Dr.G.

Thiruvenkadam Post Graduate Department of Pediatric & Preventive Dentistry

Substances that precipitate proteins, but do not penetrate cells, thus affecting the superficial layer Toughen the surface mechanically stronger and decrease exudation Drugs are:
Tannic acids and tannins Alcohols Mineral astringents

Tannic acid
Present in many plants Obtained from nutgalls of oak

Tannins
Tea, catechu, nutmeg, areca nut

They denature the proteins forming protein tannate Uses:

Bleeding gums as glycerine of tannic acid Bleeding piles as tannic acid suppository Alkaloidal poisoning precipitates the ingested alkaloids as tannates

Ethanol and methanol are good astringents at 50 -90% concentrations Denatured spirit rubbed on the skin prevents bed sores Highly irritating to raw surfaces Ethanol is also used as after - shave and on minor cuts

Heavy metal ions are astringents and antiseptics Alum (hydrated + aluminium sulphate + sulphate of other salts) has been used as after shave and as local haemostatic on minor cuts
Potassium alum (potassium sulphate) Ammonium alum (ammonium sulphate)

Local haemostatics agents These are substances used to stop bleeding from a local approachable site They are particularly effective on oozing surface They should never be injected

Brand name: Thrombostat Obtained from bovine plasma Applied as dry powder or freshly prepared solution on the bleeding surface Used in cases of haemophilia, neurosurgery, skin grafting Adverse reaction:

Allergy may occur in patients with known sensitivity to bovine materials Must not be injected into the tissues or vasculature Cause severe or often fatal clotting

Precautions:

Prepared from human plasma Used as sheets or foam for covering or packing bleeding surfaces It is left in situ: gets absorbed in the body

Brand name: Gelfoam Prepared from pork skin It is spongy gelatin available in various shapes It is moistened with saline or thrombin solution and used for packing wounds Gets absorbed in 1 2 months if left inside

Applied locally, it acts as a thromboplastin Used to stop external bleeding in haemophilics

1% solution of adrenaline may be soaked in sterile cotton gauze and packed to stop epistaxis and other similar bleeding

Brand name: Oxycel Most effective when applied to wound dry as opposed to moistened Chemically modified form of surgical guaze Adverse reactions:
May cause foreign body reactions

Precautions

Extremely friable and difficult to place Should not be placed adjacent to bone Should not be used as a surface dressing
Inhibits epithelialization Impairs bone regeneration

Brand name: Surgicel Available as sheets Prepared from cellulose treated with an alkali Can be used as surface dressing as it doesnt interfere with epithelialization Adverse reactions
Encapsulation Cyst formation Foreign body reaction

Precautions

Should not be placed in deep wounds

Interfere with wound healing and bone regeneration

Brand name: Collacote, Collaplug, Collatape Adverse reactions:

Potentiates abscess formation Hematoma and wound dehiscence Allergic/foreign body reaction

Precautions:
Interfere with wound healing

Dental plaque is defined as a highly specific variable structural entity formed by sequential colonization of microorganism on the tooth surface, epithelium and restorations.

It is the removal of microbial plaque and the prevention of its accumulation on the teeth and adjacent gingival tissues. It also deals with the prevention of calculus formation.

Should decrease plaque & gingivitis Prevent pathogenic growth Should prevent development of resistant bacteria Should be biocompatible Should not stain teeth or alter taste Should have good retentive properties Should be economic

CHEMICAL PLAQUE CONTROL AGENTS

FIRST GENERATION Eg: antibiotics, phenol,quarternary ammonium compounds & sanguinarine

SECOND GENERATION Eg: Bisbiguanides,(chlorhexidine)

THIRD GENERATION Eg: delmopinol

TRICLOSAN

Phenol derivative Is synthetic and ionic Used as a topical antimicrobial agent Broad spectrum of action including both gram positive and gram negative bacterias It also includes mycobacterium spores and Candida species

TRICLOSAN

ACT ON CYTOPLASMIC MEMBRANE

INDUCE LEAKAGE OF CELLULAR CONSTITUENTS

BACTERIOLYSIS

Triclosan is included in tooth paste to reduce plaque formation Used along with Zinc citrate or co-polymer Gantrez to enhance its retention within the oral cavity Triclosan delay plaque formation It inhibits formation of prostaglandins & leukotrienes there by reduces the chance of inflammation

Ex: Zn & Cu ions

MECHANISM OF ACTION It reduces the glycolytic activity in bacteria &delays bacterial growth

Cationic antiseptics & surface active agents Effective against gram positive organisms

MECHANISM OF ACTION

Positively charged molecule reacts with negatively charged cell membrane phosphates and thereby disrupts the bacterial cell wall structure Eg: Benzanthonium chloride, Benzalleonium chloride and cetylpyredinium

It is a benzophenanthredine alkaloid It is most effective against gram ve organisms Used in mouth rinse

CHLORHEXIDINE GLUCONATE(0.2%)

It is a cationic bisbiguanide Effective against gram +ve, gram ve organisms, fungi, yeasts and viruses Exhibit antiplaque & antibacterial properties

MECHANISM OF ACTION Antiplaque action of chlorhexidine

1.

2.

3.

Prevents pellicle formation by blocking acidic groups on salivary glycoproteins thereby reducing glycoprotein adsorption on to the tooth surface Prevents adsorption of bacterial cell wall on to the tooth surface Prevents binding of mature plaques

It shows two actions

1. Bacteriostatic at low concentrations

Bacterial cell wall(-ve charge)

Reacts with +ve charged chlorhexidine molecule

Integrity of cell membrane altered CHX binds to inner membrane phospholipids & increase permeability Vital elements leak out & this effect is reversibl

Increased concentration of chlorhexidine

Progressive greater damage to membrane Larger molecular weight compounds lost

Coagulation and precipitation of cytoplasm Free CHX molecule enter the cell & coagulates proteins Vital cell activity ceases cell death

ADVERSE EFFECTS OF CHLORHEXIDINE

1. 2. 3.

4.

Brownish staining of tooth or restorations Loss of taste sensation Rarely hypersensitivity to chlorhexidine has been reported Stenosis of parotid duct has also been reported

Enzymes has been used as active agents in antiplaque preparations It is due to the fact that enzymes would be able to breakdown already formed matrix of some plaques and calculus Some are proteolytic and have bactericidal action eg:Mucinase, mutanase, dextranase etc

Inhibits plaque growth and reduces gingivitis

Mechanism of action

Interfere with plaque matrix formation & also reduces bacterial adherence It causes weak binding of plaque to tooth, thus aiding in easy removal of plaque by mechanical procedures It is therefore indicated as a pre brushing mouth rinse

Adverse effect of delmopinol

1. 2. 3.

Staining of tooth & tongue Taste disturbances Mucosal soreness & erosion

Dentifrice is a substance used with a tooth brush for the purpose of cleaning the accessible surfaces of the tooth It contains
Therapeutic agent such as fluoride to inhibit caries Antimicrobial agents- chlorhexidine, cetrimide Anticalculus agent - zn-chloride

Polishing/ abrasive agents Ca carbonate Dicalcium phosphate dihydrate Alumina Silica Functions Mild abrasive action aids in illuminating plaque Removes stained pellicle, restores natural luster, enhances enamel whiteness
1.

2.Binding/ thickening agents

a. Water soluble agents

Alginates, Sodium carboxy methyl cellulose etc

b. Water insoluble agents

Colloidal silica, Magnesium aluminium salts etc

Functions

Controls stability &constitency of tooth paste

3.Detergents/ surfactants
Sodium lauryl sulfate

Functions
Produces foam & removes food debris Antimicrobial property

4. Humectants Sorbitol, glycerine, polyethylene glycol Function reduces the loss of moisture from tooth paste 5. Flavoring agents Peppermint oil, spearmint oil, oil of wintergreen Function Render the product pleasant to use & leaves a fresh taste in mouth after use

6. Sweeteners and colouring agents 8. Anti bacterial agents

Triclosan, delmopinol, metallic ions & Zn-citrate trihydrate

9. Anticaries agents Na fluoride, stannous fluoride 10. Anticalculus agents(crystal growth inhibitors) Pyrophosphate, Zn citrate, Zn chloride

12. Desensitizing agents

Sodium fluoride, potassium nitrate

A disclosing agent is a preparation in liquid, tablet or lozenge

from which contains a dye or other coloring agents

A disclosing agent is used for identifying bacterial plaque

When applied to the teeth, the agents imparts its colour to soft
deposits but can be rinsed easily from clean tooth surface

Intensity of colour Duration of intensity Taste Irritation to mucous membrane Diffusibility Astringent and antiseptic property

Iodine preparations
Skinners iodine solution Diluted tincture of iodine Mercurochrome soln 5 Flavored mercurochrome disclosing solution

Mercurochrome preparations

Bismark brown Mebromin Erythrosine Fast green Fluoresin Two tone solutions Basic fuschin

 Discussion

about antibiotics usage in endodontic treatment

Myth #1: Antibiotics cure patients. Myth #2: Antibiotics are substitutes for surgical intervention Myth #3: The most important decision is which antibiotic to use Myth #4: Antibiotics increase the hosts defense to infection Myth #5: Multiple antibiotics are superior to a single antibiotic Myth #6: Bactericidal agents are always superior to bacteriostatic agents Myth #7: Antibiotic dosages, dosing intervals and duration of therapy are established for most infections Myth #8: Bacterial infections require a complete course of antibiotic therapy

Except in patients with a compromised immune system, antibiotics are not curative, but instead function to assist in the re-establishment of the proper balance between the hosts defenses (immune and inflammatory) and the invasive agent(s). Antibiotics do not cure patients; patients cure themselves.

Very seldom are antibiotics an appropriate substitute for removal of the source of the infection (extraction, endodontic treatment, incision and drainage, periodontal scaling and root planing). Only when the infection is too diffuse or disseminated to identify a nidus for incision, or the clinical situation does not allow for immediate curative treatment It is imperative to remove the cause of the infection prior to, or concomitant with, antibiotic therapy, when the cause is readily identifiable. Whenever antibiotic therapy is used the risk of bacterial selection for antibiotic resistance is present.

The most important initial decision is not which antibiotic to prescribe but whether to use one at all. It has been estimated that up to 60% of human infections resolve by host defense alone following removal of the cause of the infection without antibiotic intervention.

Antibiotics that can penetrate into the mammalian cell (erythromycin, tetracycline,clindamycin and metronidazole) are more likely to affect the host defenses than those that cannot (beta-lactams) Tetracyclines may suppress white cell chemotaxis Most antibiotics (except tetracycline) do not depress phagocytosis and T- and B-lymphocyte transformation may be depressed by tetracyclines. The greatest potential harm to the host defenses may result from antibiotics that easily penetrate into the mammalian cell and the least harm is observed with bactericidal,nonpenetrating agents (penicillins and cephalosporins).

When the purported benefits of antibiotic combinations are weighed against the possible consequences to the host as well as to the bacterial environment, this assumption is not always reality. The usual sequela to combined antibiotic therapy results in a greater selective pressure on the microbial population to develop drug resistance. The greater the antibacterial spectrum of the antimicrobials used, the greater the number of drug-resistant microorganisms that develop, and the more difficult it is to treat a resulting superinfection. The primary clinical indication for combined antimicrobial therapy is a severe infection in which the offending organism(s) is unknown and major consequences may ensue if antibiotic therapy is not instituted immediately

Bactericidal agents are required for patients with impaired host defenses. Bacteriostatic agents are usually satisfactory when the hosts defenses against infections are unimpaired. Postantibiotic effects (PAEspersistent suppression of bacterial growth after previous exposure to antibiotics) are more persistent and reliable with bacteriostatic agents (erythromycin, clindamycin) than with bactericidal agents (betalacatamase)

After more than 80 years of antibiotic usage, the proper dosages, dosing intervals and duration of therapy are essentially unknown for most specific infections The current recommendation is to employ an antimicrobial on an intensive basis with vigorous dosage for as short a period of time as the clinical situation permits. The major factor in the clinical success of most antimicrobial agents is the height of the serum concentration of the drug and the resulting amount in the infected tissue(s).

The goal of antibiotic dosing is to achieve drug levels in the infected tissue equal to or exceeding the minimal inhibitory concentration of the target organism. It is advisable to initiate antibiotic therapy with a loading dose An oral antibiotic should ideally be administered at dosing intervals of three to four times its serum half-life, particularly if steady-state blood levels are desired (as may be indicated with beta-lactam agents)

There is no such thing as a complete courseof antibiotic therapy. The only guide for determining the effectiveness of antibiotic therapy, and hence, the duration of treatment, is the clinical improvement of the patient. A common misconception asserts that prolonged (after clinical remission of the disease) antibiotic therapy is necessary to prevent rebound infections from occurring. Orofacial infections do not rebound if the source of the infection is properly eradicated.

1st category irreversible pulpitis with moderate/ severe symptoms 2nd category irrversible pulpitis with an acute apical periodontitis 3rd category necrotic pulp, chronic apical periodontitis, no swelling and no/mild symptoms 4th category necrotic pulp, acute apical periodontitis, no swelling and moderate to severe symptoms 5th category necrotic pulp, chronic apical periodontitis and cases with sinus tracts 6th category necrotic pulp, abscess with swelling and moderate to severe symptoms of infection