Antibiotics Analgesics in Dentistry

ANTIBIOTICS & ANALGESICS IN
DENTISTRY
Dr. Hala Helmi A. Hazzaa

Assistant professor of Oral Medicine, Diagnosis,
Priodontology & Radiology.
Faculty of Dentistry(Al-Azhar University)
Outline:
 Terminology
 Indications
 Classification
 Types, uses & side effects
 Guidelines
 Recommendations
Dr.Hala Helmi Hazzaa

Chemotherapeutic Agent:
Antibiotic:
Antiseptic:
Disinfectant:
It It
is is a
a general
naturallyterm for a
occurring,
It is a chemical antimicrobial agent
chemical
semisynthetic
applied
They are substance
or
topically synthetic
antimicrobial that
type
or sub-gingivally of
agents
toprovides
mucous a
anti-infective
(subcategory clinical
agent
membranes, therapeutic
of that destroys
wounds,
antiseptics)
or
intact benefit,
generally
dermal
or inhibits theeither
applied
surfaces
growththrough
to of
destroy
inanimate
MO
selective
&
surfaces
inhibitto destroy
their multiplication
antimicrobial
micro-organisms MO.
actions
(MO), or or
generally
metabolism.
at increasing
low concentrations.
host’s resistance).
??? Antibiotic
 Antibiotics:
o They are a type of antimicrobial drugs used in the
treatment & prevention of bacterial infections.
o They may either kill or inhibit the growth of bacteria.
o A limited number of antibiotics also possess

antiprotozoal activity.
o Antibiotics are not effective against viruses.

??? Antibiotic
o Antibiotics revolutionized medicine in the 20th century,
and have together with vaccination led to the near
eradication of diseases such as tuberculosis (T.B.) in the
developed world.
o Their effectiveness and easy access led to overuse,

prompting bacteria to develop resistance.
o This has led to the most common widespread problem

known as antibiotic resistance.

??? Antibacterial versus antibiotic
 To distinguish;
Antibacterials are used in soaps & cleaners Antibiotics are used as medicine
 No difference
 Triclosan?
 Microflora?
FDA

Indications ???

Therapeutic
In certain conditions, to treat &
stop the spread of infection.
Prophylaxis. Host modulation.

To avoid bacteremia, that is To modulate (control) some
anticipated following immunologic aspects in the
invasive dental procedures. host.

Classification ???

I) According to the route of administration:
Systemic Topical
 Different routes:  Rationale:
• Oral (Tablets & Syrup) A more safe route for antibiotics to
• Injection (IV or IM) avoid their undesirable side effects.
 Controlled release device:
 Advantages:
It is a system designed to prolong
• Rapid action.
the retention of chemotherapeutics
• Wide spectrum. in periodontal pockets with a
• Availability. regular & steady release of the
• Affordable cost. agent at therapeutic level.
 However, these members are
 Disadvantages: expensive, sometimes difficult
• The undesirable side effects in application & not easily
are the main obstacle???? available.
II) According to the mode of action:
Bactericidal:
Bacteriostatic:
(penicillins, cephalosporins,
(tetracycline, chloramphenicol,
metronidazole, high
low concentration of macrolides).
concentration of macrolides).

SYSTEMIC ANTIBIOTICS

Therapeutic indications of antibiotics:
 Continued periodontal disease activity as measured

by continuing attachment loss, purulent exudate, and
bleeding on probing. Non responding cases to
treatment (refractory periodontitis).
 Aggressive periodontitis.
 NUG or NUP.
 Acute gingival or periodontal abscess.
 Oro-dental infections in medically compromised
patients (e.g.; DM).
 Severe acute peri-apical infections.
 A rapidly spreading or persistent infection.

Avoid using antibiotics in the following;
Abscess needs drainage to Pain needs analgesics for relief

bacteria
Viral
infection
It needs antiviral therapy

Table (1): Orofacial painful/inflammatory conditions that may be encountered in
dental practice and their important features
Dar-Odeh et al., 2010

Indications for antibiotic
administration in prophylaxis:
 Notice that:
Utilization of antibiotic prophylaxis for patients at
risk does1.not provide absolute prevention of
1.Immunosuppression
Dental
Immunosuppression secondary
Dentalpractitionerssecondary
practitioners to:
should
shouldto: consider
considerprophylactic
prophylactic
infection.
1. Antibiotic
A.
1. AntibioticA.Post-procedural
These
humanprophylaxis
humanprophylaxis
non-cardiac
is
immunodeficiency
measures to symptoms
not
not
immunodeficiency
measures to
indicated
is minimize virus
the
indicated
minimize
factors virus
can the
forof
(HIV).
risk
for
(HIV).
place
acute
dental
of
dental
risk aof IEpatients
IE in
patients
in
patient
with
patients
with
patients
with
pins,
pins, These
B. plates,
severe non-cardiac
plates, screws,
combined
with
screws, or factors
other canconditions.
hardware
immunodeficiency.
underlying
or cardiac
other hardware place
that
thataisispatient
not
not within
withinwithaa
infection may
B. severe
compromisedindicate
compromised
synovial
combined
with
joint.
antibiotic
immunity
immunity at
cardiac
at risk
failure
immunodeficiency.
underlying conditions.
risk for
and
for distant-site
need
distant-site infection
infection
C.
synovial
C. neutropenia.
joint.
neutropenia.
for2.2.further from
from
ItItisis evaluation.
aadental
dental
indicated
D. cancer
indicated
procedure.
procedure.
routinely
chemotherapy.
routinely for This
formost
most
category
Thisdental
category
dental
includes,
includes,
patients
patients with but
withbut
isisjoint
total
total
not
not
joint
D. cancer
limited to, chemotherapy.
patients with the following medical conditions:
limited
replacements.
E. to, patients
hematopoietic
replacements. with
stem the
cell or following
solid medical
organ conditions:
transplantation.
E. hematopoietic stem cell or solid organ transplantation.
3.3. Antibiotics
2.2.Head
Head&
Antibiotics &may
neck be
be considered
considered when
neckradiotherapy.
may radiotherapy. when high-risk
high-risk dental
dental
procedures are
areperformed
diseasefor patients
SLE). within
within22years
yearsfollowing
Indications: 3.3.Autoimmune
procedures
implant
Autoimmune
surgery,
disease
performed (e.g.
for SLE).
patients
(e.g.
immuno-compromised
following
4.4.Sickle
implant cell
surgery,
Sickle cell immuno-compromised patients
anemia.
anemia. patients with
with total
total
 Patients with
joint cardiac
arthroplasty,
5.5.Asplenism
joint arthroplasty,
Asplenism or conditions
or
or patients
orstatus post who???.
have
have had
postsplenectomy.
patients
status who
splenectomy. had previous
previous joint
joint
infections.
6.6.Chronic
infections. steroid usage.
 Patients with shunts,
Chronic steroidor medical devices.
usage.
7.7.DM.
DM.
 Patients with compromised immunity.
 Patients with prosthetic joints.
Viridans streptococci have the
Viridans streptococci have the
unique ability to synthesize
unique ability to synthesize
dextrans from glucose, which
dextrans from glucose, which
allows them to adhere to fibrin-
allows them to adhere to fibrin-
platelet aggregates at damaged
platelet aggregates at damaged
heart valves. This mechanism
heart valves. This mechanism
underlies their ability to cause
underlies their ability to cause
subacute valvular heart disease
subacute valvular heart disease
following their introduction into
following their introduction into
the bloodstream (e.g., following
the bloodstream (e.g., following
dental extraction)
dental extraction)
We should stay friends forever

Host modulation
This term refers to the use of some drugs in a way to
modulate the host response in the management of
periodontal diseases.
Non-steroidal anti-inflammatory drugs (NSAIDs):
Sub-antimicrobial dose of doxycycline (periostat):
Bisphosphonates:
-Tetracycline They decrease bone loss by modifying

-
in low dose inhibit tissue
- They destruction host inflammatory
are chemical analogues response
of (thattoofbacteria.
by its anti-collagenase
-NSAIDs interfere with arachidonic acid
pyrophsphate known
PNLs) effect i.e. to inhibitrate
decrease bone
of collagen
metabolism & inhibits the inflammatory
break down.
resorption (in process.
periodontitis &
-Tetracycline is able to chelate metal ions.
following periodontal
-Somesurgery).
NSAIDs affect response of PNLs to
Collagenases are Ca++ dependent enzymes.
inflammation.
Periostat
 It is a proprietary product which is composed of a very

low dose of doxycycline.

 It is taken several times a day & is used principally for
its inhibition effect on collagenase since the dose is too
low to effectively act as an antibiotic (i.e. to kill germs).
Guidelines in systemic
administration of antibiotics
 Antibiotic is a necessary therapeutic adjunct in
controlling bacterial infection because bacteria can
invade the tissues, making mechanical therapy alone
sometimes ineffective.
 Antibiotics should be used as adjunct to dental

treatment and never used alone as the first line of care.
 Make proper diagnosis & consider using narrow

spectrum antibiotic to minimize disturbing the normal
flora and keep the broad spectrum antibiotic to more
complex infections.
 Currently, no ideal antibiotic for treatment of peri-
apical or periodontal disease, as no single antibiotic at
its achieved conc. in body fluid can inhibit all the
involved pathogens. Thus, combination therapy may
be necessary (avoid bactericidal with bacteriostatic).
 Antibiotics are indicated when systemic signs, that

possibly indicate spread of infection, are evident e.g.;
fever, lymphadenopathy, truisms ...etc…
 Keep in mind the drug interactions and the side effects

of the prescribed type.
 An effective antibiotic regimen should be directed against
the most likely infecting organism, with antibiotics
administered shortly after the procedure.
 The conservative use of antibiotics is indicated to minimize

the risk of developing resistance to current antibiotic
regimens.
 The duration of antibiotics???. Ideally antibiotics are

prescribed for 3-5 days + sufficient loading dose (stress on
the full course of therapy) for proper treatment and avoiding
the infection relapse.
 When procedures involve infected tissues or are

performed in a patient with a compromised host response,
additional doses of antibiotics may be necessary.
 Avoid the sub-therapeutic doses or long duration to avoid

resistance.
 On treating a patient with hepatitis, Penicillin,

Clindamycin, Metronidazole are the safest antibiotics,
while Tetracycline & Erythromycin should be avoided.

 With renal patients, avoid nephrotoxic drugs (Tetracycline,
aspirin, NSAIDs) & adjust the dosage of drugs metabolized
by the kidney (e.g.; lidocaine, penicillin V, cephalexin &
metronidazole).
 Aggressive management of infections (culture, sensitivity

test & antibiotics).
 Hospitalization is indicated for severe infection or major

procedures as sepsis & febrile illness can lead to fatal
acidosis.

Penicillins
Q-What
-Q-
TheyHow
are aboutwe safety
can
bactericidal overcome
broad with
this
spectrum
-Notice that: B-Lactamase are enzymes
pregnancy….?
problem?
antibiotics (inhibit bacterial cell wall
secreted by some bacteria e.g.
synthesis) containing a B-lactam ring e.g.
Staphylococci, leading to inactivation of
-amoxicillin.
1. Side effects:
Unasyn
B-lactam
--2.They antibiotics → resistance to these
are(anaphylactic
Augmentin
Allergy considered among
shock the safest
???)
drugs.
antibiotics.
3. Curam resistance.
-Bacterial

Ampicillin
It is safe in lactation & pregnancy, but weak.
Adult dose Children dose

 500-1000 mg/ 6-8 hours.  50-100 mg/ kg / 3
 The available capsule times /day.
either 250 or 500 mg.  The available form
 The available vial
either 250, 500 or 1000
is:
mg.
 125-250 mg/ 5 ml. susp.
 Other market names:  Other market names:
Epicocillin. Epicocillin.

Notice that:
 Certain added preparations are used to
increase the effectiveness of the drug by
resisting the action of B- lactamase enzyme:
 Ampiflux (Ampicillin + Dicloxacillin):
 Available dose is; 250 mg (either capsule or
suspension).
 Cloxapen: as 250 or 500 mg capsules,
250 mg syrup.

Amoxycillin
 Adults or children over 10 years: 3 × 500 mg
daily.
 Children 5 - 10 years: 3 × 250 mg daily.
 Children 2-5 years: 3 × 125 mg daily.
 0 - 2 years: 3 × 100Amoxil
E-Mox
mg daily.
Amoxil
Amoxycillin
1.1. 125
125––250
250mg
mg (suspension).
(suspension).
1. 125 – 250 mg (suspension).
2.2. 500 mg (capsule).
2. 250 – 500(capsule).
500 mg mg (capsule).
3.3. 500
250
250––1000
500
500(vial).
(vial).
(vial).

Notice that:
 Certain added preparations are used to

increase the effectiveness of the drug by
resisting the action of B- lactamase enzyme:
 Flumox (Amoxycillin + Flucloxacillin):
 Available dose is; 250 mg (suspension) or 500
mg (capsule).

AMOXICILLIN + CLAVULINIC
AMPICILLIN + SULBACTAM AMOXICILLIN + CLAVULINIC
ACID
AMPICILLIN + SULBACTAM ACID
 Names: Unasyn,  Augmentin, available
Sulbin, Ampictam. as:
 Available as: (375-625 mg tablets,
375 mg tablets, or: 750- 156 mg suspension,
1500 mg vials. 600-1200 mg vials)
Curam , available as:


(625 -1000 mg tablets,

156 -312 mg suspension).
Although they are more effective formulas,
safety with pregnancy may be questionable.
Cephalosporins
-- Clinically, ST they’re not used to treat dental

Side
Notice effects:
that,
infections
They are
1
(Why?)
generation Cephalosporins may
B-lactam antibiotics similar to
be Urticarial
1. used clinically with &some benefits e.g.
-penicillins inrashes,
As the penicillins fever
their mode
are more GIT disturbance.
of action,
superior
but are
in more
their
DURICEF,
2. There’s CURISAFE,& cross-resistance
cross-allergy VELOSEF (against with
range of action
resistant
against
to B-lactamase.
dental / periodontal
G+ve & some G-ve).
penicillin.
pathogenic bacteria.

Duricef
 It is available as:
1. 125 – 250 - 500 mg syrup.
2. 500 mg capsule.
3. 1 gm tablet.
 Clinical use:
 In adult it can be used 500 mg – 1 gm (twice
daily),
 1 - 6 years: 250 mg (twice daily),
 Under 1 year: 25 mg / kg (twice daily).
Metronidazole
Side effects:
Market names:
1.
-ItItAnt-abuse effect when alcohol is ingested.
-It is
is
-2.ItDrug a
offersabactericidal
some
Flagyl, benefit
Amrizole,
bactericidal … … (How?)
in the
Anazole.
(How?) treatment
offers
can some
be as
interactions benefit
a
(with in the
monotherapy
oral treatment
anticoagulants or
& oral
-It disrupts
of (the
refractory
-Ithypoglycemic drugs). bacterial
periodontitis, DNA) of
combined,disrupts
of (the
refractory
with bacterial
periodontitis,
root DNA)
planing
3. Metallic taste, sometimes CNS-manifestations & rash.
of
or
anaerobic
particularly
4.anaerobic
MOMO e.g.
when
Dosage:
e.g. P. gingivalis
combined
P. gingivalis &
with & P.
P.
with particularly
Several trials
other have when combined
suggested
antibiotics. an increasedwith
risk for
intermedia. amoxicillin.
250 or 500 mg tablets.
preterm birth among women given metronidazole
intermedia. amoxicillin.
during pregnancy. However, the current scientific
250 mg
evidence accepted suspension.
its clinical use at the recommended
doses, without an elevated risk of birth defects.

Tetracyclines
-They exert an Side effects:

anticollagenase effect (esp.
--1. Its conc. in Side is
GCF effects:
2-10 times which
that in
against
They are
Gastrichost bacteriostatic
neutrophil
irritation & paincollagenases
i.e effective against
is
1. Gastric irritation & pain
serum.
rapidly
more multiplying
dangerous),
2.2. Containdicted in bacteria.
when lactation
pregnancy, used
Containdicted in pregnancy, lactation & less
in
& lessa
-subantimicrobial
They
It than
also act
8 against
bindsyears dose,
to A.
the
(it actinomycetemcomitans,
tooth bone
causes surface
&& from
teeth
-being than 8 years (it causes bone teeth
Thus
where good
itthey
canadjuncts
inhibit
discoloration). tissue
in treatment
can release destruction
of LAP.
& aid in
(substantivity).
discoloration).
bone regeneration&
3.3. Hepatotoxicity (arrest bone loss).
phototoxicity.
Hepatotoxicity & phototoxicity.

Q- What are the different
members of tetracyclines?
Minocycline
Doxycycline
Tetracycline
-100mg
-100 mgtwice
twicedaily
daily infor
1st1day
week, as 100
then, halfmg
lifeonce
is
-250 mg (4 t/day), the half life is 6-10 hr.
16-18
daily hr., thus it facilitates compliance.
-It (i.e pt. is more compliant),
shouldn’t be given for the same spectrum
patients withas
-It’s a broad
Minocycline spectrum
& not affected&bysuppress
antacids.spirochetes
impaired renal function, (excreted in urine).
upuse
-Its to 3 with
months posoperatively.
surgery for 2 weeks in refractory
-Absorption is reduced with milk & antacids
periodontitis,
-It can be used withwith
significant reduction
less renal of A.a.
toxicity up to
(Why?)
12(GIT absorption).
… As it’sas
months well as PD
excreted reduction & CAL gain.
in feces.

Macrolides
I)Erythromycin
-They can be bacteriostatic or bactericidal, depending on the
-They can be bacteriostatic or bactericidal, depending on the
-concentration
concentration
--Their spectrum
Their inhibit
spectrum
of the drug & the nature of MO.
ofis
isthe drug &
similar
similar butthenot
but nature
not of MO.
identical
identical to
to penicillin,
penicillin, useful
useful
They protein synthesis at ribosomal level (bind to
for -
-forThey
It’s not
bacterial
inhibit
patients
patients
-It’s notbut
protein
allergic
allergic
effective to
to
not to human
effective
Side
penicillin.
penicillin.
against
against
most effects:
synthesis at ribosomal
periodontal
ribosomes).
most periodontal
putativelevel (bind
pathogens
putative pathogens
to
bacterial
Orally,
-(PPP)
-Orally, but
250-500
250-500not
mg/8
mg/8to human
h.
h. in
in ribosomes).
adults
adults (20-50
(20-50 mg/kg/day).
mg/kg/day).
& doesn’t concentrate in GCF, so, it’s not indicated as an
(PPP) & doesn’t concentrate in GCF, so, it’s not indicated as an
adjunct
Mildtoto
1.adjunct periodontal
GIT therapy.vomiting & diarrhea.
upset: nausea,
periodontal therapy.
2. Reversible hepatotoxicitytatic in form of cholestatic
jaundice with eosinophilia (contraindicated in liver
diseases).

II)Azithromycin
-It is effective against anaerobes & G-ve bacilli.

-It penetrates fibroblasts & phagocytes (actively
transporting the drug to the sites of inflammation
to be directly released when they ruptured) in
concentration 100-200 times > extracellular
compartment.
-Long t ½, allowing once-daily dosing . After an
oral dose of 500 mg for 3 days, significant level of
azithromycin can be detected in most tissues for 7 –
10 days.

III)Clindamycin
It’s used specifically against anaerobic

infections & effective in situations in which the
patient allergic to penicillin.
-Dose: 150 & 300 mg capsules.
-Side effects:
1. Skin rash, diarrhea & liver dysfunction.
2. Pseudomembraneous colitis. (How?) (it kills
intestinal Flora→ flourishment of
colistridium dificile & its toxins→colitis).

Quinolones
Ciprofloxacin:
-It is bactericidal (inhibits DNA synthesis).
-Active against G-ve rods (including all facultative
& some anaerobic
They’rePPP).
contraindicated in
-It is the only antibiotic in periodontal therapy to
pregnancy, lactation &
which, all strains of A. actinomycetemcomitans are
susceptible.patients less than 18 years
-It enhances(maythelead to arthropathy).
effect of warfarin & other
anticoagulants. In addition to, nausea, headache &
metallic taste.
Recommendations
Don’t
Don’tforget
forgetthat:
that:
Given
Given the
the increasing
increasing number
number of of organisms
organisms
that
that have
have developed
developed resistance
resistance to to current
current
antibiotic
antibiotic regimens,
regimens, as as well
well as
as the
the potential
potential forfor
an
an adverse
adverse anaphylactic
anaphylactic reaction
reaction toto the
the drug
drug
administered,
administered, itit is
is best
best to
to be
be judicious
judicious inin the
the use
use
of
of antibiotics
antibiotics for
for the
the prevention
prevention of of IE
IE and
and other
other
distant-site
distant-siteinfections.
infections.

The decision making-tree in the
different causes of oral problems
Pulpal Periodontal
Periodontal
Pulpal
**Periodontal
**Periodontal
*Reversible
*Reversible abscess
abscess
pulpitis
pulpitis **Gingival
**Gingival
Miscellaneous abscess
abscess
*Irreversible
*Irreversible Miscellaneous
pulpitis **Pericoronitis
**Pericoronitis
pulpitis
*Periapical **Osteomyelitis
**Osteomyelitis *Plaque
*Periapical *Plaqueinduced
induced
periodontitis
periodontitis gingivitis
*Cysts gingivitis
*localized *Cysts
*localized Dry
dento-alveolar Drysocket
socket** **Non-plaque
**Non-plaque
dento-alveolar
abscess Infected induced
inducedgingivitis
gingivitis
abscess Infected**
**
**Facial socket
socket
**Facial *Chronic
cellulitis Tumors
Tumors** *Chronic
cellulitis periodontitis
periodontitis
*Operative intervention is needed, e.g.; filling, root canal treatment, local **Aggressive
**Aggressive
irrigation, incisional drainage, removal & oral hygiene measures. periodontitis
periodontitis
**Antibiotic prescribing is needed as an initial treatment. Operative **NUG/P/S
intervention(s) may be initiated on the same visit or later. Oral hygiene **NUG/P/S
measures are mandatory.
Care should be taken with immuno-comporomized patients. Dr.Hala Helmi Hazzaa
Antibiotic recommendations in
implant dentistry
 Although the use of prophylactic antibiotics in implant
dentistry is controversial,
 Antibiotics are generally considered beneficial for reducing

failure of dental implants placed in ordinary conditions to
minimize infections, (2 g or 3 g of amoxicillin given orally, as a
single administration, one hour preoperatively significantly
reduces failure of dental implants).
 The use of postoperative antibiotics is still controversial. (Esposito et

al., 2013)
However, special attention should be paid to

immediate implant placement especially on
replacing peri-apically infected teeth.

ANALGESICS

Non Steroidal Anti-inflammatory
Drugs (NSAIDs).
 There are two main types of NSAIDs,
nonselective & selective.
 The terms nonselective and selective refer to
different NSAIDs’ ability to inhibit specific
types of cyclo-oxygenase (COX) enzymes.
Nonselective NSAIDs:
Selective NSAIDs:
They inhibit both COX-1
They inhibit COX-2,and
an COX-2
enzymeenzymes to sites
found at a of
significant degree.
inflammation, more than the type that is normally
found in the stomach, blood platelets, and blood
vessels (COX-1).
:Mechanism of action
Their general mechanism of action:

The inhibition of prostaglandin synthesis
(Cyclo-oxygenase Enzyme inhibitors).

Figure (2)

Side Effects of NSAIDs
 Blood pressure may rise with use of NSAIDs.
 If NSAIDs are required, they should be used at the lowest effective

dose and for the shortest duration necessary for the given
indication.
 If chronic use of NSAIDs is anticipated, control of treated

hypertension may be adversely affected.
 Therefore, changes in blood pressure medications may be required.
 Anyone who is at risk for or who has cardiovascular disease

(coronary artery disease) may have a further increase in risk of
heart attacks when taking an NSAIDs (especially with COX2-
inhibitors).

 Short-term use of NSAIDs can cause stomach upset.
 Long-term use of NSAIDs, especially at high doses, can lead to

peptic ulcer disease and bleeding from the stomach.
 Inhibitor of stomach acid production:

High doses of antacid histamine blockers, such as famotidine (Pepcid®),
.can reduce the risk of developing an ulcer (related to use of an NSAID)
 People with platelet disorders, such as von Willebrand disease,

with abnormal platelet function from uremia, and with a low
platelet count (thrombocytopenia) are advised to avoid
NSAIDs.

 Most clinicians recommend stopping all NSAIDs approximately
one week before elective surgery (e.g. tooth extraction) to
decrease the risk of excessive bleeding. This usually includes
aspirin, ibuprofen, naproxen.
salts that block further

chemical activity for the rest
of the life of that platelet (7-
14 days).
 Use of NSAIDs, even for a short period of time, can harm the
kidneys, in people with underlying kidney disease (???).

 Selective NSAIDs have less potential to cause ulcers or
gastrointestinal bleeding.
 Selective NSAIDs are sometimes recommended for people who

have had a peptic ulcer, gastrointestinal bleeding, or
gastrointestinal upset when taking nonselective NSAIDs.

Precautions with selective NSAIDs
 Rofecoxib (Vioxx®) & valdecoxib (Bextra®) were taken off the
market in 2004 when it was discovered that people who took
these medications had a slightly increased risk of heart attack
and stroke.
 People with known coronary artery disease (e.g.; past history of

heart attack, angina [chest pain due to narrowed heart arteries],
history of a stroke, or narrowed arteries to the brain) should
avoid using COX-2 inhibitors.
 Of the nonselective NSAIDs, naproxen may be the safest for

people with coronary artery disease, but a clinician should be
consulted before use of this or any other NSAID.

Interaction with other medications
• People using anticoagulant medications such as warfarin
or heparin should generally not take NSAIDs or
aspirin because of an increased risk of bleeding when
both classes of drugs are used (Both will increase the
prothrombin time & INR).
• Taking an NSAID & phenytoin (Dilantin) can increase

the phenytoin level. As a result, people who take
phenytoin should have a blood test to monitor the
phenytoin level when starting or increasing the dose of
an NSAID.

• People who take cyclosporine (e.g.; to prevent rejection
after an organ transplant or for a rheumatic disease, such
as rheumatoid arthritis) should take particular care when
taking an NSAID ……………… Why??
 There is a theoretical risk of kidney damage when

cyclosporine and NSAIDs are taken together. To monitor
for this complication, blood testing may be recommended.
• People taking one NSAID should not take a second

NSAID at the same time because of the increased risk of
side effects.

• People with medical conditions that require diuretics,
including heart failure, liver disease, and kidney damage, are
at increased risk of developing kidney damage while taking
NSAIDs.
• NSAIDs can worsen kidney function in people whose kidneys

are not functioning normally. Therefore, most people with
chronic kidney disease are advised to avoid all types of
NSAIDs.

Safety with pregnancy
• NSAIDS are not generally recommended for
pregnant women during the third trimester due to
an increased risk of complications in the newborn
(persistent pulmonary hypertension of the
newborn).
• NSAIDs are safe for use during breastfeeding.
Fetal exposure to a NSAIDs was

confirmed by meconium analysis

Meconium analysis
 Meconium drug testing is a sensitive method for identifying
infants who have been exposed to drugs in utero. Meconium
represents the first series of green stools, which the infant excretes
after birth.
 The concept was based on initial research in animals, which

showed, that a high concentration of the drugs, which the
pregnant animal was exposed to, were present in the meconium
of their fetuses. Drugs, which the fetus is exposed to during
pregnancy, are metabolized by its liver into water-soluble
metabolites and excreted into the bile or urine.
 It is postulated that drug deposition in meconium occurs either

through bile secretion or through swallowing by the fetus of its
urine via the amniotic fluid.

Recently, analysis of the infant's hair for drugs has been
Recently, analysis of the infant's hair for drugs has been
used. Technical problems in the analysis and sample
used. Technical problems in the analysis and sample
collection make this method not practical in the neonate.
collection make this method not practical in the neonate.
 Unfortunately, the drug-exposed neonate is not easy to recognize.
Many of the drugs which the fetus was exposed to do not produce
immediate, recognizable effects.
 Even with maternal cooperation, information on the type and/or

extent of drug usage is often inaccurate.
 One alternative is to test the infant's urine for drugs, but this
procedure has its limitations since the successful detection of
drug metabolites in the infant's urine is dependent on time of the
last drug intake by the mother or when after birth the infant's
urine was collected.
 The high rate of false negative urine test often arises from the
mother's abstention from the use of the drug a few days before
she delivers or to the inability to obtain a sample of the infant's
urine soon after birth.

The most common types
Diclofenac
DiclofenacPotassium
Sodium
Ketoprofen
Ibuprofen
-It is an analgesic & anti-inflammatory
-It is an analgesic, antipyretic & anti-
NSAID.
-inflammatory
It
-25 oris an analgesic,
NSAID. antipyretic & anti-
mg50supp…
mg tab……
-inflammatory (Baby(Cataflam).
relief or Dolphin).
-75, 100 or 150 NSAID.
mg tab…… (Biprofenid).
-7525mg
or 50
amps…….
mg tab…… (Cataflam,
(Declofenac).
Dolphin-K).
-25
200,
75
mg
mg
400
tab.
or or
60050,
amps…….
mg75,tab……
200 mg(Brufen).
(Epifenac).
cap…..(Ketofan).
-150 mg supp……..(Ketofan).
-Its use is safe with hypertension, with
-avoidance
Contra-indicated
of gastric
with
sidehypertension.
effect.

Cyclo-oxygenase-2 inhibitors
Meloxicam
Celecoxib
-It is a NSAIDs, acting selectively to inhibit
-It is a NSAIDs, acting selectively to inhibit
COX2 , not COX1.
COX2
-It is , contraindicated
not COX1.
in case of hepatic
-It is contraindicated in case of patients with
impairment, bleeding disorders or renal
ischemic heart & cerebrovascular diseases.
failure.
-capsules : 100 - 200 mg.
-Tablets : 7.5 or 15 mg.

Paracetamol
 Paracetamol, also known as acetaminophen.
 Paracetamol is generally safe at recommended doses.
 It is on the WHO Model List of Essential Medicines, the most

important medications needed in a basic health system.
 Paracetamol is available as a generic medication with trade

names including Panadol with low cost.
 Safe with pregnancy, lactation, children, hepatitis and kidney

affected patients.

Paracetamol
 In contrast to aspirin, paracetamol does not prevent blood
from clotting (it is not an antithrombotic).
 It does not cause gastric irritation.

Disadvantages
Disadvantages
• IfParacetamol
paracetamol is generally considered
taken with opioids, there safe for evidence
is weak children, as itit
that
• If paracetamol is taken with opioids, there is weak evidence that it
may cause
ismay
not hearing loss.
associated with a risk of Reye's syndrome in
cause hearing loss.
children with viral illnesses.
• Paracetamol does not help reduce inflammation, while aspirin does.
• Paracetamol does not help reduce inflammation, while aspirin does.
• Compared
Although it isto ibuprofen,
well paracetamol
tolerated and safe for use has fewerwith
in patients adverse
hepatic
• Although it is well tolerated and safe for use in patients with hepatic
disease, acute overdoses
gastrointestinal of paracetamol can cause potentially fatal
effects.
disease, acute
liver damage. overdoses of paracetamol can cause potentially fatal
liver damage.
• Serious skin rashes can rarely occur.
• Serious skin rashes can rarely occur.
THANKS & GOOD LUCK

Antibiotics Analgesics in Dentistry

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Antibiotics Analgesics in Dentistry

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ANTIBIOTICS & ANALGESICS IN

Dr. Hala Helmi A. Hazzaa

Dr.Hala Helmi Hazzaa

o They may either kill or inhibit the growth of bacteria.

o A limited number of antibiotics also possess

o Antibiotics are not effective against viruses.

o Their effectiveness and easy access led to overuse,

o This has led to the most common widespread problem

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

Prophylaxis. Host modulation.

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

 Continued periodontal disease activity as measured

Dr.Hala Helmi Hazzaa

Abscess needs drainage to Pain needs analgesics for relief

It needs antiviral therapy

Dar-Odeh et al., 2010

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

Sub-antimicrobial dose of doxycycline (periostat):

-Tetracycline They decrease bone loss by modifying

 It is a proprietary product which is composed of a very

 Antibiotics should be used as adjunct to dental

 Make proper diagnosis & consider using narrow

 Antibiotics are indicated when systemic signs, that

 Keep in mind the drug interactions and the side effects

 The conservative use of antibiotics is indicated to minimize

 The duration of antibiotics???. Ideally antibiotics are

 When procedures involve infected tissues or are

 Avoid the sub-therapeutic doses or long duration to avoid

 On treating a patient with hepatitis, Penicillin,

Dr.Hala Helmi Hazzaa

 Aggressive management of infections (culture, sensitivity

 Hospitalization is indicated for severe infection or major

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

Adult dose Children dose

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

 Children 2-5 years: 3 × 125 mg daily.

Dr.Hala Helmi Hazzaa

 Certain added preparations are used to

Dr.Hala Helmi Hazzaa

Curam , available as:

(625 -1000 mg tablets,

-- Clinically, ST they’re not used to treat dental

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

-They exert an Side effects:

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

-It is effective against anaerobes & G-ve bacilli.

Dr.Hala Helmi Hazzaa

It’s used specifically against anaerobic

Dr.Hala Helmi Hazzaa

Dr.Hala Helmi Hazzaa

 Antibiotics are generally considered beneficial for reducing

 The use of postoperative antibiotics is still controversial. (Esposito et

However, special attention should be paid to