Therapeutic agent [drugs] in edndodontic

Endodontic treatment is the most clinical situation amenable to drug therapy in dentistry Why the therapeutic agent to describe to patient? 1- To decrease fear and anxiety of the patient 2-To control the pain 3- To control the infection

Management of anxiety
What is meaning anxiety ? Irrational anxiety and rational fear of the patient toward dental treatment are major factors limiting access to dental care N B many patient having a dental problem but he did not go to dental clinical SICKEL treatment just fear just anxiety This fear may be improper handling from another doctors Or may be history he tell from another one

Why are have control anxiety of pt before start treat?

1-To cooperation of patient is very important for successful any dental treatment 2-Through control anxiety of pt to make dental treatment is very easy for pt or practitioner as like 3-Through control anxiety providing excellent dental treatment for patient So dentist provide optimal dental care

Management of anxiety
Patient reassurance

Chemical drugs

Nitrous oxide

1-Patient reassurance Dentist smile Dentist explain the steps of

procedure for patient [explain every steps] as what is caries what are you going to-do? If patient need endotreatment and any problem in tooth the dentist explain the steps of this procedure

2-Chemical drug Sedative

A- Benzodiazepam B- Sedative hypnotic C-Antihistaminic

Benzodiazepine
Group of the drugs have sedative effect and calming effect on the pt Benzodiazepine according to duration divided into

1-Long acting as valium Librium 2-Medium or short acting

The pharmacological effect

1- Antianexiety 2-Sedative and hypnotic [small dose it is sedative and calming but increasing dose leading to sleeping effect drug for sleep] 3- Anticonvulsant 4-Skeletal Ms relaxation 5-Hallucination 6-Addiction

Side effect
1- Drowsiness 2-Ataxia and lethargy 3-Visual motor impairment co ordination 4-Behaviour changes and daytime sedation 5-Chronic drug dependence 6-C N S depression

Classification of hypnotics
1-Urea derivatives A-Diureides barbiturates
B Related ureides glutethimide

2-Benzodiazepines
3-Alcohols chloral hydrate 4-Aldehydes-paraldhyde
5-Acetylated carbinols- ethinamate

6-Imidazopyridine - zolpidem
7-Miscellaneous antihistaminic scopolamine Meprobamate
8-Drugs like morphine and pethidine besides acting as analgesic also possess hypnotic

2-Sedative and hypnotic drugs

Barbiturates

Non barbiturate

Barbiturate group dividing according to duration into

Ultra short acting short acting intermedium acting long acting NB The effect of barbiturate depend on the dose if given in the dose of 15mg 3 to 4 times day acts as daytime sedative [large dose produce sleep The hypnotic effect appear within 15 to 30 min and maintained for 4 to 5 hours ] Anesthetic effect short acting thiobarbiturates IV produce general anesthesia Side effect 1-physical dependence 2-Respiratory depression and death

Nonbarbiturate
Nonbarbiturate have different chemical structure than barbiturate so no cross allergy and it have similar pharmacological effect Less potent than barbiturate Side effect Ataxia euphoria neurological insomnia visual motor in coordination hypotension dyspnea respiratory depression nervousness buellered vision insomnia Types of nonbarbiturate as Benzodiazepine ethyl alcohol chloral hydrate antihistaminic

Nitrous oxide inhalation

It is inorganic gas compressed into liquid [ laughing gas]
It is wide used in dental clinic used for uncooperative patient to control anxiety It is neither inflammable nor explosive colorless sweet smelling It is not irritated to respiratory tract

Why using it ? Advantage

1-Rapid onset and recovery [ onset within 3- 5 min ] and no need recovery room as general anesthesia 2- Easy administration[ minimum side effect Effect on patient [reasonable reverse side effect] 1- Mental and physical relaxation 2- Indifference in surrounding 3- Elevation in pain perception 4- Euphoria drowsiness floating drink Side effect minimum side effect [behavior alteration as euphoria ]assume shock Contraindicate 1-Acaustic anxiety 2- history of pschycosis 3-migrain neurological damage with prolonged abuse

2-Pain control
It is one of the most challenge aspect of the clinical practice of endodontic and one by which the skillful endodontic called be a major Your skill in patient judged by pain control [ proper control of pain of patient you will good doctor] What's the pain ? Unpleasant physical and emotional experience trigged by noxious stimulus which transmitted and received in higher brain center along special pathway NB stimulus of the pain transited by pathway to higher brain center which receive this signal

How can management the endodontic pain ? 1-Preoperative

-Accurate diagnosis [before starting your treatment making proper diagnosis] - Anxiety reduction - What's the relation of the anxiety to pain ? - If proper control to anxiety of the patient that postoperative pain will decrease as the case report

2-Operative -

-Effective local anesthesia

-Operative technique endodontic treatment

3-Postoperative control pain through using the drugs -

Pain management strategies The [ 3 Ds ]

Diagnosis
Definitive treatment

Drugs

Diagnosis it is a critical initial step in mange pain because some condition have referred pain which not odontogenic relation as sinusitis so proper diagnosis to prevent misdiagnosis Definitive treatment According to condition to make pulpotomy or pulpectomy Why the definitive treat is important to reduce pain? In emergency condition of endodontic as
Acute pulpitis
Acute apical abscess Acute peri apical periodontitis

Why decreasing the pain by pulpotomy or pulpectomy and

drainage ?
1- Removing pulp tissue which cause interpulpal pressure from pressing on nerve fiber [pus drainage leading to remove the present pressure so pain relief 2-Removing or reducing inflammatory mediator of the disease which stimulate nerve fiber NB Definitive treatment reduce or eliminate peripheral causative factors cause hyperemia Predictable pain reduction strategies in emergency are \\[ pulpotomy or pulpectomy as in case of Acute pulpitis and secondly canal depridment and occlusal reduction ] In case of acute per apical periodontitis treat by pus drainage Definitive treat in per apical abscess is drainage pus through tooth and incision and drainage

NB IF patient have painful irreversible pulpitis is effective to management pulpectomy or pulpotomy

When make pulpotomy or pulpectomy ? If you haven't enough time and in multirooted canal so removing pulp tissue in pulp chamber [ pulpotomy] But if you have time pulpectomy is indicated The final conclusion that optimum mange of pain of odontogenic origin should be focus on two issue Definitive treatment is removing etiological source of infection at primary site with pharmacological mange if needed [ analgesic to control pain]

Analgesic
Narcotic opioid
analgesics morphine- like

Non narcotics Non Narcotics

1-Non steroid anti inflammatory drugs

2-Non anti inflammatory analgesics antipyretic

Analgesics
The drug that has the ability to raise visceral threshold to sub cortical level Drug used to decrease or eliminate pain without unconsciousness but GA with unconsciousness

1-Non steroid anti inflammatory drugs

It is first strategies for management the endodontic pain

1. 2. 3. 4. 5. 6.

Acetyl salicylic acid [ aspirin ] -Prop ionic acid [Ibrufen Advil ] -Ketoprofen ibuprofen -Mefenmic acid ponstan -Piroxicam folden -Zomax

Mod of action of NSADs

It inhibit synthesis of prostaglandin from arachonic acid [one of the inflammatory mediators] So they available to managing of pain and inflammation N B most of the pulp diseases are inflammatory disease so it need this drug for treat NB NSADs have the same of pharmacological effect but different in chemical structures

Pharmacological effect 1-Anagisic

2-antipyritic 3- Anti inflammatory 4-Antireheumtic -Gastric ulcer gastric acidity ulceration G IT disturbance - Blood reaggregation bleeding -Nephrotoxicty if it is used in large dose it have side effect on kidney -Allergic NB we must start definitive treatment and used drugs if needed at the last -In 90% the conditions of endo dontic pain reliefing after pulpotomy or pulpectomy whatever you using analgesic or not

Contraindications of NSADs
1-Sensitivity to drug 2-G I T disturbance peptic ulcer 3- Bleeding disorder renal disease 4-Chronic liver diseases 5-Pregnancy and nursing may be responsible for low birth weight babies

Non anti inflammatory analgesic antipyretic

Acetaminophen [ paracetamol]
Indication -Save in using during pregnancy -In case of G i T disturbance -No effect on bleeding time

Contraindication of acetaminophen
No absolute conaindication unless use in large dose 1- Allergy 2-Hepatic toxic and renal failure NB this drug is the second choice as less effective and not have anti inflammatory effect

Opioid [ Narcotic ] analgesic

It is natural or synthetic drug that bind specifically to opioid brain receptor and produce some or all pharmacological effect of morphine

Mode of action
Opioid means that drug make activation to opioid receptor in the brain which block to pathway of signal transmission from trigeminal neuralgia

NB Opioid work in high brain center so it is very effective but N S A D work

peripherally

Pharmacological effect
1-Analgesic 2-Hypontosis 3-Euphoria 4-Musle relaxation NB it have wide adverse side effect so it used only in sever orofacial pain

Dyesnae Drowsiness constipation Cough suppression Respiratory depression Physical dependence and addiction Indication
1-In moderate to sever pain

NB opioid are frequently used in combination with other drugs because the
combination permit lower dose of the opioid that can reduce the side effect [ Oxycodone + Acetaminophen ]

Analgesic strategy
Flexible prescription strategy has been purposed to maximize analgesic benefit with minimal exposure with side effect Analgesic strategies 1- to optimize dose of Narcotic before enter in Narcotic NB if pain not responded for routine treatment you can used combination of Narcotic plus N S A DS to decreasing the dose of Narcotic and simultaneously decreasing its side effect 2-Make balance between patient need for analgesic and potential averse side effect

Long acting anesthesia to control pain Duration is 8 -10 hours

3- Infection control
Optimum management of endodontic infection involved definite treatment and pharmacological adjunct when indicated Management of infection 1-Definitive treatment 2- Pharmacological adjunct

Definitive treatment
How to control the infection in root canal system? -Clean and shaping [instrumentation combined with irrigation with intracanal medicament Irrigation solution act as antimicrobial activity which irrigate inaccessible area [lateral canal and some area in pulp chamber ]that difficult for entering by file -It is flushing agent for debris Irrigation solution as sodium hypo chloride antibacterial

Secondly use may be need antibacterial [antibiotics ] Antibiotics are natural compound that posses antimicrobial effect and are use as holding adjunct to control of infection [ just helping ] NB if patient have periapical abscess you have starting endodontic treatment and finally description antibiotics if needed [antibiotic is consider to be help for agent Management of infection The simple most important decision in antibiotic treatment is not so much which antibiotic should be use but which antibiotic used at tour 1- Before prescribed antibiotic you must known if virtually need antibiotic 2-Which types of antibiotic you can to use

When prescription antibiotic to patient ?

There are must be clear evidence of bacterial invasion that is greater than host defense capability -There are must be clear evidence that invasion of microorganism above limit of immune system -In some cases virulence of microorganism is very high above immune system so described antibiotic 1-For treatment infection -Acute infection and patient have systemic manifestation [hotness redness lymphoadenopathy ] NB antibiotic described in acute infection not in chronic infection Diffuse swelling -Virulence of microorganism is very high and immune system cannot localize infection so you must help it To localized infection 2-As prophylaxis before infection -in immunocopromised patient -bacterial endocarditis

When antibiotic are not indicated ? When not use

antibiotic?

1-Irrevesible pulpitis 2-Acute apical periodontitis -Complete pulpectomy and reduction occlusion to relief pain and infection 3-Drainging localized swelling [chronic periapical abscess] -In localized swelling or sinus tract drainage the immune system is very good because it is tried to confined the infection and it need only removing irritant from root canal 4-Endo surgery -If site is clean and aseptic condition as body will heal without antibiotic NB antibiotic indicated in surgery in cases of implant or prosthesis as plates

Why not to prescribe antibiotics ?

1-Antibiotic are harm and not save as all lit cause GIT disturbance nepherotoxicity 2-Antibiotic are used as prophylaxis isn't commonly useful 3- Bacteria may achieve antibiotic resistance [ patient not respond to antibiotic ]
Antibiotic divided according to the potent into 1- Bacteriostatic suppress growth of microorganism stop growth lead to immune system control organism 2-Bacteriocidial direct killing -Antibiotic divided according to coverage into 1-Narrow spectrum work on single species 2-Extended spectrum worked on gram +ve plus some of gram ve 3-Broad spectrum work against both species Antibiotic dividing according to mode of action into 1-Ihibation of cell wall synthesis 2-Alteration of cell membrane integrity 3-Ihibation of R NA synthesis and suppress of nucleic acid

Road map [before prescription antibiotic]

1-Whate is the appropriate antibiotic ? 2- What is the dose and what's duration ? 3-When will are going to selected antibiotic ? Sensitivity test \\ Most endodontic infection are facultative anaerobic microorganism so we dont work sensitivity test NB Sensitivity test need 4 days to one week to performed so in endodontic infection dont depend on it but the choice is empirical Dose depended on age weight Adult in case acute infection \\ first give high loading dose [ 2 capsules 1000 mg at first time to high serum level ] Maintenance dose 500 mg every 6 hours Duration \\ how you known the proper selection to anti biotic ? After 24- 48 hours patient follow up if sign and symptom of acute infection [decrease swelling and redness hotness ] relief or patient good response and prognosis to antibiotic Duration after sign and s relief extended your time for using antibiotic two days to three days to prevent microorganism resistance [mutation of microorganism ]

All duration is 6 -10 days [2-3 days plus 2-3 days after s s relief ]

 Penicillin

What's antibiotic ?

It has spectrum of microbial activity including both facultative and anaerobic microorganism Penicillin Vk oral rout 500 mg \ 6 h Penicillin G I m injection Mod of action bactericidal Why penicillin is first choice in used ? -It is very save -Mode of action against antibacterial [facultative anaerobic microorganism ] Adverse side effect 1-Allergy All penicillin have up to 10% allergy G I T disturbance or anaphylactic shock To prevent allergy taking history from the patient if have allergy to one product he allergic to all types of penicillin -After 24 h follow up and take history of patient as[ diarrhea GiTdisturbancance -You can management anaphylactic shock 2- Gastro intestinal disturbance 3-Bacterial resistance [ develop pencillinase enzyme that destruction ring structure of penicillin Broad spectrum penicillin as amoxicillin cloxacillin dycloxaciillin NB To overcome problem of resistance of microorganism adding Kgluconate to amoxicillin prevent ring destruction as augmentin Neocene amoxicillin k gluconate

Treatment of anaphylactic shock

It is medical emergency and need immediate treat of laryngeal edema bronchospasma and hypotension Acute allergic reaction occurs within 1\2 h after administration penicillin Smooth ms contraction urticaria caused by release of histamine and bradykinin If treat does not begin immediately death can result 1-Lay patient flat and raise his legs 0.01ml of 1 : 1000 solution per kg i. m or 1 : 10.000 per kg slowly i.v 2-Attend air way in children 3- Administration of adrenalin Adult 0.5ml of 1: 1000 solution i. m or 3-5 ml of 1: 10.000 solution I m or slowly I v [the drug may be repeated after 15 20 min ] if patient sever ill and there is doubt about adequancy of circulation use adrenaline i. v ] NB iv injection of adrenaline 1 :1000 solution can be hazardous and can induce lethal cardiac arrhythmias and in patient on non-selective beta blocker sever anaphylaxis may not responded to adrenaline and addition of I. v salbutamol Administration of I v fluid hypotetion corrected by i. v fluid [ colloids] Corticosteroids hydrocortisone hemisuccinate 100mg I .v followed by oral prednisolone Antihistaminic drugs chlorpheniramin I. v slowly in dose 10 -20 mg over one min and repeated for 24 -48 h to prevent late manifestations of allergy it must be given after adrenaline Bronchodilators I. v aminophylline or nubulised salbutamol to resist bronchospasm Supportive measures oxygen and assisted ventilation

Cephalosporin
It is the second choice but the third generation is very expensive ;100pound] Indication use alternative to penicillin in cases resist to penicillin Side effect 1- Allergy 2- G I T disturbance 3- Anti vit K bleeding

Erythromycin 500 mg \ 6-8 h

If patient allergy to penicillin you will go to use erythromycin Adverse side effect Nausea vomiting hepatomegally toxicity

NB\\ it is not very effective

and blocking metabolism of certain drug

Metronidazole or flagel 500 mg \ 6- 8 h

Mode of action Bacteriocidial effective against anaerobic bacteria and protozoa but ineffective against facultative bacteria 1-G I T disturbance 2- Unpleasant metallic taste 3- brown discoloration Contraindication in alcoholic patient Use it can be used in combination with penicillin helping in sever dental infection [specially in periodontal infection ]

Adverse side effect

Clindamycin [Dalacin 150- 300 mg\ 6h] Mode of action Bacteriostatic and effective against facultative strict anaerobic bacteria Side effect 1-Sever G I T disturbance [ulceration in GIT Sometimes need to emergency in hospital if abuse of dalacin 2-Pseudomembranous enterocolitis NB\\ it is the last choice [ penicillin is more save ] used in serious anaerobic infection

Tetracycline

Used in periodontal infection not used in endodontic

Antibiotic prophylaxis for medically compromised patient

1-Cardiac patient [ bacterial endocarditis caused by streptococci ] 2- Patient with total joint placement NB\\ streptococci seeding in defect in heart or joint artificial or natural
3-Incidnous dependant diabetic patient uncontrolled
glucose] [ 60 80 mg \ dl normal blood

4- malnutrition patient
5- Patient with hemophilia and immune suppressed patient

When use antibiotic as prophylaxis

1- Intra alignment injection anesthesia 2- Root canal treatment 3- Endosurgery

What antibiotic used ? 1- Amoxicillin and ampicillin

It is effective against facultative anaerobic It dont develop penecillinase resistance organism Finally rapidly absorbed led to high serum level so it effective during work Dose \\ 2 gm 30 min before procedure [ or 4 capsule orally one hour before procedure ] If allergy to penicillin can used Erythromycin or clindmycin cephalixin

Before start to drug selection you have known 1-The efficiency of the drug 2-Adverse side effect 3-Medical history of the patient NB\\ Dont forget antibiotic are not substitute for proper local treatment before you select antibiotic there must be clear evidence of bacterial invasion that is greater than the host defense capability NB\\ All antibiotics are allergic nepherotxicity and hepatotoxicity It can produce ulcer pseudomembrane entercolitis