ANTIBIOTICS

&
ANALGESICS
CLASSIFICATION OF ANTIBIOTICS

CLASSIFICATION BASED ON SUSCEPTIBILITY OF

ORGANISMS
I. Antibiotics effective against :
1) Gr +ve bacteria
Eg: penicillin , erythromycin
2) Gr -ve bacteria
Eg: aminoglycosides,cephalosporins
3) Gr +ve & Gr –ve bacteria
Eg: ampicillin, amoxycillin, tetracycline,
chloramphinicol,cephalsporins
4) Acid fast bacilli
Eg : Streptomycin
5) Fungi
Eg : Nystatin
II) Based on mechanism of action
1. Inhibitors of cell wall synthesis -Eg: Penicillin, cephalosporins,
vancomycin,bacitracin.
2. Inhibitors of protein synthesis
➢Affect the function of 30s or 50s (reversable inhibition of protien
synthesis)-Eg: Chloramphenicol, erythromycin,tetracyclin,
clindamycin.[static drugs]
➢Bind to 30s and alter protein synthesis- Eg: Aminoglycosides
[Cidal drug]
3. Inhibitors of membrane function
Eg:nystatin,ampohoteresin-B [polyene antifungals]
4. Anti-metabolites
5. Inhibitors of nucleic acid synthesis
 MECHANISM OF ACTION

Intracellular Extracellular

Penicillins
Tetracyclins
cephalosporins
chloramphinicol
polymyxin
aminoglycosides
bacitracin
clindamycin
polyenes
1. Inhibitors of Cell Wall
synthesis
Beta-lactams
•Penicillins
•Cephalosporins
•Monobactams
•Carbapenems
Glycopeptides
Fosfomycins
 CLASSIFICATION OF PENICILLIN

I) Natural penicillins :
Penicillin G (Benzyl penicillin),procain penicillin-g, benzathine penicillin.
II) Semisynthetic penicillin-
1.Acid resistant penicillins :
Phenoxymethyl penicillin (penicillin V)
2 . Penicillinase – resistant penicillins :
Acid labile : Methicillin, nafillin, cloxacillin, dicloxacillin
Acic resistant: flucloxacillin.
3. Extended spectrum penicillins :
a.Carboxypenicillins : Carbenicillin, ticarcillin,
b. Aminopenicillin : Amipicillin, amoxicilllin.
c. Ureidopenicillin : Mezlocillin, piperacillin.
4. Beta lactamase inhibitors : Clavulanic acid, Sulbactum.
 Cephalosporins
First generation- Second generation- Third generation Forth generation
More active

More active against more selective Highly active simillar

gram positive against gram against gram antibacterial
organism positive and gram negative otganisms activity as that 0f
negative organisms third generation but
highly resistent to
beta lactamases

Parenteral- Parenteral Parenteral- Parenteral-

Cephalothin Cefuroxim Cefotaxim Cefepime
Cefazolin Cefoxitin Ceftizoxime Cefiperome
Cephaloridine Oral Ceftraxone
Cefoperazone
Oral- Cefaclor
Oral-
Cephalexin Cefuroxim axetal cefexim
Cephadine
Cefadroxil
Monobactams- inhibits gram negative
bacilli .
•It is resistant to gram negative beta-
lactemases .
•hospital acquired infections.
• T1/2 1.8 hrs

Imipenem - it is extremely potent and most

broad spectrum beta-lactam antibiotic

Imipenem spectrum of activity

2. Inhibitors of Protein Synthesis

•Aminoglycosides
•MLSK (Macrolides, Lincosamides, Streptogramins,
Ketolides)
•Tetracyclines
•Glycylcyclines
•Phenicols
•Oxazolidinones
•Ansamycins
 AMINOGLYCOSIDES
USES
•Gram-positives, except Streptococus
and Enterococcus.
•combine with aminoglycoside
(Gentamicin or Streptomycin) &
penicillin, ampicillin or vancomycin for
severe enterococcal infections
(Synergy)
• In serious infection, with beta-lactams
or fluoroquinolones
•Gram-negative nosocomial infections
•severe systemic infections
•Broad spectrum of action
•Rapid bactericidal effect
• Inhibitors of Protein Synthesis
• Related in structure and function
• Drugs differ based on location of radical
groups attached to the 3 ring basic
structure
Kanamycin
•develops resistance quickly
•Hospital use only
• Nephrotoxic and toxic for ears
•Drug Dosage Adjustment:
•Monitoring mandatory.
•Control the serum level for peak -ensure
the bactericidal effect and avoid side
effects
 Tetracycline
Broad spectrum antibiotic.
Low absorption through git.
Rapid renal excretion,
Low phototoxic
Marked alteration of intestinal bacteria.
Demiclocycline-
Intermediate potency.
High plasma binding capacity.
Slower renal excretion.
Highest phototoxic.
Doxicycline-
High potency.
Complete absorbtion from intestine.
High plasma binding.
T1/2- 18-24 hr.
Leaast alteration of intestinal flora.
Low toxixcity &metabolised in liver.
 Erythromycin (Macrolides )
•anti bacterial spectrum – similar penicillin.
•against penicilin resistant staphylococci.
•small intestine.
•partially destroyed by gastric juice, (enteric coated tablets)

•Various preparation- enteric coated tablets

Estolate form (most resistant by gastric acid)
Sterate
Ethylsuccinate [parenteral]
Glucoheptonate[parenteral ]
•drugs belonging to this group- olindomycin, Spiramycin
(Anti microbial -higher than erythromycin)
New macrolids- roxithromycin, clarithromycin
• Simillar spectrum of erythromycin
• More resistant to acid hydrolysis.
• Better tissue level are achieved.
 Clindamycin

Is a lincosamide

•Widely distributed in tissue fluids and tissues, including bone.

•Avoid in the routine odontogenic infection
•An excellent alternative drug in penicillin-resistant anaerobic
infections
•Used in Osteomyelitis of the jaws
•Antimicrobial activity in colon is for 5days.
 CHLORAMPHENICOL
Uses-
•for extra-intestinal
•severe salmonella infection.
• Empiric treatment of meningitis,
• crosses BBB well.
Toxicity:
•bone marrow aplasia
•Hematological abnormalities.
•Relatively small molecule, easily
enters Gram-positive and Gram-
negative Bacteria
•Spectrum of Action:Gram-positive
and Gram-negative bacteria,
Chlamydia, Mycoplasma and
Rickettsiae.
•Target is Ribosome
•Binds to 50S subunit -inhibits
elongation step of protein synthesis
3. Inhibitors of Membrane Functions
•Polymixins
•Cyclic lipopeptides
 Lipopeptides: Polymyxins
Polymyxin B

•Target =Membrane phospholipids, LPS)

Uses
•Gram-negative UTI, blood, CSF and
eye infections.
•used in combination against very
resistant Pseudomonas, KPC.
• High toxicity – neurotoxic and
nephrotoxic
& lipoproteins
• Outer and Cytoplasmic Membrane
Effect
•More permeable membrane. leakage of
cellular molecules, inhibition of
respiration and increased water uptake
leading to cell death.
•Gram-positives are naturally resistant
(too thick to permit access)
4. Anti - Metabolites
•Sulphonomaides
•Trimethoprim
 Anti-Metabolites
sulphonomides
Trimethoprim/Sulfamethoxazole:

•Natural Resistance
•Enterococcus –poorly expressed
•S. pneumoniae
•Ps. aeruginosa (impermeability)

USES-
•UTI’s
• otitis media in children,
chronic bronchitis in adults,
• enteritis
•Travelers’ Diarrhea.
5. Inhibitors of Nucleic Acid Synthesis

•Quinolines
•Furanes
Quinolones
• Small and hydrophilic
• easily diffuse n reach Target =
Topoisomerases
• Rapid bactericidal activity
• 1st Generation Quinolones:
Gram-negatives, UTI
high concentrations -infection.
• Fluoroquinolones: Garenoxacin
Gram-negative and Gram-positive ( Anaerobes,
Atypicals, S.pneumoniae and Pseudomonas)
• Ciprofloxacin, Levofloxacin, Norfloxacin,
Ofloxacin - More effective (lower MIC values).
Spectrum -Staphylococci, Streptococci and
Pneumococci (sparfloxacin).
More widespread tissue distribution .
Ciprofloxacin and Ofloxacin -systemic infections.
• Sparfloxacin, Gatifloxacin, Moxifloxacin
Trovafloxacin (removed cardiac arrhythmias, liver
destruction, phototoxicity.)
•Gatifloxacin (Tequin®) removed from market
05/01/06 - diabetes.
III) Classification based on spectrum of activity
➢Narrow spectrum
➢Eg: Penicillin G
➢Broad spectrum
➢Eg: Tetracyclines,chloramphenicol

➢IV) Based on type of action

" Bactericidal antibiotics " Bacteriostatic antibiotics
" Penicillin(s) " Tetracyclines
" Cephalosporin(s) " Erythromycin
" Aminoglycosides " Clindamycin
" Vancomycin " Chloramphenicol
" Metranidazole
" Imipenem
Anti-fungal antibiotics

• A. polyenes-
• Amphotricine B, nystatin, hamycin,natamycin
• B. heyerocyclic benzofuran-
• Griseofulvin
 Metronidazole
USES-
•Adverse Effectsantibiotic
Nitroimidazole
•anaerobes in intra-abdominal abscess, •Nausea, bacteria
•anerobic diarrhea,and
metallic taste
protozoa
(B.fragilis, spp, Fusobacterium •IV adminstration-
•antibiotic, Thrombophlebitis
amebicide, and antiprotozoal.[
spp, Clostridium spp, Peptostreptococcus
spp, Prevotella spp ) •DOC-mild-to-
•Infrequent adverse effects
moderate Cl.difficle infection
include: Hypersensitivity reactions
• bone and joint infections, septicemia,
(rash, itch, flushing, fever), headache,
•endometritis, or endocarditis. •MOA-taken up by diffusion,
dizziness, vomiting, glossitis,isstomatitis,
selectively
dark urine,absorbed by anerobic
and/or paresthesia.
•Pseudomembranous colitis due
•High doses
bacteria & protoza.
and/or long-term systemic
to Clostridium difficile
•Leukopenia, neutropenia, peripheral
•Helicobacter pylori eradication therapy, •non-enzymatically
neuropathy reduced by reacting
•CNS
with reduced
toxicity.ferredoxin, which is
•MDR -peptic ulcer disease
• National by
generated pyruvate
Toxiology oxido-reductase.
Program (NTP) -
•periapical abscess, periodontal abscess, human carcinogen
acute pericoronitis of impacted or partially •sulfinamides and thioether linkages with
erupted teeth; often used in conjunction cysteine enzymes deactivate these
with Amoxicillin critical enzymes.
 MIC-MINIMAL INHIBITORY
CONCENTRATION
Quantitative Measure
• MIC = lowest concentration of antibiotic that inhibits growth
(measured visually)
• Interpretation of quantitative susceptibility tests is based on:
relationship of the MIC to the achievable concentration of
antibiotic in body fluids with the dosage given
•For treatment purposes, the dosage of antibiotic given should
yield a peak body fluid concentration 3-5 times higher than the
MIC
or
MIC x 4 = dosage to obtain peak achievable concentration
MBC – Minimum Bacterial Concentration

Quantitative Measure
• MBC = lowest concentration of antibiotic that
kills bacteria
 PRINCIPLES FOR CHOOSING THE APPROPRIATE
ANTIBIOTIC

•Identify the causative organism

•Empirical therapy
•70% infections- mixed flora
•5% aerobes
•25% anaerobes

Indications for obtaining cultures

✓Patient who has received treatment for three days without
improvement
✓postoperative wound infection
✓recurrent infection
✓actinomycosis is suspected
✓Osteomyelitis is present
 DETERMINATION OF ANTIBIOTIC
SENSITIVITY
➢Broth dilution susceptability test using a micro dilution plate-
determine quantitative result.

➢Disc diffusion method -qualitative susceptability result.

➢Gradient diffusion test [ E- test]- qualitative susceptability result.
MAXIMUM DOSAGE FOR LIFE-THREATENING INFECTIONS
Antibiotic Total daily dosage " Dosage interval (hr)
Amikacin 15-25 mg/kg 8
Ampicillin 12 g/day 4
Carbenicillin 24-40 g 4
Cefamandole 6-12 g 4
Cefazolin 4-8 g 6
Cefoxitin 6-12 g 4
Cephalothin 8-12 g 4
Chloramphenicol 50 mg/kg 6
Clindamycin 2-5 g 6
Erythromycin 2-4 g 6
Gentamicin 3-6 mg/kg 8
Metronidazole 21 mg/kg 8
Oxacillin 8-12 g 4-6
Penicillin G 10-12 x 106 U 4
Tetracycline 2g 6
Tobramycin 3-6 mg/kg 8
Vancomycin 2g 6
 TOXIC EFFECTS OF ANTIBIOTIC
Some antibiotic kill / injure human cells

" ANTIBIOTIC " PROBLEM

Hematologic

Chloramphenicol Aplastic anemia,Leukoplakia

Carbenicillin (and ticarcillin) Decreased platelet aggregation
Nervous system
Tobramycin Deafness
Gentamicin Vertigo
Penicillin and cephalosporin Myoclonic seizures
Vancomycin Vertigo
Gastrointestinal system
Tetracycline Hepatitis
Clindamycin Diarrhea
Erythromycin Pseudomembranous colitis
Renal urinary system
Penicillin
Amphotericin B
Cephaloridine tubular necrosis
Aminoglycosides
Drugs to avoided in liver disorders-

• Erythromycin estolate
• Tetracyclin
• Ampicillin
• Dose reduction :
– Chloramphinicol
– Metronidazole
– Clindamycin
 PREGNANCY AND ANTIBIOTICS

Safe antibiotics
penicillins
cephalosporins
erythromycin

Drugs contraindicated in children-

 Chloramphinicol
 Tetracycline
 CAUSES OF FAILURE IN TREATMENT OF INFECTION
➢Inadequate surgical treatment
➢Depressed host defenses
➢Presence of foreign body
➢Antibiotic problems
▪ Drug not reaching infection
▪ Dose not adequate
▪ Wrong bacterial diagnosis
▪ Wrong antibiotic
Combination antibiotic therapy :
.
Indications :
•increase the antibacterial spectrum in life-threatening sepsis of
unknown cause.
•to increase the bactericidal effect against a specific organism.
•In the prevention of the rapid emergence of resistant bacteria

• Adjunctive treatment :
– Endodontic therapy or extraction
– Surgical drainage
– Many chronic dentoalveolar abscesses need
curettage.
 Odontogenic infection, oral and
maxillofacial implications

• Initial stage- Aerobic bacteria invade

•Severe infection- Aerobic and anaerobic bacteria invade

•Advanced stage- anaerobic infection

Abscess
 Therapeutic uses of antibiotics in maxillofacial
surgery

Pericoronitis :
•Acute pericoronitis, if severe, may require antibiotic therapy.
•Treatment - debridement, drainage of the site,
penicillin 500 mg qid,
amoxacillin 500mg qid,
clindamycin 300mg qid

Dento Alveolar Abscess :Acute dentoalveolar abscess and cellulitis

Penicillin is the drug of choice
Soft tissue wounds
•open for six hours or more, (considered infected,)
•if primary closure is elected, a delayed primary closure is preffered
•delayed technique cannot be utilized,-antibiotic support is helpful.
•early primary closure -amoxicillin with clavulanic acid

Chronic inflammatory periodontal diseases-

•TOPICAL MEASURES - Tetracyclins, metronidazole 250mg tid, ,
penicillins500mg qid, cephalosporins
ANUG-Topical measures with systemic antibiotic penicillin,
metronidazle400mg qid,
 Principles for the use of
prophylactic antibiotics
•procedure has risk of significant bacterial contamination and a high
incidence of infection.
•organism & antibiotic susceptibility of the causative organism must
be known.
•To be effective and to minimize adverse effects, the antibiotic must
be in the tissue at the time of contamination (operation) and it must
be continued for no more than four hours after cessation of
contamination.
•The drug must be given in dosages sufficient to reach four times the
MIC of the causative organisms.
 Surgical prophylaxis-
Under L.A
• Amoxacillin 3 gm or clindamycin 600mg 1 hr pre- operatively and
amoxacillin 1gm after 6 hr
Under G.A
• Amoxacillin 0.5 gm IM after 6 hr or 3 gm 4 hr + 1 gm probensid post-
operatively.
OR
• Clarithromycin 500mg or azithromycin 2 gm 6 hr post- operatively.
• With previous history of infective endocarditis- Amox 1gm+ gentamycin
120mg IM and Amox 0.5 oral gm after 6 hr
OR
• Vancomycin IV 1gm + gentamycin 120 mg 6 hr post- operatively.
Principle of skin testing
•allergen is introduced into the skin

•contact with cutaneous mast cells

•Binding of the allergen occurs

•patient's mast cells are coated with IgE recognizing that specific allergen.

•then adjacent allergen-specific IgE -cross-linked on the mast cell surface & activated

•positive skin test,

•transient "wheal-and-flare" reaction (15 to 20 min)
•central area of superficial skin edema (wheal) surrounded by erythema (flare). pruritic
reaction represents the immediate phase.
•cutaneous mast cells are not activated, (no edema or erythema develo& the test is
negative)
• Falsely negative skin tests such as antihistamines
Penicillin skin testing , Solensky, Franklin Adkinson Jr, UpToDate, Feb 2014
 Cross-reactivity

•Semi synthetic penicillins such as ticarcillin and piperacillin contain the same
nucleus as penicillin G.
•Cephalosporins share a common beta-lactam ring with the penicillins - cross-
reactivity is quite low.
•3-7% of those with penicillin allergy, may have allergic reactions to
cephalosporins as well.

•Monobactams such as aztreonam may be safely administered to penicillin

allergic subjects.

•carbapenems (imipenem) represent a significant risk to penicillin-allergic

patients.

ASCIA HPIP Antibiotic allergy 2014,351.38 KB

ANALGESICS
DENTAL PAIN

43
 PAIN CONTROL STRATEGY

Preoperative During Intervention

 Oral Sedation • IV Sedation

 Preoperative Pain • Nitrous Oxide

Analgesics
• Local Anesthesia

Post-Operative • Analgesic
Prescription
• Opioids 44
• Non-opioids
CLASSIFICATION

ANALGESICS

Non-opioid analgesics(NSAIDS) Opioid analgesics

Non- Preferential Selective Analgesic – Natural opioids Semi-synthetic Synthetic opioids

selective COX-2 COX-2 antipyretics with opioids
COX Inhibitors Inhibitors poor
Inhibitors antiinflammatory
action

45
The major analgesic drug class
for treating endodontic pain

46
NSAIDS
Beneficiary actions due to PG synthesis
inhibition

• Analgesia.
• Antipyresis.
• Antiinflammatory.
• Antithrombotic.

48
Toxicities due to PG synthesis inhibition

• Gastric mucosal damage.

• Bleeding: inhibition of platelet function.

• Limitation of renal blood flow.

• Delay / Prolongation of labour.

• Premature ductus arteriosus closure.

• Asthma & anaphylactoid reactions in susceptible

individuals.
NSAIDS

• Non narcotic/non opioid/ aspirin like drugs.

• Weaker analgesics except for inflammatory pain.
• Analgesic, antipyretic & antiinflammatory properties.
• Physical Dependence, abuse liability
• Primary action: peripheral pain mechanism
interruption.
 Salicylates
Aspirin

Pyrazolone derivatives
Phenylbutazone, Oxyphenbutazone

(traditional NSAIDs)
Non selective COX
Indole derivatives
Indomethacin

inhibitors Propionic acid derivatives

Ibuprofen, Naproxen, Ketoprofen

Anthranilic acid derivative

Mephenamic acid

Aryl-acetic acid derivatives

Diclofenac

Oxicam derivatives
Piroxicam, Tenoxicam

Pyrrolo-pyrrole derivative
51
Ketorolac
 NON-SELECTIVE COX INHIBITORs
SALICYLATES: History
• In England 18th century- Reverend Freudman first -cure of
agues(Fever)
• willow bark was a bitter glycoside -Salicin, 1st isolated in
1829 by Leroux, -antipyretic effect.
• Sodium salicylate was 1st used for -rheumatic fever
• And as antipyretic in 1875 &
• its utility in the gout soon followed.
• Hoffman -prepared acetyl salicylic acid.
• 1899 introuduced by Dreses under the name aspirin.
ASPIRIN

• Acetyl salicylic acid.

• Rapidly converted in the body to salicylic acid which is

responsible for most of its action.

• Only drug amongst NSAIDs which irreversibly inhibit COX.

Therapeutic Uses

• Analgesic, Antipyretic, Anti inflammatory.

• Acute rheumatic fever.

• Rheumatoid arthritis.

• Osteoarthritis.

• Postmyocardial infarction and post stroke

patients.
PYRAZOLONE DERIVATIVES

• Aminopyrine and antipyrine [1884]: agranulocytosis.

• Phenylbutazone and Oxyphenbutazone [1949].

• Potent antiinflammatory drug,but poor analgesic and

antipyretic action.

• Banned: risk of bone marrow depression.

METAMIZOL
• Potent and promptly acting analgesic and antipyretic.
• Few cases of agranulocytosis reported.

PROPIPHENAZONE
• Similar to metamizol.
 INDOLE DERIVATIVES
(Indomethacin, Sulindac )
• Potent anti-inflammatory drug, comparable to
phenylbutazone.

• Analgesic action is better than phenylbutazone, it

relieves only inflammatory or tissue injury related pain.

• Highly potent inhibitor of PG synthesis and suppresses

neutrophil motility.
Sulindac

• A prodrug that converts into an active sulfide metabolite.

• Antiinflammatory action < Indomethacin.

• At lower doses, selectively inhibit extrarenal

prostaglandin synthesis.

58
 Propionic acid derivatives
Ibuprofen
• Rated as the safest (SADR reporting system in U.K.)
• Better tolerated than aspirin.
• Anti- inflammatory,analgesic & antipyretic efficacy is
lower than high dose of aspirin.
• Most commonly used NSAID .
Dose: 400-800mg TD, Ibuprofen
250mg BD-TD, Naproxen
• Naproxen : more potent, but inhibits platelet aggregation &
prolong BT.
• 200mg Ibuprofen has same analgesic effect as
acetaminophen 650mg/ codeine 60mg
• 400mg and 600mg doses produced greater levels of
analgesia.

Hargreaves K,Abott PV; Aust Dent J 2005

 ANALGESIC –ANTIPYRETICS WITH POOR
ANTIINFLAMMATORY ACTION
PARA-AMINO PHENOL DERIVATIVES (Paracetamol )
• Introduced in 1887.
• Acetaminophen- deethylated active metabolite of phenacetin.
• CNS -raises pain threshold.
• negligible anti-inflammatory action.
• Poor inhibitor of PG synthesis in peripheral tissues, but more
active on COX in brain.
• Gastric irritation is insignificant –except in overdose
• Does not affect function or clotting factors and is not
uricosuric.
For Elderly Patients:
• Acetaminophen is the drug of choice.
• Selective COX-2 inhibitors are the second option.
Liver & Kidney Disases:
• Regular strength Acetaminophe(2-2.5 grams in divided
doses/ day)
• Codeine+Acetaminophen.
• Oxycodone/Hydrocodone+Acetaminophen.
Asthamatic Patients:
• Nimesulide is the drug of choice.
61
When additional pain control is
needed

Opioids
CLASSIFICATION
•

NATURAL SEMI SYNTHETIC SYNTHETIC

Morphine Di acetyl morphine Pethidine
codeine pholcodeine Fentanyl
Methadone
Detropropoxyphene
Tramadol
Mechanism Of Action

64
Morphine
(Prototype)
Pharmacological Action:
CNS: interacts primarily with μ opiod
receptor
• Analgesia: strong analgesic; suppression of
pain is selective, without affecting other
sensations; degree increases with dose.
• Sedation: drowsiness, higher doses induce
sleep and coma.
•Codeine •Pethidine •Methadone •Tramadol

•Methyl •Chemically •Binds to tissue •Additional

morphine. unrelated to protiens. mechanism of
•60mg codeine morphine. •T ½ 24-36hrs pain control.
comparable to •Nearly similar •90% plasma •Medium
600mg aspirin. to morphine in protein bound intensity , short
•Selective cough analgesic •Liver – acting.
supressant. property,but demethylation •Partially
•Constipation is more than •1mg reversed by
the prominent codeine. methadone = opioid
side effect at •Not a cough 4mg morphine antagonist
analgesic dose. supressant. • •T ½ 3-5hrs.
•T ½ 2-3hrs. 2mg heroine •100mg IV =
•Side effects – • 10mg IM
accumulation of 20mg pethidine morphine.
norpethidine(tre •Not effective in
mors, mydriasis, severe pain.
hyperreflexia).
 67
Haas DA.J Can Dent Assoc 2002
COMBINATION ANALGESIA
• NSAID-OPIOID COMBINATION
• NSAID-NSAID COMBINATION
1000mg paracetamol + 600mg ibuprofen

Two general methods for drug combination :

1. Alternating regimen consisting of an NSAID
followed by an acetaminophen-opioid combination.
2. Single NSAID-opioid combination
e.g. Combunox (5mg oxycodone+400mg ibuprofen)
68
GLUCOCORTICOIDS

The potent antiinflammatory properties of

glucocorticoids were first appreciated & utilized
as an adjunct to endodontic therapy more than
50years ago.

Used as an intracanal medicament & systemically

as a means to decrease pain & inflammation in
endodontic patients.

69
Ingle’s endodontics 6th Ed.
Systemic administration

Dexamethasone
• Very potent & highly selective glucocorticoid.
• Long acting.
• Pituitary depression.
• Used in inflammatory & allergic condition.
• Dose: 8mg loading dose,followed by 4 mg every
eight hours (upto max. 5 days).