An exploratory view of pharmaceutical drugs used in prosthodontics and dental implant procedures

Mukesh Sabat; Jeyaraj Brintha Jei; Muthukumar Balasubramanium

doi:10.4103/jnam.jnam_4_22

REVIEW ARTICLE

Year : 2022 | Volume : 1 | Issue : 2 | Page : 41-46

An exploratory view of pharmaceutical drugs used in prosthodontics and dental implant procedures

Mukesh Sabat, Jeyaraj Brintha Jei, Muthukumar Balasubramanium
Department of Prosthodontics, SRM Dental College, SRM University, Ramapuram, Chennai, India

Date of Submission	03-Mar-2022
Date of Decision	24-May-2022
Date of Acceptance	31-May-2022
Date of Web Publication	27-Dec-2022

Correspondence Address:
Jeyaraj Brintha Jei
Department of Prosthodontics, SRM Dental College, SRM University, Ramapuram, Chennai
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnam.jnam_4_22

Abstract

Pharmacology is concerned with the study of action of drugs and is a branch that comes under biology and medicine. The two chief concerns are the effect of the drugs on the human systems and the effect of the human systems on the ability and metabolism of drugs. Prosthodontics is the dental specialty that deals with different age groups of patients, and it is necessary to understand the different effects of drugs. This article describes information regarding the drugs used during the prosthodontic treatment.

Keywords: Denture adhesives, Dentures, Local anesthetics, Prosthodontics, Sialagogues

How to cite this article:
Sabat M, Jei JB, Balasubramanium M. An exploratory view of pharmaceutical drugs used in prosthodontics and dental implant procedures. J Niger Acad Med 2022;1:41-6

How to cite this URL:
Sabat M, Jei JB, Balasubramanium M. An exploratory view of pharmaceutical drugs used in prosthodontics and dental implant procedures. J Niger Acad Med [serial online] 2022 [cited 2023 Jun 9];1:41-6. Available from: http://www.jnam.com/text.asp?2022/1/2/41/365602

Introduction

Drugs in dental practice will facilitate dental procedures in pretreatment and posttreatment phases. Drugs mainly help to improve the response of the patients during various dental treatments. So the success and failure of the prosthodontic procedure are determined by the understanding of pharmacological principles of locally acting drugs. Prosthodontics is a division of dental specialty that primarily concerns with the replacement of missing teeth. Different drugs are provided during the treatment phase and pre- and posttreatment phases to treat infections, lesions, xerostomia, and pain.^[1] So a successful prosthodontist should have a fundamental knowledge about the pharmacology, mode of action, side effects, and also the recent advancements in the field.

In the oral cavity, while the edentulous area is replaced by partial or complete dentures, it could create some adverse changes in the oral environment due to the presence of saliva, muscles, and soft and hard tissues.^[2] Different dental materials used for the prosthesis preparation may further create some soft tissue reactions such as mucosal irritation, gagging, carious lesion in the abutment, burning mouth syndrome, resorption of residual ridge, weakening of periodontal tissues, and oral galvanism. Prosthodontics is the dental specialty that deals with different age groups of patients, and it is necessary to understand the different effects of drugs. This article describes information regarding the drugs used during the prosthodontic treatment. So, a prosthodontist should have good knowledge about the various drugs used during treatment.

Drugs Associated with Removable Prosthodontic Restorative Procedure

Sialagogues and antisialagogues

Sialagogues have their special application in the treatment of patients affected with xerostomia. They increase the salivary flow by activating muscarinic cholinergic receptors. The drugs used as sialagogues are pilocarpine hydrochloride and cevimeline hydrochloride. They increase the salivary flow for procedures requiring duration up to 3 h. Bromhexine and anethole trithione are also used as they are direct-acting cholinergic agonists.^[3] Citric acid is used in cases of antidepressants inducing xerostomia. Salivary substitutes containing lubricant such as carboxymethylcellulose (CMC) or hydroxyethyl cellulose, preservatives, artificial sweeteners, and fluoride and chloride salts are also used as alternatives to sialagogue agents. These are available in the form of sprays, solutions, or gels.^[4] They have restricted duration of action, hence have to be applied repeatedly. Commonly available salivary substitutes are Moist-Stir, Salix, Salivart, Orex, and Xero-Lube. Two commonly used active ingredients in denture adhesives are poly(vinyl methyl ether maleate) (Gantrez) and CMC. CMC can hydrate and undergo ionic adherence to denture and oral mucosal epithelium in the presence of water.^[5]

Antisialagogues are cholinergic antagonists that reduce the flow of saliva for a minimum period of 1–2 h. During the impression procedure or denture insertion, the patients may encounter hyperactive gag reflex or otherwise called gagging. Side effects are very rare in this group of drugs, because blocking of salivary glands can be done at quite low doses.^[6]

Denture drug delivery

In completely edentulous patients, the dentures could be poorly tolerated due to reduced salivary flow, which leads to poor adhesion between the denture prosthesis and the underlying tissues. The reservoir denture containing a salivary substitute offers a clinician an alternative method of treating patients suffering from xerostomia with a slow, sustained, and continuous release of the salivary substitute.^[3],[4] The advantages of salivary reservoir in the maxillary denture in patients with xerostomia over a reservoir in the mandibular denture includes larger reservoir size, which provides flow of saliva to the entire oral cavity, whereas the reservoir in the mandibular denture is confined only to the floor of mouth. By placing reservoir in the maxillary denture, it might enhance the weight of the denture and subsequently lead to loss of retention and stability. This salivary reservoir has a capacity of 3 mL for 2 h during working.

Antibiotics

The antifungal antibiotics advised in prosthodontics are majorly for action against Candida albicans. The drug given for action against Candida species is nystatin, which has fungicidal and fungistatic effects.^[7] Nystatin is supplied as nystatin tablet, which is to be held in the mouth until it totally dissolves, and the other form is nystatin solution, in which the dentures are placed directly in the solution. Clotrimazole is another alternative that unlike nystatin has a fungistatic effect only.^[8] It is prescribed as 10 mg troche 5 times a day for 2 weeks. Other optional drugs are amphotericin B and miconazole. Treatment should be continued with this drug for a minimum period of 4 weeks along with meticulous oral hygiene maintenance.

The local anti-infective agents are also available as mouth rinses, most of them having ethanol as a primary ingredient. Thymol as a mouth rinse has an objectionable taste, hence not much popular in use. Cetylpyridinium is a surface-active agent with a slight bacteriostatic effect. It is unpleasant and bitter after taste.^[9] Povidone iodine is a halogen-releasing compound and also iodophor. It is usually combined with cetylpyridinium hydrochloride and also has an unpleasant taste. It is used as a surgical scrub in concentrations of 7.5%–10%.

Antibiotic prophylaxis

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Denture adhesives

Denture adhesives help in retention of denture by increasing the interfacial forces, increasing cohesive and adhesive properties, and increasing viscosity of the medium between the denture and basal seat. They reduce the voids in the denture due to the presence of sodium CMC, keraya gum, tragacanth, and flavoring agent. Thus, they prevent any form of burning mouth syndrome or residual ridge resorption. They are available in a powdered form, which is sprinkled over the dentures, and in a paste form, which is applied as beads in incisor and molar regions.^[10]

Denture cleansers

Oxygenating cleanser contains alkaline perborate, which has the disadvantage of heavy calculus deposits plus abrasion of soft liners. Sodium hypochlorite that is another constituent bleaches the resin bases, discolors the soft liners, corrodes the base alloys, and produces an unpleasant odor. In all, 6% hydrogen peroxide strips and 15% carbamide peroxide 15% gel loaded tray has significantly shown greater results in tetracycline-stained teeth (TST) patients. Over a 3-month period, both performed equally well in TST.^[11]

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Drugs Associated with Fixed Dental Prosthesis

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Local anesthesia

Local anesthetics (LAs) are drugs that can cause reversible loss of neurological perception in the limited area of the body, which is inevitable for the fixed prosthodontics procedure. Hence, the prosthodontist must have the knowledge about the local anesthetics and their pharmaceutical action. They are basically classified as the amide and ester group. The commonly added preservatives are metabisulfite and sodium bisulfate, sometimes this may cause allergy. Mechanism of action of local anesthesia occurs by reversible conversion of RNH+ into RN+ and H+. To enter nerve, a local anesthesia should diffuse through RN(+), but binding to the receptors is done inside the nerve by RNH(+). During infection, the amount of RNH(+) is greater; hence, local anesthesia has no action in that region. Addition of CO₂ into LA results in rapidity of action.^[12]

Vasoconstricting agents are classified into three categories:

Pyrocatechin derivatives: Epinephrine Norepinephrine

Phenol derivatives: Phenylephrine

Benzol derivatives: Levonordefrin

In healthy patients, the recommended dose of lignocaine with vasoconstrictor is 0.2 mg and 0.04 mg in patients with cardiovascular disease. In all, 2% lidocaine with 1:100,000 epinephrine is used for crown preparation and 5% bupivacaine with 1:200,000 epinephrine is used during implant procedures. Addition of CO₂ with local anesthesia results in rapidity of action. Allergy is seen more with the topical route in case of benzocaine. In treatment of traumatic ulcers, benzocaine 20% is supplied topically as dologel and benzalkonium hexachloride is supplied as mucopain. In severe inflammation, triamcinolone acetonide 0.1% available as kenacort gel is advised. Local anesthesia toxic reaction is due to inadvertent intravascular injection or overdose. First sign of toxicity is seen as talkativeness. Toxicity of local anesthesia is reversed by barbiturates given intravenously. Anticonvulsant action of local anesthesia is at levels of 2–4 μ/mL. Anticonvulsive levels in blood are seen at a level of 0.5–4 μg/mL, pre-seizures are seen at a level of 4.5–7 μg/mL, and above the level of 7.5 μg/mL, a patient experiences generalized tonic clonic seizures.^[8] Antiarrhythmic effect of local anesthesia is seen at a level of 1.5–5 μg/mL.

Astringents

This drug is basically a metallic salt that causes retraction of marginal gingiva by its protein precipitation, thus obstructing hemorrhage. Commonly used astringents are aluminum chloride, zinc chloride, and ferrous sulfate. Aluminum chloride is most commonly used, but with concentrations greater than 10%, which can cause tissue damage. Racemic epinephrine is also used as an astringent.^[13] Astringents act by activating alpha adrenergic receptors that cause vasoconstriction of capillaries at the site of action, thus resulting a decrease in tissue volume.

Hemostatic agents

These are the type of drugs that control hemorrhage and protect the wound. The drugs under this category are epinephrine 1:100,000; thrombin; and absorbable gelatin sponge. Epinephrine as 1:100,000 controls superficial bleeding from capillaries. Thrombin is applied as liquid or powder on clotted blood-free sites, whereas absorbable gelatin sponge is available in the form of porous sheet and powder. Its properties are improved by soaking it in a solution of thrombin just before application.^[14]

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Drugs Associated with Implantology

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Treatment of periimplantitis varies according to the stage of its affect. During the incipient stage, treating peri-implant mucositis, which consists of mechanical and/or chemical plaque control agents along with decontamination of prosthetic abutments with chlorhexidine gel and antibiotics, is advised. Minocycline combined mechanical debridement shows lesser effect over a period of 12 months when compared to a combination of chlorhexidine and mechanical debridement. Laser devices constituting erbium-doped yttrium aluminium garnet (ER:YAG) is also a nonsurgical treatment modality. Advanced stage treatment consists of surgically debridement of soft peri-implant tissues affected by chronic infection along with decontamination of microimplant surface and application of bone regeneration techniques, which vary from guided bone regeneration to application of bone substitutes like nanocrystalline hydroxyapatite.^[15]

Antibiotics

An implant may show failure mainly if it gets infected; hence, the antibiotic finds its role here. It is essential to keep the patient under antibiotic coverage for conventional loading and immediate loaded implants. The antibiotics elevate the antibiotic concentration level in blood, thus reducing the chances of bacterial proliferation and dissemination. Standard regimen is amoxicillin 2 g orally 1 h before the procedure and then 1.5 g 6 h after the initial dose. For those patients allergic to amoxicillin/penicillin, the regimen is erythromycin ethylsuccinate 800 mg or erythromycin stearate 1.0 g orally 2 h before the procedure and then half the dose 6 h after the initial dose,^[16] and clindamycin 300 mg orally 1 h before the procedure and 150 mg 6 h after the initial dose. A recent protocol suggests the use of short-term antibiotic prophylaxis.

Chlorhexidine is a biguanide that mainly acts against gram-positive organisms, and is less effective against fungi and gram-negative organisms and ineffective against viruses and spores. Chlorhexidine as chlorhexidine gluconate 0.12% is used in the treatment of gingivitis, controlling plaque formation and treating oral ulcers. The chlorhexidine mouth rinses aid to promote healing after denture insertion. It is advised to rinse with chlorhexidine twice daily after placement of dental implant till the removal of sutures.

Analgesics

Analgesics are normally classified into nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics.

The most commonly used analgesic NSAIDs decrease pain during surgical stage of implant placement. They are known to be peripherally acting drugs because their anti-inflammatory and analgesic effects are achieved mainly through the peripheral mechanism. They act by inhibiting the cyclooxygenase pathway, which decreases the prostaglandin formation, thus reducing the pain. The commonly used drugs are paracetamol, ibuprofen, aceclofenac, or diclofenac. Paracetamol is the safest drug advised during pregnancy. Opioids have their limited use in prosthetic dentistry.

Tramadol is the most commonly used opioid used in dentistry. Tramadol’s maximum analgesic efficacy for relieving acute pain after implant surgery appears to be similar to that of 60 mg of codeine alone but less than that of a complete dosage of NSAID or combination of codeine.^[16],[17] The significant adverse drug reaction is onset of seizures (high dosage for more than 2 days).

Steroids

The commonly used corticosteroids in prosthodontics are hydrocortisone and triamcinolone. These two drugs are applied topically over the lesion. The adverse effect of the use of corticosteroids is increased local side effects. Postoperative usage is for reduction of posttreatment complications of trismus and edema. Dexamethasone is advised in reducing postoperative swelling following implant placement. Prednisolone is used in attuning osseointegration during implant placement.^[18] The prescription for steroids in a patient currently not under steroid medication but had 20 mg or more of hydrocortisone for more than 2 weeks within the past 1 year is 60 mg intravenously (IV) or intramuscularly (IM) on day before the implant surgery, 60 mg IV or IM on the day of surgery, 40 mg IV or IM 2 days after the surgery, and 20 mg IV or IM 3 days after the surgery.

Drugs used in Anxious Patients

Anxiolytics

Centrally acting muscle relaxants are basically classified as

Mephenesin congeners: Methocarbamol, carisoprodol, mephenesin, and chlorzoxazone

Benzodiazepines: Diazepam

GABA derivative: Baclofen

Central alpha-2 agonist: Tizanidine

The most popular and safest drug advised in anxious patients before any dental procedure is benzodiazepine. They act by getting attached at the nerve receptor terminal of gamma-aminobutyric acid, which is a major neuroinhibitory transmitter. It opens the chloride channel, thus increasing the chloride uptake and causing the hyperpolarization of nerve terminal, and thus, no action potential is seen. Some of the common features of benzodiazepines are flat dose–response curve, less hangover, less distortion of sleep, and less prone for drug interactions. Barbiturates also have same inhibitory action but are not advised due to steep dose–response curve, as when high abuse liability exists, no specific antidote can be used in case of barbiturate poisoning.^[2] The drugs under this category are temazepam, triazolam, oxazepam, and lorazepam. The newer hypnotics, a subunit of benzodiazepine receptors as non-habit forming sedatives, are zolpidem and zaleplon.

Drugs in Oral Hypoglycemic Shock

Diabetes is a disease in which the body either fails to produce insulin (type 1) or the insulin produced is no longer effective (type 2). Insulin is produced in the beta cells of Langerhans of pancreas; from there, it gets released into the blood stream, and hence, it is considered to be a part of the endocrine system. Type 1 diabetes is seen in juvenile population majorly but can also be seen in a middle-aged population. Type 2 has older age onset. Treatment for type 1 diabetes varies according to bolus form (short-acting insulin) and basal form (long-acting insulin). The short-acting insulin is injected before snacks or meals containing dietary carbohydrate (CHO). The drugs under short-acting insulins are regular insulin–5–8 h active and semilente—8–12 h active. They deal with rise in glucose levels after eating. The long-acting insulin is available in an injectable form, which is given once or twice a day. It has a slow and peak action for 4–12 h with the duration of action being 16–35 h.^[19] The drugs under basal forms are lente and neutral protamine hagedorn insulin also known as isophane insulin, both having activity for 16–20 h. They deal with background levels of glucose (caused by anti-insulin hormones found in blood during day).

Type 2 diabetic drugs are aimed to increase the effectiveness of endogenous insulin using metformin (biguanides) and rosiglitazone (thiazolidinediones— that act on paraoxyzome proliferative acting receptor gamma) and also sulfonylureas, which act on pancreas and increase insulin production. The normal blood glucose level is 4–7 mmol/L before meals and <9 mmol/L for most of the time. Hypoglycemia is a state in which the blood sugar level falls below 4 mmol/L. The symptoms of hypoglycemia are caused by the release of adrenaline. It is this adrenaline that causes sweating, shakiness tachycardia, and anxiety.

All new dental patients should be questioned as to their diabetic status. Patients with diabetes experience periodontal disease more frequently and with greater severity than the general population, there being a bidirectional relationship centered on an enhanced inflammatory response manifested both locally and systemically.^[20] The possible way to improve glycemic control is by maintaining periodontal treatment. Current scientific evidence suggests that periodontal treatment could lead to a mean reduction of 0.4% in the hemoglobin A1c level.

Drugs in Dental Emergencies

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Conclusion

Pharmacology is the basic therapeutic intervention for most of the conditions. Geriatric prosthetic patients are most commonly affected with different systematic diseases, so special care should be given during the prosthetic phase. They also should be well-versed with handling the emergency that may arise in the dental chair. So this article provides basic knowledge regarding the commonly used drugs in prosthodontic practice. This helps the prosthodontist to apply this knowledge in their clinical procedures, which prevents the drug interactions and helps to maintain the patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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