Department of Endodontics

Application of
Therapeutics in
Endodontics

Prof. Dr. Maged Negm

Cases requiring therapeutic treatment in
endodontics:

• Anxiety Pharmacosedations
• Pain Analgesics
• Infection Antibiotics
 ANXIETY

ANXIETY TRUE FEAR

TREATMENT:
1. Benzodiazepines.
2. Sedative-hypnotics.
3. Antihistaminics.
 BENZODIAZEPINES

• Diazepam (Valium).
• Chlordiazepoxide (Librium).
• Oxazepam (Serax).
• Lorazepam (Ativan).
• Flurazepam (Dalman).
 DIAZEPAM (VALIUM)

Pharmacologic effects:
1. Antianxiety.
2. Anticonvulsant.
3. Sedative-hypnotics.
4. Skeletal muscle relaxant.
5. Amnesic.
• Well absorbed from GI. tract.
• Administration: oral – IV- IM.
• Adult oral dose: 2-10 mg.
Adverse effects:

• Drowsiness.
• Ataxia .
• Motor impairments.
• CNS depression.
• Drug dependence.
Contraindications:

Allergy.
Glucoma.
First trimester of pregnancy.
 SEDATIVE – HYPNOTICS

1-BARBITURATES 2- NON
BARBITURATES

• SEDATION CALMING

• HYPNOSIS SLEEPING
 BARBITURATES

• Pentobarbital (Nembutal).
• Secobarbital (Seconal).
• Phenobarbital (Luminal).
• Methohexital (Brevital).
• Administration: Oral – Rectal – IV – IM

• Adult dose: 100 – 200 mg

• Barbiturates dose dependent.

• Sedation Hypnosis Anaesthesia

Death (respiratory depression)

 Adverse effects:

• Psychological dependence.
• Physical dependence.
• Fall in heart rate.
• Fall in blood pressure.
• Respiratory depression.
Contraindications:

Allergy.
Respiratory distress.
Liver damage.
 NON-BARBITURATES

Drugs not chemically related to barbiturates yet they

possess sedative hypnotic properties.
Differ from barbiturates in two aspects:

• Less potent.
• Not cross-allergenic with barbiturates.

 Possess the same adverse effects as barbiturates.

 ANTIHISTAMINES

• Benadryl.
• Phenergan.
• Atarax.
• Avil.

Administration oral -IV-IM

Adverse effects:

• Dizziness.
• Drowsiness.
• Motor incoordination.
• Blurred vision.
• CNS depression.
NITROUS OXIDE-OXYGEN PHARMACOSEDATION

• Colorless inorganic gas compressed into liquid.

• Non irritating to mucosa.
• Sweet odor.
• Rapid onset of action ( 3-5 min).
• Rapid recovery.
• Ease of administration.
Symptoms:

• Euphoria
• Dreaming.
• Drowsiness.
• Mental and physical relaxation.
• Indifference to surroundings and passage of time.
• Lessened pain awareness.
• Feelings of warmth.
• Tingling sensation in the extremities (fingers, tongue
& lips)
• Heaviness of chest.
• Distortion of sounds (seem distant).
Adverse effects:

Nausea.
Vomiting.
Perspiration.
Behavioral alterations.
Contraindications:

• History of psychosis.
• Migraine.
• Headache.
• Prolonged drug abuse (neurologic damage).
Analgesics

Definition?
ANALGESICS

Drugs having the ability to raise the pain

threshold at a subcortical level.

Classification:

Non-narcotic
Narcotic
 NON-NARCOTIC ANALGESICS

Non steroidal anti inflammatory

Antipyretic analgesics
agents (NSAIAs or NSAIDs)
NON NARCOTIC ANALGESICS

Non steroidal anti-inflammatory agents

(NSAIAs)

Group of drugs: - Differing in chemical structure

- Sharing pharmacologic &
toxicologic properties.
Pharmacologic properties of NSAIDs.
• Analgesic.
• Antipyretic.
• Anti-inflammatory.
• Anti-rheumatic.
Toxicologic properties of NSAIDs.
• Allergy.
• GI. irritation.
• Bleeding.
• Liver damage.
 Non-Narcotic Analgesics

“NSAIDs”
Aspirin
“acetyl salicylic acid”

Analgesic - Antipyretic – Anti-inflammatory – Anti-rheumatic -

Keratolytic
 ASPIRIN
(Acetyl salicylic acid)

Mode of action:
1. Hypothalamus.
2. Peripheral vasodilatation.
• Aspirin hypothalamus decrease
synthesis of
• prostaglandin.

pain sensitizing effect. Anti-inflammatory

effect.
-Well absorbed from the upper part of small intestine.

-Metabolized in liver.

-Food slows rate of absorption but not its effect.

Adverse effects:
• GI. irritation.
• Allergy.
• Bleeding (decrease platelets agglutination).
• Analgesic nephropathy (renal endothelial damage).
• Liver toxicity (liver damage).
• Aspirin intolerance.
• Salicylism (intoxication).
• Teratogenic effect.
• Drug interactions.
Aspirin intolerance syndrome:

Urticaria – Angioedema – Bronchospasm – Severe

rhinitis – Shock.
Occur within 3 hours.
Salicylism (intoxication):

Headache – Dizziness – Tinnitus – Drowsiness - Nausea

– Vomiting.
Teratogenic effect:
• Prolongs pregnancy and labor.
• Decreases birth weight.
• FDA warning against the use of Aspirin in the 3rd
Trimester.
Contraindications:
• Allergy.
• Peptic ulcer.
• Bleeding tendency.
• Renal failure.
• Asthma.
• Systemic lupus erythromatosis.
 IBUPROFEN

( Motrin, Advil)
• Analgesic – Antipyretic – Anti-inflammatory – Anti-
rheumatic.
• Well absorbed when taken orally.
• Food delays rate but not total amount absorbed.
• Excreted via kidneys as metabolites.
Adverse effects:

• GI. irritation (only half as common as with aspirin).

• Epigastric pain.
• Anorexia.
• Nausea.
• Vomiting.
• Dizziness.
• Vertigo.
• Headache.
Contraindications:

Allergy.
Peptic ulcers.
 ZOMPIRAC

(zomax)

• Orally effective.
• Food decreases degree and rate of absorption.
• Excreted by the kidneys.
Effects, adverse effects and contraindications similar to
NSAIAs.

Zompirac is nephrotoxic in long term use.

Diflunisal (Dolobid):

 Derivative of Salicylic acid and possesses the same

pharmacologic and toxicologic properties of NSAIAs.

 Long term duration of action (8-12 hours), however

it has a slow onset of action (3 hours).
 Contraindicated in patients with aspirin intolerance.
Piroxicam (Feldene):
Long acting & relatively stable
Can be taken in a single daily dose.
Diclofenac (Voltaren, Cataflam):
 Well absorbed orally. Can also be taken
parenterally.
The same effects, adverse effects and indications like
the rest of NSAIDs.
 Dose 50 mg/8hours.
 ANTIPYRETIC
ANALGESICS
ACETAMINOPHEN
Analgesic & Antipyretic.
Introduced as an Aspirin Substitute.
Marketed under more than 200 formulations.
The most known one is Tylenol.
• Does not cause GI. irritation
• Does not affect platelet aggregation
• Does not affect prothrombin synthesis
• Rarely causes allergy
 - Absorption in the small intestine
- Food decreases the rate but not total amount
absorbed
- Detoxified in the liver
Adverse effects:

• Urticaria
• Hypoglycaemia
• Jaundice
• CNS disturbance(stimulation or depression)
• The most serious effect is severe, fatal hepatic
necrosis with high doses.
Contraindications:

Impaired hepatic function

Impaired renal function
Anaemic patients
Chronic alcoholism
 Narcotic Analgesics

When additional pain control is needed

 NARCOTIC ANALGESICS

These drugs work on the narcotic receptors in the CNS

Narcotic Opioid or opiate

 Narcotic Analgesics
• Work on the narcotic receptors in the CNS
• Narcotic drugs = Opium or Opiates
• Examples:
Natural: Morphine and Codeine
Semisynthetic: Hydromorphone and
Oxymorphone
Synthetic: Methadone and Tramadol
 Narcotic Analgesics

• Morphine:
-natural constituent of opium along with narcotine,
papaverine & codeine.
-well absorbed parenterally but poorly absorbed orally.
-Adult dose: 5-20 mg.
-Drug of choice in case of severe pain:
Postoperative pain – traumatic pain – accidental pain &
neoplastic pain.
 Narcotic Analgesics

• Effects & adverse effects:

1. Analgesia 10. Respiratory depression
2. Sedation 11. Cough suppression
3. Euphoria 12. Mood alteration
4. Dysphoria 13. Mental clouding
5. Emesis 14. Delirium
6. Constipation 15. Insomnia
7. Miosis 16. Sweating
8. Nausea 17. Flushing
9. Vomiting 18. Hypotension
 Narcotic Analgesics

• Effects & adverse effects:

19. Dizziness 27.Hallucination
28.Coma
20. Drowsiness
29.Psychic dependence
21. Tinnitus 30.Physical dependence
31.Tolerance
22. Narcosis
32.Asthma
23. Convulsions

24. Headache
 Narcotic Analgesics

• Contraindications:
-Head injury
-Increased intracranial pressure
-Asthmatics
-Allergy
 Narcotic Analgesics

• Codeine:
 Narcotic Analgesics

• Codeine:
-Commercially synthesized from morphine.
-Well absorbed both orally and parenterally.
-Adult dose: 15-60 mg.
-Drug of choice for cough suppression.
 Narcotic Analgesics

• Hydromorphone:
- Synthetic derivative of morphine.
- 8 times more potent than morphine.
- Adult dose 2 mg oral or parenteral.
 Narcotic Analgesics

• Hydromorphone:

- 8 times more potent than morphine.

-Adult dose: 2 mg (oral or parenteral).

-Pharmacologic effects and adverse effects are similar

to morphine.
- Synthetic derivative of morphine.
- 8 times more potent than morphine.
 Narcotic Analgesics

• Methadone:

- Synthetic form of morphine.

- Well absorbed both orally and parenterally.
- Adult dose 2.5-10mg IM,SC,oral.
- Effects, indications and contraindications are
comparable to morphine.
- Contraindicated under age of 18 years.
 Narcotic Analgesics

• Tramadol:
100 mg = 10 mg morphine
- Used for short lasting as well as
chronic pain.
- Oral or parenteral.
 Narcotic Analgesics

• Meperidine (Demerol):
-Well absorbed both oral and parenteral.
-Metabolized in liver
-Adult dose: 50 - 100 mg
-Possesses atropine-like effects and hence
contraindicated with glaucoma and
prostatic patients.
-Effects, adverse effects, and
contraindications are similar to morphine.