Antibiotics and analgesics in pediatric dentistry (2)
2. INTRODUCTION
Most common clinical situations in dentistry
amenable to drug therapy in children are pain and
infection.
The prescription of medications are more complicated
than in the past.
The necessity to adjust the dosages of medications to
accommodate their lower weight and body size.
3. Adjustment of dosages in pediatric
patients
Following formulas are used to calculate drug dosages
for pediatric patients
Clarks rule
Childs weight in lb/150 x
adult dose = child’s dose
4. Young’s formula
Age of child / age + 12 = child’s
dose
Dilling’s formula
Age of child/20 x adult dose =
child’s dose
6. ANLAGESICS USED IN PEDIATRIC
DENTISTRY
Management of dental pain in pediatric patients is
important
Drugs prescribed to relive pain are called analgesics
7. CONCEPTS ABOUT PAIN IN
CHILDREN
Children have high tolerance to pain.
Pain perception low because of biologic immaturity.
More sensitive to side effects of analgesics.
Special risk for addiction to narcotics .
9. CENTRALLY ACTING
More effective against acute pain
More adverse effects
No anti inflammatory or antipyretic effects
10. NON NARCOTIC ANALGESICS
Mild to moderate pain
Site of action peripheral nerve endings
Less drug toxicity
Absence of drug dependency
11. Drugs in this class include
• Acetaminophen,
• Aspirin
• Non-steroidal anti-inflammatory drugs (NSAIDS)
12. ACETAMINOPHEN
Antipyretic
Mild analgesic
Administer Per oral or Per rectal
Pediatric Oral dose 10-15 mg/kg/dose every 4 hr
Infant dose is 10-15 mg/kg/dose every 6-8 hr
Adult dose 650 mg-1000 mg/dose
13. Onset 30 minutes
MOA: inhibition of the synthesis of prostaglandins
Contraindications: Hypersensitivity to acetaminophen
Warnings/Precautions: Do not exceed the maximum
dose. Acute over dosage may cause severe hepatic
toxicity
14. •SUPPLIED AS:
•Drops: 100 mg/ml (15 ml) or 80 mg/0.8ml (15ml)
•Elixir: 32 mg/ml (120ml)
•Tablets: 80 mg chewable or 325 mg regular or 500
mg extra strength
•Suppository, rectal: 120mg, 325mg, 650mg
15. NONSTEROIDAL ANTI-INFLAMMATORY
DRUGS – NSAIDS (IBUPROFEN, NAPROXEM)
Antipyretic
Analgesic for mild to moderate pain
Anti-inflammatory
COX inhibitor Prostaglandin inhibitor
Platelet aggregation inhibitor
Main drugs used are ibuprofen, naproxem
16. IBUPROFEN
Propionic acid derivative
Used in rheumatoid arthritis , osteoarthritis
Indicated in soft tissue injuries , tooth extraction,
fractures, vasectomy
17. Dose for infants : 10 mg/kg/dose every 6 hours
Adult dose 400-600 mg/dose every 6 hours
Onset 30-45 minutes
Maximum daily dosing
<60 kg: 40 mg/kg
>60 kg: 2400 mg
May use higher doses in rheumatologic diseases
19. NAPROXEM
Another drug of propionic acid family
Same action that of ibuprofen
More anti inflammatory action
Molecular structure different
20. Combination therapy
Ibuprofen and paracetomol
Diclofenac and paracetomol
Nimesulide and paracetomol
Mefenamic acid and paracetomol
21. NARCOTIC DRUGS
Centrally acting
Moderate to severe pain
Infants younger than 3 months have increased risk of
hypoventilation and respiratory depression
Low risk of addiction among children
22. SIDE EFFECTS OF OPIOIDS
All opioid have side effects that should be anticipated &
managed
Respiratory depression
Nausea, vomiting
Constipation
Pruritis
Urinary retention
24. COEDINE
Oral analgesic (also anti- tussive)
Weak opioid
Used often in conjunction with acetaminophen to increase
analgesic effect
Metabolized in the liver and demethylated to morphine
Some patients ineffectively convert codeine to morphine so
no analgesia is achieved
Dose 0.5-1 mg/kg every 4-6 hours
26. ALFENTANIL AND RAMIFENTANIL
Rapid onset
Metabolized in liver
Half life is 1 to 2 hr
Uses : short painful procedures,
Ramifentanil for long neurosurgical procedures
35. Antibiotics
Drugs that are produced by microbes to produce an
antibacterial action.
The widespread use of antibiotics has resulted in common
bacteria developing resistance.
Drug therapy should extend at least 5 days
If discontinued prematurely, the surviving bacteria can
restart an infection that may be resistant to the original
antibiotic.
36. ORAL WOUND MANAGEMENT
Oral wounds are associated with an increased risk of
bacterial contamination.
If the oral wound seems to have been contaminated by
extraoral bacteria, antibiotics therapy should be
considered
38. Dental Infection
Not indicated if the infection is contained within the
pulpal tissue or the immediately surrounding tissue
Patients presenting with facial swelling secondary to a
dental infection.
Infection is of such severity then prescription of
antibiotics for a period of 5-10 days should be
considered before rendering treatment.
39. Pediatric Periodontal Diseases
In pediatric periodontal diseases (neutropenias,
Papillon-Fevere syndrome, leukocyte adhesion
deficiency) the immune system is unable to control
the growth of periodontal microbes.
Effective drug selection may be accomplished by
culture and susceptibility testing.
40. Viral diseases
Antibiotics should not be prescribed for viral
conditions (acute primary herpetic gingivostomatitis)
unless there is strong evidence to suggest that a
secondary infection exists.
41. Antibiotics can be categorized by the bacteria they
target.
They are either narrow or wide spectrum.
Narrow spectrum antibiotics are effective specifically
against either gram-positive or gram-negative
antibiotics.
Broad spectrum antibiotics are effective against a
wider range of bacteria.
46. Mechanism of penicillins action
They form complexes with enzymes - trans- and carboxypeptidases
(PCP), which control synthesis of peptidoglycan – component of cell-
wall of microorganisms
47. Adverse drug reactions
mild diarrhea
nausea
oral candidiasis.
Severe reactions of angioedema
The alternative antibiotic is clindamycin.
The preferred dosing is one hour before meals or two hours
after meals.
48. Contraindications: Hypersensitivity to penicillin
Warnings/Precautions:
• Caution in patients with severe renal impairment
(modify dosage)
• History of seizures
• Hypersensitivity to cephalosporins.
49. The usual daily dose of penicillin for
treating odontogenic infections is:
Children ≤ 12 years of age: 25-50 mg/kg of body weight
in divided does every 6-8 hours.
Children > 12 years of age and adults: 250-500 mg
every 6 hours for at least 10 days.
Supplied as 125 or 250 mg/5ml solution or 250 and 500
mg tablets
50. CLINDAMYCIN
Alternative choice in treating mild or early odontogenic
infection.
Broad spectrum of activity
Resistance to beta-lactamase degradation
It is not effective against mycoplasma or gram-negative
aerobes..
52. Warnings/Precautions:
• Use with caution in patients with liver
dysfunction (modify dosage);
• Can cause severe and fatal colitis;
• Discontinue drug if significant diarrhea,
abdominal cramps or blood and mucus passage
occurs.
53. The usual daily oral dose for treating
odontogenic infections in children is:
Children under 12 years: 10-25 mg/kg/day in 3 equally
divided doses for 10 days.
Children over 12 years and adults: 600-1800 mg/ day in 3
divided doses for 10 days. The maximum dose is 2-3
gms/day.
Supplied as a 75 mg/5ml solution or 150, 300, 450, 600,
750, 900 mg tablets.
54. AMOXICILLIN
More convenient dosing regimen e.g.; 2-3 doses daily
for amoxicillin versus 4 doses daily for penicillin VK
Less effective than penicillin against aerobic gram
positive cocci
Contraindications: Hypersensitivity to amoxicillin,
penicillin or any component of the formulation
55. Warnings/Precautions:
• Use with caution in patients with severe renal
impairment (modify dosage)
• Low incidence of cross-allergy with other beta-lactams
and cephalosporins exists.
56. The usual daily oral dose for treating
odontogenic infections in children is:
Children under 12 years: 20-40 mg/kg divided in 2-3
doses daily for 10 days.
Children over 12 years and adults: 250 –500mg 3
times/day, maximum 2-3 gm/day for 10 days.
57. Clavulanate potassium can be administered in
conjunction with amoxicillin (Augmentin®).
Contraindications: Hypersensitivity to amoxicillin,
clavulanic acid, penicillin or any history of hepatic
dysfunction.
58. Warnings/Precautions:
• Prolonged use may result in superinfection.
• Use with caution in patients with severe renal
impairment
• Incidence of diarrhea
59. The usual daily oral dose of
Augmentin® for treating odontogenic
infections in children is:
Children ≥ 3 months and < 40 kg: 20-40 mg/kg/day in
3 divided doses.
Children > 40 kg and adults: 250-500 mg every 8 hours
or 875 mg every 12 hours.
Augmentin® is supplied as 125, 200, 250 400 mg /5ml
solution, chewable tablets and tablets.
60. CEPHALOSPORINS
First Generation
Alternatives to penicillin for the treatment of
odontogenic infections.
Bacterially effective against aerobes but not anaerobes.
They are active against gram-positive staphylococci
and streptococci, but ineffective against enterococci.
62. Contraindications: hypersensitivity to cephalexin, any
component of the formulation, or other
cephalosporin's.
Warnings/precautions: severe renal impairment;
prolonged use may result in super infection.
Cephalexin (Keflex®) is the first generation
cephalosporin most often used to treat odontogenic
infections.
63. The usual daily oral dose for treating
odontogenic infections in children is:
Children under 12 years: 25-50 mg/kg/day in divided
doses every 6 hours.
Children over 12 and adults: 250-1000 mg every 6 hours
with a maximum of 4 g/day.
Supplied as a 125, 250 mg/5ml suspension and 250 and
500mg capsule
64. Second generation
• More effective against some of the anaerobes
• Contraindications: hypersensitivity to cefaclor,
• Warnings/precautions: modify dosage in patients with
severe renal impairment; prolonged use may result in
superinfection.
65. The usual daily oral dose for treating
odontogenic infections is:
Children under 12 years: 20-40 mg/kg/day divided
every 8-12 hours with a maximum dose of 2 g/day.
Children over 12 years and adults: 250-500 mg divided
every 8-12 hours.
Cefaclor and cefuroxine are supplied as 125, 187, 250,
375 mg/5ml suspensions and 250 and 500 mg capsules.
69. Macrolides (Erythromycin,
Clarithromycin, Azithromycin)
The macrolides are antibiotics with a spectrum of
coverage similar to penicillin, with the addition of
some penicillanase-producing staphylococci,
chlamydiae, Legionella, mycoplasma and others
70. Its most common side effect is gastrointestinal upset.
Clarithromycin and azithromycin are structural
derivates of erythromycin
Macrolides are bacteriostatic rather than
bacteriocidal
Not recommended in immuno-compromised
patients.
71. Contraindications: Hypersensitivity to erythromycin or any
component of the formulation.
Warnings/Precautions: Use with caution in patients with
hepatic impairment. Administration may be accompanied by
malaise, nausea, vomiting, abdominal colic and fever.
72. The oral dosages and dosage forms of
the macrolides are:
Erythromycin
o Infants and children < 12 years
i. Base: 30-50 mg/kg/day in 2-4 divided does; do not
exceed 2 g/day.
ii. Estolate: 30-50 mg/kg/day in 2-4 divided doses; do
not exceed 2g/day
iii. Ethylsuccinate: 30-50 mg/kg/day in 2-4 divided
doses; do not exceed 3.2 g/day
iv. Stearate: 30-50 mg/kg/day in 2-4 divided doses; do
not exceed 2 g/day
73. Clarithromycin (Biaxin®)
Children ≥ 1 month: 15 mg/kg/day divided every 12
hours for 7 days; maximum 1 gm/day
Adults: 250-500 mg every 12
Supplied as:
1. Granules for oral suspension: 125 mg/5ml,
250mg/5ml (50 ml, 100 ml)
2. Tablet: 250 mg, 500 mg
3. Tablet, extended release: 500 mg
75. Azithromycin (Zithromax®)
Children > 6months: 10 mg/kg -day 1, followed by 5
mg/kg/day for 4 days.
Dose should be given 1 hour before a meal or 2 hours
after. Maximum 250 mg/day
Adolescents ≥ 16 years or adult: 500 mg – day 1 then
250 mg days 2-5
77. Side affects of macrolides
Dispeptic disorders, disbacteriosis, superinfection
Cholestasis, cholestatic jaundice (erythromycin)
Depression of liver microsome enzyme activity
(erythromycin, oleandomycin can not be combined
with theophylline, ergot alkaloids, carbamazepine)
Development of resistance in process of treatment