Lec 4 Fixed (PART 1)

Therapeutics in Endodontics (PART 1)

NOTE: The pt. comes to clinic with (Pain , infection OR Regular recalls But pt. Fearing the dentist )

ANALGESIC
Def. of pain : An unpleasant sensory emotional experience associated with tissue damage.

3D'S OF SUCCESSFUL MANAGEMENT

( 1-Diagnosis , 2-Defintive dental treatment , 3-Drugs )
1-Diagnosis : means → to Determine what is wrong ( ‫)اعرف المشكلة فين‬.
2- Definitive a treatment plan : Definitive TTT plan is made after proper Diagnosis
3-Drugs → are auxiliary factors (not Essential factor) in Endodontic Treatment
( ‫هي بس عامل مساعد‬، ‫)بمعنى ان الدرجز مش حاجة أساسية‬

Nociceptive pain (nociceptors) Neuropathic pain

Pain from (C-fibers and A-delta fibers) transmit Arises from PNS and CNS.
pain via trigeminal nerve to → trigeminal
nucleus in medulla. Treatment of Neuropathic pain:
1- Tricyclic antidepressants (TCAs)
Treatment of Nociceptive pain: 2- & Antiepileptic drugs (AEDs).
1- NSAIDS
2- & Opioids.

NOTE: Drugs having the ability to raise the pain threshold at a subcortical level
(‫ثريشولد بتاعه‬-‫ )بيقعد فترة طويلة عبال مايحس عشان انا رفعت البين‬.
Analgesics types could :
1- Non -narcotic Analgesics : Non -narcotic Analgesics → doesn't cause addiction
A-NSAIDs → as : ( ibuprofen ,Asprin , Diclofenac ) narcotic Analgesics → cause addiction
B-Antipyretic → as : (paracetamol ,Panadol)
2- Narcotic Analgesics → ( Morphine ,Codeine , meperidine)
 Arachidonic Acid Pathway
NOTE: (cell membrane consist of phospholipid )
1-when injury occurs to the cell membrane
phospholipase enzyme is formed
2-this phospholipase enzyme convert the
phospholipid to → Arachidonic acid
3-this Arachidonic acid through (COX) & (LUX)
will form (PGs) & (Leukotriens)
NOTE: Arachidonic acid through cyclooxygenase
(COX = COX1 & COX2) will form → (PGs)
NOTE: Arachidonic acid through lipoxygenase
(LUX) will form → (Leukotriens)
4- the (PGs) is responsible for Pain &
inflammation
5- so, in order to stop the (Pain & inflammation) → we Either use (corticosteroids) OR (NSAIDs)
NOTE: (corticosteroids) → will stop the formation of phospholipid
NOTE: (NSAIDs) → will stop the formation of COX1 & COX2

Arachidonic Acid
A- COX1 (constitutive) → TXA2 → house keeping Functions as :
(GI - Mucosal protection ‫ مبطنها‬, Kidney - Renal blood flow , Platelet aggregation)
B- COX2 (inducible) → (PGE2 & PGE1) → inflammation & Neoplasm as:
(Tumor invasion , Angiogenesis, cell proliferation , macrophages , Synoviacytes)
NOTE: (cytokines ,mitogens, carcinogens, oncogenes ) → (PGE2 & PGE1)
NOTE (‫ )مهم‬: Non-Selective NSAIDS affect → (COX1 & COX2) and stop them ..
so, Non-Selective NSAIDS will stop :
1-( house keeping Functions of COX1 as : (GI - Mucosal protection , Kidney - Renal blood flow , Platelet
aggregation ) ‫ عشان معدة العيان هتوجعه‬، ‫ودي حاجة عواقبها مش حلوة‬
2-in addition , it will stop inflammation & Neoplasm produced by COX2
NOTE (‫ )مهم‬: COX2 Selective NSAIDS affect → (COX2) ONLY and stop (inflammation & Neoplasm)

NSAID Selectivity
1-Cox-2 selective NSAIDS → (as : cefocoxib)
2-Semei-selective NSAIDS → (as : diclofanic)
3-Non-selective→ (as : Ibuprofen)
4-Irreversible Non-selective → (as : Aspirin)
NOTE:AS a result of these information , The Cox-2 selective NSAIDS is my 1st choice in the clinic ‫ماالخر‬
Analgesics types could :
1- Non -narcotic Analgesics : ( A-NSAIDs B-Antipyretic )
2- Narcotic Analgesics → ( Morphine ,Codeine , meperidine)

Analgesics
1-NON-NARCOTIC ANALGESICS
(A-Non steroidal anti-inflammatory agents (NSAIDs) )
NSAIDs Group of drugs:
1-Differing in chemical structure (‫)مختلفين في التكريبة الكيميائية عشان كدا فيه اختالف في اسماهيهم‬
2-BUT Sharing pharmacologic & toxicological properties
3- all NSAIDs are (Metabolized in → liver & Excreted in Kidney ) ‫مهم‬
pharmacologic Properties of NSIDs (4A):
1-Analgesic. 2-Antipyretic. 3-Anti-inflammatory. 4-Anti-rheumatic.
Toxicological properties of NSIDs:
1-Allergy 2- G.I irritation (Peptic ulcer) 3- Bleeding Tendency 4-liver damage
Examples of NSIDs: (1-ASPIRIN , 2-IBUPROFEN )

1-ASPIRIN (Acetyl salicylic acid)

1- Act on Hypothalamus. 2- Do Peripheral vasodilatation (VD) .
3- Asprin is Well absorbed from the upper part of small intestine. 4- Metabolized in → liver.
5-Asprin is Excreted in → Kidney 6- Food slows Asprin rate of absorption BUT not its effect.
7- its pharmacological effect →(1-Analgesic , 2-Antipyretic , 3-Anti-inflammatory , 4-Anti-rheumatic )
Adverse effect of Asprin (8):
1- analgesic nephropathy (renal endothelial damage) ‫اهم حاجة‬
2-GI. irritation.
3-Allergy. NOTE (MCQ) : Avoid prescribing
4-Bleeding (decrease platelets agglutination). Asprin with (pt. having Renal disease)
5-Liver toxicity (liver damage) as analgesic nephropathy may occur

6-Aspirin intolerance syndrome (‫ ساعات‬3 ‫)الجسم مش قادر يتحمله وبيقعد يهرش ووشه يورم وميبقاش عارف يتنفس فخالل‬
(Urticaria - Angioedema - Bronchospasm - Severe rhinitis – Shock) Occur within 3 hrs.
7-Salicylism (intoxication)
(Headache - Dizziness - Tinnitus - Drowsiness - Nausea – Vomiting) 2-IBUPROFEN

8-teratogenic effect (‫ )تراتو= تالتة‬on 1-Has same effect of

1-Prolongs pregnancy and labor. Asprin BUT the Gi irritation
2-Decreases birth weight (By decreasing the blood supply to the baby ). is 1/2 as Aspirin (‫)اقل النص‬
3-FDA warning against the use of Asprin in the 3rd Trimester. 2-Metabolite via liver
3-Excreted via kidney
Contraindications of Asprin : NOTE: it is better prescribe
1-Allergy. 2-peptic ulcer. 3-Bleeding tendency. to pt. instead of Asprin
4-Renal failure. 5-Asthma 6-Systemic lupus erythematosis. (‫)يعني احسن اني اكتبه للعيان بدل االسبرين‬
 Analgesics
Analgesics :
1- Non -narcotic Analgesics → (A-NSAIDs ‫ دن‬, B-Antipyretic)
2- Narcotic Analgesics → ( Morphine ,Codeine ,mepredin)

1-NON-NARCOTIC ANALGESICS
(B-ANTIPYRETIC ANALGESICS → ACETAMINOPHEN)
ACETAMINOPHEN → is Analgesic & Antipyretic (Not anti-inflammatory)
NOTE: the maximum dose of acetaminophen → is 4 g (4000 mg) in a 24-hour period.
NOTE: the over-dose of acetaminophen causes the following :
1-Fatal hepatic necrosis with high doses
2-jaundice (‫ بص على عينيه هتالقيها مصفرة وعنده الصفرا‬، ‫)الي بياخد بنادول عمال على بطال‬
3-hypoglycemia
NOTE: Does not Cause (GI irritation)
NOTE: Does not effect (platelet aggregation)
NOTE: Does not effect (Prothrombin synthesis)
NOTE: Rarely causes allergy

NOTE: a combination of Ibuprofen and Acetaminophen may provide greater pain relief than
either drug alone (‫ بمعنى انك لما تديه الكومبو دا افضل بكتير من انك تديله ابوبروفين لوحده‬.. ‫)دا احلى كومبو ياباشا‬

WHICH PAINKILLER IS MOST EFFECTIVE FOR TOOTHACHE?

1-painkiller and anti-inflammatory
2- reduces pain, swelling ,fever
IBUPROFEN 3-take 400mg every 4hrs
NOTE: it is perfect for managing tooth ache (as it reduces swelling & fever)

1-painkiller and anti-inflammatory

2- reduces pain, swelling ,fever BUT can also promote bleeding + has ↑ G.I
ASPRIN irritation
3-take 400mg every 4hrs
NOTE: Can effectively manage toothache BUT don't take if you are bleeding

1-Painkiller only
2-(Not an anti-inflammatory)
PARACETAMOL 3-Can Be taken in conjunction with Ibuprofen or Aspirin
4-Take 500mg every 4 hours
NOTE: Not great at controlling a toothache (as it does not reduce swelling)
 Analgesics
Analgesics :
1- Non -narcotic Analgesics → (A-NSAIDs ‫ دن‬, B-Antipyretic‫) دن‬
2- Narcotic Analgesics → ( Morphine ,Codeine ,mepredin)

2-Narcotic Analgesics
(Opium OR opiates)
NOTE: They work on → Narcotic receptors in the CNS
Used in:( Accidental pain , Traumatic pain , Neoplastic pain) ‫ ممكن تستخدمها مرة مثال‬، ‫نادر اوي انك تستخدمها فحياتك‬

Adverse effect:
1- Nausea, emesis, dizziness, drowsiness, & the potential for respiratory depression & constipation
2-Chronic use is associated with tolerance and dependence (‫)بيسببلي ادمان لو استخدمته فترة طويلة‬
‫) و اجيبله ادمان‬narcotic drug( ‫ اوصفله‬، ‫ اكيد مش عشان عايز اسكن للعيان الم فاسنانه‬: )‫نوت (بالعربي‬

This Study shows the following :

1-ibuprofen (600/800)mg → Relief 86 % of the toothache pain
2-Tramadol (50)mg → Relief 19 % of the toothache pain
3-Codeine (60)mg → Relief 15% of the toothache pain
NOTE: Tramadol & Codeine → are Very effective in case of (cancer)
 ‫)‪2-Narcotic Analgesics (cont.‬‬
‫)‪(Opium OR opiates‬‬

‫‪NOTE: Prescribe drug on (clock base‬‬

‫‪OR Regular base ) not as needed to‬‬
‫‪ensure sufficient blood level for‬‬
‫‪analgesia‬‬
‫نوت (بالعربي) ‪( :‬الكالم دا معناه اني ادي العيان‬
‫الدوا بانتظام مثال كل ‪ 8‬ساعات حباية عشان‬
‫مستوى المسكن يفضل كافي فالدم )‬

‫‪PAIN MANEGMENT STRATIGEIS‬‬

‫نوت ‪ :‬الستراتيجي الي فالصورة دي‬

‫مهمة اوي اوي اوي والزم نبقى عارفينها‬
‫بالتفضيل وحافظينها‬

‫→ ‪NOTE: pain could be‬‬

‫‪(Mild, Moderate, Severe) pain‬‬

‫‪NOTE: odontogenic pain usually‬‬

‫‪reliefs when pt. takes (600 mg‬‬
‫‪ibuprofen ) + (1000 mg‬‬
‫)‪acetaminophen‬‬
‫نوت (بالعربي) ‪ :‬يعني عادة ما بيقف األلم‬
‫بتاع االسنان لما ياخد ‪ 066‬ملجم من‬
‫اليبوبروفين ‪ 0666 +‬ملجم من‬
‫االسيتامينوفين (بيبقى كافي جدا جدا )‬
 ANXIETY (Odontophobia)
(TRUE FEAR)
The odontophobic pt. has 2 main problems :
1-increase in Pain threshold
2-decrease Metabolism of LA (leading to ↓ time of anesthetization)
NOTE: Anxiety management is Very important as pain management is (‫)االتنين ليهم نفس األهمية زي بعض‬.
NOTE: "Deal with fear first, then pain will be a minor problem"
NOTE: Dealing with Dental fear & anxiety can be through (1-Iatrosedation , 2-Pharmaco-sedation )

1-Iatrosedation
NOTE: when Dealing with Dental fear & anxiety we start with Iatrosedation
NOTE: Iatrosedation can be achived by making the following :
1- the stuff are happy
2-presence of music & flowers in clinic
3-never using Fear words
4-tell pt. if you have any pain
while working stop me
5-assure the pt.

2-Pharmaco-sedation
NOTE: in case of NO control on pt. anxity and fear → using Pharmaco-sedation is Required
NOTE: Pharmaco-sedation → are (CNS depressants) drugs

Routes of administration:
1-NITROUS OXIDE-OXYGEN (N2O-O2) → ‫دا افضل واول خيار ليا انا ممكن اعمله كـ دكتور اسنان في العيادة عندي‬
2-Oral moderate sedation → the easiest way
3- Intravenous Moderate Sedation
4-Intramuscular sedation
5- Intranasal sedation
 Routes of Pharmaco-sedation administration
1-NITROUS OXIDE-OXYGEN (N2O-O2)

NOTE: The most controllable technique of sedation

NOTE: colorless inorganic gas , compressed into liquid

Advantages of NITROUS OXIDE-OXYGEN (‫ )مهم‬:

1- Non irritating to mucosa.
2- Sweet odor.
3- rapid onset of action ( 3-5 min).
4- rapid recovery.
5- ease of administration
6- small tracers may be detected in the operating
Subjective symptoms of NITROUS OXIDE-OXYGEN (‫ )مهم‬:
1-Dreaming. ‫ ساعات في دكاترة بترش‬:)‫نوت (بالعربي‬
2-Mental and physical relaxation. )‫اوكسايد فالجو (فالعيادة‬-‫شوية نيتروس‬
3-Indifference to surroundings and passage of time. ‫عشان العيان يبقى هادي وهو داخل‬
4-Tingling sensation in the extremities (fingers, tongue & lips)
5- Lessened pain awareness.
6- Feelings of warmth.
7-Heaviness of chest
8-Distortion of sounds ( seems distant) – ‫صدى صوت‬
Adverse effect of NITROUS OXIDE-OXYGEN :
1-Nausea
2-Vomiting
3-Perspiration
4-Behavioral alterations ( ‫)مبتعرفش تسيطر على تصرفات المريض في الفترة دي‬

Contraindications of NITROUS OXIDE-OXYGEN:

1- avoid giving Nitrous oxide to (Migraine pt.)
2- avoid giving Nitrous oxide to (pt. with Headache)
NOTE: avoid giving Nitrous oxide to (Migraine pt.) & (pt. with Headache) as → Vasodilation of the
blood vessels may be caused by consumption of nitrates, which may → trigger a vascular headache
 Routes of Pharmaco-sedation administration (cont.)
2-Oral moderate sedation

NOTE: The least controllable route ( ‫ )مش بعرف اتحكم فيه اوي‬as some pt. has →
peptic ulcers for example
NOTE: (success rate 50%-60%)
NOTE: the easiest way for Pharmaco-sedation ( ‫)كل الموضوع حباية وكوباية مياة‬

Advantages of Oral moderate sedation: It is easier for both the doctor and the patient.
Disadvantages of Oral moderate sedation:
1- Slow onset of action (∼1 h for most drugs).
2- Erratic absorption of the drug from the gastrointestinal (Gl) tract - ‫عندي امتصاص غير منتظم‬.
3- Some drugs, a significant hepatic first-pass effect.
4- The level of CNS depression reached by oral drugs is not easily increased or decreased
E.G : Alprazolam, Diazepam.
NOTE: NEVER ALLOW PT. TO DRIVE THE CAR BY HIS OWN TO THE OPPOINMENT AFTER TAKING THE
ORAL DRUG ( ‫)ممنوع يجيلي العيادة وهو سايق بنفسه عشان هيبقى مدروخ ومش مركز وممكن يعمل حادثة‬

3-Intravenous Moderate Sedation

NOTE: success rate of 90%.
NOTE: (moderate and deep sedation, as well as general anesthesia) so, it require an Anesthetist to
be preformed .. ‫الطريقة دي الزمها دكتور تخدير‬

Advantages of Intravenous Moderate Sedation:

1- rapid onset (FASTEST WAY) .
2- increasing control over the effect of the administered drug
3- Ability to rapidly increase the level of sedation.
Disadvantages of Intravenous Moderate Sedation:
1- The requirement of fasting prior to the procedure (‫ )الزم العيان يجي صايم‬.
2- Inability to quickly lessen the level of CNS depression.
3- Inability to reverse the clinical actions of some drugs
E.G : ??????? and diapizam
 Routes of Pharmaco-sedation administration (cont….)
4-Intramuscular sedation
NOTE: absorbed directly into the systemic (venous) circulation.
NOTE: Doses determined on a weight (e.g. mg/kg) basis.
NOTE: limited to a moderate level
NOTE: success of about 67%

Disadvantages of Intramuscular sedation:

1- Recovery from IM drugs is prolonged (‫ )بياخد وقت طويل عبال ماتاثيره يروح‬.
2- titration is not possible, as the onset is not rapid enough.
3- It is also not possible to rapidly lessen or deepen the level of sedation.

5- Intranasal sedation
NOTE: Nasal mucosa is highly vascular absorption is more rapid.
NOTE: Used usually with Pediatrics (‫ )غالبا مع األطفال بيستخدم‬.
NOTE: limiting in adults endodontic cases

Advantages of Intranasal sedation:

1- More rapid onset of action (compared with enteral routes)
2- The lack of need for injection

Disadvantages of Intranasal sedation:

1- Inability to titrate IN drugs (‫)صعب تعايرها‬
2- it is also not possible to rapidly lessen or deepen the level of the resultant CNS depression
 2-Pharmaco-sedation
NOTE: Pharmaco-sedation → are (CNS depressants) drugs
CNS depressants are : NOTE: SEDATION = CALMING
1- Benzodiazepines.
2- Sedative - hypnotics. NOTE: HYPNOSIS = SLEEPING
3- Antihistaminic.

Pharmaco-sedation (CNS Depressant)

Sedative-hypotonics
Benzodiazepines (Barbiturate) (Non-Barbiturate) Anti-histamincs

1-Diazepam 1-Pentobarbital Drugs not 1-Benadryl.

(Valium) MCQ . (Nembutal). chemically
related to (Bb), 2-Phenergan.
2-Midazolam 2-Secobarbital BUT have the
Types (versed) MCQ (Seconal). same 3-Atarax.
pharmacologic &
3-Trizolam MCQ 3-Phenobarbital adverse effects
(Luminal).

Administration Oral-IV-IM Oral-IV-IM-rectal Oral-IV-IM Oral-IV-IM

Adult dose 2-10 mg 100-200 mg 100-200mg 75 mg

1-Anti-anxiety. Dose dependent Differ from (Bb) in 1-Sedative-

2-Anticonvulsant sedation 2 aspects: hypnotics
Pharmacologic 3-Sedative - 1- Less potent 2-Anti-anexity
effect hypnotics. ‫هنشرحها بالتفصيل‬ 2- Not cross-
4-Skeletal muscle ‫في الصفحة الجاية‬ allergic
relaxant

Depression CNS. Psychological dependence. (B,C,D,E,M,N)

Drug Physical dependence. Blurred vision.
dependence. fall in heart rate (↓). CNS depression
Adverse effects Drowsiness. fall in blood pressure (↓) Dizziness
Motor Respiratory depressant (↓) Euphoria
impairment Motor incoordination
Nervousness.
1-Allergy 1-Allergy 1-Hypertension
Contraindications 2-Glucoma 2-Liver damage 2-CVS disease
3-1st trimester of 3-Respiratory distress 3-Urinary retention
pregnancy
 Dose dependent sedation OF (Barbiturate)
NOTE: The more I increase the dose of the Barbiturate → the more liability pt. to Coma → Ending
with Death (‫الغيبوبة‬/‫)يموت بعد ما يدخل فالكوما‬

The following occurs when the dose of

Barbiturate increases (‫)بيحصل بالترتيب دا‬:
1-SEDATION
2-HYPNOSIS
3-ANESTHESIA
4-RESPIRATORY DEPRESSION
5-DEATH