary when the organ of its disposal is defectie"
11
Antimicrobials contraindicated or for whom dose modification is required in renal insufficieny are(
6ose reduction needed in renal failure 6rugs to be aoided
Een in mild failure @nly in moderate% Cephalothin
Aminoglycosides seere failure Cephaloridine
Cephalosporins *etronida+ole 8alidixic acid
1ancomycin Cotrimoxa+ole 8itrofurantoin
Amphotericin 9 Carbenicillin #alampicillin
Ethambutol -luoroquinolones #etracyclines
-lucytosine ,doxycycline/
Antimicrobials to be aoided or used at lower dose in lier disease are(
6rugs to be aoided 6ose reduction needed
Erythromycin estolate Chloramphenicol
Pyra+inamide *etronida+ole
#aiampicillin Clindamycin
#etracyclines Isonia+id
Rifampin
7. Local factors: #he conditions preailing at the site of infection greatly affect the action of A* As"
a" Presence of pus and secretions decrease the efficacy of most A*As, specially sulfonamides
and aminoglycosides"
Presence of necrotic material or foreign body ma!es eradication of infection practically impossible"
10
b" =aematomas foster bacterial growthH tetracyclines, penicillins and cephalosporins get
bound to degraded haemoglobin in the haematoma"
c" &owering of p= at site of infection reduces actiity of macrolide and amino%glycoside
antibiotics"
d" Anaerobic enironment in the centre of an abscess impairs bacterial transport processes
which concentrate aminoglycosides in the bacterial cell"
7" Drug allergy : =istory of preious exposure to an A*A should be obtained" If a drug has caused
allergic reaction G it should be aoided in that patient"
2" Impaired host defence: Integrity of host defence plays a crucial role in oercoming an infection" In an
indiidual with normal host defence, a bacteristatic A*A may achiee cureH while intensie therapy with
cidal drugs is imperatie in those with impaired host defence ,conditions gien on p" ?03/ or when the
organisms are protected by a barrier G as in $A9E"
8. 're"nancy All A*As should be aoided in the pregnant because of ris! to the foetusH contraindicated
drugs are(
#etracyclines( teeth and bone discolouration and deformity in the offspringH ris! of acute yellow atrophy
of lier, pancreatitis and !idney damage in the mother"
Aminoglycosides
2oetal abnor%alities %ay be produced
Cotrimoxa+ole
'OINTS TO RE+E+BER 5,ILE 'RESCRIBING DR1GS
-. Aller"ies
$erious anaphylactic allergic reactions are rare with oral penicillins and cephalosporins, although
they are possible" If allergic to one penicillin, the patient should be considered allergic to all penicillins and
possibly to cephalosporins as well"
1:
9. Resistance
#he main biochemical structural similarity of penicillins and cephalosporins is the p%lactam ring"
$ome bacteria can produce an en+yme, called p%tactamase or penicillinase, which cleaes this ring, thus
disabling the antibiotic" Potassium claulanate has been added to amoxicillin, to ma!e it stable in the
presence of p %lactamase" #he combination is called Augmentin."
7. A good specimen for culturing can often be obtained by needle aspiration from an abscess that has not
yet drained" A culture can be a bid adantage when a patient does not respond to the first antibiotic" #he
practitioner can telephone the laboratory and quic!ly learn which drug to use next"
:. Suprainfection ;Superinfection<
Ese of most A*As causes some alteration in the normal microbial flora of the body" @rdinarily, the
pathogen has to compete with the normal flora for nutrients etc" to establish itself" &ac! of competition may
allow een a normally nonpathogenic component of the flora, which is not inhibited by the drug ,e"g"
Candida), to predominate and inade" *ore complete the suppression of body flora, greater are the chances
of deeloping suprainfection" #hus, it is commonly associated with the use of broad4extended spectrum
antibiotics, such as tetracyclines, chloramphenicol, ampicillin, newer cephalosporinsH specially when com%
binations of these are employed"
#o minimi+e suprainfections(
,i/ Ese specific ,narrow spectrum/ A*A wheneer possible"
,ii/ 6o not use antimicrobials to treat triial, self limiting or unbeatable ,iral/ infections, ,iii/ 6o not
unnecessarily prolong antimicrobial therapy"
=. Nutritional Deficiencies
$ome of the 9 complex group of itamins and it 5 synthesi+ed by the intestinal flora is utili+ed by
man" Prolonged use of antimicrobials which alter this flora may result in itamin deficiencies"
17
ANALGESICS
NON STEROIDAL ANTI IN2LA++ATORY DR1GS CLASSI2ICATION )
A" 8onselectie C@I inhibitors ,conentional 8$AI6s/:
1" $alicylates( Aspirin, 6iflunisal
0" Pyra+olone deriaties( Phenylbuta+one, @xyphenbuta+one"
:" Indole deriaties( Indomethacin, $ulindac
7" Propionic acid deriaties( Ibuprofen, 8aproxen, 5etoprofen, -lurbiprofen"
2" Anthranilic acid deriatie( *ephenamic acid
?" Aryl%acetic acid deriaties( 6iclofenac
C" @xicam deriaties( Piroxicam, #enoxicam"
A" Pyrrolo%pyrrole deriatie( 5etorolac"
9" Preferential C@I%0 inhibitors
C" $electie C@I % 0 inhibitors
Celecoxib, Rofecoxib, 1aldecoxib
6" Analgesic% antipyretics with poor anti%inflammatory action
1" Paraaminophenol deriatie ( Paracetamol ,Acetaminophen/
0" Pyra+olone deriaties( *etami+ol ,6ipyrone/, Propiphena+one"
:" 9en+oxa+ocine deriatie ( 8efopam
Beneficial actions due to 'G synt#esis in#ibition
Analgesia ( preention of pain nere ending sensiti+ation
Antipyresis
Anti%inflammatory
Antithromobotic
Closure of ductus arteriosus
12
S#ared to&icities due to 'G synt#esis in#ibition
)astric mucosal damage
9leeding ( inhibition of platelet function
&imitation of renal blood flow ( 8a
J
and water retention
6elay 4 prolongation of labour
Asthma and anaphylactoid reactions in susceptible indiiduals
1ses
1" As analgesic ( -or headache, bac!ache, myalgia, <oint pain, pulled muscle, toothache, neuralgias and
dysmenorrhoeaH it is effectie in low doses ,3":%3"?g ?%A hourly/
0" As antipyretic ( It is effectie in feer of any originH dose is same as for analgesia" =oweer,
paracetamol, being safer, is generally preferred"
Aspirin has been a standard drug for dental pain for many years and is still useful" It, howeer,
prolongs bleeding, and for this reason is a poor presurgical drug" #he anticoagulant effect comes from
interference with platelet formation" Aspirin irreersibly binds the en+yme cyclooxygenase, !ey to the
pathway from in<ury%induced arachidonic acid, that is released from the membranes of all cells, leading to
production of inflammation and pain%causing prostaglandins" Platelets in circulation do not hae enough
protein synthesis reseres to replace the bound cyclooxygenase and are thus unable to participate in clotting
for the remainder of their cell life%around 11 days" *any patients are on routine, low%dosage aspirin therapy
for prophylaxis against stro!e or heart attac!" Prior to endodontic surgery, consultation with their physician
may be in order"
-or patients with stomach problems, consider the use of coated aspirin, such as Ecotrin." #he
coating will not dissole until reaching the al!aline conditions of the small intestine" #his means that drug
action will be delayed for the usual 0%hour stomach transit time" Alternatiely, aspirin buffered with
chemicals such as magnesium, calcium, or aluminium compounds to decrease stomach complaints
,9uffering., Ascription./ can be considered for sensitie patients"
1?
INDOLE DERI/ATI/ES)
INDO+ET,ACIN) it is a potent pain !iller and also is a strong antipyretic
Dosa"es) 02 % 23 mg qid,
Ad(erse Effects) leu!openia, rashes are also common"
'RO'IONIC ACID DERI/ATI/E) ibuprofen was the first member" It was better tolerated than aspirin"
#he analgesic, antipyretic and antiinflammation property is somewhat lower than that of the aspirin" All the
members of this group inhibit the pg synthesis naproxen being the most potent"
AD/ERSE E22ECTS) ibuprofen and its congers are all better tolerated than aspirin" #hese include some
gastric discomfort, gastric erosions, rashesH these are not to be prescribed to pregnant patients and should be
aoided"
',AR+O4O4INETICS) all of these are well absorbed, these erne the brain and the synoial fluid and
cross the placenta"
Recently ibuprofen $as rated as t#e safest con(entional NSAIDS in t#e 14.
T#e ot#er %e%bers include t#e napro&en> !etopprofen> flubriprofen.
7. ANT,RANILIC ACID DERI/ATI/E)
*EP=E8E*IC ACI6 ( an analgesic, antipyretic, anti%inflammatory drug which inhibits the C@I
as well antagoni+es the effect of P)"
AD/ERSE E22ECT)
6iarrhoea is the most common side effect in this class"
1se) it is commonly indicated as an analgesic in the muscle and the soft tissue pain" DOSAGE) 023%23 mg
I6$"
1C
:. ARYL ACETIC ACID DERA/ATI/E)
DICCLO2ENAC SODI1+ ) an analgesic, antipyretic, anti%inflammatory drug which is similar in efficacy
as the naproxen" It is a potent analgesic"
CONTRAINDICATION ) bronchial asthma, gastric bleeding and in patients bleeding disorders"
Dosa"e) 23 mg 9"6, it is also aailable in the topical preparation as the oeran gel"
=. O?ICA+ DERA/TI/E
'IRO?ICA+) long acting potent 8$AI6 with anti%inflammatory potency similar to indomethacin and
good analgesic antipyretic action" It is a reersible inhibitor of the C@I" It inhibits the inflammation in
many ways"
AD/ERSE E22ECTS) common side effects are heart effects, nausea and anorexia" It is less ulcerogenic
than indomethacin
8. 'RE2ENTIAL CO?9 IN,IBITOR)
1" 8I*E$E&I6E( #his newer 8$AI6$ is a relatiely wea! inhibitor" @f pg synthesis and there is some
eidence to indicate relatiely C@I % 0 selectiely" #he analgesic, antipyretic and anti%inflammatory
actiity of nimesulide has been to other 8$AI6" It is has been used for short lasting inflammation
conditions"
AD/ERSE E22ECTS ) gastrointestinal, dermatological effects" Recent studies hae shown that this drug
is causing fulminant hepatic failure" Adantage of this drug is that it doesn't aggraate the asthmatics and
bronchospasms"
6@$A)E( 133 mg 9"6
*E&@IICA*( this is a newer cogner of piroxicam has C@I%0, C@I%1" #his drug has been labeled as the
preferential cox%0 inhibitor" )astric side effects a are somewhat less than other 8$AI6" 6osage( C"2%12 mg"
1A
SELECTI/E CO?9 IN,IBITOR
9ecause of the theoretical adantage of inhibiting cox%0 without affecting cox%0 function, some
highly selectie cox%1 functions"
1/ #he role of Cox 0 in acute pain and the use of selectie cox%0 inhibitors for the acute pain relief ,0337/"
&ee K et al the author reiewed the usefulness of the 8$AI6$ in the pain relief" #he discoery of the
second C@I%0 led to the hypothesis that 8$AI6$ side effect could be decreased, as the inhibition of cox%0
is more directly implicated in ameliorating inflammation while the inhibition of cox%1 is related to aderse
effects in the )I tract, this deelopment of the cox%0 means that they are better tolerated than the
nonselectie cox%0 but comparable in the analgesic efficiency"
CELECO?IB) #he cox%0 selectiely in different tests, it exerts anti inflammatory with low ulcerogenic
potential" 6@$A)E %133%033 mg 9"6
RO2ECO?-B) it is the most selectie cox%0 selectie inhibitor" 6osage 10"2%02 mg @"6 occurrence of the
gastric damage is much lower than others"
/ALDECO?IB) similar to the rofecoxib actiity" 6osage is the 13 mg" @"6" ETORICO?IB) similar to
rofecoxib" Dosa"e ?3%103 mg O.D Topical NSAIDS)
*any hae been mar!eted in topical formulations for application oer painful muscles and <oints"
$ome of the topical preparations aailable are the(
1" diclofenac 1L gel
0" ibuprofen 13L gel
:" naproxen 13L geM
7" !etoprofen 0"2L gel
2" flubiprofen 2L gel
?" nimuselide 1L gel
C" piroxicam 3"2L gel
Choice of non steroidal anti%inflammatory drugs
1" mild to moderate pain with inflammation% paracetamol or low dose ibuprofen
0" acute musculos!eletal % diclofenac or rofecoxib
1B
:" post operatie or other acute but short lasting painful conditions% nefopam , !etorolac
7" )astric intolerance to the 8$AI6$% rofecoxibm, celocoxib"
2" Patients with history of asthmatic attac!s or anaphylactic reactions( nimesulide"
?" Combinations of two or more drugs in this 8$AI6$ group are beneficial but should be restricted to a
short time"
BEN3O?A3OCINE DERA/ATI/E)
-. NE2O'A+) it is a nonopoid analgesic which does not inhibit the P) synthesis, in traumatic and
postoperatie pain, it acts rapidly with an efficacy approaching morphine, yet no opoid action"
=oweer this drug produces ant cholinergic actions, it is contraindicated in the epileptics" 6osage(
:3%?3 mg I6$ oral"
'ARAA+INO',ENOL DERI/ATI/E)
Phenacitin ( =as been banned due to its implicated ion analgesic abuse nephropathy"
Paracetamol ,acetominiophen/( Actions similar to the aspirin but its anti%inflammatory action is
much wea!er than that of the aspirin"
Adantages(
1" no gastric stimulation
0" less mucosal erosions
:" does not affect the platelet function
7" non effect on the clotting factors
2" 6oes not stimulate the respiratory system"
Ad(erse effects(
-. Nausea or ras#es
Analgesic nephropathy( occurs after years of heay ingestion" 6osages( 3"2%1 "@g tab, 233mg tab"
8arcotics can cause addiction, with characteristics unique from other types of addiction" 9oth
physical and psychological addiction occur"
03
8arcotics are central nerous system ,C8$/ depressants and wor! synergistically with all other C8$
depressants" 8arcotics reduce reaction times, and narcoti+ed patients must not drie or operate machinery"
Esually, narcotics are combined with acetaminophen or aspirin or an 8$AI6 to ma!e them more effectie
without excessie narcotic side effects"
Proposyphene was originally introduced as a non%narcoticH howeer, it is now !nown as a rather
wea! narcotic" It wor!s for many patients, perhaps in part because its characteristic, di++iness, ma!es the
patient feel that it must be helping with the pain" 6aron. is aailable plain or with aspirinH with
acetaminophen, it is called 6arocdet%8."
Codeine has been a standard drug in dentistry for many years because it is usually powerful enough
to control dental pain" It is irritating to the stomach in high doses, many patients with legitimate pain are
troubled with this gastrointestinal upset"
@ccasionally, patients will experience sufficient pain from endodontic procedures to require high%
leel narcotics, such as oxycodone or meperidine ,6emerot./" *orphine is aailable orally as @ramorph.
for seere dental pain, such as when the bony cortical plates confine infection pressure, necessitating ery
strong drug therapy, morphine remains a iable choice for the astute practitioner"
#ramadol ,Eltram./ is a new, potent, synthetic pain relieer that has similarities and differences
with the classic opiates" Enli!e other opiates, tramadol is not fully reersed by naloxone ,8arcon./"
-urther, it inhibits reupta!e of serotonin and norepinephrine, a monoamineH hence, concomitant
administration with monoamine oxidase inhibitor drugs is not recommended" #ramadol is well absorbed
orally, and the usual adult does is 23 to 133 mg four times a day"
Acetaminophen ,#ylenol/ gies patients relief ia its action directly on an un!nown site in the brain"
It was populari+ed in the now unaailable FARCF formulation of aspirin, phenacetin, and caffeine" Although
it is effectie against pain and feer, inflammation remains unchanged by acetaminophen"
Acetaminophen is metaboli+ed by the lier and should be used cautiously in patients with lie
disease or chronic alcohol use"
Research data show that acetaminophen is better for eleation of the threshold for sharp pain, such
as with dental treatment, than other types of pain relieers"
1A
01
CLINICAL ST1DIES
4eenan @/ et al ;9AA8< #he Cochrane $ystematic Reiew promotes eidence%based outcomes
studies" #he reiew summari+ed here was conducted in an attempt to achiee reliable eidence concerning
the effectieness, or otherwise, of prescribing antibiotics for patients haing irreersible pulpitis" Although
the selected study used a relatiely small, low%powered sample, it did proide some eidence that there is no
significant difference in pain relief for patients with untreated irreersible pulpitis who receied antibiotics
ersus those who did not" #hese findings increase the rationale to inestigate the teaching of safe and
effectie antibiotic prescribing in endodontics and to adance the deelopment of appropriate eidence%
based clinical guidelines"
+oore 'A ;-BBB< #he use of erythromycine, a long%established macrolide antibiotic, may be limited
by gastrointestinal side effects" #he newer long%acting macrolide antibiotics%a+ithromycin, clarithromycin,
and dirithromycin are some times used instead of erythromycin" #he pharmacology, indications and
adantages of these newer drugs are reiewed" Clinical significance although, the newer macrolide
antibiotics clarithromycin, a+ithromycin, and dirithromycin are too costly for routine use in treating dental
infections, they do offer seeral adantages oer erythromycin" Clarithromycin or a+ithromycin may be
used for bacterial endocarditis prophylaxis in patients allergic to peniclillin"
Dorosc#a! A+ et al ;9AAA< ( Endodontic pain continues to pose a challenge" #hey efficacy of a
non%steroidal anti%inflammatory drug ,8$AI6/, flurbiprofen, and a new centrally acting analgesic tramadol,
was ealuated in a clinical study" Clinical significance -or patients with endodontic pain, the combination of
tramadol and the 8$AId flurbiprofen offered superior pain relief during the first 07 hours after endodontic
treatment"
Dental Abstract ;/ol. =- ;7<C 9AA8< Bac!"round( Clindamycin has proed extremely efficacious
for dental infections but is not recommended routinely because of its association with acute
pseudomembranous colitis ,ARC/" #he pertinent facts concerning the use of clindamycin were reiewed"
,enry + et al ;9AA-< ) #he effects of penicillin therapy in patients with continued symptoms after
emergency treatment for symptomatic necrotic teeth were assessed in a randomi+ed trial" Postoperatie
antibiotics may still be indicated for some patients with symptomatic, necrotic teeth, but this randomi+ed,
placebo%controlled trial finds that postoperatie penicillin does not reduce pain"
00
+ellor AC et al ;9AA=< AI+) #o examine whether an intra%oral in<ection of a nonsteroidal anti%
inflammatory drug ,!etorolac/, in association with conentional local anaesthetic techniques, would
improe the pulp extirpation rate in teeth with irreersible pulpitis" An intra%oral in<ection of !etorolac did
not improe the pulp extirpation rate in a small group of patients with irreersible pulpitis compared with a
placebo" In addition, it was associated with such significant pain on in<ection that it cannot be recommended
as a treatment in this situation" &indeboom NA et al ,0332/ AI*( #o determine the alue of clindamycin
prophylaxis in the preention of postoperatie wound infections in patients undergoing endodontic surgery"
8o statistically significant difference was found between clindamycin prophylaxis and placebo with regard
to the preention of postoperatie infection in endodontic surgical procedures"
2ar#ad A ;9AA=< ( Calcium hydroxide is a multipurpose agent, and there hae been an increasing
number of indication for its use" $ome of its indications include direct and indirect pulp capping,
apexogenesis, apexification, treatment ofH root resorption, iatrogenic root perforations, root fractures,
replanted teeth and interappointment intracanal dressing" #he purpose of this paper is to reiew the
properties and arious indications for the use of calcium hydroxide"
+odaresi @> et al ;9AA8< #he purpose of this study was to elucidate whether premedication therapy
with acetaminophen%codeine or ibuprofen is able to increase the depth of anesthesia in inflamed teeth" #his
study reflected preoperatie administration of ibuprofen, if not contraindicated, as a drug of choice 1 hour
before local anesthesia in<ection as an effectie method for achieing a deep anesthesia during RC# of teeth
with irreersible pulpitis"
Conclusion
It is imperatie that the dentist has a !nowledge about the drugs that are aailable and the way they
wor! on the human system, also the dentist must !eep his4her !nowledge up to date regarding the newer
drugs that are being launched in the mar!et"
0:
References
1" #ext boo! of pharmacology( 56 #ripathi
0" #ext boo! of endodontics ( Ingle
:" #ext boo! of endodontics ( >ein
7" $cientific foundation of 6entistry ( Cohen
2" Names 1" et al 'A Cochrane systematic Reiew fluids no eidence to support the use of antibiotics
for pain relief in irreersible pulpits N@E %1ol" :0 8o" 0 -eb 033?"
?" 6ental abstracts clinical use of long%acting macrolide antibiotics" 1BBB
C" 6ental abstracts 8$AI6 4 @piate combination may be useful for managing pain in endodontic
emergency patients 1ol" 72 issue 1, 0333"
A" 6ental abstracts clindamyain for dental infections and prophylaxis 1ol" 21 Issue :, 033?"
B" 6ental abstracts penicllin usefull for postoperatie endodontic pain 0331"
13" Int endod N" 033? AprH *ellor AC et al the use of an intra%oral in<ection of 5etorolac in the
treatment of irreersible pulpits"
07