1.Antibiotics and analgesics in pediatric dentistry

Content
s
 REVIEW OF PEDIATRIC PHYSIOLOGY
 PEDIATRIC DOSAGE FORMULA
 INTRODUCTION
 DEFINITION
 HISTORY
 SELECTION OF ANTIMICROBIALS
 PRINCIPLES OF ANTIBIOTIC ADMINISTRATION
 GOLDEN RULES FOR ANTIBIOTIC USAGE
 FUNDAMENTAL CONCEPTS OF ANTIBIOTIC THERAPY
 CLASSIFICATION
 MECHANISM OF ACTION

 DRUGS:
(INTRODUCTION, CLASSIFICATION, MECHANISM, PHARMACOKINECTICS,
ADVERSE REACTIONS, RESISTANCE, CONTRAINDICATIONS, USES IN
DENTISTRY)
 ß-LACTAM ANTIBIOTICS
 MACROLIDES
 METRONIDAZOLE
 SULFONAMIDES
 COTRIMAZOLE
 TETRACYCLINE
 AMINOGLYCOSIDES
 CHLORAMPHENICOL

 PROBLEMS THAT ARISE WITH THE USE OF ANTIBIOTICS
 ANTIBIOTIC RESISTANCE
 NEWER ANTIMICROBIALS
 USE OF ANTIBIOTICS
 ENDODONTIC MANAGEMENT
 LEDERMIX
 TRIPLE ANTIBIOTIC PASTE
 PERIODONTAL MANAGEMENT
 ORAL AND MAXILLOFACIAL MANAGEMENT
 PREGNANT PATIENTS
 ANTIBIOTIC PROPHYLAXIS
 RISK GROUPS
 DENTAL PROCEDURES
 CHILDREN REGIMEN
 SURGICAL PROPHYLAXIS

 MISUSE OF ANTIBIOTICS
 DRUG ALLERGY
 DEVELOPMENT OF ALLERGY
 OVERDOSE
 GEL AND COOMBS REACTONS
 PENICILLIN ALLERGY
 AMPICILLIN RASH
 ANTIBIOTIC SENSITIVITY TESTING
 ALLERGY TESTS
 CROSS REACTIVITY
 MANAGEMENT
 TOXIC EFFECTS OF ANTIBIOTICS
 REASONS FOR ANTIBIOTIC FAILURE
 CONCLUSION
 REFERENCES

QUICK REVIEW OF PEDIATRIC
PHYSIOLOGY

DRUG CONSIDERATIONS
 Child has high AV and low FRC, the pediatric AV/FRC ratio is
almost five times that of an adult.
(LERMAN, 1933)
 This ratio difference means that children react more rapidly to
inhaled gases, such as NO and halothane, and can be
adequately anesthetized with lowest gas concentrations than
those required for adult patients.
RESPIRATORY SYSTEM

CARDIOVASCULAR SYSTEM
DRUG CONSIDERATIONS
 Changes in cardiac output can drastically affect the
uptake of inhaled anesthetic agent.
 It can even significantly depress the central nervous
system and hence lower gas concentrations are
recommended for pediatric patient than adults.
 Endodontic consideration for pediatric patients with
cardiac ailments : obturation to be done 1mm lesser to
apex along with antibiotic prophylaxis.

GASTRO INTESTINAL SYSTEM
PHYSIOLOGY and DRUG CONSIDERATIONS :
• Decreased acidity
• Altered motility
• Altered hepatic metabolism
• Infant liver is deficient of pseudocholinesterase and hence
succinylcholine is therefore administered with caution to
infant patients.
• Why is the half-life more in pediatric patients???

RENAL SYSTEM
• The young kidney is less competent to excrete drug.
• The GF participates in the excretion of commonly used pediatric drugs such
as the penicillin's , short-acting barbiturates, and phenobarbital.
Alterations in Body fluid
• Water equals 80 % of infants weight
( water soluble drugs have to be dosed at higher levels per unit of body
weight )
ANDERSON , 1991
Plasma protein differences
• Serum albumin and plasma globulin, are deficient in the newborn and
young infancy(warfarin and digoxin, must be dosed at low levels per
unit of body weight in these patients).
RADDE, 1993a

Pediatric dose =
Child's BSA in m2
1.73m2
x Adult
Dosage
Pediatric =
Dose
child's age in months
150
x Adult DoseFried's Rule
Pediatric =
dose
child's age in years
child's age in years +
12 years
x Adult DoseYoung's Rule
Clarks Rule
Pediatric
Dose =
child's weight lb/(kg)
150lb/(70kg)
x Adult Dose
Nomogram Method

Several rules exist to compute the dosage of a drug for a child, the most common
Clark’s rule. Clark’s rule determines the dose suitable for a child based on the
typical adult weight of 150 lb (or 70 kg).
Clarks rule:
Pediatric =
dose
child's weight lb/(kg)
150lb/(70kg)
x Adult Dose
For example, if the adult dose of Penicillin V is 500mg every 6 hours, the dose for
a 40 lb (18 kg) paediatric patient would be calculated as:
133 mg every 6
hrs. =
40 lb/(18 kg)
150lb/(70kg)
x 500mg
Clark’s rule may also be used to calculate dosages for underweight, ill or elderly patients

Introduction
 Antibiotics are one of the most frequently used as well as
misused drugs.
 Their importance is magnified in the developing countries,
where infective diseases predominate.
Selman A. Waksman introduced the term “antibiotic” in
1942.

In dentistry, antibiotics are used mainly in the following
purposes:
1) as adjuncts to therapy for oro-facial infection
2) to prevent local infection associated with dental
procedures
3) to prevent the spread of oral micro-organisms to
susceptible sites elsewhere in the body

Antibiotics are the substances produced by
microorganisms, which suppress the growth or kill other
microorganism at very low concentration without causing
any harm to host.
The term antibiotic means
"against life”
(Tripathi, Essentials of medical pharmacology)
DEFINITION

Brief history of Antibiotics
1928 1956
1932 1962
1948 1970
1952 2000 Fluoroquinolones
Sulphonamides -Erlich
Cephalosporins-G.Brotzu
Erythromycin - Mc. Guire
Vancomycin-M.H.Cormick
Quinolone
Linezolide
Penicillin-Fleming

FUNDAMENTAL CONCEPTS OF ANTIBIOTIC THERAPY
 Identify causative
organism
 Most effective narrow
spectrum antibiotics
should be used.
 A bacteriostatic drug
should not be used with a
bactericidal antibiotic.
Proper route, dose and
duration of antibiotic should
be managed.
 Combination therapy
19
Principles of
antibiotic
administration
Proper Time
Interval
Proper Route
Of
Administration
Consistency in
route of
administration
Proper Dose
Combination
antibiotic
therapy

 Don't use antibiotics unnecessarily
 Avoid broad spectrum Antibiotics as far as possible
 Don’t prolong the antibiotic therapy unnecessarily
 In cases of chronic infections like Tuberculosis, Leprosy, etc
employ multiple drug regime.
GOLDEN RULES FOR ANTIBIOTIC USAGE

Antibiotics with specification
 Effective against odontogenic infections -------- Penicillin,
Clindamycin,
Erythromycin,
Cefadroxil,
Metronidazole,
Tetracyclines
 Amoxicillin ------ first choice antibiotic against endocarditis prophylaxis
 Child is allergic to penicillin ------ Macrolides, Clarithromycin and Azithromycin
 Metronidazole ------ Against anaerobic bacteria
 Cefadroxil ------- Commonly used under cephalosporin
 Tetracyclines ------- Limited use in dentistry

Classification
Sulfonamides
:
Sulfadiazine,
Dapsone
Quinolones:
Norfloxacin,
Ciprofloxacin
Tetracyclines:
Tetracycline,
Doxycycline
β-lactam
antibiotics:
Penicillins,
Cephalosporins
Aminoglycosides:
Streptomycin,
Gentamicin
Nitrobenzene
derivatives:
Chloramphenicol
Macrolides:
Erythromycin,
Azithromycin
Nitroimidazoles:
Metronidazole,
Tinidazole
Lincosamide:
Clindamycin,
Lincomycin
Glycopeptides:
Vancomycin
Polyene antibiotics:
Nystatin,
Amphotericin-B
Based on chemical structure

Based on type of Action
Bacteriostatic
Sulfonamides
Tetracyclines
Chloramphenicol
Erythromycin
Ethambutol
Clindamycin
Bactericidal
Penicillins
Cephalosporins
Aminoglycosides
Metronidazole
Ciprofloxacin
Based on spectrum of Activity:
Narrow Spectrum:
Penicillin G
Streptomycin
Erythromycin
Broad Spectrum:
Tetracycline
Chloramphenicol

Based on their sites of action
and its mechanism

 The antibiotics administered for 5 days following
resolution of major clinical signs and symptoms of
infection.
 Following treatment of the source of infection and
adjunctive antibiotic therapy, significant improvement in
patient's status should be seen in 24 to 48 hours.
 If improvement is not seen within 48 hrs, a combined use
of antibiotics may be recommended.
26
DURATION OF ANTIBIOTIC THERAPY

Beta-Lactam Antibiotics
• These have a β-lactam ring.
• Two major groups:
Penicillins Cephalosporins
• Also,
Carbapenem and Monobactams.
• They act by inhibiting the cell wall
synthesis.

Penicillins
Introduction:
• First antibiotic to be used in 1941.
• Obtained originally from the fungus Penicillium notatum.
• Presently obtained from P.chrysogenum.
• Has wide therapeutic range and is a safest drug
• Most commonly used penicillin is Penicillin G or Benzyl
Penicillin

Mechanism of Action
 Bactericidal drugs
 Penicillins interfere with the last step of bacterial cell wall
synthesis, resulting in exposure of the osmotically less
stable membrane leading to cell lysis.
1. Penicillin binding proteins(PBPs)
2. Inhibition of transpeptidase
3. Production of autolysins

Classification
Penicillin
Natural Penicillin Penicillin G (Benzyl Penicillin)
Semi synthetic
Penicillin
Penicillinase resistant penicillins:
Methicillin, Cloxacillin
Extended spectrum penicillin
Ampicillin, Amoxicillin, Carbenicillin,
Piperacillin
Acid resistant alternative to Penicillin G:
Phenoxymethyl penicillin
(Penicillin V)
β-lactamase
Inhibitors
Clavulanic acid,
Sulbactam

Penicillin G
• Narrow spectrum antibiotic.
• Activity limited to gram positive
bacteria.
• Susceptible to inactivation by β-
lactamases.
Resistance:
1. β-lactamase activity
2. Decreased permeability to the
drug:
3. Altered PBPs
Pharmacokinetics:
 Penicillin G is destroyed by
gastric acid.
 Should be given IV/IM.
 Insignificant metabolism as it is
rapidly excreted from the body.
 Poor penetration into CSF.
Adverse Drug Reactions:
1. Hypersensitivity
2. Angioedema
3. Super infection
4. Diarrhoea
5. Jarisch- Hexheimer reaction

Amoxicillin
 Better oral absorption.
 Higher and sustained blood
levels are produced.
 Diarrhoea is rare.
 Dose: 0.25-1g TDS,orally/i.m
125mg/5ml syrup
Commonly used in dental practice
 Acid stable; better oral
absorption.
 Uses:
Streptococcal pharyngitis,
Sinusitis, trench mouth,
Actinomycosis.
Dose
 Infants : 60mg
 Children : 125-250mg, given
6 hourly.

Uses in
dentistry
Amoxicillin is the
most frequently
prescribed drug for
infections of dental
origin.
In infections
associated with
both gram +ve and
–ve aerobic and
anaerobic
organisms,
amoxicillin
combined with
metronidazole is
the agent of choice.
It is administered
orally, which is the
safest, most
convenient and least
expensive mode of
drug
administration.
Many physicians now prefer it over ampicillin for Bronchitis, Urinary infections, SABE, Gonorrhoea.

Cephalosporins
INTRODUCTION:
 Semisynthetic antibiotics derived from Cephalosporin-C obtained from the
fungus Cephalosporium.
 Chemically related to penicillins.
 Effective against both gram +ve and gram –ve organisms.
 Bactericidal drugs.
 Inhibit cell wall synthesis

CLASSIFICATION
First
generation-
Second
generation-
Third
generation-
Fourth
generation-
Fifth
generation-
• More active
against
gram +ve
organism
• Against
gram +ve
and gram
-ve organism
• Highly active
against gram -
ve organisms
and
pseudomonas
• Similar to
third
generation
but highly
effective
• Developed
in the lab to
specifically
target
resistant
strains of
bacteria.
Cephalothin
Cephalexin
Cefadroxil
Cefuroxim
Cefoxitin
Cefaclor
Cefotaxime
Ceftizoxime
Ceftazidime
Cefixime
Cefepime
Cefpirome
Ceftobiprole
Ceftraroline
(both act
against MRSA)

Pharmacokinetics
 IV / IM administration.
 Doesn’t undergo any
metabolism in the body.
 Good distribution into body
fluids.
 Good penetration into bones.
 Eliminated through tubular
secretion and glomerular
filtration.
Adverse reaction
 Allergic manifestations:
It should be avoided in
those allergic to penicillin.
 Disulfiram like effect
 Bleeding

Macrolides
Erythromycin
• Used as an alternative to
penicillin in individuals who
are allergic to β-lactam
antibiotics.
Newer Macrolides:
• Roxithromycin
• Clarithromycin
• Azithromycin
Mechanism of Action
• Bacteriostatic at low
concentration and bactericidal at
high concentration.
• Macrolides bind irreversibly to a
site on the 50S subunit and
interferes with translocation, thus
inhibiting protein synthesis.
• They have a large lactone ring
• They are alternative to penicillins in many conditions

Pharmacokinetics
 Acid labile, given as enteric
coated tablets.
 Food interferes with
absorption.
 Widely distributed in the body.
 Crosses the placenta but not
the BBB.
 Metabolized and excreted in
bile.
 Minor renal excretion (hence,
can be given in pts. with renal
failure).
Adverse drug
reactions
 Epigastric distress.
 Ototoxicity
 Cholestatic jaundice: Occurs
with the estolate form.
 Contraindicated in pregnant
patients.

Uses in
dentistry
It has a long and
successful history of
use against acute
oro-facial infections.
Used as a substitute
for patients allergic
to penicillin.
Azithromycin at
500mg/day for 3 days
has demonstrated
comparable efficacy to
amoxicillin at 500mg
three times daily for
5-10 days in the
management of acute
periapical abscesses.

Metronidazole
INTRODUCTION
 Synthetic nitroimidazole.
 Anti-protozoal drug.
 Used extensively for the
treatment of anaerobic
bacterial infections.
Mechanism of action
 Bactericidal drug.
 Affects DNA synthesis.
 It enters into the cell and
reduces into its nitro
group to produce
metabolites that damage
DNA, eventually inducing
cell death.

Pharmacokinetics
 Completely absorbed
from the GIT.
 Widely distributed in the
body.
 Excellent CNS
penetration.
 Metabolised in liver.
Adverse drug reactions
 Nausea and vomiting
 Reversible neutropenia
 Metallic taste
 Dark or red brown
urine

USES
 Bone and joint infections, septicemia.
 Endometritis, or endocarditis.
 Pseudomembranous colitis due to Clostridium difficile
 peptic ulcer disease
 Periapical abscess, periodontal abscess, acute
pericoronitis of impacted or partially erupted teeth;
Often used in conjunction with Amoxicillin

Sulfonamides
Introduction
 Were the first
antimicrobial agents
effective against
pyogenic bacterial
infections.
 Limited use currently,
due to rapid
development of bacterial
resistance.
Mechanism of action
PABA /
(p-aminobenzoic acid)
Folic acid
Sulfonamide
Inhibit the bacterial folate synthase

Uses
 Topically used to prevent
infection on burn surfaces.
 Combined with
trimethoprim for many
bacterial infections.
 Not used to treat dental
infections.
Adverse reactions
 Crystalluria;
nephrotoxicity may
result.
 Hypersensitivity
 Hematopoietic
disturbances in patients
with G6PD deficiency.
 Kernicterus, may occur in
newborn.
Contraindications:
 Newborns and infants <
2months.
 Pregnancy

Cotrimoxazole
Introduction
• Trimethoprim + Sulfamethaxazole
= Cotrimoxazole
• It has a synergistic bactericidal
action
• Greater antibacterial activity.
:
Mechanism of action
PABA
Dihydrofolate
(DHFA)
Tetrahydrofolate
(THFA)
Sulfonamide - - -
Trimethoprim - - -

Antibacterial spectrum
 Broader spectrum of
action.
 Effective in treating
 UTIs
 RTIs
 Gonorrhea
 Otitis media
 Pneumocystis
pneumonia (in AIDS).
Adverse reactions
 Nausea, vomitting, stomatitis
 Megaloblastic anemia,
leukopenia, thrombocytopenia
(can be reversed by
administration of folic acid).
 High incidence of fever, rash,
bone marrow hypoplasia in
AIDS patient.
 Renal toxicity.

Tetracycline
Introduction
 These are a class of
antibiotics having a
nucleus of four cyclic
rings.
 Broad spectrum of action.
Resistance:
 Inability of the organism
to accumulate the drug.
 Production of bacterial
proteins that prevent
tetracyclines from
binding to the ribosome.
Mechanism of Action:
 Bacteriostatic agent.
 Inhibit protein synthesis by
binding to 30S ribosomes
thereby blocking access to
the amino acyl-tRNA to the
mRNA-ribosome complex at
the acceptor site.

Uses:
• Chronic periodontitis:
Doxycycline 20mg bid daily for 2-4 weeks
• Traveller’s diarrhoea
• Acne treatment:
Tetracycline 250mg bid for 4 weeks

Pharmacokinetics
 Adequately but incompletely
absorbed after oral ingestion.
 High concentration in liver,
kidney, spleen and skin.
 Enterohepatic circulation is a
feature of tetracyclines.
 Binds to tissue undergoing
calcification (teeth and bone).
 Crosses the placental barrier
and concentrates in fetal bones
and dentition.
 Excreted by kidney
Adverse Drug Reactions
 Gastric discomfort: epigastric pain,
nausea, vomitting, diarrhoea.
 Effects on calcified tissue: alcium
 Tetracycline chelate gets deposited
in developing teeth and bone.
(Midpregnancy to 5mths of
extrauterine life: deciduous teeth
are affected).
 Fetal hepatotoxicity
 Photosensitivity
 Vestibular toxicity
 Superinfections
 Nephrotoxicity

Aminoglycosides
Introduction
 All are bactericidal and more
active at alkaline pH.
 Do not penetrate brain or CSF.
 Drug of choice for aerobic
gram –ve infections.
 Used as anti-tuberculous drug
 Includes ,
1. Streptomycin
2. Gentamycin
3. Tobramycin
4. Amikacin
5. Kanamycin
Mechanism of Action
 They act by blocking the
mRNA , thus inhibiting
bacterial protein
synthesis.

Resistance
 Decreased uptake of drug.
 An altered 30S ribosomal subunit
aminoglycoside binding site that has
a decreased affinity for the drug.
 Plasmid associated synthesis of
enzymes that modify and inactivate
aminoglycosides.
 Ototoxicy
 Nephrotoxicity
 Neuro muscular toxicity
Precautions & Contraindications
 Avoid during pregnancy.
 Cautious use in patients those with kidney damage.
 Avoid concurrent use of other ototoxic and nephrotoxic
drugs.
Not used to treat dental infections.

Chloramphenicol
 Active against a wide range of
gram +ve and –ve organisms.
Pharmacokinetics:
 Oral / IV administration.
 Widely distributed in the body.
 Enters the CSF.
 Metabolised in the liver to
glucoronic acid and then
secreted by the renal tubule.
Mechanism of Action
 It binds to bacterial 50S
ribosomal subunit and
inhibits protein synthesis at
the peptidyl transferase
reaction.

Resistance
 Presence of an R factor that
codes for an acetyl coenzyme
acetyl-transferase which
inactivates chloromphenical.
 Inability of the drug to
penetrate the organism.
 Hypersensitivity
 Gray baby syndrome (due to
cardio vascular collapse and
glucuronyl transferase in
infants).
 Bone marrow depression
Antimicrobial Spectrum
Broad spectrum antibiotic.
Excellent activity against
anaerobes.
Maybe bacteriostatic or
bactericidal, depending upon
the concentration.
Drug of choice for typhoid
Contraindicated in infants

Problems that arise with the
use of antibiotics
Toxicity
-Local
-Systemic
Hypersensitivity
Reactions
Drug Resistance
-Natural
-Acquired
-Cross Resistance
Super infection
Masking of an infection

ANTIBIOTIC RESISTANCE
55
The greatest possibility of evil in self-medication
is the use of too small doses so that instead of
clearing up infection, the microbes are educated to
resist penicillin and a host of penicillin-fast
organisms is bread out which can be passed to other
individuals and from them to other until they reach
someone who gets a septicemia or a pneumonia
which penicillin cannot save.
Sir Alexander Flemming

COMMON MODES OF ANTIMICROBIAL RESISTANCE
e.g.Penicillins
e.g. aminoglycosides ,
chloramphenicol &
penicillins
e.g.tetracyclines
e.g. aminoglycosides &
tetracyclines

MECHANISM OF MICROBIAL RESISTANCE TO
ANTIBIOTICS
• ENZYMATIC ANTIBIOTIC
INACTIVATION
 β lactamases : β lactams
(Penicillins,
Cephalosporins)
 Acetyltransferases :
(Aminoglycosides,
Chloramphenicol,
Streptomycins)
57
Splits the amide bond hydrolyzing the β-lactam ring

WHO IS THE WINNER ?
• The microbe always
has the last world.
-LOUIS PASTEUR
(1822-1895)
58

Need newer antimicrobials, why ???
• Bacterial resistance to antimicrobials develop
• Health and economic problems
• Chronic resistant infections contribute to increasing health
care cost
• Increase morbidity & mortality with
resistant microorganisms

Newer
Oxazolidinones
Linezolid-
 Approved for adults use in
2000
 Recently approved for
pediatric use in 2005
MOA:
Bind to the 23S portion of
the 50S subunit preventing
translation initiation
Newer
Cephalosporins
 Ceftaroline: Approved in
2010
 For the treatment of
o community - acquired
pneumonia &
o complicated skin and
soft - tissue infections
Bind strongly to (MRSA)
 DOSE: 600 mg IV every 12
hours

NEWER
Lipopeptides
 Daptomycin-Only drug in
this class
 Approved in 2003
 Rapidly bactericidal
 No cross resistance
 Warning issued by FDA in
July 2010------can cause
life-threatening
eosinophilic pneumonia.
NEWER
Glycylcyclines
 Only one glycylcycline
antibiotic for clinical use:
 TIGECYCLINE
 Approved in 2005
 MOA:
 Bind to 30 S subunit of
bacterial ribosome
 20-fold more efficient
than tetracycline
 Slow IV infusion of 100
mg
 Also active against MRSA

USE OF ANTIBIOTICS IN ENDODONTIC
TREATMENT
 Once the source of infection has been established, dental
procedures should be used immediately to disrupt the
microorganisms involved.
 Antibiotics should be used as an adjunct .
62
1 = apical foramen with delta; 2 = lateral
accessory canal; 3 = furcation accessory
canal; 4 = dentinal tubules.

ROUTES OF ENDODONTIC
INFECTION (MICROBIAL INGRESS)
– Through open cavity
– Through dentinal tubules
– Through gingival sulcus or periodontal
ligament
– Through the blood stream
– Through a broken occlusal seal or faulty
restorations of a tooth previously
treated by endodontic therapy
– Through extension of a periapical
infection from adjacent teeth

Systemic involvement
 Fever> 100°F
 Malaise
 Lymphadenopathy
 Trismus
Progressive infection
(present/suspected)
• Increasing swelling
• Cellulitis
• Osteomyelitis
In treatment of endodontic infections antibiotics are indicated (as an adjunct)
when certain signs and symptoms of involvement are evident.
These include:
 Cavernous sinus thrombosis
 Ludwig's angina
 Mediastinal space swelling,
 Brain abscess

LEDERMIX
• It is highly effective anti-inflammatory cortisone derivative
combined with a broad range antibiotic (di-methyl chlor
tetracycline)
• Therapeutical results : Rapid relief of pain associated with
acute pulpal & PDL inflammations
65

Triple Antibiotic Paste
 METRONIDAZOLE, CIPROFLOXACIN, AND MINOCYCLINE
 Combination would be needed –in case of diverse flora in root canal
TAP first tested by Sato et al.
• Metronidazole (nitroimidazole) -a broad spectrum
against protozoa &anaerobic bacteria.
•Minocycline (semisynthetic tetracycline) : a similar
spectrum of activity.
•Ciprofloxacin, a synthetic fluoroquinolone : a bactericidal
mode of action
•30% reduction in bacteria -2 weeks.
•Successful treatment
- sterilization of canals and healing of periapical
pathology, immature root development, necrotic pulps,
and apical periodontitis
•Drawbacks of this technique : Development of resistant
bacterial strains and tooth discoloration

Antibiotics in periodontal
management
Chronic inflammatory periodontal diseases-
•TOPICAL MEASURES –
 Tetracyclins, metronidazole 250mg tid,
 Penicillins 500mg qid,
 Cephalosporins
ANUG-Topical measures with systemic antibiotic penicillin,
metronidazole 400mg qid,

Antibiotics in oral and maxillofacial
management
Initial stage -
Aerobic bacteria
invade
Severe infection-
Aerobic and
anaerobic
bacteria invade
Advanced stage-
Anaerobic
infection

Therapeutic uses of antibiotics in
maxillofacial surgery
Pericoronitis :
Acute pericoronitis severe antibiotic therapy.
Treatment - Debridement, drainage of the site,
Penicillin 500 mg qid,
Amoxicillin 500mg qid,
Clindamycin 300mg qid
Dento-alveolar Abscess :
Acute dento-alveolar abscess and cellulitis
Treatment
Penicillin is the drug of choice

Regimen for fracture
• Therapeutic doses - 10 to 14 days
• Should begin as early as possible after diagnosis
Pre-operatively
• Penicillin 2 million units or
• Cefazolin 0.5 gm-1.5 gm 12 hr
[25- 50 mg/kg]
Post-operatively
• Penicillin 500mg 6 hr [30-40 mg /kg]
• Cephalexin 500mg 6 hr [25- 50 mg/kg]
In suspected intra-cranial contamination
• Pre-operatively- Naficillin 2-6 gm/kg 6hr+ Gentamycin 3-5mg/kg 8 hr
• Post-operatrively- Cephalexin 500mg 6 hr[25-50 mg/kg]

PREGNANCY AND ANTIBIOTICS
Safe antibiotics in
pregnancy
Penicillins
Cephalosporins
Amoxicillin
Clindamycin
Drugs contraindicated in children-
 Chloramphenicol
 Tetracycline
Unsafe antibiotics in
pregnancy
Clarithromycin
Ciprofloxacin
Tetracycline

Drugs contraindicated in lactating mother :
 Metronidazole
 Tetracycline
 Sulfonamides
 Aminoglycosides
 Cotrimazole
Safe drug in lactating mother :
 Cephalexin

Triple Antibiotic Paste
3 Mix- paste
Ciprofloxacin - 200mg
Metronidazole - 500mg
Minocycline - 100mg
The drugs are powdered and mixed
Acc. To Hoshino et al, ratio = 1:1:1
carrier (MP) ratio = 1:1
Macrogol ointment, Propylene glycol
Acc. To Takushige et al, ratio = 1:3:3 and add either
Macrogol propylene glycol or a canal sealer.

COMBINATION THERAPY
AUGMENTIN :
Amoxicillin trihydrate + Potassium Clavulanate
( 25mg + 6.25mg )
Pharmacological form :
child <6years - oral suspension
(125mg/31.25mg / 5ml powder )
- pediatric sachets
child >6years - tablets
children <40kg - 20mg/5mg /kg /day - 60mg/15mg/day
given in three divided doses
Contra-indicated in case if there is history of jaundice, severe
immediate hypersensitivity rxns.
No clinical data on doses of augmentin 4:1 formulations higher than
40mg/10mg/kg per day in children under 2 years have been reported.

High-risk category
 Prosthetic cardiac valves,
including bio-prosthetic and
homograft valves
 Previous bacterial
endocarditis
 Complex cyanotic congenital
heart disease
 Surgically constructed
systemic pulmonary shunts
Moderate-risk category
 Most other congenital cardiac
malformations
 Acquired valvular dysfunction
(eg, rheumatic heart disease)
 Hypertrophic cardiomyopathy
 Mitral valve prolapse with
valvular regurgitation

Antibiotic prophylaxis in dental procedures:
RECOMMENDED :
- All dental procedures that involve gingival tissue or the periapical
region of the teeth or perforation of the oral mucosa.
NOT RECOMMENDED :
– Restorative dentistry (operative and prosthodontic) with or without
retraction cord
– Local anesthetic injections
– Intracanal endodontic treatment; post placement and buildup
– Placement of rubber dams, postoperative suture removal, taking of
oral impressions, and fluoride treatments
– Placement of removable prosthodontic or orthodontic appliances
– Taking of oral radiographs
– Shedding of primary teeth
79

THE AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
(AAPD)
Antibiotic prophylactic regimen JULY ,2015
Clindamycin 20mg/kg (maximum
600mg) IV or IM within 30 min before
dental procedure
Children allergic to penicillin and
unable to take oral medications
Clindamycin 20mg/kg (maximum
600mg) orally 1 h prior to dental
procedure
Children allergic to penicillin
Ampicillin 50mg /kg (maximum 2g)IV
or IM within 30 min before dental
procedure
Children not allergic to penicillin and
unable to take oral medications
Amoxicillin 50mg/kg (maximum 2g)
orally 1 hr prior to dental procedure
Children not allergic to penicillin

Under L.A
Amoxicillin 3 gm/kg or clindamycin 600mg 1 hr
pre- operatively and amoxicillin 1gm after 6 hr
Under G.A
Amoxicillin 0.5 gm IM after 6 hr or 3 gm 4 hr + 1 gm
probencid post-operatively.
(OR)
Clarithromycin 500mg or azithromycin 2 gm 6 hr post-
operatively.
Surgical prophylaxis

MISUSE OF ANTIBIOTICS
Treatment of Nonresponsive Infections
Therapy of Fever of Unknown Origin
Improper Dosage
Inappropriate Reliability on Chemotherapy alone
Lack of Adequate Bacteriological Information
Antibioma
82

Drug Interactions in Clinical
Dentistry
83

Antibiotics Interacting drug Effect and
Recommendation
Penicillin V, ampicillin,
Cephalexin, Vancomycin
Bacteriostatic antibiotics
(erythromycin, tetracyclines,
clindamycin)
Bacteriostatic antibiotic
interferes with action of
bactercidial antibiotic
Penicillin V, ampicillin
Tetracycline
Oral Contraceptives Decrease the activity of oral
contraceptive drug
Ampicillin Allopurinol High incidence of skin rash
substitute amoxicillin for
ampicillin
Erythromycin Carbamazipine,
cyclosporine, warfarin
Erythromycin interferes with
metabolism of these drugs
Metronidazole Alcohol Disulfiram like effect
Erythromycin, tetracyclines Bactericidal antibiotics
(penicillins, Cephalosporins)
Action of bactericidal agent
inhibited.
Doxycycline
Barbiturates, alcohol,
phenytoin, carbamazepine
Hepatic clearance of Doxy is
increased. Adjust dose
upward or use alternative
tetracycline

1% to 15% of drug causes
Majority iatrogenic
illnesses
85
Non-immunologic (90-95%):
Side effects, toxic reactions, drug
interactions, secondary or indirect
effects (e.g. opiate reactions, NSAID
reactions)
Immunologic (5-10%)
DRUG ALLERY
Factors influencing,
Route of administration:
Parenteral route more likely to cause
sensitization and anaphylaxis than oral route
Inhalational route: respiratory or conjunctival
manifestations only
Topical: high incidence of sensitization
Nature of the drug :
80% of allergic drug reactions due to:
- penicillin
- cephalosporins
- sulphonamides
- NSAIDs

Overdose
Drug toxicity
– Hepatotoxicity
– Nephrotoxicity
– Iatrogenic diseases
– Skin reactions
– Teratogenic effects

Coombs and Gel reactions
Type 1: Immediate Hypersensitivity
 IgE-mediated
 occurs within minutes to 4-6 hours of
drug exposure
Type 2: Cytotoxic reactions
 antibody-drug interaction on the cell
surface results in destruction of the cell
 eg. hemolytic anemia due to penicillin,
quinidine, cephalosporins.

Type 3: Serum sickness
 Fever, rash (urticaria, angioedema,
palpable purpura, arthralgia,
lymphadenopathy, splenomaly
 onset: 2 days up to 4 weeks
 penicillin commonest cause
Type 4: Delayed type hypersensitivity
 sensitized to drug, or preservative (e.g.
PABA, parabens )

Penicillin Allergy
2% of penicillin causes
• Penicillin metabolites:
--95%: benzylpenicilloyl moiety
(“major determinant”)
--5%: benzyl penicillin G,
penicilloates
(“minor determinant”)
• Resolution of penicillin allergy
-- 50% resolution of allergy in 5 y
--- 80-90% resolution of allergy in 10 yr
If treatment is definitely required, administer an alternative non-penicillin antibiotic
(e.g. cephalosporin,vancomycin, gentamycin or non beta-lactam antibiotic). If a
penicillin is definitely indicated, proceed with therapy, treating mild reactions
symptomatically

Ampicillin rash
• non-immunologic rash
• maculopapular, non-pruritic
rash
• onsets 3 to 8 days during the
antibiotic course
• incidence: 5% to 9% of
ampicillin or amoxicillin
courses; 69% to 100% in those
with infectious mononucleosis
or acute lymphocytic leukemia

ANTIBIOTIC SENSITIVITY TESTING
• This test determines the effectiveness of antibiotics against
microorganisms (e.g., bacteria) that have been isolated from
cultures.
• Sensitivity analysis may be performed along with:
1. Blood culture
2. Urine culture (clean catch) or urine culture (catheterized
specimen)
3. Sputum culture
4. Throat culture
5. Wound and other cultures
• Why is the Test Performed?
The test shows which antibiotic drugs should be used to treat an
infection.

Broth dilution susceptability test
• uses a micro dilution plate
• quantitative results obtained.
Disc diffusion method
• qualitative susceptability result are obtained
Gradient diffusion test [ E- test]-
• qualitative susceptability results
obtained.
DETERMINATION OF ANTIBIOTIC SENSITIVITY

ANTIBIOTIC ALLERGY TESTS
•NO SINGLE TEST FOR ANTIBIOTIC ALLERGY.
•Except Penicillin, immunoreactive drug metabolites rarely identified.
IgE-mediated hypersensitivity.
SKIN TESTING -
•Intradermal skin testing is difficult to do in children under 10 years of
age.
•Most non-pruritic maculopapular rashes can not be predicted by skin
testing.

Cross reactivity
1. Semi synthetic penicillins (ticarcillin and piperacillin) has same nucleus
as penicillin G.
2. Cephalosporins share a common beta-lactam ring with the penicillins
hence cross-reactivity is quite low.
3. 3-7% of those with penicillin allergy show allergic reactions to
cephalosporins as well.
4. Monobactams (aztreonam) safely administered to penicillin allergic
subjects.
5. Carbapenems (imipenem) can be given to penicillin-allergic patients.
ASCIA HPIP Antibiotic allergy 2014

TOXICEFFECTSOF ANTIBIOTIC
Some antibiotic kill / injure human cells
Aminoglycosides
Renal urinary system
Erythromycin Pseudomembranous colitis
DiarrhoeaClindamycin
HepatitisTetracycline
Gastrointestinal system
VertigoVancomycin
Myoclonic seizuresPenicillin and cephalosporin
VertigoGentamicin
DeafnessTobramycin
Nervous system
Carbpenicillin (and ticarcillin)
Grey baby syndromeChloramphenicol
Hematologic
" PROBLEM" ANTIBIOTIC
Renal tubular necrosis
Decreased platelet aggregation

Common reasons for antibiotic failure
 Failure to surgically eradicate the source of the infection.
 Too low blood antibiotic concentration.
 Inability of the antibiotic to penetrate to the site of infection.
 Impaired/inadequate host deafness.
 Inappropriate choice of antibiotic.
 Limited vascularity or blood flow.
 Decreased tissue pH or oxygen tension.
 Emergence of antibiotic resistance.
 Delay in diagnosis.
 Incorrect diagnosis.
 Antibiotic antagonism.

CONCLUSION
“Microbes will leave us alone; if we leave them alone”
Use of antimicrobials have to be reduced to the level
where they are necessary for our survival & not
merely for Dr & patient comfort.
97

98
“WITH ANTIBIOTICS, NO PERSON IS
AN ISLAND”

List of references:
1.N.D.Tripathi, Essentials of medical pharmacology,7th edition 2001
: 123-34.
2. R.S.Sathoskar, S.D.Bhandarkar and S.S.Ainipune, Antibiotics,
Textbook of pharmacology and pharmacotheraphy, 2nd edition 1999
123-36.
3. lippincotts textbook of pharmacology:
4.Chaudhuri, Antimicrobial agents, Textbook of Quintessae of medical
pharmacology, 1st edition 2001:67-89.
5.Bowmagarten,Torabimajed, etal, Journal of Endodontics, vol 1,2004
page no. 45-52
6.In Search For Endodontic Pathogens:Suchitra U, KUNDABALA M,
Shenoy MM- KUMJ 2006, Vol4,No4,Issue 16,525-529
7. Antibiotic Prophylaxis in dentistry:A Review & Practice
recommendations-JADA Vol 131 March 2000 366-374

8. Infective Endocarditis, dentistry, and antibiotic prophylaxis; time for a
rethink? (BDJ, Dec 2000, Vol 189,No 11, page 610-616)
9. Antibiotic resistance in general dental practice—a cause for concern?
Journal of Antimicrobial Chemotherapy (2004) 53, 567–576
10.Text book of Pediatric Dentistry; S.G Damle, 3rd Edition.
11.Textbook of pediatric dentistry ; Pinkham
12.Textbook of pediatric dentistry ; Nelson’s - Volume 1
13.Textbook of Oral & Maxillofacial Surgery; Neelima Malik, 1st Edition.
14.Pediatric Dental Medicine : Donald J. Forrester
100

 INTRODUCTION
 DEFINITION
 PAIN IN DENTISTRY
 ANALGESICS
 INTRODUCTION
 CLASSIFICATION
 SELECTION OF ANALGESICS
 ASPIRIN
 IBUPROFEN
 PARACETAMOL
 COXIBS
 COMBINATION ANALGESICS
 DRUG INTERACTION OF NSAIDS
 PG SYNTHESIS----BENEFICIARY ASPECTS, INHIBITORY ASPECTS
 ANALGESIC USE IN PREGNANCY AND LACTATION
 LIMITATION OF NSAIDS

 OPIODS
 HISTORY
 CLASSIFICATION
 MECHANISM OF ACTION
 MORPHINE
 CODIENE
 PROPOXYPHENE
 OPIOD USES IN PULPAL ORIGIN
 DRUG INTERACTIONS OF OPIODS
 OPIOD DOSAGE
 WITHDRAWAL SYMPTOMS
 SIDE EFFECTS
 COMBINATION ANALGESICS
 OTHER DRUGS WITH ANALGESIC EFFECT
STERIODS
 PAIN CONTROL STRATEGY
 CONCLUSION
 PRINCIPLES OF PRESCRIPTION WRITING
 REFERENCES

Pain plays a major role specially in
treating kids.
Poorly controlled pain contributes to
anxiety among the pediatric patient
about future treatment.
Hence, effective control of pain
management is recommended which
instills in patients a better confidence
towards the doctor.

• Pain (algesia) is an
unpleasant sensory and
emotional experience
associated with actual or
potential tissue damage, or
described in terms of such
damage (IASP)
• Odontogenic pain is caused
by physical stimuli or the
release of inflammatory
mediators

 Chronic inflammation
 Bacterial by-products,
 Influx of immune cells and activation of the
cytokine network and
 Other inflammatory mediators .
Teeth are innervated by Aδ and C neurons and the dual
mechanism operating through Aδ processes most likely
operates in the trigeminal nuclei. However, there is
often branching of peripheral nerve processes to
adjacent teeth and considerable convergence of primary
sensory neurons on to thalamic projection neurons in
the trigeminal sensory nuclear complex .
DENTAL PAIN

DEFINITION:
A drug that selectively relieves pain by acting
on the CNS or on peripheral pain mechanisms,
without significantly altering consciousness.
• Analgesics are common pain relievers.
• Many analgesics have anti-pyretic property and anti-inflammatory
properties

CLASSIFICATION
Non-opioid analgesics(NSAIDS) Opioid analgesics
Non-selective
COX Inhibitors
Preferential
COX-2
Inhibitors
Selective
COX-2
Inhibitors
Analgesic –antipyretics
with poor
antiinflammatory
Action
Natural opioids Semi-synthetic
opioids
Synthetic opioids

How does one select the most effective analgesic?
 Severity of pain
 Past history of pain
 Any analgesic regimen should include a non-opioid
drug even if pain is severe enough to require the
addition of an opioid
 Pharmacologic management of mild to moderate
dental and orofacial pain should begin with a non-
opioid analgesic

 Inhibition of one or more components of the
inflammatory response.
 Differ from the opioids in that there is a
on their analgesic response.

Non-selective COX
Inhibitors
Preferential
COX 2
Inhibitors
Selective COX
2 Inhibitors
Analgesic -antipyretic
but poor
Anti-inflammatory
Salicylates : Aspirin
Pyrazolone Derivatives:
Phenylbutazone
Indole derivatives : Indomethacin
Propionic acid derivatives :
Ibuprofen, Naproxen
Anthranilic acid Derivative:
Mefenamic acid
Aryl Acetic acid Derivative :
Diclofenac
Oxicams : Piroxicam
Pyrole pyrole derivative: Ketorolac
Nimesulide
Meloxicam
Nabumetone
1.Phenol derivative
Acetaminophen
(Paracetamol)
2.Pyrazolone
Derivative
(Dipyrone)
Celecoxib
Rofecoxib
Valdecoxib

 salicylic acid, Inhibits COX irreversibly
 Prevention of prostaglandin mediated
sensitization
 Analgesic dose – 600 mg t.i.d.
• Inhibits platelet aggregation
• Induces asthma by inhibition of prostaglandin
• Hypersensitivity - salicylism
• Aspirin use in children has declined since the
1970’s after reports of its association with
Reye’s hepatic encephalopathy (Reye’s
syndrome).
Precaution
• Avoided in diabetics, heart
failure and pregnant
• Contraindicated with oral anti
coagulants(warfarin)
• stop 1 week before elective
surgery
Uses
 Analgesic, anti-pyretic and
anti-inflammatory
 First drug to be used in acute
rheumatic fever and arthritis
 Local application as a
keratolytic, fungistatic and
anti-septic.

Ibuprofen
• Ibuprofen is used as an anti-pyretic in pediatric
practice
• Better tolerated alternative to aspirin
Side effects:
 Milder than aspirin,
 Should be avoided in patients who have:
asthma, bleeding disorders, gastric ulcers, or
surgical bleeding.
C/I – pregnancy, peptic ulcer
Dose – 400 – 800 mg tds
 Rated as the safest conventional NSAID by the
adverse drug reaction reporting system (U.K.)
 Ibuprofen , the primary
NSAID used in pediatrics, is
well tolerated even after
over-dose.
 Ibuprofen also modestly
suppresses swelling after
surgical procedure
 This provides additional
therapeutic advantage
without the potential
liabilities of using steroids.
 This makes ibuprofen the
drug of choice for
controlling pain in most
patients.

INDOMETHACIN
 Potent anti-inflammatory drug
with prompt antipyretic action
 Used in conditions requiring
prominent anti-inflammatory
actions
 Prominent adverse effects on
CNS and gastrointestine.
 25-50 mg /qid
 Used in post-operative
inflammatory conditions
 Side effects:
Epigastric pain, nausea,
headache, Gastric ulceration and
bleeding especially when combined
with misoprostol.
 Dosage :
50 mg 8 hrly

PARACETAMOL ( ACETAMINOPHEN)
 One of the most commonly used drug
 Prominent antipyretic effect
 Central analgesic action
 Weak peripheral anti-inflammatory
component
 Poor ability to inhibit COX in presence of
peroxides
 Children ≤ 44kg:
10-15mg/kg every 4-6 hours max = 2.6 g/day
 Supplied as :
Drops:80mg/0.8ml calibrated dropper
Suspension:160mg/5ml
Chewable tabs:80mg/tabs
Tablets: 325mg - 500mg
 In contrast to aspirin,
paracetamol does not stimulate
respiration and has insignificant
gastric irritation
 Paracetamol does not affect
platelet function or clotting
factors
 Acetaminophen overdose occurs
after ingesting as little as 120
mg/kg, and should be treated
with NAC (N-acetylcysteine) at a
dose of 70 mg/kg every 4 hours,
as early as possible

1st Generation
 Celecoxib
 Rofecoxib
2nd Generation
 Valdecoxib/ Parecoxib
 Etoricoxib
 Lumaricoxib
Uses of COX Inhibitiors
COX-2
Reduce
inflammation
Reduce pain
Reduce
fever
NSAIDs : anti-platelet—decreases ability of blood to clot

1. Multiple sites of action targets
multiple pain pathways
2. Potentially synergistic effect
Eg:
• Aspirin + acetaminophen
• Ibuprofen + acetaminophen
• Caffeine + acetaminophen
• Ibuprofen + caffeine
• NSAIDs/acetaminophen +
opioids
• Analgesic + sedative

Toxicities due to PG synthesis inhibition
• Analgesia.
• Antipyresis.
• Anti-inflammatory.
• Anti-thrombotic.
121
1. Gastric mucosal damage.
2. Bleeding: inhibition of platelet function.
3. Limitation of renal blood flow.
4. Delay / Prolongation of labour.
5. Premature ductus arteriosus closure.
6. Asthma & anaphylactoid reactions in
susceptible individuals.
Beneficiary actions due to PG
synthesis inhibition

Limitations of NSAIDs
 Delayed onset of orally administered NSAID
 Inability to relieve severe pain consistently
 Apparent lack of effectiveness when given repeatedly for chronic
pain.
 Most NSAIDs commonly used in dentistry have gastric irritation and
inhibition of platelet aggregation as adverse effects.

Obtained from Papaver
somniferum .
• Opiod is the term used for drugs with
“morphine-like” reactions.
• They were earlier called as narcotic analgesics

Natural
opium
alkaloids
• Morphine
• Codeine
Semi-
synthetic
opiates
• Heroin
(diacetyl
morphine)
• Pholcodeine
Synthetic
opioids
• Pethidine,
Fentanyl,
Methadone
• Dextro
propoxyphene,
Tramadol

Mechanism Of Action of Opioids
125

MORPHINE
• Specific depressant and
stimulant in CNS
• Poorly localized visceral pain
relieved better than sharply
defined somatic pain
• Depresses respiratory centers
• High first pass metabolism
• Plasma t1/2 → 2-3 hrs.
• Doses – 10 -15 mg. i.m./s.c.
• Morphine abuse is higher
among medical and
paramedical personnel.
• Side effects – sedation,
constipation, respiratory
depression
Antidote – Naloxone 0.4-0.8 mg
i.v. repeated every 2-3 mins

Therapeutic uses :Mood and subjective effects
 “Euphoric” /anxiolytic for
patients in pain.
 Morphine has a “Calming”
effect- loss of apprehension,
feeling of detachment, lack
of initiative, mental crowding
and inability to
concentrate.
 Analgesia
 Opioids induce sleep – can
be used to supplement the
sleep inducing properties of
benzodiazepines
 Treatment of diarrhoea.
 Relief of cough.

CODEINE
 Less potent than morphine
 Codeine is metabolized in part to
morphine, which is believed to account
for its analgesic effect
 Used for mild to moderate pain and for
antitussive effects
 60 mg codeine ≥ 600 mg aspirin
 side effect – constipation
 Abuse liability is lower than that of
morphine
 Can be taken for relatively longer period
of time as less risk of physical
dependence
PROPOXYPHENE
• Half as potent as codeine
• Abuse liability is lower than
codeine
• Combination with aspirin and
paracetamol is supra-additive
• Doses – 60-120 mg t.i.d
Codeine + acetaminophen commonly used for relieving pain of pulpal origin

Exaggerated fear of “addicting” patients
exists
Physical dependance on opioids are a
consequence of long term medical use
Such long term use is not prevalent for
managing pain of pulpal origin.

 Opioid + CNS depressant supra-additive
 Opioid + phenothiazine increased respiratory depression
 Tricyclic antidepressant + opioid increased hypotension
 Local anaesthetic + opioid safe ( however large doses have
supra-additive effect)

Withdrawal Reactions
Acute Action
• Analgesia
• Respiratory Depression
• Euphoria
• Relaxation and sleep
• Tranquilization
• Decreased blood pressure
• Constipation
• Pupillary constriction
• Hypothermia
• Drying of secretions
• Reduced sex drive
• Flushed and warm skin
Withdrawl Sign
• Pain and irritability
• Hyperventilation
• Dysphoria and depression
• Restlessness and insomnia
• Fearfulness and hostility
• Increased blood pressure
• Diarrhoea
• Pupillary dilation
• Hyperthermia
• Lacrimation, runny nose
• Spontaneous ejaculation
• Chilliness and “gooseflesh”

Side Effects of opiods
Short term
• Dulling of Pain
• Euphoria
• Slow Nervous system
• Slowed heart rate
• Loss of cough reflex
• Nausea
• Overdoses can lead to death
• Possibility of stroke
• Overall slowdown of
biological systems
Long Term
• Addiction and very strong
withdrawal effects
• Constipation
• Loss of libido
• Disruptions in menstruation
• “Cross-tolerance”
• Loss of appetite
• Problems associated with
buying street drugs i.e.
sharing needles AIDS and
prostitution.

OTHER DRUGS WITH ANALGESIC EFFECT
134

• Corticosteroids comprise
glucocorticoids and mineral corticoids
• The adrenal cortex produces
approximately 10mg/day of cortisol in
the non-stressed adult Under severe
stress, this level may be increased more
than 10 fold
MOA of steroids:
 interfere in arachidonic acid
metabolism
 a decrease in the release of
vasoactive and chemo
attractive factors,
 Decrease the secretion of
lipolytic and proteolytic
enzymes,
 decreased extravasation of
leukocytes to areas of tissue
injury,
Thus, the pharmacological effects of glucocorticoids oppose many of the
inflammatory processes that are known to occur during periapical
inflammation
STERIODS

Glucocorticoids have been used
1. as a pulp-capping agent ,
2. as an intracanal medicament
either alone or in combination
with antibiotics and systemically
as a means to decrease pain
and inflammation
C/I - Peptic ulcer,
Heart disease,
Diabetes,
Osteoporosis,
Glaucoma
• If a systemic steroid is to be
administered, an intra-oral IM
injection or an intraosseous
injection would be preferable over
an extra-oral IM injection
• A dose of 6–8mg of
dexamethasone or 40mg of
methylprednisolone has been used
• If an oral route is chosen 48mg
methylprednisolone/day for 3days
and followed by 10–12mg
dexamethasone/day for 3 days
should provide significant post
treatment pain relief

Procedure/condition Initial choice If severe
i. Apical periodontitis
ii. Canal debridement
iii. Overfilling/incomplete
debridement
Aspirin or other NSAID
Eg. Ibuprofen 200-400mg
or
Diclofenac sodium 50mg
NSAIDs
iv. Periapical or
amputational surgery
with minimal trauma
Aspirin or other NSAIDs
or
NSAIDs
Ibuprofen or diclofenac sodium
600-800mg 50-75mg
or
valdecoxib 40 mg
v. Extensive surgery with
considerable trauma
Aspirin or other NSAID
or
Preferably pre-op loading
dose
NSAIDs
600-800mg 50-75mg
or
valdecoxib 40 mg
Suggested analgesics for endodontic procedures/conditions
400-600mg 50-75mg
or
valdecoxib 20-40 mg

During InterventionPreoperative
Pain
Post-Operative
PAIN CONTROL STRATEGY
138
 Oral Sedation
 Preoperative
Analgesics
• IV Sedation
• Nitrous Oxide
• Local Anesthesia
• Analgesic Prescription
• Opioids
• Non-opioids

Anti-inflammatory drug
Chymoral :
Anti-inflammatory drugs
Mucolytic (breaks down bronchial secretion)
Anti-exudate (reduces swelling)
 Used as an adjuvant for oro-dental infections in children
 Should be taken only on empty stomach or 1hr bfr meal
 Administered by oral route
 Dosage: 5-12 yrs  1 gastro-resistant tablet t.i.d
 Recommended dose given 48 hrs before surgery
 No known clinically significant interactions
 Side effects: very rarely GI upset and allergic
manifestations

Better understanding of pulpal pain
mechanism and pharmacotherapy of pain
enables the pedodontist to manage
different pain conditions effectively, thus,
reducing public dental phobia in children

Prescription includes,
•Superscription- Date, the name, address and age of the patient; and the
symbol Rx
•Inscription - body of the prescription, containing the name and amount or
strength of each ingredient.
•Subscription - The directions to the pharmacist, usually consisting of a short
sentence such as: "make a solution,“
"mix and place into 10 capsules,"
"dispense 10 tablets."
•Signatura- From the Latin "signa,“, contains the directions to the patient
"take as directed”/ “avoided”.
•Doctor’s signature

Table 1. Common Terms and Abbreviations
Term or Phrase Abbreviation Meaning
ante cibos a.c. before meals
aqua aq. water
bis in die b.i.d. twice a day
cum aqua cum aq. with water
dispensa disp. dispense
et et and
gutta, guttae gtt. drop, drops
hora somni h.s. at bedtime
misce m. mix
non repetatur non. rep. do not repeat

omni die o.d. daily
omni mane o.m. every morning
omni nocte o.n. every night
per os p.o. by mouth
placebo placebo to please
post cibos p.c. after meals
quantum sufficiat q.s. sufficient quantity
quater in die q.i.d. four times a day
recipe Rx take
si opus sit s.o.s. if necessary
ter in die t.i.d. three times a day
trochiscus, torchisci troch. lozenge, lozenges
unguentum ungt. ointment
ut dictum ut dict. as directed

 Pharmacology and Therapeutics in Dentistry;
Yagiela, Dowd, Niedle; 5th edition
 Endodontics John I Ingle Leif K Balkland: 5th
Edition
 Endodontics John I Ingle Leif K Balkland: 6th
Edition
 Essentials of Medical Pharmacology ; K.D.
Tripathi : 5th edition
 Katzung basic and clinical Pharmacology; 9th
edition
 Pathways Of The pulp ,Stephen Cohen,Kenneth
M Hargreaves:9th edition

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