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Drugs used in Pediatric Dentistry

Analgesics & Antibiotics

ANALGESICS

Classification of Analgesics

Analgesics can be broadly classified into:

Centrally acting(narcotic) and Peripherally acting (non-narcotic) analgesics

Centrally acting analgesics

These are more effective against acute pain, but have a greater incidence of adverse effects. They usually are administered parentally and are devoid of anti-inflammatory and antipyretic effects . Serious drug dependence and abuse liability has limited their use in pediatric dentistry .e.g., morphine, codeine, pethidine, methadone, dextro propxyphene.

Recent opioid Analgesics

1. Alfentanil2. Remifentanil3. Tramadol

Alfentanil & Remifentanil

Mechanism of action Rapid onset(within 1-1.5 mins) Metabolized in liver Half life is 1-2 hrs

Uses Short, painful procedures requiring intense analgesia

and blunting of stress responses. Remifentanil for longer neurosurgical procedures

where rapid emergence from anesthesia is important.

Commercial forms ALFENTA (Alfentanil) ULTIVA (Remifentanil

Tramadol Mechanism of action Weak against all types of opioid receptors with

some selectivity for µ receptors.

Uses Mild to moderate pre- and postoperative pain Severe acute or chronic pain, cancer

pain(sc,im,iv)

Dosage Adolescents over 14 yrs of age—single dose

100mg Maximum daily dose—400mg Children—1 to 1.5 mg/kg

Cont..Contraindications Respiratory depression Acute attack of asthma Head injury

Commercial Forms Contramal Dolomed Dolotram Tramol

Peripherally Acting Analgesics

These are less effective against severe and show a lower incidence of adverse effects. They are usually administered orally and are used chronic and low grade pain. Some possess anti-inflammatory and anti-pyretic effects. They are frequently combined with other drugs.

Their low drugs dependence abuse liability has increased scope in pediatric dentistry, e.g., ibuprofen,diclofenac,nimesulide,paracetamol

Combination Therapy for Pain

The combination of two analgesic drugs which produce analgesia by different mechanisms(central vs. peripheral)might be expected to produce additive effects. This may not be true for analgesia acting by the same mechanisms.

The common combinations of analgesic drugs used in our practice are:

• Ibuprofen and paracetamol• Diclofenac sodium and paracetamol• Nimesulide and paracetamol• Mefenamic acid and paracetamol

New Approaches to Analgesics

• Enkephalinase inhibitors such as thiorphan and experimental drug RB 120 act by inhibiting metabolic degradation of endogenous opioid peptides. It has morphine-like effects without causing dependence.

• Various neuropeptides, such as somatostatin and calcitonin produce powerful analgesia when applied intrathecally.

• Non-peptide antagonist of substance P, have recently been developed and may prove to be useful analgesic drug.

• Adenosine analogues and adenosine kinase inhibitors,• Agonist at nicotinic acetylcholine based on epibatidine.• Transplantation of enkephalin-secreting adrenal medulla

into spinal canal.

Antibiotic Therapy for children

• No aspect of pharmacology is more widely misunderstood or improperly applied than the antibiotic therapy for children. The following review should improve the art and science of drug therapy in situations of infections in children.

• The rationale for choice and use of antibiotics begins with review of likely microorganisms responsible for common orofacial infections

Development of oral Microflora

• Oral cavity is usually sterile at birth.• Number of microorganisms increase following 6 to 8hrs after birth.• At 12 months of age, most children have the following microorganisms in their oral

cavity.

• Streptococcus a) S. salivaris is the first oral streptococcus. b) S. mutans ands S. sanguis are not established until teeth erupt in the oral cavity . c) S. mutans disappears when a full mouth extraction is done and again reappears

with dentures along with following microorganisms. Staphylococcus Velionella Actinomyces Lactobacillus Norcadia Fusobacterium

• Preschool Age groupOral flora resembles that of an adult except that Bacteriodes melanogenics and

spirochetes are uncommon.

Principles of Antibiotic Therapy

• The principles of antibiotic therapy ensure that these agents are employed when indicated(presence of infection confirmed by clinical signs and symptoms and/or laboratory tests and antibiotic prophylaxis in a well-defined situation) and at optional usage(proper choice, dose and duration with a minimum attendant harm to the patient).

• Antibiotics do not cure the patient, but function to provide time for the normal host defenses, initially overwhelmed by microbes, to gain control and eliminate the infectious process.

a) Antibiotics are not a substitute for surgical drainage: the drainage of pus thus established, increases the efficacy of antibiotics in a particular case.

Antibiotic dosages for children are similar to those in adults(as adjusted by body weight).The exceptions, however, are the neonates who have reduced gastric acid, plasma protein binding ,blood flow to muscles ,renal and hepatic activity and body fat and increased extracellular fluid compared to older infants and adults. Hence, a lower antibiotic dosing is required in neonates.

Dose calculation by weight

• Manufacturer recommended doses are based on extensions trials and are usually indicated for the average, healthy adult makes of average weight and age. Thus age, sex, weight and chronic disease of the major organs of metabolism(liver) and excretions(kidney) may affect the usual safe and effective FDA approved dose recommendations. Creatinine clearance, peak and trough and symptomatic patient response are often used to titrate doses for a given, therapeutic effect.

• Dentists seldom treat infant, but doses for pediatric patient require an adjustment from usual adult dose, as determined by body surface area for calculating dosages:

1. CLARK’S RULE Child’s weight in lb x adult dose = child’s

dose 1502. YOUNG’S RULE: Age of child x adult dose = child’s dose Age+ 12

• Anders in 1992 Administration of the drug used on

infant’s weight is seldom appropriate.

Dosep = dosea x wt. pd wt. ad

But the surface rule is better which is

Dosep = dosea x wt. pd

wt. ad

o.7

Dosep = dose of childDosea = dose of adultWt. pd = weight of childWt. ad = weight of adult

Antibiotic Resistance• Sooner or later the

microorganisms may develop resistance to any antimicrobial agent. This could be attributed to either improper dose or duration. Thus, only practical method to delay or restrict microbial resistance would be limit the antibiotic use to proper indication, dosages and duration. Following the manufacturer’s instructions and/or physician’s instructions would reduce the chances of misuse and prolong or prevent antibiotic resistance

Antibiotic Prophylaxis

• It is the administration of antibiotics to the patients without the evidence of infection to prevent bacterial colonization, to reduce subsequent postoperative complications, e.g., antibiotic prophylaxis to prevent infective endocarditis. It is also required in case of immunosupressed patients with blood disorders, cancer chemotherapy and graft recipients.

Fluoroquinolones

Antibiotic prophylactic for infective endocarditis in

children

Patients at-risk from induced infections

Commonly used antibiotics in children

Cont…

Recent Advances in Antibiotics

• Fourth generation Cephalosporins Cephime Developed in 199o. Antibacterial spectrum similar to 3rd generation. Resistant to β-lacatamases Cepirome Recently marketed in India Used for treatment of serious hospital-based

infections Better penetration through gram-negative

bacteris Resistant to β-lactamases

Newer Macrolides

Roxithromycin• Semi-synthetic, long-acting ,acid-

stable with antimicrobial spectrum resembling erythromycin.

Indication• Respiratory infections• ENT infections• Skin and soft tissue infections• Genital tract infections

• Dosage• Adult- 150 mg BD• Children-2.5 to 5 mg/kg BD

• Commercial Forms• ROXID• ROXEM• ROXIBID• 150mg and 50 mg kid tablets

• Clarithromycin Antimicrobial spectrum erythromycin

• IndicationsFirst line drug in Mycobacterium avium complex in

AIDS patients.

• Dosage250 mg BD for 7 daysSevere cases 500mg BD for 14 days• Commercial FormsCLARIBIDCELEXCLARMAC

• AzithromycinAntibacterial spectrum expanded as compared to

erythromycin Active against H.influenzaeHigh activity on respiratory pathogensGood activity against Mycobacterium avium

complex in AIDS patients

• IndicationsPharyngitisTonsillitisSinusitisStaphylococcus and streptococcal skin and soft

tissue infections

• Dosage500 mg ODChild above 6 months 10mg/kg for 3

days

• Commercial namesZITHROMACAZITHRALAvailable as 100mg kids tablet .Should

be given 2 hours before meal.

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