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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.
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
Young’s formula
Age of child / age + 12 = child’s dose
Dilling’s formula
Age of child/20 x adult dose = child’s dose
ANLAGESICS USED IN PEDIATRIC DENTISTRY
ANLAGESICS USED IN PEDIATRIC DENTISTRY
Management of dental pain in pediatric patients is important
Drugs prescribed to relive pain are called analgesics
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 .
CLASSIFICATION
Centrally acting( narcotic)
Peripherally acting (non narcotic)
CENTRALLY ACTING
More effective against acute pain
More adverse effects
No anti inflammatory or antipyretic effects
NON NARCOTIC ANALGESICS Mild to moderate pain
Site of action peripheral nerve endings
Less drug toxicity
Absence of drug dependency
Drugs in this class include
• Acetaminophen,
• Aspirin
• Non-steroidal anti-inflammatory drugs (NSAIDS)
ACETAMINOPHEN Antipyretic
Mild analgesic
Administer Per oral or Per rectal
Pediatric Oral dose 10-15 mg/kg/dose every 4 hr
Infant dose is 10-15 mg/kg/dose every 6-8 hr
Adult dose 650 mg-1000 mg/dose
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
•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
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
IBUPROFEN Propionic acid derivative
Used in rheumatoid arthritis , osteoarthritis
Indicated in soft tissue injuries , tooth extraction, fractures, vasectomy
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
Side effects Gastric irritation, nausea , vomiting ,
CNS sideeffects : head ache , tinnitus ,depression
Rashes itching , hypersensitivity
Aspirin induced asthma
NAPROXEM Another drug of propionic acid family
Same action that of ibuprofen
More anti inflammatory action
Molecular structure different
Combination therapy Ibuprofen and paracetomol
Diclofenac and paracetomol
Nimesulide and paracetomol
Mefenamic acid and paracetomol
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
SIDE EFFECTS OF OPIOIDS All opioid have side effects that should be anticipated &
managed Respiratory depression
Nausea, vomiting
Constipation
Pruritis
Urinary retention
OPIOIDS
Codeine
Oxycodone
Morphine
Fentanyl
Hydromorphone
Methadone
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
Recent opoid analgesics Alfentanil
Remifentanil
Tramadol
ALFENTANIL AND RAMIFENTANIL Rapid onset
Metabolized in liver
Half life is 1 to 2 hr
Uses : short painful procedures,
Ramifentanil for long neurosurgical procedures
COMMERCIAL NAMES Alfenta
Ultiva
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
CONTRAINDICATIONS
Respiratory depression
Acute attack of asthma
Head injury
Raised intracranial pressure
COMMERCIAL NAMES Contramal
Contraal DT
Dolomed
Dolotram
ANTIBIOTICS USED INPEDIATRIC DENTISTRY
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.
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
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.
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.
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.
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.
Classification Beta-lactam antibiotics
Macrolides, azalides, streptogramins, prystinamycines.
Linkozamides.
Tetracyclines.
Aminoglycosides.
Chloramphenicols.
Glycopeptides.
Cyclic polipeptides (polimixins).
Other antibiotics
The choice of antibiotic is influenced by a number of factors
Stage of infection development
medical conditions or allergy.
Antibiotics may also be categorized by their method of attack:
Bactericidal antibiotics
Bacteriostatic antibiotics
PENCILLIN
Beta-lactam antibiotic
Bactericidal against gram-positive cocci and the major microbes of mixed anaerobic infections.
Mechanism of penicillins action
They form complexes with enzymes - trans- and carboxypeptidases
(PCP), which control synthesis of peptidoglycan – component of cell-
wall of microorganisms
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.
Contraindications: Hypersensitivity to penicillin
Warnings/Precautions:
• Caution in patients with severe renal impairment (modify dosage)
• History of seizures
• Hypersensitivity to cephalosporins.
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
CLINDAMYCIN
Alternative choice in treating mild or early odontogenicinfection.
Broad spectrum of activity
Resistance to beta-lactamase degradation
It is not effective against mycoplasma or gram-negative aerobes..
Adverse effects :
• Abdominal pain
• Nausea
• Vomiting
• Diarrhea
Contraindications:
• Hypersensitivity to clindamycin
• Previous pseudomembranous colitis
• Regional enteritis,
• Ulcerative colitis.
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.
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.
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
Warnings/Precautions:
• Use with caution in patients with severe renal impairment (modify dosage)
• Low incidence of cross-allergy with other beta-lactamsand cephalosporins exists.
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.
Clavulanate potassium can be administered in conjunction with amoxicillin (Augmentin®).
Contraindications: Hypersensitivity to amoxicillin, clavulanic acid, penicillin or any history of hepatic dysfunction.
Warnings/Precautions:
• Prolonged use may result in superinfection.
• Use with caution in patients with severe renal
impairment
• Incidence of diarrhea
The usual daily oral dose of Augmentin® for treating odontogenicinfections 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.
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.
Cefazolin
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 odontogenicinfections.
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
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.
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.
Cefotaxime (C III)
Cefobid (Cefoperazone, C III)
Claphoran (cefotaxime, C III)
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
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.
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.
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
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
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
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
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