DEFINITION
Dental Drug: It can be defined as a drug that is being prescribed or used by a dentist in his general practice.
Usually in dental prescription locally acting drugs are used more often as compared to systemically acting drugs except in the situations where systemic administration of the drugs are essential for example in severe pain, infection and in minor or major surgical procedures where drugs like analgesics, antibiotics and sedatives are used systemically. It should be considered that even locally acting drugs are also not absolutely free from minor or major systemic side or adverse effects.
DENTIFRICES
Dentifrices are therapeuto-mechanical aids meant for cleaning the teeth with the help of a toothbrush. They are available as tooth powders and toothpastes. They are also employed for filling and polishing the teeth. The powder should be of a fineness which passes through a 60-mesh powder sieve. Though the prime function of a dentifrice is to assist the brush in cleaning the teeth, addition of few specific substance like fluoride and antiseptics can produce some additional benefits. The ingredients of dentifrices are:
- Detergents: Detergents are cleansing agents which act by following mechanism:
- Lowering the surface tension such as hard soap, i.e. they are having emulsifying properties.
- Dissolving fatty substances and mucous plaques and loosening the debris adhering to the teeth.
- Foaming and scrubbing the teeth, act as lubricants.
- Liberate oxygen such as hydrogen peroxide.
Hard soap: It has multipurpose action. It includes sodium ricinoleates, spoanimales, sodium alkyl sulphate a pale yellow powder is effective in both acidic and alkaline medium and in hard water.Other detergents: Sodium bicarbonate (act by dissolving proteins), hydrogen peroxide and sodium perborate (act by liberating free oxygen and detaching the debris). - Abrasive agents: Dental abrasives are fine powdered substances which assist mechanically the scouring action of the toothbrush. They are basically the inorganic salts of low solubility, e.g. pumice (light porous stone of volcanic origin), calcium phosphate, calcium and magnesium carbonates, magnesium oxide, charcoal, silicates and kaolin.Uses:
- Whiting (polishing) the teeth and silver amalgam fillings.
- In toothpastes and tooth powders for cleaning the teeth.
- Antiseptics: They are used in very small amounts. This small amount of antiseptics may not be sufficient to exhibit adequate antiseptic action. Commonly used antiseptics in dentistry are thymol, menthol, benzoic acid, boric acid, eugenol, calcium and magnesium peroxide (2–5%) and cinnamon (up to 1%). Eugenol has the odor of clove and is also a local anesthetic used for dental filling while thymol is a powerful antiseptic, used in mouthwashes and gargles.
- Coloring agents: These agents are used to make the preparation more attractive and acceptable for commercial purpose. Liquor rubri, liquid azorubri, tincture cocci (2%), and caramini are used to imparts red color while methylene blue (0.001%) is used to impart blue color. Red color in acidic mouthwashes is employed with magenta (0.05%).
- Sweetening agents: Commonly used sweetening agent is saccharine. It enhances the palatability. Though sucrose can also be used, it causes fermentation and is therefore not preferred while lactose is less likely to do so.
A good preparation of dentifrice should posses the following properties:
- It must be caustic, should be pleasant in taste.
- It must be non-decalcifying and non-over-abrasive
- Sufficient cleansing action
- It must not affect the action and synthesis of saliva, and should not damage the gums or the the teeth.
OBTUNDENTS (Table 14.1.1)
Obtundents are agents which are used to diminish or eliminate the dentine sensitivity so as to make the excavation procedure painless. Obtundents can act by one of the following mechanisms:
- Destruction of the nervous tissue: e.g. Absolute alcohol.
- Precipitating surface proteins: e.g. Astringents like zinc chloride and silver nitrate.
Paralyzing the sensory nerve endings: e.g. phenol, camphor, menthol, thymol, clove oil, benzyl alcohol, etc.
Properties
- It should be free from pain.
- There should not be any staining over the dentine.
Its penetration should be sufficient so as to remove the dentine sensitivity.
Limitations: With the use of obtundents, irritants may stimulate the formation of secondary dentine (if applied for long period) and pulp may shrink. This group of drugs is now mostly replaced by local anesthetics like lignocaine or xylocaine which are used topically for painless excavation.
DESENSITIZING AGENTS
Dentine sensitivity is the most common problem affecting thousands of people all over the world which is characterized by pain that could be elicited by mechanical, chemical or thermal stimuli, i.e. the patient experiences pain while eating specially hot and cold food, sweet or sour food or even sometimes while brushing the teeth. This hypersensitivity is either due to removal of enamel or denudation (exposure) of the root surface. Loss of enamel may be due to mechanical injury or chemical erosion due to acidic food. The root surface gets exposed either due to wrong habit of tooth brushing or due to chronic periodontal diseases.
Characterstic features of Desensitizing Agents
- They should be non-irritant, non-toxic.
- They should be rapid acting, easy to use and have a long-lasting effect.
No such single agent is available at present. Hence multi-modal approach could be employed.
Different Desensitizing Agents Used in the Management of Dental Hypersensitivity
- Physical methods : Restorations-Glass ionomer.
- Tubule sealants : 4-Methacryloxyethyl trimellitate, of the tubule
- Agents occluding dentinal tubules: Tresiolan, Potassium oxalate and nitrate, Calcium hydroxide, Sodium and Stannus Fluorides and Formaldehyde
- Agents precipitating proteins:
- Astringents: Silver nitrate, Zinc chloride
- Precipitating tubule proteins: Strontium chloride and Formaldehyde causing occlusion
- Physical methods: Restorations to cover the dentinal tubules using glass ionomer and composites are found to be effective in patients with eroded gingiva. A combination of glass ionomer and composite resins is more beneficial when compared to either agent used alone. In patients with gingival loss, soft tissue grafts cover the exposed dentin to relieve the sensitivity.
- Tubul sealants: The newer agents including 4- methacryloxyethyl trimellitate have been tried as desensitizers.
- Agents occluding dentinal tubules
- Fluorides: High doses of fluorides act by hardening the dentine surface and is claimed to be effective in 3–4 weeks. Fluoride iontophoresis (2% NaF) may be used to occlude the dentinal tubule. The procedure is very effective but is expensive and may require repetition.
- – Sodium fluoride paste or gel: It is applied to dried sensitive area and left for 3 minutes. This leads to an increase in secondary dentine formation, which blocks dentine tubules and reduces sensitivity.
- – Stannous fluoride: It acts by inactivating enzymes within the odontoblastic process and by inducing mineralization within the dentine tubules which reduces sensitivity.
- Tresiolan: It is prepared by mixing two siloxane esters. When applied to dentine, it polymerizes in the presence of moisture to form an organosiloxane resinous skin. This plugs the orifices of the dentine tubules and forms a mechanical barrier against various stimuli.
- Strontium chloride: They have very high affinity for calcified tissues and they act by enhancing the rate of calcification which obliterates dental tubules.
- Potassium nitrate: It acts by occluding the dentinal tubules through crystallization. Used as a toothpaste twice a day, potassium nitrate (5%) is a popular and effective desensitizing agent.
- Calcium hydroxide: It supplies calcium ions which hasten remineralization of the exposed dentin. But it has to be applied by a dentist and may require repeated application.
- Agents precipitating proteins
- Astringents-Silvernitrate and Zinc chloride: They act by precipitating proteins. They cause permanent staining of the teeth and appear to be toxic to the gingival tissue and pulp and therefore not preferred now a days.
- Formaldehyde and Strontium chloride: They act by precipitating proteins within the tubules and occluding them. They have been used in the form of dentifrices in the past but currently they are also not used.
BLEACHING AGENTS
Bleaching agents are the chemical agents used to remove pigmentation of the teeth. They include:
- Oxidising agents: Like sodium peroxide (50% aqueous solution), pyrozone (25% H2O3) and perhydrol (30% H2O2 in water) are commonly used oxidizing bleaching agents. Sodium peroxide forms sodium hydroxide on losing oxygen, therefore use of fat solvent is not necessary.
- Reducing agents: Like saturated solution of sodium thiosulphate (hyposulphate), which is used to remove the superficial staining with silver (Ag), permanganate and iodine.
- Chloride compounds: A mixture of chlorinated lime and a few drops of acetic acid is used, this leads to liberation of chlorine. Sometimes, liquor sodium chlorinate may be used but potency is very less.
- Ultraviolet rays: It can be used for bleaching of the dentine from a carbon or mercury arc lamp or some modern device.
- Iontophoresis: Hydrogen peroxide can be used to remove stains from the teeth.
Specific Stain Treatment
- Silver stain: bleaching agents— hypochlorite.
- Iodine stain: bleaching agents—weak ammonia or sodium thiosulphate.
- Aniline dyes: bleaching agents—chlorinated lime + acetic acid.
- Iron stain: bleaching agents—hypochlorites and oxalic acid.
MUMMIFYING AGENTS
Mummifying agents are the substances used to harden and dry the tissues of the pulp and root canal. This hardening makes the tissues resistant to infection and can maintain aseptic condition. This treatment is essential when it is not possible to remove the pulp and the content of root canal completely. Astringents and antiseptics are used either separate or in combination as a paste for this purpose. Some mummifying agents are:
- Iodoform: It acts by liberation of iodine. It is made into a paste with eugenol, phenol, tannic acid, cinnamon oil and glycerol for use as an mummifying agent.
- Liquid formaldehyde: It is used with zinc-oxide and glycerine with local anesthetics like lignocain to harden the tissues. It should be diluted 3 to 4 times with water before use.
- Paraform: It acts by releasing of formaldehyde very slowly and is used in combination with zinc oxide and glycerine or other combination like zinc oxide, cresol and zinc sulphate.
- Cresol, tannic acid and ammonia silver nitrate: These are the other substances which can be used as mummifying agents.
ASTRINGENTS
Astringents are agents which act by precipitating proteins in superficial cells of the skin or mucous membrane and inhibit or diminish their excretions or exudations when applied. This leads to the formation of an insoluble layer of precipitated protein and hardening (act as a mummifying agents) of the surface which ultimately:
- Protect the membrane from irritants.
- Protect the membrane by resisting bacterial infection.
- Check minor hemorrhages and reduce bleeding.
- Delay absorption from the surface.
Classification: They are subdivided into two groups :
- Vegetable astringentTannic acid, catechu, gall and kremeria. Tannic acid possesses acid radicle, which precipitate gelatine and protein and therefore it is an powerful astringent. It hardens superficial cells, reduces mucous secretions, prevent toxin absorption and prevent inflammatory reactions. Used in lotions (3 to 5%). Catechu has similar actions like tannic acid.
Uses:
- As mummifying agent
- As hemostatic agent
- As obtundent
- As astringent dentifrice
- As an astringent mouthwash
- Metallic AstringentSalts of zine, copper, iron, aluminium and silver, lead; also alum.Alum: It acts by precipitating proteins, it is an astringent, hemostatic agent, antiseptic. Copper sulphate: It is specifically used for the treatment of indolent ulcers of gums and to syringe pyorrheal pockets. Zinc chloride: It is a caustic astringent useful for aphthous ulcers, ulcerative gingivitis and for syringing pyorrheal pockets. Other astringents includes Ferric chloride solution and Lead acetate, but because they stain the teeth, therefore these are rarely used now a days, while Silver nitrate and Mercuric chloride are the weak astringents.
Uses:
- As an astringent mouthwash for stomatitis.
- As astringent paint for mastoiditis.
- As hemostatic agent.
- As lotion for chronic alveolar abscess.
- As astringent for syringing pyorrheal pockets.
- As astringents for ulcerative gingivitis and aphthous ulcer.
MOUTHWASHES
Mouthwash is meant to rinse the mouth with mechanical cleansing action and freshening action (deodorising the oral cavity). Approximately 15–30 ml of the diluted solution is used for rinsing and gargling the mouth for at-least 30 seconds to one minute. Mouthwashes contain astringents, antiseptics with or without obtundents, coloring and sweetening agents. They are also helpful in reducing plaque formation and in the treatment of various diseases discussed below. They are of various types which includes mouthwash for daily use, antiseptic and astringent mouthwash, detergent mouthwash, obtunding mouthwash and some specific mouthwashes. Prolonged use of concentrated solutions result in staining.
Types of Mouthwashes
- Plaque inhibitory mouthwash: Chlorhexidine–2% mouthwash or 1% gel, it specifically inhibits plaque formation on teeth.
- Antiseptic mouthwashes: They contain cetylpyridinium chloride 0.05%, povidone iodine 1%. Other mouthwashes also contain oxidizing agents like hydrogen peroxide 6% or sodium perborate 68.6%, are useful for the treatment of acute ulcerative gingivitis (anaerobic-organism) + They also posses mechanical cleansing property.
- Obtundent mouthwash for sensitive oral lesion: It contains (zinc chloride + resorcinol)
- Detergent mouthwash used for cleansing and deodourising action.
For different specific problems of the oral cavity, different and specific mouthwashes are available, e.g. Amphotericin B or nystatin mouthwash for oral candidiasis, pilocarpine mouthwash for xerostomia, tannic acid mouthwash for the prevention of bleeding after oral surgery, etc.
Uses
- Sensitive oral lesions
- Halitosis (bad breath)
- Soreness under dentures
- Postoperative and other bedridden patients for maintaining oral hygiene; mouthwashes are also refreshing
- Stomatitis
- Surgical impaction-after removal of impacted tooth.
Chlorhexidine (CHLORHEX REXIDINE) and Povidine iodine (BETADINE) are some commonly used mouthwashes.
DRUGS USED IN DENTAL HEMORRHAGE
Postoperative hemorrhage is one of the most common complication of dental extraction. Prolonged bleeding following extraction of the tooth is usually the first indication of a hemostatic abnormality.
Dental hemorrhage is usually managed by careful suturing, debridement of socket and application of firm pressure, preferably under local anesthesia.
Local hemostatics are also called styptics. On its application they control (arrest) local bleeding following extraction of the tooth and other dental procedures. Some important styptics are:
Local Hemostatics (Styptics)
- Epinephrine (Adrenaline) in 1:1000 dilution. It control bleeding by vasoconstriction
- Thrombin powder
- Thromboplastin powder
- Tannic acid (Astringent).
Some important styptics are discussed below:
Oxidized cellulose: It is treated with nitrogen dioxide and it stops bleeding by forming a clot on moistening.
Human fibrin foam: An alternative absorbable agent which can be packed into the socket and sutured if required.
Gelatin sponge: It is used to treat bleeding tooth socket and can remain in position for 2 weeks and later on absorbed completely.
Vasoconstrictor agents: They include adrenaline and nor adrenaline 1 : 10,000 solution of adrenaline soaked in sterile cotton is commonly used in tooth-sockets.
Aluminum chloride solution: Aluminium chloride solution of 5–10% has been used and these produce some hemostatis. Concentration stronger than this results in tissue destruction and are not recommended.
Ferric sulfate solution: NF (Monselis Solution): This solution is a styptic form of astringent and is applied with cotton pellets. It is more effective if applied under pressure.
Side effect: Black stain on teeth.
Gingival retraction cords: Cords impregnated with local hemostatic agents such as epinephrine, aluminum chloride or ferric sulfate.
It should not be used in patients with cardiovascular diseases.
- Thrombin powder: It is dusted over bleeding surface.
- Thromboplastin powder: It is used as styptics specially in surgical procedures.
- Astringents: Tannic acid are used.
DISCLOSING AGENTS
Disclosing agents are the agents (dyes) which are used to make the supragingival plaques visible. Dental plaques are usually invisible. To stain the plaque, solutions of disclosing agents may be used either by painting the teeth with a cotton swab or by chewing the tablet and then rinsing the mouth with water.
Following are the examples of disclosing agents:
Fluorescein dye: Fluorescein dye stains the plaque yellow on application. It does not stain the soft tissues. It requires special UV light to see the stained plaque.
Erythrosin: Erythrosin dye stains the plaque area red but it may also stain the soft tissues. It is the most commonly used disclosing agent.458
Two-tone dyes: It is a solution containing a combination of two dyes. New plaques are stained red, while mature plaques are stained blue, therefore it can be used to differentiate mature and immature plaque and it also do not stain the gingival tissues.
DENTAL PLAQUE AND ITS TREATMENT
Periodontal Diseases and Management
Classification of periodontal diseases:
- Inflammatory diseases: Gingivitis, Periodontitis (Pyorrhea)
- Dystrophic diseases: Gingivosis, Juvenile Perio-dontitis
- Neoplastic diseases
- Anomalies
Plaque is a thin transparent, soft biofilm deposits on tooth surface containing microorganisms which could be mineralized or non-mineralized. These deposits are formed on inadequately cleaned teeth. Poor oral hygiene and carbohydrate rich diet encourage plaque formation. Plaque contains 80% of water.
Plaque is the most important factor responsible for periodontal diseases as it induces inflammation of gingival and periodontal fibers. It is more harmful than calculus because it contains more bacteria and causes more irritation to gingival tissues. Therefore complete plaque removal by any means i.e. by mechanical or chemical means is therefore essential in controlling and preventing periodontal diseases.
Treatment: Plaques are more harmful and dangerous than calculus because it contain more micro-organisms specifically (strept. mutans and strept. sobrinus), causes irritation to gingival tissue and are more susceptible to periodontal disease and caries. Therefore all plaque should be removed as quickly as possible. Suitable antibacterial agents (antibiotics) are used to control these organisms (infection). Alternatively it can also be treated by altering tooth surface to prevent the bacterial attachment to the plaque.
Antibacterial Agents. Penicillins, aureomycin, erythromycin and tetracyclines are used systemically while bacitracin, kanamycin, vancomycin and polymyxin-B are used as topical mouth rinses or gels. Long-term use of antibiotics should be avoided because of the risk of toxicity. Preference should be given to those antibiotics which are not absorbed from the oral mucosa. Tetracyclines given systemically or as a mouth wash or by direct irrigation reduces bacterial colonization of teeth and periodontal pockets. Systemic administration of metronidazole or tinidazole retard plaque formation and the development of gingivitis. Other agents that can be used in plaque control are:
Fluorides: Fluorides inhibit enzymatic reactions involved in glycolysis.
Oxygenating agents: Like hydrogen peroxide and sodium perborate. They act by liberating nascent oxygen.
Enzymes: They are the mucinases, extracts from dried pancreas containing trypsin, chymotrypsin, lipase, amylase, dextranase, etc. which are incorporated in chewing gums and toothpaste.
Halogens: They releases chlorophors and iodophors which act like (antiseptics) and are used in many mouthwashes.
Bis-biguanides: Chlorhexidine and Alexidine are also used as antiplaque agents. They are used as mouth rinses, gels and in dentifrices for the control of plaque and gingivitis.
Antiseptics: i.e. Chlorhexidine 0.2% aqueous solution as mouth wash is also quite effective.
DENTAL CARIES AND THEIR TREATMENT
Dental caries is a slowly progressive, degenerative, infective, irreversible condition characterized by demineralization and decay of hard and soft parts of the teeth resulting in cavitations and disintegration.
Role of carbohydrate and acids: Easily fermentable carbohydrate, e.g. sucrose plays an important role in the development of caries. Fermentation of carbohydrates in the oral cavity results in the production of acids like lactic acid, aspartic acid etc. These acids are responsible for demineralization and decalcification of the teeth. Carbohydrates also leads to synthesis of certain polysaccharides (glucan, levan and dextran) in the presence of certain enzymes, these polysaccharides hold the plaque tightly over tooth surface and therefore responsible for caries.
Role of microorganisms: Dental caries is a bacterial disease. Streptococcal mutans and lactobacilli are the important strains responsible for caries. These bacteria forms large amount of sticky, insoluble polysaccharides and also produces lactic acid from sucrose which is responsible for caries.
Role of plaque: Plaque is a thin transparent, mucinous film over tooth surface. This film may hold the bacteria over tooth surface. It also prevents the escape of acid into saliva and therefore indirectly responsible for dental caries.
Thus both organic and inorganic matter of the teeth are destroyed. As the process continues, the pulp is penetrated and the infection may spread into the systemic circulation.459
Prophylaxis [Prevention of caries]: Dental caries can be prevented by the following measures:
- Public education especially to children regarding dental hygiene, proper use of toothbrush, dentifrices and prevention of caries (early management)
- Soluble carbohydrates should be avoided specially in the person who are suffering from dental caries. Sweets, ice-creams, chocolates, etc. are rich sources of soluble carbohydrate and are also good substrate for bacterial, growth.
- “Fluoride therapy” can be used to increase resistance of the host.
- Prevent formation of plaque, by using anti-plaque drugs.
- Try to reduce ‘in-between’ eating habits.
Treatment
Fluorides: Fluoride, a halogen (electronegative compound) has been shown to reduce the incidence of dental caries. Its suggested mechanism of actions are:
- It inhibits the bacterial enzymes which are responsible for producing lactic acid and therefore prevents acid decalcification of the tooth structures.
- Hydroxyapatite is the major constituent of the enamel and dissolves easily in the presence of lactic acid. Application of sodium fluoride either internally or externally converts hydroxyapatite of enamel, dentine or bone to fluorapatite which is more resistance to acid attack. Thus fluorides make the outer layers of enamel harder and more resistant to demineralization.
- It inhibits plaque formation and also reduces anaerobic glycolysis and lactic acid formation within the formed plaque.
Systemic administration via water supply
- 0.5–l ppm i.e. 1 part of fluorine to 1 million part of water is considered adequate for prophylaxis purpose. Fluoridation of drinking water is the most effective measure in preventing dental caries, if consumed prior to eruption of the permanent teeth. Several large-scale studies have established the beneficial effects of optimum fluoridation of communal water supplies in preventing caries. More than 1–2 ppm results in toxicity, causes dental fluorosis.
- Adequate prophylaxis can also be achieved by supplementing fluorine in the form of sodium tablets (1 mg F/ tablet) in diet. It is suggested that using one tablet a day during the period of tooth development to nursing mother and to children up to the completion of calcification of third molars.
Topical application
- 2% sodium fluoride, or 8–10% stannous fluoride once a week for 4 weeks also prevent caries.
- Fluoride (dentifrices) mouth rinses [0.2% sodium fluoride solution containing 900 ppm of fluoride] for one minute-to be used twice a week will also effectively prevent caries.
- The topical application of sodium fluoride every six months may result up to 40% reduction in the incidence of dental caries.
Toxicity
Acute toxicity: It results from accidental or suicidal ingestion of fluoride-containing rat poisons. 2.5–5 gm is the lethal dose in adults. Symptoms due to overdose include nausea, vomiting, burning abdominal pain and diarrhea. Hypotension and cardiac arrhythmias are the cardiac manifestations.
Chronic toxicity: It results due to ingestion of fluorine over a long period or in a higher dose (more than 2 ppm / day regularly). Dental fluorosis leads to mottling of the enamel. Mottled enamel occurs as dull paper white patches over the surface of the enamel and brownish discoloration of teeth. Skeletal fluorosis resembles osteomalacia histologically characterized by joints pain and stiffness, osteosclerosis of the spine and pelvis causing spontaneous fractures.
Antibiotics: Dentifrices containing penicillin, chloramphenicol, bacitracin and streptomycin can be used to reduce bacterial index. But using antibiotics alone is not sufficient to prevent caries formation.
Silver nitrate: Area should be cleaned properly, careful assessment of infection should be done and then silver nitrate is applied on the deciduous teeth.
Chlorophyll: This green colored pigment found in leaves of the plants is found to be beneficial for dental health and protective against dental caries.
ROOT CANAL THERAPY AND APEXIFICATION DRUGS USED FOR FILLING ROOT CANAL
- First of all rendered aseptic cleaning of root canal is required before using the materials for the root canal.
- Root canal therapy and apexification is done on those teeth, where inflammation has extended in radicular pulp also.
- The material used for filling should be insoluble and non-irritant.
- In root canal procedure, all the pulpal tissues either radicular or coronal, are removed and root canals are prepared to retain an inert obturating material.
- Commonly used materials are gutta-percha, chlorapercha (10% gutta-percha in chloroform), euco-percha (10% gutta-percha in eucalyptol), silver amalgum, silver points.
- Combination of any two or more of the above may be used.
- Many pastes were used previously for the same purpose such as:Oxpera containing equal parts of cresole, formaldehyde, and alcohol mixed with a powder composed of alum, thymol and zinc oxide each 25 parts.
- Apexification is the procedure in which apex formation is induced in the tooth by replacing necrosed pulpal tissues with calcium hydroxide paste or camphorated chlorophenol.
- Only a small amount of pulpal tissue is left which causes the apex formation.
- Apexification is done in immature permanent teeth with wide open apices (blunderbuss apices), because preparation and obturation of these teeth is too difficult.
DRUGS USED IN THE TREATMENT OF ORAL INFLAMMATION, ULCERATION AND ORAL PAIN (Table 14.1.2)
Oral mucosal inflammation/ulceration may be caused by trauma (physical or chemical), recurrent aphthae (small white spots on the mucous membrane of mouth seen in thrush), sprue or with vincent's angina, carcinoma, infections, nutritional deficiencies, gastrointestinal diseases, hemopoietic disorder and drug therapy. It is necessary to establish the diagnosis, so that the treatment can be directed to the cause. Local treatment is given to protect the ulcerated area, reduce inflammation and relive pain.
Plain mouthwashes: A plain saline or thymol glycerine mouth wash is used to relieve pain in traumatic ulceration.
Local analgesics: Oral diseases and dental proceduring often results in postoperative pain which may be mild (expected after scaling), moderate (expected after simple extensive oral surgery).
Mild variety of pain can be treated with an analgesic like (aspirin or acetaminophen)
Drugs Used for the Treatment of Moderate Pain
Aspirin
Dosages: | In adults 650–1000 mg, 4–6 hourly, orally. In children 10–20 mg/ kg per day. |
Preparations:
ECOSPRIN: Tab. 325 mg (Aspirin)
DISPRIN: Tab. aspirin 325 mg + Calcium carbonate 97.5 mg + Anhydrous citric acid 32.5 mg.
Contraindications: Gastric ulcer, bleeding disorders or anticoaguant therapy, asthma, gout, allergy, nasal polyp.
Side Effects: Nausea, vomiting, allergy, liver damage, respiratoty problems, etc.
Codeine: This drug is indicated in toothache, muscular pain, neuralgia and headache.
Preparations and dosage: Codeine sulfate - Tab. 15 mg. Dose up to 60 mg can be safely used.
Side effects: Nausea, vomiting, allergy, overdosemalaise, constipation, drowsiness, etc.
Pentazocine: It is substituted for codeine for treating moderate to severe pain in a dose of 50 mg (equivalent to 60 mg codeine)
|
Preparations: | Pentazocine- FORTWIN Tab. 25 mg Inj. 30 mg/ml. SC or IV |
Side effects: Nausea, vomiting, allergy (rash) irritability, hypertension, tachycardia, respiratory depression, etc.
Contraindications: Allergy to the drug, pregnancy, patients of respiratory, liver and kidney disease, children less than 12 years of age and patients with history of seizures and head injuries.
Warnings
- Chances of addiction (habit forming).
- It causes disorientation, confusion, visual disturbances and hallucinations therefore it also interferes with driving and operating machinery.
Clove oil, Menthol: It contains-tincture of pellitory, water and alcohol 10%.
Contraindications: Drug allergy, pregnancy, liver disease, respiratory disease and kidney disease, patients with acute abdomen (spasms of biliary and urinary tract), patients with history of seizures, head injuries, along with anti hypertensive agents.
Side effects: These include lightheadedness, nausea, vomiting, sedation, hallucinations, excitement, euphoria, dysphoria and tremors.
LOCAL ANESTHETICS (LA) DENTAL
- Discussed in detail in the chapter of LA.
Lidocaine
- It is an amide.
- Chemical name-diethyl-amino-2,6 acetoxylidide
- It is used with 1:100,000 epinephrine during dental procedures.
Adverse Reactions: Rash, irritation, sensitisation.
Contraindications: Severe liver disease and hypersensitivity.
Precautions: Pregnancy, denuded skin and sepsis.
Preparation: Lidocaine-XYLOCAINE – 30 ml.
Mepivacaine
- Chemical name-1-methyl-2–6 pipecoloxylidide hydrochloride
- Use: Dental procedures for infiltration and nerve block.
This LA is extremly useful in patients with cardiovascular disease. This drug produces acceptable depth and duration of local anesthesia without a vasoconstrictor effect.
Side effects: Rash, irritation, sensitization, convulsions, respiratory depression following seizure.
Contraindications. Hypersensitivity, liver disease, and cardiovascular diseases.
Preparation: Mepivacaine- CARBOCAINE – 300 ml.
Procaine
- It is an ester type agent.
- Chemical name - 2-diethylamino ethyl-4-aminobenzoate hydrochloride.
- Use. This drug is recommended in dental procedures for infiltration and never block anesthesia.
It is very useful in patients with liver disease as it is not metabolized by liver.
Precautions: Since [PABA] Para-Amino Benzoic Acid (a metabolite of procaine) inhibits action of sulfonamides, therefore it should be used with caution in patients on sulfonamide therapy.
Preparation: Procaine-NOVOCAIN- 30 ml.
ANTISEPTICS AND DISINFECTANTS
Antiseptics: They are the chemical or drug which, when applied over the living surfaces, inhibits the growth and multiplication of bacteria without killing them.
Disinfectants: They are the drug or chemical which are used on non living or inanimate objects to kill the bacteria. Usually they are used for sterilizing the instruments.
Phenol: It is used as mouthwash in a concentration of 3%.
Cresol: Compared to phenol, it is three times more potent (while toxicity remain same)
- Cresol, tricresol and para-amino chlorphenol are used as root canal antiseptics.
- It is also commonly used as a disinfectant solution.
Chloroxylenols: For the sterilization of dental instruments it is broadly used in a concentration of 5% solution. example is Dettol.
Preparations: DETTOL - Chloroxylenol 4.8%, Absolute Alcohol 13.1% and Terseniol 9%.
Halogens
- Chlorine: It is a germicide and in dentistry it is used as sodium hypochlorite for irrigation of root canals (1% solution).
- Iodine: It is a strong bactericidal and fungicidal agent with little antiviral activity also. It is used as a sterilizing agent for skin prior to surgery in concentration of 2.5% iodine and 2.5% potassium iodide in an alcoholic solution. In traumatic periodontitis its weak solution is used as a counterirritant.
- Povidone-iodine: It is also used as a pre-surgical scrub.Preparations. Povidone-Iodine BETADINE- 1% W/V of available iodine and Absolute alcohol-8.38%.
Hexachlorophene: It is a bisphenol which is bacteriostatic in action (i.e. it inhibits the growth of bacteria rather than killing them).
- It is more effective against gram+ve than gram –ve organisms (bacteria)
- It is used as a scrub prior to any surgical procedure.
Chlorhexidine
- It is effective against both gram+ve and gram –ve organisms (bacteria)
- It is used for:
- – Wound cleaning (1:2000 solution)
- – Disinfecting instruments (3 minute immersion) and storage of instruments (0.5% solution in 70% alcohol)
- – Preoperative skin scrub (0.5% solution in 70% alcohol)
- – As a disinfectant in (root canal treatment) RCT (in a concentration 1.5% with cetrimide 15% solution)
- – As a daily rinse (0.2% solution) to inhibit deposition of bacterial plaque on tooth surface and at dento-gingival junction
Preparation
- – Chlorhexidine-PERIDEX- oral rinse as 0.12% in 450 ml. bottle.
- – Chlorhexidine- HIBITANE- 0.5% solution in alcohol-70%
Adverse effects: Altered taste sensation, staining of teeth and tongue.
Oxidizing agents: These act by releasing oxygen and water on coming in contact with body tissues.
- Hydrogen peroxide: It is useful as an antiseptic mouthwash (15–20 ml in a ½ tumbler of water) due to its antibacterial action. Ten volume hydrogen peroxide diluted with an equal quantity of warm water used for debridment of root canals in RCT.
- Sodium perborate as a mouthwash: It releases oxygen when comes in contact with body tissues and is used in management of acute ulcerative gingivitis but not in the chronic variety.
Quaternary ammonium compounds
They are derivatives of ammonium chloride and effective against both gram +ve and gram –ve organisms. They are used for the application to skin and mucous membranes and sometimes for sterilizing surgical instruments.
- Binzalkonium Chloride (ROCCAL, TEPHIRAN) and Cetrimide (CETAVLON) most commonly used.
- Cetrimide in combination with chlorhexidine is a popular dental antiseptic – CETRIHEX.
Alcohols: Ethyl alcohol (Ethanol) in a concetration of 50–70% by weight used as a skin antiseptic prior to injection.
Gum paints: They are mainly used as an antiseptic and gum astringent and are for topical use only.
Preparations
Tannic acid | 30% |
Glycerine Iodine | 70% 0.3% |
Potassium Iodide | 0.5% |
Thymol Menthol | 0.05% 0.08% |
Glycerine | qs |
Mechanical barrier: Mechanical protection can be provided by applying carmellose gelatine paste.
Corticosteroids (topical)
- Corticosteroids like hydrocortisone acetate lozenges or triamcenolone acetonide 0.1% topically or triamcenolone hexacetonide intra-lesionally or betamethasone valearate topical spray is used for treating oral ulceration and mucosal lesions. Prednisolone is preferred for systemic use only.
- For treatment of pulpal inflammation, steroids are applied over exposed dental pulp. LEDERMIX – which is a combination of triamcenolone + tetracycline is preferred.
- Intra-articular injection of hydrocortisone or prednisolone can be administered to control pain and inflammation of temporomandibular joint.
- Methyl – Prednisolone and betamethasone IM should be administered just prior to surgery for extraction of impacted third molar and after orthodontic surgery to reduce pain and inflammation
- Systemic steroid (predisolone) should be prescribed to treat unilateral facial palsy (Bell's palsy).
- For treating anaphylactic shock, hydrocortisone IV along with adrenaline 0.2 ml in 1:1000 solution SC or IV and anti-histaminics should be given.
ADVERSE EFFECT OF DRUGS IN THE ORAL CAVITY
Xerostomia (Dry Mouth)
[Anticholinergic drugs]: Atropine, atropine substitutes and derivatives. Propantheline, oxyphenonium, benztropine, 463benzhexole, TCA [tricyclic antidepressant], phenothiazines, clonidine, etc.
Taste Disturbances [Partial or Total Loss of Taste]
Penicillamine, clofibrate, carbimazole, lithium carbonate, lincomycin, griseofulvin metallic taste: metronidazole, tinidazole, metformin, all heavy metals, etc.
Discoloration of
Mucosal tissue: Lead, chloroquine, phenothiazines, OCP, chlorhexidine.
Teeth: Tetracycline, chlorhexidine, iron salts, stannous chloride, etc.
Halitosis (Bad Breath)
Isosorbide dinitrate (sublingually), disulfiram.
Pain and Swelling of Salivary Glands
Oxyphenbutazone, iodides, bethanidine, methyldopa, clonidine, nitrofurantoin, chlorhexidine.
Gingival Hyperplasia and Hypertrophy
Phenytoin, oral contraceptives, nifedipine, cyclosporine.
Oral Ulceration
NSAIDS like Aspirin, potassium, isoprenaline (sublingually), naproxane, methotraxate, fluorouracil, actinomycin D, doxarubin, bleomycin.
Oral Infections Induced or Aggravated by Drugs
Corticosteroids, broad spectrum antibiotics (tetracycline and chloramphenicol), topical fluorouracil, immunosuppressive drugs, azathioprim, etc.
Treatment of Xerostomia (Dry mouth)
Dry mouth may be caused by damage or disease of the salivery glands or by the administration of drugs with antimuscarinic side effects – anticholinergic, antispasmodics, tricyclic antidepressants, antipsychotics, clonidine, or by irradiation of the head and neck.
Dry mouth can be relieved by:
- Frequents sips of cold drinks, sucking pieces of ice or sugar free fruit drops.
- Artificial saliva of natural pH and containing electrolytes corresponding approximately to the composition of saliva.
- Pilocarpine nitrate tablets 5 mg orally, three times a day with or after meal. They are particularly useful in xerostomia following irradiation of head and neck cancer.