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Drugs in dentistry

Antibiotic

:Use only when there is an indication

Choose the narrowest spectrum drug that will be effective Consider the risk/benefit equation Prescribe an adequate dose Adequate frequency Adequate duration

Antibiotic

Antibiotic

Reasons for Failure of antibiotic

Wrong drug or dose Bacterial resistance Host defenses depressed Poor compliance

Antibiotic actions

BactericidalPenicillinsMetronidazole CephalosporinsAminoglycosides* Vancomycin*

BacteriostaticClindamycin Erythromycin Tetracyclines

Penicillin

Oral penicillin are penicillin V and amoxicillin

Pen V is narrow-spectrum against gram-positive Strep and others Drug of choice for orofacial infections Dose = 300-600 mg q6h Amoxicillin is broad-spectrum and better absorbed orally Dose = 250-500 mg q8h

Dental usesdental abscesses, infections around wisdom teeth and infections after surgery

Adverse reactions of penicillin

Allergy Diarrhea Nausea and vomiting Pseudo membranous colitis Candidacies

Allergy rate is 1-10% of the population Penicillins responsible for 75% of anaphylaxis deaths

Combine B_lactamase inhibitor:augmentinExtended specterum:ampicillin|amoxicillin_

Penicillin: Contraindication(None except hypersensitivity to penicillin)

amoxicillinIndications

Used to treat bacterial infection such as a dentalabscess. Used prophylactically

in the prevention of infective endocarditis

ContraindicationsHypersensitivity.

PrecautionsRenal disease.Glandular fever

Glossitis and tongue discolouration.Candidiasis.Hypersensitivity.Gastrointestinal upset.Pseudomembranous colitis.Hypokalaemia

Side effect

Cephalosporin

*Cephalosporins are bactericidal agents (which means that they kill bacteria)

Side Effectsmild stomach cramps or upset, nausea, vomiting, and diarrhea. Cephalosporins can also cause overgrowth of fungus normally present in the body.

Cross allergy with penicillinsBecause the cephalosporins are structurally similar to the penicillins, some patients allergic to penicillins may be allergic to a cephalosporin antibiotic.

antibiotic useful for the treatment of a number of bacterial infections. It is of the glycopeptide antibiotic class and is effective mostly against Gram-positive bacteria.

Vancomycin

* treatment of penicillin-resistant Staphylococcus aureus

Vancomycin should be reserved for a condition that does not respond to metronidazole

Side effectsIV vancomycin include: local pain

nephrotoxic and ototoxic drug

Vancomycin should be reserved for a condition that does not respond to metronidazole

Group includes tetracycline, doxycycline (Vibramycin, Periostat) and minocycline (Minocin)

Broad-spectrum, bacteriostaticUseful in treatment of periodontal disease Widespread resistance Host of adverse effects including: tooth staining, photosensitivity,

blood dyscrasias, GI effects

Tetracycline

Contraindications: Renally impaired patients should not be

treated with any of the tetracyclines except doxycycline. Accumulation of tetracyclines may aggravate preexisting azotemia (a higher-than-normal level of urea or other nitrogen-containing compounds in the blood)by interfering with protein synthesis, thus promoting amino acid degradation. The tetracyclines should not be employed in pregnant or breast-feeding women or in children less than 8 years of age.

Tetracycline

Aminoglycoside

Aminoglycosides are a group of bactericidal antibiotics, which act by

inhibiting bacterial protein synthesis. Their use is restricted because of potential side effects, as they can cause ear and kidney damage. All the aminoglycosides resemble each other in antibacterial activity, pharmacokinetics and toxicity.

Group includes erythromycin, clarithromycin and azithromycinErythromycin was the former drug of choice for penicillin-

allergic/penicillin-resistant patients Numerous GI adverse effects Active against gram-positive aerobic/facultative staph and strep and

gram-negative anaerobes

Macrolides

Contraindications: Patients with hepatic dysfunction should be

treated cautiously with erythromycin, telithromycin, or azithromycin, because these drugs accumulate in the liver. severe hepatotoxicity

An alternative for penicillin-allergic or penicillin-resistant patients

*Active against gram-positive and gram-negative anaerobes and facultative/aerobic bacteria

*Dose = 150-300 mg q6h

Clindamycin

Clindamycin

Metronidazole

Antibiotic adverse reaction

Overall incidence is 6-7% Possible reactions include: GI tract complications Colonization of resistant or fungal strains Cross reactions with other medications Pseudomembranous colitis Development of resistant bacteria and superinfectionLittle concern about short-term use

Antibiotic prophylaxis

Indicated for patients with:

Prosthetic heart valves History of infective endocarditisCardiac transplant with subsequent heart valve problem Some congenital heart conditions Unrepaired cyanotic disease (incl. shunts and conduits) Repaired defect (<6 months) with prosthetic material or device Repaired defect with residual defect at or adjacent to the site of

repair Antibiotic Prophylaxis

Indicated for the following procedures:

Implant placement Extractions Periodontal procedures Reimplantation of avulsed teeth Endodontics beyond the apex of the tooth Intraligamentary injections Subgingival placement of fibres or strips Placement of orthodontic bands Polishing of teeth or implants where bleeding is expected

May be indicated for patients at increased risk including:

< 2 years post-surgery Inflammatory joint disease Immunosuppressant (incl. drug-induced, radiation-induced, HIV) Previous joint infections Type I diabetes mellitus

Hemophilia Malignancy

Two randomized controlled studies were subjected to meta-analysis Showed a statistically significant higher number of implant failures in

the group that did not receive antibiotics “It might be recommendable to suggest the use of one dose of

prophylactic antibiotics prior to dental implant placement

Antibiotics & Implant Surgery

Indication of antifungal drugs

-Stop spread of infection

-Treat oral thrush

-Denture stomatitis

-Used in combination with antibiotic in case of abscess

DescriptionA polyene antifungal

IndicationsUsed to treat candidal infections

Amphotericin B

Side effect-Gastrointestinal disturbances.-Renal damage.-Hypokalaemia.-Myopathy and neuropathy-Dependence.-Respiratory depression

PrecautionsRespiratory disease.Pregnancy and breastfeedDrug and alcohol abuse.Psychoses.Porphyria.

Amphotericin B

IndicationsUsed in the treatment ofcandidal infections

ContraindicationsHypersensitivity.

Side effectsHypersensitivity.Gastrointestinal upset

Nystatin(nystan)

DescriptionDiazole antifungal agent.IndicationsUsed to treat oral fungal infections

Fluconazole (diflucan)

ContraindicationsPrevious hypersensitivityBest avoided during pregnancy and when breastfeeding.

PrecautionsUse with caution in patients with renal and hepatic disease.

Side effectsHypersensitivity reactions.Gastrointestinal problems

Fluconazole

Mechanism

Inhibit synthesis of ergosterol

Used for the treatment of

a. systemic infections

b. mucocutaneous candida infections

c. cryptococcal meningitis

Avoid use in patients with kidney problems

ketoconazole

Clotrimazole

Indicated for the local treatment oforopharyngeal candidiasisUsual adult dose is one lozenge five

Antiviral drugsTreatment of viral infections has posed the

greatest problem of all infectious organisms

Viruses are obligate intracellular organisms

The herpes virus is of the most interest to the

dental health care worker

Acyclovir (Zovirax)Indication

Used in topical , IV, oral formulations

Herpes simplex virus 1,2 (HSV)

Varicella zoster virus

And used in treatment of herpes simplex

Herpes Simplex

Herpes viruses are associated with “coldsores”

Most antiviral agents are either purine orpyramiding analogues that inhibit deoxyribonucleicacid (DNA) synthesis

Adverse reactionsTopical administration: produces burning, stinging,

or mild pain in about one third of patientsOral administration: headache (13%) is one of the

most common; other central nervous system(CNS) and GI effects

Parenteral administration: local reactions at the

injection site are the most common

Side effect of acyclovir

-Stinging sensation at site of application, altered taste, gastrointestinalupset, renal failure, bone marrow depression, tremors and convulsions,lichenoid reactions, rash and urticaria

Penciclovir

Available topicallyShown to reduce both the duration of the lesion

and the pain of the lesions on the lips and faceassociated with both primary and recurrent herpes

Docosanol 10%

Available topically and without a prescriptionHas been shown to decrease healing time by

about a half day in patient with recurrent orolabialherpes when started within 12 hours of theappearance of prodromal symptoms

Famciclovir

IndicationsUsed in the treatment of herpes zoster and genital herpetic infections

ContraindicationsHypersensitivity, children.

PrecautionsRenal and liver disease, pregnancy and breastfeeding.

Side effectMaitenance of adequate fluid intake is required with high doses.Fever, gastrointestinal upset, dizziness, confusion, and hallucinations,headache and sinusitis, rash.

Valaciclovir (Valtrex)DescriptionAn antiviral drug. It is a pro-drug for aciclovir.

IndicationsUsed to treat herpes simplex and varicella-zoster infections..

ContraindicationsHypersensitivity, children.

PrecautionsRenal disease, pregnancy and breastfeeding.

Side effectsGlossitis, altered taste, gastrointestinal upset, renal failure, bonemarrow depression, tremors and convulsions, rash, and urticaria.

Muscle relaxant

Muscle relaxant

DescriptionA benzodiazepine sedative and anxiolytic drug with anticonvulsantproperties.

Valium))diazepam

IndicationsUsed in dental sedation and preoperative anxiolysis (although it hasnow been superseded by midazolam when intravenous techniquesare employed: for oral sedation temazepam is the drug of choice).Also indicated in the emergency treatment of epilepsy in the dentalsurgery.

Severe respiratory disease.Severe liver disease.Porphyria (although should be used in emergency management ofstatus epilepticus).

PrecautionsHistory of drug abuse.Severe liver disease.Severe muscle weakness (myasthenia gravis).Pregnancy and breastfeeding.Unwanted effectsXerostomia.Respiratory depression.Hypotension.Visual disturbances

Contraindication

OxazepamDescriptionA benzodiazepine anxiolytic.

IndicationsUsed in the short term treatment of anxiety.

Effects on oral and dental structuresXerostomia may occur.

Effects on patient managementAs the drug is only used short term xerostomia should not producesignificant problems, however a preventive regimen may be considered.The main interaction in the management of patients receivingany benzodiazepine therapy is the use of benzodiazepine sedation.

TemazepamDescriptionA benzodiazepine anxiolytic drug.

IndicationsUsed as an oral sedative for dental treatment (also used short term totreat insomnia).

ContraindicationsSevere respiratory disease.Severe liver disease.Myasthenia gravis.

PrecautionsRespiratory disease.Pregnancy and breastfeeding.

Chlordiazepoxide (Librium)DescriptionA benzodiazepine anxiolytic.

IndicationsUsed in the short term management of anxiety and in alcoholwithdrawal.Effects on oral and dental structuresXerostomia can occur.

Effects on patient managementAvoid concurrent prescription of CNS depressant agents.

Analgesic

Mechanism of action

Paracetamol inhibits prostaglandin biosynthesis under somecircumstances (e.g. fever), but not others. The difference fromother NSAIDs is still under investigation

Adverse effectsThe most important toxic effect is hepatic necrosis leading toliver failure after overdose, but renal failure in the absence ofliver failure has also been reported after overdose. There is noconvincing evidence that paracetamol causes chronic liverdisease when used regularly in therapeutic doses (4 g/24

hours). Paracetamol is structurally closely related to phenacetin

NSAIDS

Ibuprofen

CelebrexDescriptionA selective COX-2 inhibitor.

IndicationsPain and inflammation in osteoarthritis or rheumatoid arthritis

Effects on oral and dental structuresStomatitis, sinusitis and taste disturbances can occur.Effects on patient managementIf patient develops celecoxib-induced stomatitis then the drugshould be stopped and a full blood count carried out

Acetaminophen

IndicationsPain and inflammation associated with musculoskeletal disorders,e.g. rheumatoid arthritis, osteoarthritis, and ankylosingspondylitis.Postoperative analgesia.

Effects on oral and dentalPatients on long-term NSAIDs such as acemetacinmay be affordedsome degree of protection against periodontal breakdown. This arisesfrom the drug’s inhibitory action on prostaglandin synthesis. l

NSAID contraindications

Gastric ulcers Bleeding dyscrasias or concerns Significant renal disease asa (or other NSAID) hypersensitivity Combination of severe asthma, nasal polyps and multiple allergies Can lead to ARDS

Pregnancy Especially in the 3rd trimester Children asa only Elderly Concurrent use of certain other drugs

NSAID Adverse Effects

Increased bleedingGastric mucosal damage Dyspepsia RenotoxicityAnaphylactoid reactions

Cox-2inhibitor

Usually used for analgesia for moderate to severe pain in dentistry Other opioid effects: Sedation Mood alteration AntitussiveRespiratory depression Nausea and vomiting Constipation

Opioid

It is N-allyl analogue of oxymorphonehave a high affinity for mu receptorand,

lower affinity at delta and kappa

sites. It selectively antagonizes the

respiratory depression produced by

opioids.

NALOXONE

NALTREXONEIt is a pure antagonist and chemically related to naloxone. It is more potent thannaloxone and because of its longer duration of action, it can be used as maintenancedrug for morphine addicts.

Morphine

Meperidine

Codein

Oxycodon

Hydromorphone

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