Pharmacology
in Dentistry
Khadijeh Al-Zubi, DDS, MDSc
Periodontology and implantology specialist
Department of Periodontology – University of Jordan
February 2021
Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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01
Local anesthesia
It’s a drug use to reversibly prevent the
generation and conduction of nerve impulses Nociceptors > sympathetic >
in the area where it is applied, so there is loss Temperature nerves >>> Motor
of pain and sensation in that area only without nerves
affecting the consciousness of the patient as
<< General rule >> small fibers are
in General anesthesia.
more susceptible to anesthesia
compared to large fibers.
Cocaine was the first drug to be discovered by
Neiman 1860.
Novocaine was the first drug used in Dentistry.
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Mechanism of Local anesthesia
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Mechanism of Local anesthesia
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Mechanism of Local anesthesia
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Ionized and un-ionized
forms
Weak base pKa 8-9 Weak base pKa 8-9
UN-IONIZED form can penetrate cell IONIZED form can NOT penetrate cell
membrane = effective membrane = Ineffective
Physiological PH = 7
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Local
anesthetics
Esters Amides
→ breaks down in plasma by → Stays stable in plasma, breaks down in
Pseudocholinesterase → Shorter liver (biotransformation by Cytochrome
duration of action P450-CYP3A4) → longer duration of
action → less medical concerns than
→ Medical concerns: Pseudocholinesterase
Esters
deficiency
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Local
anesthetics
An example of each category:
Esters Amides
Cocaine Lidocaine
Procaine Bupivacaine
Prilocaine
Benzocaine
Articaine
Mepivacaine
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Local
anesthetics
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Local
anesthetics
Lidocaine Articaine (Septocaine) Bupivacaine (Marcaine)
Most common, and gold standard Most effective when anesthetized buccally in the mandible → can
penetrate bone more than other LA agents.
Other names: lignospan/xylocaine Longest duration of action but very slow
DO NOT USE IT AS A NERVE BLOCK ONLY INFILTRATION can cause
onset
Vasoconstrictor: both +/- permanent parasthesia
Medium tissue penetration
Max. Dose for a 70kg human is 500mg Can cause ulceration in sites of injection specially in the palate.
which is almost 11 carpules High cardiac toxicity
Only Amide that is partially metabolized in plasma
Can be used as a drug as an anti- Can be used in long procedures compared to Lidocaine.
arrhythmic
Max dose = 500mg, about 5 carpules
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Topical
anesthetics
Ester Amide
Benzocaine 20% Lidocaine 20%
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Vasoconstrictors
in LA
Levonordefrin
Similar Epinephrine
Epinephrine
❖Naturally occurring hormones (epinephrine =
Adrenaline) – short action
❖Act on blood vessels around the area of Felypressin
injection and causes constriction of blood vessels Synthetic and not natural
hormone
❖This controls the bleeding in that area and
reduces the systemic absorption of LAs→ thus
prolongs the duration of anesthesia and reduces
the toxicity of those drugs→ more effective or
profound anesthesia.
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Injection into muscles or tissues
Complications
Pain and swelling, for example buccinator or TMJ ligaments
Trauma to other tissues
of Local CNS
Dizziness and confusion
anesthesia
(if large dose injected in artery→ CNS depression →
respiratory depression
Facial nerve palsy if injected in Parotid gland
CVS
Bleeding. ALWAYS ASPIRATE before injecting the LA. Specially
with Marcaine (Bupivacaine)
Prilocaine causes Methemoglobinemia
Increases blood pressure, heart rate, and respiratory rate.
Beware of Syncope (MOST COMMON MEDICAL EMERGENCY)
Vasoconstrictor in LA can interact with non-selective Beta-
blockers.
Infection
Spread the infection
Allergy
Very rare.
Lidocaine is the only choice for pregnant, but for breast
2/6/2021 feeding pts any LA is ok except Articaine and Prilocaine.
20
How much LA in a carpule?
2% means 2gm/100ml or
2000mg/ml
How much Lidocaine in 1 carpule (Lidocaine 2%)? Or add 0 to the % then it becomes
mg/ml
•Each carpule has 1.8ml or 1800mg of liquid
•So if carpule has 100% of lidocaine (nothing else) then Lidocaine weighs 1800mg
•But if only 1% of lidocaine in the carpule then in mg 1800mg/100 → you will have 18mg of Lidocaine
•If lidocaine is 2% then 18*2 or 1800/100*2 → 36mg
•Or you can add a 0 to the % so 2% of lidocaine is 20mg/ml. Then you multiply it by 1.8ml → 36mg
•Another drug Articaine 4% → either you 18*4 or 1800/100*4 or 40*1.8→ 72mg
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How much Vasoconstrictors in a
carpule?
How much Epinephrine in 1 carpule (Epinephrine is 1:100,000)?
•Each carpule has 1.8ml or 1800mg of liquid
•The bigger the ratio the less concentration of that vasoconstrictor
•Convert ratio to mg.
•1:100,000 means 1gram/100,000 ml ----- convert to mg---- 1mg/100 ml → 0.01mg/ml so in 1.8ml carpule →
0.01*1.8 = 0.018mg
1 gram / 100,000 ml convert
to mg that’s 1/1000ml
•Marcaine has 1:50,000 epinephrine
•To convert 1gram/50,000 ml ----- convert to mg ---- 1mg/50ml → 0.02mg/ml so in 1.8mg carpule →
0.036mg
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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02
Antibiotics
Antibiotics
• Definition: Drugs that are used to treat
BACTERIAL infection, either by killing
or inhibiting growth of bacteria.
• Was discovered by accident in the lab!
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Antibiotics
• Drug resistance happens when:
1. Prolonged treatment time causes superinfection mainly by Candida
2. Interrupted course
3. Inadequate dose
4. Abuse of drug
• Can lead to:
1. Resistance
2. Superinfection (by candida)
3. Drug toxicity
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Antibiotics
• Based on their therapeutic spectrum:
1. Narrow spectrum: for example
penicillin kills streptococci and oral
anaerobic bacteria, but can't kill
staphylococci of skin and GI bacteria
2. Broad spectrum: for example when
adding Clavulanate acid to Amoxicillin
(Augmentin) its a broad-spectrum not
only kills streptococci and oral
anaerobic but also kills staph of skin
and GI bacteria
• Based on their mode of action:
1. Bactericidal: capable of killing bugs
2. Bacteriostatic: capable of inhibiting
growth or reproduction of bugs
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Cell wall inhibitors
• Bactericidal
• Narrow spectrum except for Augmentin
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Cell wall inhibitors
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Protein Synthesis
inhibitors
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Protein Synthesis
inhibitors
• Macrolides:
1. Bacteriostatic – 50s Ribosomal unit
2. Kinda broad spectrum (compared to Tetra)
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Protein Synthesis
inhibitors
• Lincosamides:
1. Bacteriostatic – 50s Ribosomal
unit
2. Narrow spectrum
3. Structurally close to Macrolides
(same function too)
4. Includes:
Clindamycin
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Protein Synthesis
inhibitors
• Tetracyclines:
1. Bacteriostatic – 30s Ribosomal
unit
2. Broadest spectrum antibiotic
3. Includes:
• Tetracycline
• Doxycycline
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• Minocycline 35
Nucleic Acid
Synthesis inhibitors
Nucleic Acid
Synthesis inhibitors
• Bactericidal – inhibits DNA replication.
• Metronidazole has Narrow spectrum (only anaerobic
bac) but Quinolones have broad spectrum of activity.
• Metronidazole is known as Flagyl.
Cell membrane
disruptors
• They act by creating pores in the membrane
• Daptomycin -> uses Ca to create pore-like complex and let K ions to
leak through – For Gram +ve
• Polymyxins -> Integrates with the membrane structure and causes
structural changes of cell membrane (pores) – For Gram -ve
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Folic acid pathway
inhibitors
• Bacteriostatic agents
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Folic acid pathway
inhibitors
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Antibiotics
• Pre-op = prophylaxis
• Post-op or infection = therapeutic
Prophylaxis according to recent guidelines:
1. Prosthetic heart valve NOT PACEMAKER
2. History of rheumatic fever, previous endocarditis or rheumatic heart disease (NOT RHEUMATIC FEVER
WITHOUT VALVULAR DYSFUNCTION)
3. Congenital heart disease (ex. Down syndrome)
4. Dialysis (with arteriovenous shunts)
5. Organ transplant patients.
6. Chemotherapy patients (might have bone marrow transplantation)
7. Artificial joint patients ??
8. Immunosuppressed patients
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Antibiotics
• Pre-op = prophylaxis
• Post-op or infection = therapeutic
Therapeutic ->
1. Perio:
Periodontitis (only some cases)
Necrotizing ulcerative periodontitis (not for NUG and only if there is systemic symptoms)
Periodontal abscess (only if systemic symptoms available)
2. Endo:
Only when systemic symptoms or when infection is persistent
NOT for PA lesion, or pulpitis or if there is sinus tract, or localized gingival swelling
3. Oral surgery:
Systemic symptoms and cellulitis or progressive swelling
Medically compromised patients
Osteomyelitis
Involvement of fascial spaces
Not for dry socket (unless there are systemic symptoms), not for mild pericoronitis, not for minor abscess even
if its chronic.
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Antibiotics
Interactions
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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03
Analgesics
Non-steroidal anti-inflammatory drugs (NSAIDS)
are a group of Medications that have similar
antipyretic and anti-inflammatory effects, but they
differ in their chemical structures
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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Mediates Mediates Mediates
Vasodilation and Vasoconstriction inflammation
Anti-Platelet and Platelet and pain
aggregation aggregation Gastric acid
(protects
stomach)
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Mediates Mediates Mediates
Vasodilation and Vasoconstriction inflammation
Anti-Platelet and Platelet and pain
aggregation aggregation Gastric acid
(protects
stomach)
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Mediates Mediates Mediates
Vasodilation and Vasoconstriction inflammation
Anti-Platelet and Platelet and pain
aggregation aggregation Gastric acid
(protects
stomach)
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Outline
01 Local anesthesia
• Mechanism of Action
• Types of LA
• Vasoconstrictors
• Complications of LA
02 Antibiotics
• Classification
• Categories
• Usage
03 Analgesics
• Mechanism of Action
• Types and complications
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ASA -
Irreversible
Salicylism and
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Irreversible
Selective COX-2 has even less GI problems
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Reduces the risk of peptic ulcer or GI bleeding.
However → Heart issues
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Paracetamol (acetaminophen)
1
Knowns as Panadol or Tylenol
500-1,000 mg q 4-6 h to a maximum of 4 grams
per day
3
NOT A PART OF NSAIDs High doses can cause acute Liver failure
(more than 4g/day)
Mode of action → selective COX-3 inhibitor??
2
Antipyretic and analgesic but not anti-inflammatory
(not part of NSAIDs) → Doesn’t cause bleeding or
ulceration
→ Safe for pregnant women and children
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05
Closing
Please feel free to email me for the
PDF file and if you have any
questions ☺
[email protected]
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References
Contemporary of Oral And Maxillofacial Surgery Textbooks
Scully’s Medical Problems in Dentistry Textbooks
Carranza’s Clinical Periodontology
American Heart Association’s website
WHO (World health Organization)’s website.
ADA’s website (American Dental Association)
Materials for NBDE
Pharmacological Agents in Dentistry: A Review by Mohan et al 2011
Pharmacology in Dentistry by Dr. Nkansah 2013
Pictures in this presentation are from google.com or youtube.com as an open access source.
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