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

5. ANLAGESICS USED IN
PEDIATRIC DENTISTRY

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 .

8. CLASSIFICATION
 Centrally acting( narcotic)
 Peripherally acting (non narcotic)

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

18. Side effects
 Gastric irritation, nausea , vomiting ,
 CNS sideeffects : head ache , tinnitus ,depression
 Rashes itching , hypersensitivity
 Aspirin induced asthma

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

23. OPIOIDS
 Codeine
 Oxycodone
 Morphine
 Fentanyl
 Hydromorphone
 Methadone

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

25. Recent opoid analgesics
 Alfentanil
 Remifentanil
 Tramadol

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

27. COMMERCIAL NAMES
 Alfenta
 Ultiva

28. 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

29. CONTRAINDICATIONS
 Respiratory depression
 Acute attack of asthma
 Head injury
 Raised intracranial pressure

30. COMMERCIAL NAMES
 Contramal
 Contraal DT
 Dolomed
 Dolotram

34. ANTIBIOTICS USED IN
PEDIATRIC DENTISTRY

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.

42. Classification
 Beta-lactam antibiotics
 Macrolides, azalides, streptogramins, prystinamycines.
 Linkozamides.
 Tetracyclines.
 Aminoglycosides.
 Chloramphenicols.
 Glycopeptides.
 Cyclic polipeptides (polimixins).
 Other antibiotics

43. The choice of antibiotic is
influenced by a number of factors
 Stage of infection development
 medical conditions or allergy.

44.  Antibiotics may also be categorized by their method of
attack:
 Bactericidal antibiotics
 Bacteriostatic antibiotics

45. PENCILLIN
 Beta-lactam antibiotic
 Bactericidal against gram-positive cocci and the
major microbes of mixed anaerobic infections.

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..

51.  Adverse effects :
• Abdominal pain
• Nausea
• Vomiting
• Diarrhea
 Contraindications:
• Hypersensitivity to clindamycin
• Previous pseudomembranous colitis
• Regional enteritis,
• Ulcerative colitis.

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.

61. Cefazolin

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.

66. Cefotaxime (C III)

67. Cefobid (Cefoperazone, C III)

68. Claphoran (cefotaxime, C III)

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

80. THANK YOU