Antibiotics & Analgesic in pediatric dentistry

1. GOOD
AFTERNON
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2. Antibiotics
And
Analgesic
In pediatric
Dentistry Hasanin alkendi
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3. ~~Hasanin ALkendi~~

4. 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.
Drug therapyshould extend at least 5 days
If discontinued prematurely, the surviving bacteria can
restart an infection that may be resistant to the original
antibiotic.
~~Hasanin ALkendi~~

5. 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
~~Hasanin ALkendi~~

6. 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”
DEFINITION
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7. Brief history of Antibiotics
1928
1932
1948
1952
1956
1962
1970
2000
Vancomycin-M.H.Cormick
Quinolone
Linezolide
Fluoroquinolones
Penicillin-Fleming
Sulphonamides -Erlich
Erythromycin - Mc. Guire
Cephalosporins-G.Brotzu
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8. Classification
Sulfonamides
:
Sulfadiazine,
Dapsone
Tetracyclines:
Tetracycline,
Doxycycline
Quinolones:
Norfloxacin,
Ciprofloxacin
β-lactam
antibiotics:
Penicillins,
Cephalosporins
Aminoglycosides:
Streptomycin,
Gentamicin
Macrolides:
Erythromycin,
Azithromycin
Nitrobenzene
derivatives:
Chloramphenicol
Nitroimidazoles:
Metronidazole,
Tinidazole
Lincosamide:
Clindamycin,
Lincomycin
Glycopeptides:
Vancomycin
Polyene antibiotics:
Nystatin,
Amphotericin-B
Based on chemical structure
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9. 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
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10. Based on their sites of action
and its mechanism
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11. * 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
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12. DURATION OF ANTIBIOTIC THERAPY
 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.
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13. 1-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.
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14. 2-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
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15. 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
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16. Classification
Penicillin
Natural Penicillin
Semi synthetic
Penicillin
β-lactamase
Inhibitors
Penicillin G (Benzyl Penicillin)
Penicillinase resistant penicillins:
Methicillin, Cloxacillin
Extended spectrum penicillin
Ampicillin, Amoxicillin, Carbenicillin,
Piperacillin
Acid resistant alternative to Penicillin G:
Phenoxymethyl penicillin
(Penicillin V)
Clavulanic acid,
Sulbactam
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17. 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.
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18. 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
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19. First
generation-
Second
generation-
Third
generation-
Fourth
generation-
Fifth
generation-
•Moreactive
against
gram+ve
organism
•Against
gram+ve
andgram
-veorganism
•Highlyactive
againstgram-
veorganisms
and
pseudomonas
•Similarto
third
generation
buthighly
effective
•Developed
inthelabto
specifically
target
resistant
strainsof
bacteria.
Cephalothin
Cephalexin
Cefadroxil
Cefuroxim
Cefoxitin
Cefaclor
Cefotaxime
Ceftizoxime
Ceftazidime
Cefixime
Cefepime
Cefpirome
Ceftobiprole
Ceftraroline
(bothact
againstMRSA)
CLASSIFICATION
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20. Erythromycin
• Used as an alternative to
penicillin in individuals who
are allergic to β-lactam
antibiotics.
Newer Macrolides:
• Roxithromycin
• Clarithromycin
• Azithromycin
Mechanism ofAction
2-Macrolides
• They have a large lactone ring
• They are alternative to penicillins in many conditions
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21. 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.
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22. 3-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.
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23.  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
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24. 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
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25. 5-Cotrimoxazole
Introduction
• Trimethoprim + Sulfamethaxazole
= Cotrimoxazole
• It has a synergistic bactericidal
action
• Greater antibacterial activity.
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26.  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
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27. 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.
~~Hasanin ALkendi~~

28. 6-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.~~Hasanin ALkendi~~

29. Uses:
• Chronic periodontitis:
Doxycycline 20mg bid daily for 2-4 weeks
• Traveller’s diarrhoea
• Acne treatment:
Tetracycline 250mg bid for 4 weeks
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30. 7-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 ~~Hasanin ALkendi~~

31. Resistance
 Decreased uptake of drug.
 An altered 30S ribosomal subunit
aminoglycoside binding site that has
a decreased affinity for the drug.
Adverse drug reactions
 Ototoxicy
 Nephrotoxicity
 Neuro muscular toxicity
 Plasmid associated synthesis of
enzymes that modify and inactivate
aminoglycosides.
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.
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32. 8-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.
~~Hasanin ALkendi~~

33. Adverse drug reactions
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.
infants).
 anaerobes.
vascular collapse or cardio
glucuronyl depending in
Antimicrobial Spectrum
Broad spectrum antibiotic.
Excellent activity against
Hypersensitivity
 Gray baby syndrome (due to
Maybe bacteriostatic and
bactericidal, transferaseupon
the concentration.
 Bone marrow depression
Drug of choice for typhoidContraindicated in infants~~Hasanin ALkendi~~

34. Problems that arise with the
use of antibiotics
Toxicity
-Local
-Systemic
Drug Resistance
-Natural
-Acquired
-Cross Resistance
Hypersensitivity
Reactions
Super infection
Masking of an infection
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35. ANTIBIOTIC RESISTANCE
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.
SirAlexander Flemming
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36. 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
~~Hasanin ALkendi~~

37. 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
~~Hasanin ALkendi~~

38. 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~~Hasanin ALkendi~~

39. 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 .
1 = apical foramen with delta; 2 = lateral
accessory canal; 3 = furcation accessory
canal; 4 = dentinal tubules.
~~Hasanin ALkendi~~

40. 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
~~Hasanin ALkendi~~

41. 



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:
Systemic involvement




Cavernous sinus thrombosis
Ludwig's angina
Mediastinal space swelling,
Brain abscess
~~Hasanin ALkendi~~

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

43. Antibiotics in oral and maxillofacial
management
Initial stage -
Aerobic bacteria
invade
Severe infection-
Aerobic and
anaerobic
bacteria invade
Advanced stage-
Anaerobic
infection
~~Hasanin ALkendi~~

44. 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
~~Hasanin ALkendi~~

45. 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]
~~Hasanin ALkendi~~

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

47. Drugs contraindicated in lactating mother :
 Metronidazole
 Tetracycline
 Sulfonamides
 Aminoglycosides
 Cotrimazole
Safe drug in lactating mother :
 Cephalexin
~~Hasanin ALkendi~~

48. ANTIBIOTIC
PROPHYLAXIS
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49. 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
~~Hasanin ALkendi~~

50. 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
~~Hasanin ALkendi~~

51. Childrennotallergictopenicillin Amoxicillin50mg/kg(maximum2g)
orally1hrpriortodentalprocedure
Childrennotallergictopenicillinand
unabletotakeoralmedications
Ampicillin50mg/kg(maximum2g)IV
orIMwithin30minbeforedental
procedure
Childrenallergictopenicillin Clindamycin20mg/kg(maximum
600mg)orally1hpriortodental
procedure
Childrenallergictopenicillinand
unabletotakeoralmedications
Clindamycin20mg/kg(maximum
600mg)IVorIMwithin30minbefore
dentalprocedure
THE AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
(AAPD)
Antibiotic prophylactic regimen JULY ,2015
~~Hasanin ALkendi~~

52. 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
~~Hasanin ALkendi~~

53. Drug Interactions in Clinical
Dentistry
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54. Antibiotics Interactingdrug Effectand
Recommendation
PenicillinV,ampicillin,
Cephalexin,Vancomycin
Bacteriostaticantibiotics
(erythromycin,tetracyclines,
clindamycin)
Bacteriostaticantibiotic
interfereswithactionof
bactercidialantibiotic
PenicillinV,ampicillin
Tetracycline
OralContraceptives Decreasetheactivityoforal
contraceptivedrug
Ampicillin Allopurinol Highincidenceofskinrash
substituteamoxicillinfor
ampicillin
Erythromycin Carbamazipine,
cyclosporine,warfarin
Erythromycininterfereswith
metabolismofthesedrugs
Metronidazole Alcohol Disulfiramlikeeffect
Erythromycin,tetracyclines Bactericidalantibiotics
(penicillins,Cephalosporins)
Actionofbactericidalagent
inhibited.
Doxycycline
Barbiturates, alcohol,
phenytoin, carbamazepine
Hepatic clearance of Doxy is
increased. Adjust dose
upward or use alternative
tetracycline
~~Hasanin ALkendi~~

55. Adverse drug reactions
1% to 15% of drug causes
Majority iatrogenic
illnesses
Immunologic (5-10%)
DRUG ALLERY
Non-immunologic (90-95%):
Side effects, toxic reactions, drug
interactions, secondary or indirect
effects (e.g. opiate reactions, NSAID
reactions)
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~~Hasanin ALkendi~~

56. Overdose
Drug toxicity
– Hepatotoxicity
–
–
–
–
Nephrotoxicity
Iatrogenic diseases
Skin reactions
Teratogenic effects
~~Hasanin ALkendi~~

57. 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
~~Hasanin ALkendi~~

58. 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.
~~Hasanin ALkendi~~

59. 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.
~~Hasanin ALkendi~~

60. 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
~~Hasanin ALkendi~~

61. 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.
~~Hasanin ALkendi~~

62. Pediatric dose
Pediatric
Dose
Pediatric
dose
Pediatric
Dose
=
=
=
=
Child's BSA in m2
1.73m2
child's age in months
150
child's age in years
child's age in years +
12 years
child's weight lb/(kg)
150lb/(70kg)
x Adult
Dosage
x Adult Dose
x Adult Dose
x Adult Dose
Nomogram Method
Fried's Rule
Young's Rule
Clarks Rule
~~Hasanin ALkendi~~
Pediatric dosage formulas

63. 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
~~Hasanin ALkendi~~

64. 



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
~~Hasanin ALkendi~~

65. 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
Antibiotics with specification
~~Hasanin ALkendi~~

66. List of references:
1.N.D.Tripathi, Essentials of medical pharmacology,7th edition 2011
: 123.
2. R.S.Sathoskar, S.D.Bhandarkar and S.S.Ainipune, Antibiotics,
Textbook of pharmacology and pharmacotheraphy, 2nd edition 2000
123-36.
3. lippincotts textbook of pharmacology:
4.Chaudhuri, Antimicrobial agents, Textbook of Quintessae of medical
pharmacology, 1st edition 2001:67-89.
5. Antibiotic Prophylaxis in dentistry:A Review & Practice
recommendations-JADA Vol 131 March 2000 366-374
~~Hasanin ALkendi~~

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

68. ~~Hasanin ALkendi~~

69. 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.
Introduction
~~Hasanin ALkendi~~

70. Definition
• 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 ~~Hasanin ALkendi~~

71.  Chronic inflammation
 Bacterial by-products,
 Influx of immune cells and activation of the
cytokine network and
 Other inflammatory mediators .
DENTAL PAIN
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 .
~~Hasanin ALkendi~~

72. 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
~~Hasanin ALkendi~~

73. 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
Syntheticopioids
~~Hasanin ALkendi~~

74. 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
~~Hasanin ALkendi~~

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

76. Non-selective COX
Inhibitors
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
Preferential
COX 2
Inhibitors
Nimesulide
Meloxicam
Nabumetone
Analgesic -antipyretic
but poor
Anti-inflammatory
1.Phenol derivative
Acetaminophen
(Paracetamol)
2.Pyrazolone
Derivative
(Dipyrone)
Selective COX
2 Inhibitors
Celecoxib
Rofecoxib
Valdecoxib
~~Hasanin ALkendi~~

77. Uses
 salicylic acid, Inhibits COX irreversibly
 Prevention of prostaglandin mediated
sensitization
 Analgesic dose – 600 mg t.i.d.
•
•
•
• 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
Inhibits platelet aggregation
Induces asthma by inhibition of prostaglandin  Analgesic, anti-pyretic and
Hypersensitivity - salicylism anti-inflammatory
 First drug to be used in acute
rheumatic fever and arthritis
 Local application as a
keratolytic, fungistatic and
anti-septic.~~Hasanin ALkendi~~

78. 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.~~Hasanin ALkendi~~

79. 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
~~Hasanin ALkendi~~

80. 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
~~Hasanin ALkendi~~

81. 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
COX-1
Gastric
ulcers
Bleeding
Acute renal
failure
~~Hasanin ALkendi~~
COXIBS

82. 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
***But different
in mechanism**
~~Hasanin ALkendi~~

83. Drug interactions of NSAIDs
~~Hasanin ALkendi~~

84. Toxicities due to PG synthesis inhibition
•
•
•
•
Analgesia.
Antipyresis.
Anti-inflammatory.
Anti-thrombotic.
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
~~Hasanin ALkendi~~

85. 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.
~~Hasanin ALkendi~~

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

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

88. Mechanism Of Action of Opioids
~~Hasanin ALkendi~~

89. 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
~~Hasanin ALkendi~~

90. 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.
~~Hasanin ALkendi~~

91. 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
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
 Can be taken for relatively longer period
of time as less risk of physical
dependence
Codeine + acetaminophen commonly used for relieving pain of pulpal origin
~~Hasanin ALkendi~~

92. ~~Hasanin ALkendi~~

93. 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.
~~Hasanin ALkendi~~

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

95. 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”
~~Hasanin ALkendi~~

96. 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.
~~Hasanin ALkendi~~

97. OTHER DRUGS WITH ANALGESIC EFFECT
~~Hasanin ALkendi~~

98. •
•
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




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 MOA of steroids:
~~Hasanin ALkendi~~

99. Glucocorticoids have been used
1.
2.
as a pulp-capping agent ,
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
~~Hasanin ALkendi~~

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

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

102. 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
~~Hasanin ALkendi~~

103. 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
~~Hasanin ALkendi~~

104.  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
~~Hasanin ALkendi~~

105. * Paediatric drug therapy and immunization by
RK Suneja.
* Textbook of paediatric dentistry by Braham and
Morris.
* Text book of paediatric dentistry by Shobha
Tandon.
~~Hasanin ALkendi~~

106. THANK YOU
~~Hasanin ALkendi~~