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INTRODUCTION
 Most common clinical situations in dentistry
amenable to drug therapy in children are pain and
infection.
...
Adjustment of dosages in pediatric
patients
 Following formulas are used to calculate drug dosages
for pediatric patients...
Young’s formula
Age of child / age + 12 = child’s
dose
Dilling’s formula
Age of child/20 x adult dose =
child’s dose
ANLAGESICS USED IN
PEDIATRIC DENTISTRY
ANLAGESICS USED IN PEDIATRIC
DENTISTRY
 Management of dental pain in pediatric patients is
important
 Drugs prescribed t...
CONCEPTS ABOUT PAIN IN
CHILDREN
 Children have high tolerance to pain.
 Pain perception low because of biologic immaturi...
CLASSIFICATION
 Centrally acting( narcotic)
 Peripherally acting (non narcotic)
CENTRALLY ACTING
 More effective against acute pain
 More adverse effects
 No anti inflammatory or antipyretic effects
NON NARCOTIC ANALGESICS
 Mild to moderate pain
 Site of action peripheral nerve endings
 Less drug toxicity
 Absence o...
 Drugs in this class include
• Acetaminophen,
• Aspirin
• Non-steroidal anti-inflammatory drugs (NSAIDS)
ACETAMINOPHEN
 Antipyretic
 Mild analgesic
 Administer Per oral or Per rectal
 Pediatric Oral dose 10-15 mg/kg/dose ev...
 Onset 30 minutes
 MOA: inhibition of the synthesis of prostaglandins
 Contraindications: Hypersensitivity to acetamino...
•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...
NONSTEROIDAL ANTI-INFLAMMATORY
DRUGS – NSAIDS (IBUPROFEN, NAPROXEM)
 Antipyretic
 Analgesic for mild to moderate pain
 ...
IBUPROFEN
 Propionic acid derivative
 Used in rheumatoid arthritis , osteoarthritis
 Indicated in soft tissue injuries ...
 Dose for infants : 10 mg/kg/dose every 6 hours
 Adult dose 400-600 mg/dose every 6 hours
 Onset 30-45 minutes
 Maximu...
Side effects
 Gastric irritation, nausea , vomiting ,
 CNS sideeffects : head ache , tinnitus ,depression
 Rashes itchi...
NAPROXEM
 Another drug of propionic acid family
 Same action that of ibuprofen
 More anti inflammatory action
 Molecul...
Combination therapy
 Ibuprofen and paracetomol
 Diclofenac and paracetomol
 Nimesulide and paracetomol
 Mefenamic acid...
NARCOTIC DRUGS
 Centrally acting
 Moderate to severe pain
 Infants younger than 3 months have increased risk of
hypoven...
SIDE EFFECTS OF OPIOIDS
 All opioid have side effects that should be anticipated &
managed
 Respiratory depression
 Nau...
OPIOIDS
 Codeine
 Oxycodone
 Morphine
 Fentanyl
 Hydromorphone
 Methadone
COEDINE
 Oral analgesic (also anti- tussive)
 Weak opioid
 Used often in conjunction with acetaminophen to increase
ana...
Recent opoid analgesics
 Alfentanil
 Remifentanil
 Tramadol
ALFENTANIL AND RAMIFENTANIL
 Rapid onset
 Metabolized in liver
 Half life is 1 to 2 hr
 Uses : short painful procedure...
COMMERCIAL NAMES
 Alfenta
 Ultiva
Tramadol
 Weak agonist of all types of opioid receptors
 Uses
1. Mild to moderate pain
2. Cancer pain
 Dosage
Children:...
CONTRAINDICATIONS
 Respiratory depression
 Acute attack of asthma
 Head injury
 Raised intracranial pressure
COMMERCIAL NAMES
 Contramal
 Contraal DT
 Dolomed
 Dolotram
ANTIBIOTICS USED IN
PEDIATRIC DENTISTRY
Antibiotics
 Drugs that are produced by microbes to produce an
antibacterial action.
 The widespread use of antibiotics ...
 ORAL WOUND MANAGEMENT
 Oral wounds are associated with an increased risk of
bacterial contamination.
 If the oral woun...
Dental Infection
 Not indicated if the infection is contained within the
pulpal tissue or the immediately surrounding tis...
Pediatric Periodontal Diseases
 In pediatric periodontal diseases (neutropenias,
Papillon-Fevere syndrome, leukocyte adhe...
Viral diseases
 Antibiotics should not be prescribed for viral
conditions (acute primary herpetic gingivostomatitis)
unle...
 Antibiotics can be categorized by the bacteria they
target.
 They are either narrow or wide spectrum.
 Narrow spectrum...
Classification
 Beta-lactam antibiotics
 Macrolides, azalides, streptogramins, prystinamycines.
 Linkozamides.
 Tetrac...
The choice of antibiotic is
influenced by a number of factors
 Stage of infection development
 medical conditions or all...
 Antibiotics may also be categorized by their method of
attack:
 Bactericidal antibiotics
 Bacteriostatic antibiotics
PENCILLIN
 Beta-lactam antibiotic
 Bactericidal against gram-positive cocci and the
major microbes of mixed anaerobic in...
Mechanism of penicillins action
They form complexes with enzymes - trans- and carboxypeptidases
(PCP), which control synth...
 Adverse drug reactions
mild diarrhea
 nausea
oral candidiasis.
Severe reactions of angioedema
 The alternative anti...
 Contraindications: Hypersensitivity to penicillin
 Warnings/Precautions:
• Caution in patients with severe renal impair...
The usual daily dose of penicillin for
treating odontogenic infections is:
 Children ≤ 12 years of age: 25-50 mg/kg of bo...
CLINDAMYCIN
 Alternative choice in treating mild or early odontogenic
infection.
 Broad spectrum of activity
 Resistanc...
 Adverse effects :
• Abdominal pain
• Nausea
• Vomiting
• Diarrhea
 Contraindications:
• Hypersensitivity to clindamycin...
 Warnings/Precautions:
• Use with caution in patients with liver
dysfunction (modify dosage);
• Can cause severe and fata...
The usual daily oral dose for treating
odontogenic infections in children is:
 Children under 12 years: 10-25 mg/kg/day i...
AMOXICILLIN
 More convenient dosing regimen e.g.; 2-3 doses daily
for amoxicillin versus 4 doses daily for penicillin VK
...
 Warnings/Precautions:
• Use with caution in patients with severe renal
impairment (modify dosage)
• Low incidence of cro...
The usual daily oral dose for treating
odontogenic infections in children is:
 Children under 12 years: 20-40 mg/kg divid...
 Clavulanate potassium can be administered in
conjunction with amoxicillin (Augmentin®).
 Contraindications: Hypersensit...
Warnings/Precautions:
• Prolonged use may result in superinfection.
• Use with caution in patients with severe renal
impa...
The usual daily oral dose of
Augmentin® for treating odontogenic
infections in children is:
 Children ≥ 3 months and < 40...
CEPHALOSPORINS
 First Generation
 Alternatives to penicillin for the treatment of
odontogenic infections.
 Bacterially ...
Cefazolin
 Contraindications: hypersensitivity to cephalexin, any
component of the formulation, or other
cephalosporin's.
 Warning...
The usual daily oral dose for treating
odontogenic infections in children is:
 Children under 12 years: 25-50 mg/kg/day i...
 Second generation
• More effective against some of the anaerobes
• Contraindications: hypersensitivity to cefaclor,
• Wa...
The usual daily oral dose for treating
odontogenic infections is:
 Children under 12 years: 20-40 mg/kg/day divided
every...
Cefotaxime (C III)
Cefobid (Cefoperazone, C III)
Claphoran (cefotaxime, C III)
Macrolides (Erythromycin,
Clarithromycin, Azithromycin)
 The macrolides are antibiotics with a spectrum of
coverage simil...
 Its most common side effect is gastrointestinal upset.
 Clarithromycin and azithromycin are structural
derivates of ery...
 Contraindications: Hypersensitivity to erythromycin or any
component of the formulation.
 Warnings/Precautions: Use wit...
The oral dosages and dosage forms of
the macrolides are:
 Erythromycin
o Infants and children < 12 years
i. Base: 30-50 m...
Clarithromycin (Biaxin®)
 Children ≥ 1 month: 15 mg/kg/day divided every 12
hours for 7 days; maximum 1 gm/day
 Adults: ...
Azithromycin (Zithromax®)
 Children > 6months: 10 mg/kg -day 1, followed by 5
mg/kg/day for 4 days.
 Dose should be give...
Side affects of macrolides
 Dispeptic disorders, disbacteriosis, superinfection
 Cholestasis, cholestatic jaundice (eryt...
THANK YOU
Antibiotics and analgesics in pediatric dentistry (2)
Antibiotics and analgesics in pediatric dentistry (2)
Antibiotics and analgesics in pediatric dentistry (2)
Antibiotics and analgesics in pediatric dentistry (2)
Antibiotics and analgesics in pediatric dentistry (2)
Antibiotics and analgesics in pediatric dentistry (2)
Antibiotics and analgesics in pediatric dentistry (2)
Antibiotics and analgesics in pediatric dentistry (2)
Antibiotics and analgesics in pediatric dentistry (2)
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Antibiotics and analgesics in pediatric dentistry (2)

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Antibiotics and analgesics in pediatric dentistry (2)

  1. 1. 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.
  2. 2. 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
  3. 3. Young’s formula Age of child / age + 12 = child’s dose Dilling’s formula Age of child/20 x adult dose = child’s dose
  4. 4. ANLAGESICS USED IN PEDIATRIC DENTISTRY
  5. 5. ANLAGESICS USED IN PEDIATRIC DENTISTRY  Management of dental pain in pediatric patients is important  Drugs prescribed to relive pain are called analgesics
  6. 6. 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 .
  7. 7. CLASSIFICATION  Centrally acting( narcotic)  Peripherally acting (non narcotic)
  8. 8. CENTRALLY ACTING  More effective against acute pain  More adverse effects  No anti inflammatory or antipyretic effects
  9. 9. NON NARCOTIC ANALGESICS  Mild to moderate pain  Site of action peripheral nerve endings  Less drug toxicity  Absence of drug dependency
  10. 10.  Drugs in this class include • Acetaminophen, • Aspirin • Non-steroidal anti-inflammatory drugs (NSAIDS)
  11. 11. 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
  12. 12.  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
  13. 13. •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
  14. 14. 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
  15. 15. IBUPROFEN  Propionic acid derivative  Used in rheumatoid arthritis , osteoarthritis  Indicated in soft tissue injuries , tooth extraction, fractures, vasectomy
  16. 16.  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
  17. 17. Side effects  Gastric irritation, nausea , vomiting ,  CNS sideeffects : head ache , tinnitus ,depression  Rashes itching , hypersensitivity  Aspirin induced asthma
  18. 18. NAPROXEM  Another drug of propionic acid family  Same action that of ibuprofen  More anti inflammatory action  Molecular structure different
  19. 19. Combination therapy  Ibuprofen and paracetomol  Diclofenac and paracetomol  Nimesulide and paracetomol  Mefenamic acid and paracetomol
  20. 20. 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
  21. 21. SIDE EFFECTS OF OPIOIDS  All opioid have side effects that should be anticipated & managed  Respiratory depression  Nausea, vomiting  Constipation  Pruritis  Urinary retention
  22. 22. OPIOIDS  Codeine  Oxycodone  Morphine  Fentanyl  Hydromorphone  Methadone
  23. 23. 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
  24. 24. Recent opoid analgesics  Alfentanil  Remifentanil  Tramadol
  25. 25. ALFENTANIL AND RAMIFENTANIL  Rapid onset  Metabolized in liver  Half life is 1 to 2 hr  Uses : short painful procedures,  Ramifentanil for long neurosurgical procedures
  26. 26. COMMERCIAL NAMES  Alfenta  Ultiva
  27. 27. Tramadol  Weak agonist of all types of opioid receptors  Uses 1. Mild to moderate pain 2. Cancer pain  Dosage Children:1 – 1.5 mg /kg
  28. 28. CONTRAINDICATIONS  Respiratory depression  Acute attack of asthma  Head injury  Raised intracranial pressure
  29. 29. COMMERCIAL NAMES  Contramal  Contraal DT  Dolomed  Dolotram
  30. 30. ANTIBIOTICS USED IN PEDIATRIC DENTISTRY
  31. 31. 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.
  32. 32.  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
  33. 33. 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.
  34. 34. 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.
  35. 35. 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.
  36. 36.  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.
  37. 37. Classification  Beta-lactam antibiotics  Macrolides, azalides, streptogramins, prystinamycines.  Linkozamides.  Tetracyclines.  Aminoglycosides.  Chloramphenicols.  Glycopeptides.  Cyclic polipeptides (polimixins).  Other antibiotics
  38. 38. The choice of antibiotic is influenced by a number of factors  Stage of infection development  medical conditions or allergy.
  39. 39.  Antibiotics may also be categorized by their method of attack:  Bactericidal antibiotics  Bacteriostatic antibiotics
  40. 40. PENCILLIN  Beta-lactam antibiotic  Bactericidal against gram-positive cocci and the major microbes of mixed anaerobic infections.
  41. 41. Mechanism of penicillins action They form complexes with enzymes - trans- and carboxypeptidases (PCP), which control synthesis of peptidoglycan – component of cell- wall of microorganisms
  42. 42.  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.
  43. 43.  Contraindications: Hypersensitivity to penicillin  Warnings/Precautions: • Caution in patients with severe renal impairment (modify dosage) • History of seizures • Hypersensitivity to cephalosporins.
  44. 44. 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
  45. 45. 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..
  46. 46.  Adverse effects : • Abdominal pain • Nausea • Vomiting • Diarrhea  Contraindications: • Hypersensitivity to clindamycin • Previous pseudomembranous colitis • Regional enteritis, • Ulcerative colitis.
  47. 47.  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.
  48. 48. 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.
  49. 49. 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
  50. 50.  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.
  51. 51. 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.
  52. 52.  Clavulanate potassium can be administered in conjunction with amoxicillin (Augmentin®).  Contraindications: Hypersensitivity to amoxicillin, clavulanic acid, penicillin or any history of hepatic dysfunction.
  53. 53. Warnings/Precautions: • Prolonged use may result in superinfection. • Use with caution in patients with severe renal impairment • Incidence of diarrhea
  54. 54. 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.
  55. 55. 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.
  56. 56. Cefazolin
  57. 57.  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.
  58. 58. 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
  59. 59.  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.
  60. 60. 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.
  61. 61. Cefotaxime (C III)
  62. 62. Cefobid (Cefoperazone, C III)
  63. 63. Claphoran (cefotaxime, C III)
  64. 64. 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
  65. 65.  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.
  66. 66.  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.
  67. 67. 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
  68. 68. 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
  69. 69. 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
  70. 70. 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
  71. 71. THANK YOU

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