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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