526 Australian Dental Journal, December, 1964

Oxyphenbutazone in general dental practice*

Robin Woods

Tanderil (G.27202) is hydroxy-phenylbutazone, a n anti-inflammatory drug which is a metabolite of phenylbutazone (Butazolidin). Hart and Burleycl) and Husted and Hj@rting-Hansen(’) have described the chemistry and pharmacology of the drug in detail and have shown its relationship to the parent drug phenylbutazone. Hart and Burley have made the points that G.27202 is absorbed satisfactorily from the gastro-intestinal tract and is suitable for oral administration. It disappears slowly from the plasma once a plasma level has been attained, having an average biological half-life of three days.

Indications The indications for this drug are based on

its ability to inhibit inflammation. Inflamma- tion encountered in dental practice would seem to fall into two categories:

(1) a s a result of niechanical, chemical, or thermal irritation or

( 2 ) associated with the process of bacterial infection.

Inflammation of the first type described can occur as the result of oral surgery or is associated with apical periodontitis or hyper- aemia of the pulp. There are a number of reports of successful use of the drug as rt

*Supplies of the drug Tnnderil were made available through the courtesy of Dr. W. Inglis, Medical Director of Geigy (Australasia) Pty. Ltd.

(1) Hart, D. F., and Burley, D.-Phenylbutazone and its derivatives. With special reference to G.27202. Brit. Med. J., 1 : 1087-1089 (Apl.) 1959.

Received for publication May, 1964.

(2) Husted, E., and HjGrting-Hansen, E.-The effect of G.27202 (Tanderil. Geigy) on post-operative discomfort following removal of the lower third molar. Acta Odonc Scandinavica, 20 : 206-213 (Aug.) 1962.

prophylactic measure with oral surgery. In this study i t was used to t reat cases of hyperaemia of the pulp or apical periodontitis when such conditions were thought to be reversible.

I t must be realized that suppression of the inflammatory process is in effect suppression of one of the body defence mechanisms. In this respect inflammatory suppression should be undertaken only when the cause of the inflam- mation is no longer present, or if present no longer represents a threat to the body. If this principle is adhered to, it is clear that use of the drug alone to suppress inflammation arising from bacterial activity may result in suppression of the defence mechanism of inflammation and rapid spread of the infection to adjacent tissues. In such cases administra- tion of G.27202 should be accompanied by administration of the correct antibiotic.

Dosage In dental surgery the drug is used on a

short term basis. The dosage need not exceed 600 mg. daily and is effective a t a level of 300 mg. daily. I have found a n effective dose to be 200 mg. with meals for 24 hours followed by 100 mg. with meals for 48 hours (12 x 100 mg. tabs in all). Husted and Hj@rting-Hansen(*) found that a satisfactory prophylactic dose for the removal of third molars was 3 x 100 mg. on the day prior to operation, 4 x 100 mg. on the day of the operation, and 3 x 100 mg. on two subsequent days-13 tablets in all.

Toxic side effects One of the reasons for the interest in G.27202

is that while retaining most of the desirable qualities of phenylbutazone, it has fewer unpleasant side effects. Husted and Hj@rting-

Australian Dental Journal, December, 1964 527

Hansen‘*) list the side effects of phenylbutazone as follows: “blood changes (agranulocytosis and thrombocytopenia), nervous symptoms of central origin and symptoms from the gastro- intestinal tract (gastric and duodenal ulcera- tion, possible perforation of pre-existing ulcer) and further, retention of Na and water possibly with resulting edema (as with cortisone) and exanthemata”.

I ts use would be contra-indicated where the patient is suePering from a known chronic infection (e.g., renal disorder), or has a history of gastric or duodenal ulcers. The possible blood changes referred to a re related to long term use of this drug over a period of many weeks.

Clinical trial This clinical trial of the drug was restricted

mostly to cases of hyperaemia of the pulp and acute apical periodontitis. Differential diag- noses of hyperaemia of the pulp and of acute apical periodontitis were made according to Gro~sman. (~) On several other occasions the drug was used in accordance with the prin- ciples outlined above and these cases are described separately.

Cases treated Total cases treated: 53. Acute hyperemia of the pulp: 35. Apical periodontitis: 15. Miscellaneous: 3.

Results 35 cases of acute hypercemia of the pulp

Total recovery and elimination of all pain and discomfort within a period of 24 hours: 30 cases.

Cases in which there was no relief or relief was slight and pain recurred after the cessation of treatment: 5 cases. Of these five cases subsequent events showed that in three cases pulp damage of the tooth involved was irreversible, the pulps of these teeth were removed and the teeth were root-filled. One case of the five was the result of a recurrent maxillary sinus infection not directly related to the tooth and one case showed no immediate response to the drug but subsequently lost all symptoms.

These cases of hyperaemia invariably followed deep cavity preparations and metal restorations

~

(8) Grossman. L.-Root canal therapy. Philadelphia, Lea & Febiger. 3rd edition, 1953 (pp. 59-82) .

1:

or alternatively Class V restorations in the anterior part of the mouth. Its onset was within four days of this treatment.

Seasonal occurrence of hypermmia of the pulp January, February, March . . . . 3 cases April, May, June .. .. .. .. 13 cases July, August, September . . . . 11 cases October, November, December .. S cases

Most cases of hyperaemia of the pulp seem to occur in the colder months when patients are exposed in this district to a severe winter.

15 cmes of apical periodontitis These cases all occurred within three days of

endodontic treatment. The result in all of these cases was satisfactory, relief being reported within 12 to 48 hours. Seven cases were associated with upper or lower anterior teeth, 3 cases with bicuspid teeth, and 5 cases with molar teeth.

In 9 cases roentgenograms revealed no apical changes over a period of 1 2 months. In five cases sufficient time has not elapsed to follow up and one case required further endodontic treatment as the result of the development of a granuloma.

Three miscellaneous cases Case 1

An upper molar had been removed for this patient who stated the removal had taken some 90 minutes to perform and it had been neces- sary for extensive use of a fine bone drill. The following day the patient had a clean wound with a healthy blood clot in it, but was in considerable pain. The wound appeared to be free of infection, the pain being caused by bone damage as a result of heat generated when the burr was used during the extraction. The pain was of a throbbing nature and increased when the patient’s head was lowered. The patient was given 100 mg. Pethidine HCL orally and a course of Tanderil. All pain had disappeared when the patient awoke the following morning and the pain did not recur.

Case 2 This patient was a woman who had under-

gone a delicate ear operation six months prior to dental treatment. She required several small fillings on the lower left premolars, the same side as the ear operation. The first of these fillings was performed and required only a

5 2 8 Australian Dental Journal, December, I964

shallow cavity preparation. The patient reported later on, that after the filling she had experienced acute earache and some deaf- ness; she was quite concerned that her old ear symptoms were going to return.

On the second occasion the patient was pre- medicated with Tanderil, one tablet with meals for three days prior to the appointment. This therapy was continued for two days after the filling had been done. On this occasion there was no evidence of any referred pain of any sort and the patient had no post-operative pain.

Case 3 Owing to an acute suppurative pulpitis,

antesthrsia could not be obtained for the extrac- tion of a molar. The patient was therefore given Tanderil-two tablets with meals for one day. The following day the acute conditions had disappeared and a local anaesthetic was quite satisfactory for the removal of the tooth.

Side effects Of the 53 cases treated, in only one case were

there clinical side effects, namely nausea and gastric upset which subsided as soon as the drug was suspended.

Discussion The use of the drug G.27202 in carefully

selected cases showed consistently good results. There is no doubt that these patients gained quick relief from the severe pain associated with their conditions with a minimum of incon- venience. Further treatment such as replace-

ment of fillings with sedative dressings or surgical treatment of tooth apices after root fillings was avoided. Prophylactic use of G.27202 on several occasions seemed beneficial. For successful results with this treatment great care must be taken in diagnosis of suitable cases. Use of the drug under the wrong circum- stances could complicate the situation rather than relieve it.

Taking into consideration the climate of Yass as well as the fact that a good number of people work out of doors there is some evidence to show that hyperaemia of the pulp is a problem associated with cold climates. The two quarters from April to September are characterized in this area by severe frosts and minimum tem- peratures frequently below 30 degrees.

Conclusion As a result of this clinical trial and also the

studies of others with this particular drug I have concluded that there is a place for an anti-inflammatory drug such as G.27202 in general dental practice. As a result of the \vork of Husted and Hjflrting-Hansen@) and others it would seem that this drug can be used as a prophylactic in cases of oral surgery and possibly to assist in immediate denture cases.

Careful use of the drug can be of great assistance in relieving pain and discomfort which follow some conservative treatment.

P.O. Box 22, Yass,

N.S.W.