COMMONLY USED ANALGESICS AND ANITBIOTICS IN

PAEDIATRIC DENTISTRY-BY MAHAK RALLI

ROL NO. 41THIRD YEAR BDS

The most common clinical situations in dentistry amenable to drug therapy in children are pain and infection.

Drug control is vital to all phases of dentistry and a thorough knowledge of the art and science of analgesic therapy is essential for proper patient care.

In management of dental pain in paedriatic patient has lagged markedly behind than that in the adult patient resulting from misconceptions regarding the existence of pain sensation and its tolerance in children.

INTRODUCTION TO ANALGESICS

They have higher tolerance to pain Pain perception is low because of

immunologic immaturity Little or no memory of a painful experience They are more sensitive to side effects of

analgesics There is special risk for addiction to

narcotics

Concepts about pain in children

Most of the dental pain is associated with inflammation.

Hence, it responds well to drugs with anti-infammatory components

A good understanding of pain reaction and pain perception is required for proper pain management.

Pain is objective and measurable, initiated by physical and chemical stimuli.

Pain perception may be similar in all patients.

Origin and perception of pain

In contrast to pain perception, pain reaction depends upon learned experience, ethnic background, emotional status and presence of fear and anxiety.

Pain reaction

Analgesics can be broadly classified into-

I. Centrally acting (narcotic) analgesics eg. Morphine, codeine, pethidine.

II. Peripherally acting (non-narcotic) analgesicseg. Diclofenac, paracetamol.

III. Topical analgesicseg. Ethyl aminobenzoate

CLASSIFICATION OF ANALGESICS

These are the most effective against acute pain, but have a greater incidence of adverse effects

They are administered parenterally and are devoid of anti-inflammatory and anti-pyretic effects.

Serious drug dependence and abuse liability has limited their use in paedriatic dentistry, eg, morphine, codeine, pethedine, methadone, dextro propoxyphene.

Centrally acting analgesics

Less effective against sever pain, lower incidence of adverse effects

Administered orally and used for chronic lower grade of pain

Some possess anti-inflammatory and anti-pyretic effect

Frequently combined with other drugs Low drug-dependance and abuse liability has

increased the scope in paedriatic dentistry Eg- ibuprofen, diclofenac, paracetamol,

nimesulide

Peripherally acting analgesics

These are used to reduced soft tissue pain associated with local anesthetic administration and in management of gum pain during teething and other soft tissue irritation.

Available in as gels, liquids, ointments, patch and pressurized spray form.

Smallest effective amount is used for children to avoid anesthetizing the pharyngeal tissues.

Eg. : ethyl aminobenzoate (benzocaine- an ester local anesthetic)

Topical analgesics

Dosage Children <12 yrs : 4-10mg/kg/dose every 6-8 hours (max daily dose – 40mg/kg/day)

Children >12yrs and adults : 200-400mg every 6 hrs (max daily dose – 1.2g/day)

Advantages Anti-inflammatory, good for moderate to sever pain and can be used as anti-pyretic.

Side effects Gastric irritant, may impair clottingSupplied as • suspension, oral drops: 40 mg/ml

• suspension, oral : 100mg/5ml• Tab, chewable : 50mg, 100mg contains

phenlyanaline• Tab : 200mg, 400mg, 600mg

Ibuprofen

Trade names

Dosage : single dose every 4-6 hours max. dosage- 1.2g

Acetaminophen

AGE (year) DOSE (mg)

Under 1 60

1-6 60-120

6-12 150-300

Precautions The drug should not be administered for more than 10 days, as it is available without prescription

Side effects 1. causes renal injury2. Overdose leads to hepatic necrosis and death if

more than 3g is taken by children under 2 years of age

Availability • drops-60mg/0.6ml and 120mg/2.5ml• elixir-120mg/5ml and 150mg/2.5ml• tablets-325mg and 500mg• chewable tablets-120mg• suppositories- 120mg, 300mg, 600mg, 900mg

Acetaminophen

Trade names

Crocin 500mg tab, calpol 250mg suspension, pyrigesic 500mg tab, syrup 120mg/5ml

Dosage Children : 5-10mg/kg/dose, every 8-12 hoursAdult : oral- 220mg every 8-12 hours, up to 660mg/day.

Advantages Anti-inflammatory and good for severe pain

Side effects Gastric irritant and may delay onset of bleeding.

Supplied as Suspension- 125mg/mlTablets- 250mg, 375mg, 500mg.

Naproxen

Trade names

AspirinDosage Children : 10-15mg/kg/dose every 4-6hrs, up to a total of

80-100mg.Adult : oral, rectal – 325mg to 650mg every 4-6 hours up to 4g/day.

Advantages Analgesic, antipyretic and anti-inflammatory propertiesSide effects Allergic reaction in patients with pre-existing asthma,

atopy and nasal polypDevelopment of Reye SyndromeGastric ulcersLast choice of drug in children

Supplied as Chewable tablets – 81mgCaplets, tablets- 325mg, 500mgSuppository, rectal- 300mg, 600mg

Trade names

Disprin chewable tablets300 mg, ecosprin 75mg, 150mg, 325mg

Combinations of two analgesics having different mechanisms (central or peripheral) might be expected to produce addictive effects and may not be true for the analgesics acting by the same mechanisms.

The common combinations of analgesics used in our practice are:

1. ibuprofen and paracetamol2. diclofenac sodium and paracetamol3. nimesulide and paracetamol4. mefenamic acid and paracetamol

Combination therapy for pain

Acetaminophen + CodeineDosage Children </= 44kg-oral :

Codiene- 0.5to 1mg/kg/dose every 4-6hrsAcetaminophen- 10 to 15mg/kg/dose every 4-6hrds up to 2.6g/day

Children >/= 44kg-oral :Codeine-30 to 60mg/dose every 4-6 hoursAcetaminophen-325mg to 650mg/dose every 4-6 hours, up to 4g daily.

Advantage 1. Codeine acts at central site of pain2. Acetaminophen acts at the peripheral site for

enhanced analgesia

Side effects

Codeine can cause nausea, vomiting, sedation, constipation and dependencyAcetaminophen may cause liver damage in overdose

Supplied as Suspension : acetaminophen 120mg and codeine phosphate 12mg/5ml

Tablets : acetaminophen 300mg and codeine phosphate 60mg

Acetaminophen + Codeine

Most pain resulting from paedriatic dental procedures may be treated with mild analgesics, such as aspirin and acetaminophen. In case they are ineffective, codeine may be administered in combination to provide adequate relief.

Stronger analgesics must be provided only if all the other efforts at pain control have proven in effective.

Summary

Generic names Trade names

Ibuprofen Brufen, ibugesic 200mg, 400mg, 600mg tab. Ibugesic suspension

100mg/5mlAcetaminophen Crocin, calpol, pyrigesic

500mg tab.Drops 100mg/ml

Calpol suspension 250mg/5ml

Naproxen Naprosyn 250mg, 500mg

Aspirin Disprin 350mg, ecosprin 75mg, 150mg,325mg

Commonly used analgesics

• DEVELOPMENT OF ORAL MICROFLORA Oral cavity is usually sterile at birth Number of microorganisms increase following 6-

8hrs after birth At 12 months of age, most children have the

following microorganisms in their oral cavity.1. Streptococcus (S. salivarius, S. mutans)2. Staphlyococcus3. Actinomyces4. Veillonella5. Lactobacilli6. Nocardia7. Fusobacterium

ANTIBIOTIC THERAPY FOR CHILDREN

Antibiotics provide time for normal host defenses to gain control and eliminate the infectious process.

Antibiotics for children are similar to those in adults (as adjusted by body weight).

The exceptions are infants, who require a lower antibiotic dosing.

Principles of antibiotic therapy

Antibiotics act through specific mechanisms dictated by the site of action-

1. Cell membrane2. Cell wall loss of integrity rupture

bactericidal3. Nucleic acid content interferes with

ribosomal function replication, protein synthesis and information transfer is disrupted

4. Intermediary metabolism metabolic pathways interrupted suppression of growth

Mode of action of antibiotics

Beta lactams Penicillins effective against – gram +ve oragnisms. Eg : streptococci, clostridia, H. influenzae, Staph. Aureus (when used with clavalunic acid)

Cephalosporins effective against gram +ve (first gen.) and gram –ve (second and third gen.) and organisms that show high resistance to beta lactamase (fourth gen.)

Sulphonamides Effective against gram +ve and gram-ve bacteria. Eg : strep. Pyogens, H. influenzae, vibrio cholerae, E.coli, Nocardia

Cotrimoxazole Effective against Salmonella typhi, seratia, klebsiella, enterobacter, shigella, H. influnzae, E.coli, etc

Nitroimidazoles Metronidazole- effective against protozoal organisms. Eg : Entamoeba histolytica and giardia lamblia -anaerobic bacteria like Veilonella, Clostridia, Fusobacterium, treponema vaginalis, etc.

Classification

Dentists seldom treat infants, but doses for paediatric patient require an adjustment from the usual adult dose, as determined by body surface area and weight.

The following two formulae are used for calculating paediatric doses-

1. Clark’s rule2. Young’s rule

Dose calculation by weight

Clark’s rulechild’s weight in lb X adult dose = child dose 150 Young’s ruleAge of child X adult dose = Child’s doseage + 12 Anders in 1992 Administration of drug based on infants weight

is seldom appropriate.dose p = dose a X weight pd weight ad

Dose calculation by weight

Children vary considerably in size and weight at the same age levels.

The dose of many drugs is not always a simple linear function of body weight.

Surface area is a more accurate method in determining the dose since it can be easily determined by knowing the height and weight and referring to the nomograms which relate these body parameters.

Drawbacks of calculations based on weight

Resistance to a particular drug could be either due to improper dose or duration.

The only practical method to delay or restrict antibiotic resistance is to limit the antibiotic use to proper indication, dosages and duration.

Instructions by the physician or manufacturers should be followed.

Antibiotic resistance

Administration of antibiotics to patients without the evidence of infection to prevent bacterial colonization, to reduce subsequent post-operative complications.

Example : Antibiotic prophylaxis is required in a patient with rheumatic heart disease to prevent infective endocarditis. It is also required in case of immunosuppressed patients with blood dyscrasias, cancer chemotherapy and graft recipients.

Antibiotic prophylaxis

Prophylaxis for children with rheumatic or other valvular disease; congenital heart disease, idiopathic hypertrophic subaortic stenosis, mitral valve prolapse syndrome with mitral insufficiency and cardiac valvular prosthesis.

Two regimen given by WHO- 1. Regimen A2. Regimen B

Antibiotic prophylaxis

Regimen A Regimen B1. Parenteral-oral combined :A. Aqueous crystalline penicillin (30,

000 U/kg IM) mixed with procaine penicillin G (600, 000 U IM) 30-60mins prior to dental procedure.

B. Then penicillin V – 500mg orally every 6 hours for eight doses.

C. In children<60 pounds, penicillin V – 250mg orally every 6 hourly for 8 doses

2. Orally only :D. Penicillin V – 2g orally 30-60mins

prior to dental procedure, then 500mg every 6 hours for 8 doses.

E. In children<60 pounds, penicilllin V- 1g orally, 30-60mins prior to dental procedures then 250mg every 6 hours for 8 doses.

1. Aqueous crystalline penicillin G (30, 000 U/kg IM) mixed with procaine penicillin G (60, 000 U IM) + streptomycin (20mg/kg IM), 30-60 mins prior to dental procedures.

2. Followed by oral penicillin V- 500mg every 6 hours for 8 doses.

3. In children<60 pounds, oral penicillin V- 250mg every 6 hours for 8 doses.

4. For patients allergic to penicillin-A. Parenteral vancomycin +

erythromycin (vancomycin – 20mg/kg IV over 30-60mins + oral erythromycin 10mg/kg every 6hours for 8 doses)

B. Oral erythromycin- 20mg/kg orally 1.5-2hours prior to the dental procedure and 10mg/kg every 6hours for 8 doses.

Antibiotics Generic Names Brand Names

Penicillins Oral penicillin GPenicillin V

Pentids, Pizerpen, Ledercillin VK, Veracillin, V-cillin-K

Cephalosporins CephalexinCephradine

Keflex, Anspor, Velosef

Erythromycin Erythromycin baseErythromycin succinateErythromycin stearateErythromycin estolate

E-mycin, erythrocin, Pedia mycin, eryhtrocin ilosone

Lincosamides LincomycinClindamycin

LincocinCleocin

Generic name and brand names

Amoxicillin Amoxicillin + Clavulanate potassium Amoxicillin + cloxacillin Ampicillin Cephalexin Cotrimoxazole Erythromycin Metronidazole

Commonly used antibiotics

Actions Interferes with cell replication of susceptible organisms, the cell wall rendered osmotically unstable, swells and bursts from osmotic pressure

Dosage Per oral 20-40mg/kg/day in three doses

Availability Capsule-250mg, 500mgTablet-125mg, 250mgPowder for suspension- 50mg/ml

Side effects Increased thirst, nausea, vomiting, diarrhoea, pruritis, urticaria, angioneurotic oedema, bronchospasm, anaphylaxis.

Amoxicillin

Action Interferes with cell wall replication of susceptible organisms, the cell wall rendered osmotically unstable, swells and bursts from osmotic pressure

Dosage and route Per oral 20-40mg/kg/day in three divided doses

Available forms Capsule 250mg, 500mgChewable tablets 125mg and 250mgPowder for oral suspension 125mg, 250mg/ml.

Side effects Discoloured tongue, glossitis, increased thirst, nausea, vomiting, diarrhoea, hyperkalemia, puritis, urticaria, bronchiospam, anaphylaxis

Contra indications

Hypersensitivity to penicillin

Amoxicillin + Clavalunate potassium

Trade names

Augmentin duo, clavam 375mg (250mg+125mg), 625mg (500+125mg) tabletAugmentin duo syrup 228mg/5ml

Action Interferes with cell wall replication of susceptible organisms, the cell wall rendered osmotically unstable, swells and bursts from pressure

Dosage and route 50-100mg/kg of combination, divided in 3 divided doses

Available forms Tab 250mg and 500mgCapsule 250 and 500mgPowder for oral suspension 125mg, 150mg/15ml

Side effects Increased thirst, Nausea, Vomitting, Hyperkalemia, Pruritis, Urticaria, Bronchospasm, Anaphylaxis

Contra indications Hypersensitivity to penicillin

Amoxicillin + cloxacillin

Action Interferes with cell wall replication of susceptible organisms, the cell wall rendered osmotically unstable, swells and bursts from osmotic pressure

Dosage Per oral 50-100mg/kg/day in four divided doses (6 hourly)

Available forms Cap 200mg and 500mgPowder for oral suspension 125mg/5ml

Side effects Discoloured tongue, glossitis, rash, urticaria, glomerulonephritis, puritis, angioneurotic oedema, bronchospams, anaphylaxis, nausea, vomiting, Diarrhoea.

Contra indications Hypersensitivity to penicillin

Ampicillin

Trade namesCapsule Roscillin, Biocillin, AmpilinSyrup Amipilin 125mg/5ml

Actions Inhibits bacterial wall synthesis , rendering the cell wall osmotically unstable

Dosage and route Per oral 50-100mg/kg/day in 4 divided doses

Available forms Capsule 250mg, 500mgTablet 250mg, 500mgOral suspension 125mg, 250mg/5ml and 100mg/ml

Side effects Candidiasis, glossitis, NVD, anorexia, pseudomembranous colitis, nephrotoxicity, urticaria, rash, anapylaxis

Contra indications Hypersensitivity, pregnancy, infants <1 months.

Cephalexin

Capsule and kid tablet

Capsules and suspension

Suspension

Actions Sulfamethazole interferes with bacterial biosynthesis of proteins by competitive antagonism of PABA; trimethoprim blocks synthesis of tetrahydrofolic acid, this combination blocks consecutive synthesis of essential nucleic acids, proteins.

Dosage and route Per oral 8mg/kg (TMP) + 40mg (SMZ) [double strength]160mg TMP/800mg SMZSuspension 40mg+200mg/5ml

Side effects Candidiasis, Stevens-Johnson Syndrome, anaphylaxis, SLE, NVD, hepatitis, leukoopenia, agranulocytosis, renal failure

Contra indications Hypersensitivity to trimethoprim, sulfamethoxazole, megaloblasic anemia, infants of 2 months, pregnancy and lactation

Cotrimoxazole

Tablets

Suspension and tablet for paediactrics

Action Binds to ribosomal units of susceptible bacteria and supress protein synthesis

Dosage and route Per oral 30-5-mg/kg/day in 4 divided doses

Available forms Tab 250mg, 500mgSuspension 250mg/5dl

Side effects Candidiasis, rash, urticaria, pruritis, hypersensitivity, NVD, hepatotoxicity, abdominal pain, pseudomembranous tnnitus

Contra indications Hypersensitivity to pre existing hepatic disease

Erythromycin

Tablet and suspension

Actions In anaerobic microorganisms, metronidazole is converted to active form by reduction of its nitrogroup. This gets bound to DNA and prevents nucelic acid formation

Dosage and route Per oral 5mg/kg/TIDAvailable forms Tab 200mg, 400mg

Suspension 200mg/5mlSide effects Dry mouth, furry tongue, bitter taste, metallic taste,

leukopenia, bone-marrow aplasia, rash, urticaria, NVD, abdominal pain, nehprotoxicity

Contra indications Hypersensitivity to drug, renal disease, pregnancy and lactations, hepatic disease, alcoholic patients (disulfuram like reactions)

Metronidazole

Paediatric drug therapy and immunization by RK Suneja.

Textbook of paediatric dentistry by Braham and Morris.

Text book of paediatric dentistry by Shobha Tandon.

References

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