INTRODUCTION:

A competent and successful clinician needs to have a thorough knowledge about new drugs, their interactions, side effects, and their uses to keep updated of the latest advances in pharmacology. Drugs in dentistry are used as a primary treatment means during dental procedures. Drugs essentially help in improving the patient response during various phases of treatment. Correct understanding and application of the pharmacological principles for drugs acting locally determine the failure or success of any dental procedure.

Prosthodontics is a branch of dental specialty, which deals mainly with the replacement of missing teeth. Various drugs are administered during the pretreatment, treatment phase, and post treatment phase. The drugs play a vital role during various treatment procedures and in the treatment of infections, ulcerations, in cases of xerostomia. Drugs used can be broadly classified into therapeutic drugs, with localized effect, for clinical use in the oral cavity and drugs used for general and systemic pharmacological effects.

Therapeutic Drugs used in Prosthodontics for localized effects:

Local Anesthetics (LA) causes a reversible loss of sensation, especially of pain, in a restricted area of the body upon topical application or local injection. Chemically local anesthetics can be classified into Esters or Amide types. A higher concentration of local anesthetics is used in dentistry, as only limited can be injected into the oral mucosa. Vasoconstrictor agents addition to local anesthetic solutions is done to antagonize the vasodilation effect, to reduce the bleeding at the operated site, reduce the toxicity, and to lengthen the duration of anesthesia¹. Local anesthetics with vasoconstrictor agents should be used carefully in patients with, cardiac arrhythmias, unstable or uncontrolled angina, pheochromocytoma, hyperthyroidism, diabetes or congestive heart failure. The maximum recommended dosage of epinephrine is 0.2mg for a healthy individual and 0.04mg for a patient with cardiovascular disease. 2% Lidocaine with 1:100,000 Epinephrine is used for during crown preparation procedures, whereas for long dental procedures like implants 5% Bupivacaine with 1: 200,000 Epinephrine can be used².

Higher concentrations of the local anesthetic agents are seen in topical anesthetic preparations along with variety of ingredients to enhance acceptability. Allergic reactions are more with topical route compared with other routes of drug administration. Benzocaine is the most popular topical anesthetic. Toxic reactions to LA results due to inadvertent intravascular injection or overdose. Overdose can be avoided by, updating knowledge about the advised maximum recommended doses. Topical preparations containing benzocaine 20% and benzalkonium hexachloride, available as dologel or mucopain are used in the treatment of traumatic ulcers, seen in the denture patients due to friction between the denture and mucosa^3,4.

Astringents and agents used for gingival retraction:

Gingival displacement is displacement of the marginal gingiva away from the tooth to achieve proper margins, during impression procedures. Astringents are metallic salts causing retraction of gingiva by protein precipitation, which physically obstructs hemorrhage. Administration of astringents can be done by impregnating the retraction cord or application with cotton pellets. Commonly used astringents are Aluminum chloride, Zinc Chloride, Ferrous sulphate. Aluminum chloride is the most commonly used astringent, but at concentrations >10% causes tissue damage. Racemic epinephrine is also used for gingival retraction by impregnating the cord. Larger dose of epinephrine is present in the cord; necessary precaution should be taken because of rapid systemic absorption in areas of gingival retraction. Epinephrine has vasoconstrictor property causing gingival retraction. Local epinephrine absorption causes gingival shrinkage due to activation of a-adrenergic receptor, vasoconstriction, and decreasing the tissue volume⁵.

Hemostatic agents:

Hemostatic agents are used to control hemorrhage and for the protection of the wound. Epinephrine (1:100,000) can be topically applied as a local hemostatic agent. It effectively controls superficial bleeding from capillaries. Blood clotting factor like thrombin, can be applied as a liquid or powder on clotted blood free sites. Absorbable gelatin sponge is available in the form of porous sheet and powder. Hemostatic properties of gelatin sponge can be improved by soaking in a solution of thrombin before application^4,6.

Sialogogues and salivary substitutes:

Xerostomia is characterized by dry mouth due to a decrease in salivary flow. It can affect nutritional status, psychological,and dental health. Oral candidiasis is one of the most common oral infection associated with xerostomia. Such patients have poor tolerance to dentures used to rehabilitate the edentulous patients. Saliva acts as a medium between the denture and the oral cavity and absence of saliva decrease retention and increases oral mucosal ulceration. Denture patients often complain of poor retention with dentures, tongue sticking to the palate, and denture sores. The rationale for the treatment of xerostomia is to increase the salivary flow by activating the muscarinic cholinergic receptors. Among the currently used cholinergic agonists, most are not selective to salivary gland cholinergic receptors. Pilocarpine (Salagen) and Cevimeline hydrochloride (Evoxac), increases salivary flow for procedures of a short-duration (3-hour), indicating a certain degree of selectivity at salivary cholinergic receptors without accompanying side effects. Other drugs like bromhexine and Anethole trithione are direct-acting cholinergic agonists with some degree of salivary gland selectivity. Citric acid also provides relief in cases of xerostomia induced by antidepressants^3,7,8,9.

Salivary substitutes are used to overcome hyposalivation. Most of the salivary substitutes contain lubricants like carboxymethylcellulose or hydroxyethylcellulose, preservatives, artificial sweeteners, and fluoride or chloride salts. Salivary substitutes are available as sprays, solutions or gels and are delivered through salivary reservoirs incorporated in the prosthesis¹⁰. They have a restricted duration of action; hence, repeated application is necessary. Commonly available salivary substitutes include Salix, Salivart, Orex, Moist –stir, Xero-lube.

Antisialogogues:

They are cholinergic antagonists that cause blockage of the same receptors, activated by the cholinergic agonists used to decrease salivary secretion. Atropine and its synthetic derivatives like methantheline, propantheline, and scopolamine are commonly used. They are administered orally for the necessary reduction in the flow of saliva, usually 1 to 2 hours, before the beginning of the clinical procedure. Side effects with antisialogogues in dentistry are rare because of blocking the salivary glands can be done at quite low doses⁴.

Denture adhesives and cleansers:

Denture adhesives enhance retentive properties of the denture by improving interfacial forces and increasing the cohesive and adhesive properties and the viscosity of the medium lying between the denture and the basal seat area. They eliminate the voids between the basal seat and the denture base. They contain sodium carboxyl methylcellulose, keraya gum, tragacanth, flavouring agents polyethylene oxide, plasticizers, and, antimicrobial agent. They are generally supplied in the form of powder, which is sprinkled on the wetted denture, and paste, which is applied as beads, in incisor and molar regions¹¹.

Denture cleansers are an integral part of post insertion patient care. They are available as tablet and powder. They include Oxygenating cleansers, hypochlorite cleansers, abrasive pastes, and powders, dilute mineral acids and, Enzyme containing minerals (proteases). Fittydent, Kleenex, Stain Away, Polident, Triclean are some commercially available denture cleansers.

Drugs used in Prosthodontics for their systemic pharmacologic effects:

Analgesics:

The nonsteroidal anti-inflammatory drugs (NSAIDs) are the commonly used analgesics in Prosthodontics, which is used to manage pain during the surgical stage of the implant placement. NSAIDs also have anti-inflammatory and antipyretic properties. NSAIDs are mentioned as peripherally acting drugs because their anti-inflammatory and analgesic effects are achieved mainly through a peripheral mechanism. NSAIDs inhibit cyclooxygenase enzyme; this enzyme suppression causes a reduction in prostaglandins formation, which is involved in the mechanism of pain^11,12. Commonly used NSAIDs are paracetamol, ibuprofen, or aceclofenac, or diclofenac. Other NSAIDs are rarely used due to their other either adverse effects or higher cost. Opioids have limited use in Prosthodontics^13,14,15,4. Paracetamol is the only NSAID that is regarded as being safe during pregnancy.¹⁶

Antibiotics:

Use of Antibiotics generally during dental implant placement to minimize infections after implant placement. The recent protocols suggest the use of short-term antibiotic prophylaxis. The chances of failure of the implant increase if it is infected. Prophylactic antibiotics are generally prescribed to prevent the onset of infection at the site of implant placement by elevating the antibiotic concentration in the blood, thereby reducing the chances of bacterial proliferation and dissemination. The standard regimen includes the use of Amoxicillin 2.0g orally Clindamycin 600 mg orally¹⁷.

Antifungal antibiotics are used in the treatment of oral fungal infections. Nystatin is most commonly used, as it has both fungicidal and fungistatic effect, which is dose dependent against several fungi, including Candida albicans. Candida albicans causes candidiasis and infect the dental prosthesis. Nystatin tablet is held in mouth until they dissolve, as it not absorbed, dentures, which are colonized with candida albicans may be treated by soaking them in a nystatin solution. Clotrimazole is a fungistatic agent, which can be used for the treatment of C. albicans caused infections. It is used as 10mg troche five times a day for 14 days. It dissolves in the mouth and has minimal side effects.

Local anti-infective agents containing mouth rinses can also be used. Primary local anti-infective agent in most of the mouthwashes is ethanol. Use of mouth rinses having phenolic derivatives like thymol is limited as it has an objectionable taste. Most of the mouth rinses contain Cetylpyridinium, a surface-active agent, with slight bacteriostatic but has an unpleasant and bitter aftertaste. Povidone-iodine is a halogen-releasing compound and an iodophore, when combined with a surface-active agent act as an effective antibacterial agent, but has an unpleasant taste. Povidone –iodine at a concentration of 7.5% to 10%, is accepted as a surgical scrub. Chlorhexidine, a biguanide, is mainly effective against gram-positive organisms. It is less effective against fungi and gram-negative organisms, and ineffective against viruses and spores. At 0.12% concentration of Chlorhexidine digluconate, is used to treat gingivitis and to control plaque formation and oral ulcers¹⁸. Chlorhexidine mouth rinses are useful aides to promote healing after denture insertion. Chlorhexidine mouth rinses are advised twice a daily after placement of dental implant till the removal of sutures^17,19. Oral delivery of drug is the most preferable route of drug delivery due to the ease of administration, patient compliance and flexibility in formulation, etc.²⁰

Antianxiety Agents:

Antianxiety agents are used in apprehensive patients due to stress during the dental procedure. The most popular and safest drug and for the clinical procedure are the benzodiazepines. They act by aiding the T-aminobutyric acid (GABA), a major inhibitory transmitter of the brain bind to GABA receptors. Diazepam and alprazolam are commonly used during dental procedures²¹.

Steroids:

Steroids like hydrocortisone and triamcinolone are generally used for topical application. Topical preparations are made available for treating oral ulcers. Corticosteroids have an increased risk of causing local side effects. Mechanisms by which corticosteroids reduce inflammation is unclear. Preoperative use of corticosteroids to reduce postoperative complications of trismus and edema is advocated, but the benefits obtained is still unclear. Dexamethasone is used to decrease the postoperative swelling following the implant placement, and use of prednisolone during implant placement has attenuated the osseointegration process in some studies²².

CONCLUSION:

Drug therapy is primary therapeutic intervention for majority of conditions. Appropriate prescription of drugs is probably the most necessary aspect or overall health^23,24. This article provides knowledge about the most common drugs used in routine practice. The clinician should practically apply this knowledge during operative procedures, prevent the incidence of drug interactions, and thereby improve patient care.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 11.08.2019 Modified on 16.10.2019

Research J. Pharm. and Tech 2020; 13(6): 2997-3000.

DOI: 10.5958/0974-360X.2020.00530.2