ANALGESICS & ANTIBIOTICS IN

PEDIATRIC DENTISTRY

Dr.G.Thiruvenkadam
Post graduate
Dept of Pedodontics & Preventive Dentistry

ANTIBIOTICS
The desire to take Medicine is
perhaps the greatest feature,
Which distinguishes Man from
Animals
- Sir William Osler

Synopsis
Antibiotics in dentistry

Introduction
Definitions
Guidelines
Principles
Drug dosage calculations
Classifications
Indications
Commonly used antibiotics
Antibiotic prophylaxis

Introduction
Antibiotics are chemical substances that suppress the
growth of other microorganisms and may eventually
destroy them.
The purpose of antibiotic and antimicrobial
chemotherapy is to aid the host defences in
controlling and eliminating microbes that temporarily
have overwhelmed the protective host mechanisms
They play an essential role in the management of
odontogenic infections as it can shorten the period of
infection and minimize the associated risks.

Definitions
Antibiotics
The term antibiotic was first used in 1942 by Selman
Waksman and his collaborators to describe any substance
produced by a microorganism that is antagonistic to the
growth of other microorganisms in high dilution
Antibiotics may be informally defined as the subgroup of
anti-infectives that are derived from bacterial sources and
are used to treat bacterial infections.

Antimicrobials
They are synthetically derived agents which act against the
microbes, by killing the organisms or suppressing their
growth.

Guidelines On Use Of Antibiotic

Therapy For Pediatric Dental
Patients

Conservative use of antibiotics is indicated to minimize the

risk of developing resistance to current antibiotic regimens.
Factors related to host risk (age, systemic illness,
malnutrition) and type of wound (laceration, puncture) must
be evaluated when determining the risk of infection and
subsequent need for antibiotics.
The minimal duration of drug therapy should be limited to 5
days beyond the point of substantial improvement or
resolution of signs and symptoms.
The importance of completing a full course of antibiotic
must be emphasized, if not the surviving bacteria can restart
an infection that may be resistant to the original antibiotic.

Guidelines On Use Of Antibiotic

Therapy For Pediatric Dental
Patients

Pulpitis/Apical periodontitis/Draining sinus

Antibiotic therapy usually is not indicated if the dental infection is contained

within the pulpal tissue or the immediately surrounding tissue, without any
systemic signs

Acute facial swelling of dental origin

Depending on clinical findings, treatment may be
Treating/extracting the tooth with antibiotic coverage
Prescribing antibiotics to contain the spread of infection and then treating the involving
tooth

Dental trauma
Local application of an antibiotic to the root surface of an avulsed tooth with
an open apex and less than 60 minutes extraoral dry time has been
recommended to inhibit external resorption and aid in pulpal
revascularization
Systemic antibiotics have been recommended as an adjuctive therapy for
avulsed permanent incisors with an open or closed apex.

Guidelines On Use Of Antibiotic

Therapy For Pediatric Dental
Patients
Pediatric periodontal diseases

In pediatric periodontal diseases like Neutropenias,

Papillon LeFevre syndrome and leukocyte adhesion
deficiency, the immune system is unable to control the
growth of periodontal pathogens, so treatment may involve
antibiotic therapy.

Viral diseases
Conditions such as Acute Primary Herpetic
Gingivostomatitis should not be treated with antibiotic
therapy unless there is secondary bacterial infection.

Certain principles .
When possible, identify the etiologic agent prior to prescribing antibiotics
Use local susceptibility patterns to help direct empirical treatment
Once aetiology and susceptibility are known, change regimen to narrowest
effective spectrum
Combination therapy is usually not indicated, but for certain purposes like
To prevent emergence of resistance
For synergistic activity
Therapy against multiple potential pathogens

Choose a therapeutic agent based on

Pharmacologic data
Adverse drug reaction profile
Site of infection
Host immune status
Evidence of efficacy in clinical trials

Check for drug interactions and contraindications before prescribing

antibiotics

Drug dosage calculations

Young Formula
Dose= {Age/ (age + 12)} x adult dose

Clarke Formula
Dose= (Weight in kg/70) x adult dose
or
Dose=(Weight in lbs/150) x adult dose

Dilling Formula
Dose= (Age/20) x adult dose

Frieds Formula
Dose=(Age in Months/150) x adult dose

Based on body surface area

Dose=BSA(m2)/1.7 x adult dose

Augsbergers Formula
(1.5 x Wt(Kg) + 10) x adult dose

A new easy rule

Salisbury rule for calculating dosage for children
Less than 30 kg :Weight x 2 (% of adult dose)
More than 30 kg :Weight +30 (% of adult dose)

For example
Weight of the child = 20 kg
Adult dose
= 500 mg
Child dose
= (20 x 2) % of adult dose
= 40 % of adult dose
= 200 mg
If weight of the child = 35 kg
Adult dose
= 500 mg
Child dose
= (35+30) % of adult dose
= 65 % of adult dose
= 325 mg

Classification
Based on chemical structure
Ex: sulfonamides, quinolones, -lactams, macrolides, nitroimidazoles
etc

Based on mechanism of action

Inhibit cell wall synthesis

Inhibit protein synthesis
Inhibit DNA gyrase ex. Cipro
Interfere DNA function ex. Rifampin, metronidazole
Interfere DNA synthesis ex. Acyclovir, Zidovudine

Based on spectrum of Activity

Narrow spectrum
Broad spectrum

Type of Action
Primarily bacteriostatic
Primarily bactericidal

Classification
Based on antibiotics source

Fungi penicillin, cephalosporin

Bacteria polymyxin B, colistin
Actinomycetes aminoglycosides, tetracyclines
Chemicals

Based on organism susceptible

Active against Gram +ve bacteria

Active against Gram ve bacteria
Active against bith Gram + and ve bacteria
Active against acid fast bacilli.

Indications for antibiotics

Commonly used antibiotics in

pediatric dentistry
lactam antibiotics
Ex: Penicillins, Cephalosporins

Macrolides
Ex: Erythromycin

Clindamycin
Ciprofloxacin
Metronidazole, Tinidazole

Penicillins
First antibiotic to be used clinically in 1941
Originally obtained from the fungus Penicillium
notatum, but now, Penicillium chrysogenum
MOA:
Interfere with the bacterial cell wall synthesis
Transpeptidases enzyme is responsible for cross linkages
between peptide chains in bacterial cell wall, results in
stability and rigidity of the cell wall.
Penicillins inhibit transpeptidases, so that cross linking
doesnot takes place.
They are most effective against rapidly multiplying
organisms and are bactericidal

Classification
Acid resistant alternative to penicillin G
Phenoxymethyl penicillin (Penicillin V)

Penicillinase resistant penicillins

Oxacillin, Cloxacillin, Methicillin

Extended spectrum penicillins

Aminopenicillins
Ampicillin, Amoxicillin

Carboxypenicillins
Carbenicillin, Ticarcillin

Uriedopenicillins
Piperacillin, Mezlocillin

lactamase inhibitors
Clavulanic acid, Sulbactam

Penicillin V
Penicillin VK is a beta-lactam antibiotic and is
bactericidal against gram-positive cocci and the major
microbes of mixed anaerobic infections
Unlike natural penicillin, it is acid stable and can be
given orally
Adverse reactions:
Adverse drug reactions include mild diarrhoea, nausea and
oral candidiasis
There is a 0.7 to 10% allergy rate among patients
The usual allergic responses exhibited are skin rashes that
usually respond to antihistamine therapy
Severe reactions of angioedema have occurred, characterized
by severe swelling of the lips, tongue, face, and periorbital
tissues

Penicillin V
The usual daily dose of penicillin V for treating
odontogenic infections is:
Children 12 years of age: 25-50 mg/kg of body weight in
divided doses every 6-8 hours.
Children >12 years of age and adults: 250- 500 mg every 6
hours for at least 10 days.
Penicillin VK is supplied as 125 or 250 mg/5ml solution or
250 and 500 mg tablets.

Ampicillin
Active against Gm + ve and Gm ve organism
Antibacterial activity is similar to that of natural
penicillins i.e, Penicillin G
It is effective against Strep.viridans, Enterococci,
Gonococci, Pneumococci and Meningococci
Adverse effects:
Diarrhoea, rashes, drug fever, oral candidiasis

Drug dosage:
50 100 mg/kg/day (maximum 2-3 g/day) orally
100 200 mg/kg/day I.M/I.V

Amoxicillin
It is a close congener of Ampicillin; similar in all aspects except:
Oral absorption is better, higher and more sustained blood levels are produced
Incidence of diarrhoea is less

Dosage:
Children 25 50 mg/kg in 3 divided doses

Available as:
Capsules:
Novamox, Mox, Wymox (250 mg, 500 mg)

Dispersible tablets
Novamox (125 mg, 500 mg), Wymox (250 mg), Lamoxy (250 mg), Blumox (125 mg, 250
mg, 500 mg)

Tablets
Kid tab
Wymox, Lamoxy (125 mg)

Syrups
Drops
Injections

Cloxacillin
It is a penicillinase resistant penicillin
It is less active against Penicillin G sensitive
organisms, so it should not be used as a substitute
It is used in conjunction with ampicillin or
amoxicillin to enhance the synergism
Dosage:
Children 50 100 mg/kg/day , orally or I.V

Combinations
Amoxicillin and Cloxacillin
Children 50 100 mg/kg/day in 3 divided doses
Available as:
Cap. Novaclox (Amox 250 mg + Clox 250 mg)
Cap. Mox Kid (Amox 125 mg + Clox 125 mg)

Amoxicillin with LB
Cap Novamox LB (Amox 250 mg, Lactobacillus 6 million
Spores)

Amoxicillin with Clavulanic acid

Clavulanic acid:
Inhibits the lactamase enzyme produced by bacterias
Its a progressive inhibitor, inhibition increases with time
Its a suicide inhibitor, gets inactivated after binding to the enzyme

Enhancin, Augumentin Duo, Clavam (375 mg, 625 mg)

Kid tab Amoxclav

Adverse reactions
Frequent adverse effects

Diarrhoea
Hypersensitivity
Nausea
Rash
Neurotoxicity
Urticaria
superinfection (including candidiasis).

Infrequent adverse effects (0.11% of patients)

fever,vomiting, erythema, dermatitis, angioedema, seizures
(especially in epileptics), and pseudomembranous colitis

Cephalosporins
Semisynthetic antibiotics derived from fungus,
Cephalosporium acremonium
They are chemically related to penicillins
All cephalosporins are bactericidal and have the same
mechanism of action as penicillin
Inhibition of bacterial cell wall synthesis

Classification
Parentral
First generation
Cephalothin
Cefazolin

Second generation
Cefuroxime
Cefoxitin

Third generation

Cefotaxime
Ceftizoxime
Ceftriaxone
Ceftazidime
Cefoperazone

Fourth generation
Cefepime
Cefpirome

First generation
Oral
Cephalexin
Cephadrine
Cefadroxil

Second generation
Cefaclor
Cefuroxime axetil

Third generation

Cefixime
Cefpodoxime proxetil
Cefdinir
Ceftibuten

Range of action
First generation
Mostly effective against gram positive and some gram negative bacteria,
but not effective against anaerobes

Second generation
Have wider range of action against gram negative bacilli, less active
against gram positive cocci

Third generation
Poor activity against gram positive cocci, but are more active against gram
negative bacilli and variable activity against pseudomonas

Fourth generation
They are resistant to lactamases and can penetrate the blood brain barrier

Fifth generation
Recently discovered cephalosporin
Used in cases of severe infection
Ex: Ceftobirole

Cephalosporins
Commonly used cephalosporins
Cefazolin
Susceptible to staphlococcal lactamase
Preferred parentral cephalosporin for surgical prophylaxis

Cephalexin

Orally effective first generation cephalosporin

Less active against penicillinase producing staphylococci
Most commonly used cephalosporin
Dosage : Children: 25 100 mg/kg/day orally
Ex: Sporidex, Ceff, Sepexin

Cefadroxil

Close congener of Cephalexin

Antibacterial activity is similar to that of cephalexin
Dosage: Children: 30 mg/kg/day orally
Ex: Droxyl, Cefadur, Cefoxid

Cefaclor
Dosage : 125 250 mg daily

Cefixime
Highly active against enterobacteria
Dosage : 200 400 mg BD

Macrolides
These are antibiotics having macrocyclic lactone ring
with attached sugars
Drugs included in this category are Erythromycin,
Spiramycin, Roxithromycin, Clarithromycin and
Azithromycin
Commonly used macrolides are Erythromycin and
Azithromycin

Erythromycin
Isolated from Streptomyces erythreus in 1952
Mechanism of Action:
It is bacteriostatic
Interfere with protein synthesis by inhibiting enzyme transferase at the 50S
subunit of ribosome
It is effective against Gm + ve and Gm ve bacteria and most importantly
against penicillin resistant staphylococci
Depending upon its serum concentration, it may be bactericidal.

Uses in dentistry
Used as a prophylactic agent in infective endocarditis
Used in patients who are allergic to penicillin

Dosage:
Children : 30-50 mg/kg daily in divided doses

Adverse effects:
Abdominal pain, nausea, diarrhoea, stomatitis are common
Hepatic dysfunction is a relative contraindication for erythromycin therapy

Clindamycin
Clindamycin inhibits protein synthesis by reversibly
binding to the 50S subunit of the ribosomal thus blocking
the transpeptidation or translocation reactions of
susceptible organisms resulting to stunted cell growth.
Uses:
Used in severe anaerobic infections
Used in infective endocarditis prophylaxis

Dosage:
Children:3-6 mg/kg every 6 hr

Adverse drug reactions:

Diarrhoea, nausea, vomiting, abdominal pain, exfoliative and
vesiculous dermatitis, urticaria
Causes Gasping syndrome in Neonates

Nitroimidazoles
Antibiotics included in this category are

Metronidazole
Tinidazole
Secnidazole
Ornidazole

Commonly used drugs are

Metronidazole and Tinidazole

Metronidazole
Mechanism of action:
After entry in to the anaerobic organism,Metronidazole is
reduced at the 5-Nitro position, that interact with DNA to cause
destruction of helical DNA structure and leading to protein
synthesis inhibition and cell death in susceptible organisms.

It is effective against a wide range of organisms

including

E. histolytica
T. vaginalis
Giardia
Bacterioides sp
Fusobacterium sp
Clostridium sp
Peptococcus sp and Peptostreptococcus sp

Metronidazole
Uses:
Primarily used in the treatment of obligate anaerobes in the
oral cavity
Has been used in the treatment of periodontitis
Used along with other antibiotics to treat mixed dental
infections

Dosage:
7.5 mg/kg in thrice daily
Available as Metrogyl 200, 400 mg tabs

Adverse reactions:
Nausea, anorexia, abdominal pain and metallic taste are the
common side effects

Quinolones
They constitute a group of 1,8-naphthydrine
derivatives
They are synthetically produced drugs
Nalidixic acid is the prototype of the quinolones
drugs and was introduced in 1964
Drugs are

Ciprofloxacin
Norfloxacin
Ofloxacin
Levifloxacin
Gatifloxacin
Lomfloxacin

Ciprofloxacin
Mechanism of action:
Ciprofloxacin promotes breakage of double-stranded DNA
in susceptible organisms and inhibits DNA gyrase, which is
essential in reproduction of bacterial DNA.

Uses:
It is the first oral broad spectrum antimicrobial agent with
good activity against Pseudomonas aeruginosa
Excellent activity against wide range of Gm ve organisms.
Useful in the management of mixed infections
But most of the anareobic bacteria are resisitant.

Dosage:5-15 mg/kg bid

Adverse reactions:
Nausea, headache, diarrhoea, photosensitivity, skin rashes

Other antibiotics.
Tetracyclines
Aminoglycosides
Sulfonamides

Local application of antibiotics

Chlorhexidine 0.2 % as
Mouthwash
Intra canal irrigant

3Mix-MP as intra canal medicament

Ciprofloxacin 500 mg
Metronidazole 200 mg
Minocycine 100 mg

Metronidazole as intra canal irrigant

Doxycycline hyclate in avulsed root surface to aid
revascularization

Antibiotic Prophylaxis
A prophylaxis is a measure taken to maintain health
and prevent the spread of disease.
Bacterial endocarditis is a microbial infection of the
inner layer of the cardiac muscle (endocardium).
Patients with congenital or acquired cardiac defects
are believed to be at high risk for developing bacterial
endocarditis if a (dental) procedure causes a transient
bacteremia.
Blood-bourne bacteria may lodge on the abnormal
endocardium or heart valves, causing endocardial
infection

Bacterial endocarditis
. In 2007 the American Heart Association revised its
1997 guidelines on prevention of bacterial endocarditis.
Bacterial endocarditis is much more likely to result from
frequent exposure to random bacteremias associated with daily
activities than form bacteremia caused by dental, GI tract, or
GU tract procedures.
Prophylaxis may prevent an exceedingly small number of cases
bacterial endocarditis, in individuals who undergo dental, GI
tract or GU tract procedures.
The risk of antibiotic associated adverse events exceeds the
benefit from prophylactic antibiotic therapy.
Maintenance of optimal oral health and hygiene may reduce
the incidence of bacteremia from daily activities and is more
effective than prophylactic antibiotics for a dental procedure
for reducing the risk of bacterial endocarditis.

 The revised guidelines clarified when antibiotic

prophylaxis is/is not recommended, i.e.
Only an extremely small number of cases might be prevented by
antibiotic prophylaxis.
Antibiotic prophylaxis for dental procedures is recommended
only for patients with underlying cardiac conditions associated
with the highest risk of adverse outcomes from bacterial
endocarditis.
For patients with these underlying cardiac conditions,
prophylaxis is recommended for all dental procedures that
involve manipulation of gingival tissues or the periapical region
of teeth or perforation of the oral mucosa.
Prophylaxis is not recommended based solely on an increased
lifetime risk of acquiring bacterial endocarditis.

Regimen for a dental

procedure

Cardiac Conditions Associated with the Highest Risk

of Adverse Outcomes from Endocarditis for Which
Prophylaxis Prior to Dental Procedures is
Recommended.

Regimen for a dental

procedure
Recommended:

All dental procedures that involve manipulation of gingival

tissue or the periapical region of the teeth or perforation of
the oral mucosa

Not recommended:
Routine anesthetic injections through no infected tissue
Dental radiographs
Placement of removable prosthodontic or orthodontic
appliances.
Adjustment of orthodontic appliances
Placement of orthodontic brackets
Shedding of deciduous teeth
Bleeding from trauma to the lips and tongue

Administer single dose 30 to 60 minutes before procedure

Situation

Agent

Adults

Children

Oral

Amoxicillin

2 gm

50 mg/kg

Unable to take oral medication

Ampicillin
OR
Cefazolin or ceftriaxone

2gm IM or IV

50 mg/kg IM or IV

1gm IM or IV

50 mg/kg IM or IV

2 gm

50 mg/kg

Allergic to penicillins or ampicillinoral

Cephalexin
OR
Clindamycin
OR
Azithromycin or clarithromycin

600mg

20 mg/kg

500mg

15 mg/kg

1 gm IM or IV

50 mg/kg IM or IV

600mg IM or IV

20 mg/kg IM or IV

Allergic to penicillin or ampicillin

and unable to take oral medication

Cefazolin or ceftriaxone
OR
Clindamycin

Analgesics
Drug that relieves pain without blocking nerve
impulse conduction or markedly altering sensory
function
A drug that selectively relieves pain by acting in the
CNS or on peripheral pain mechanisms, without
significantly altering conciousness

Types of Analgesics
Narcotic analgesics
also termed opioids, are all derived from opium
narcotic analgesics vary in potency, but all are effective in
treatment of visceral pain when used in adequate doses
act on CNS receptors to inhibit pain impulses

Non Narcotic analgesics

Classified under NSAIDS

They do not depress CNS
Do not produce physical dependence or abuse liability
They act primarily on peripheral pain mechanism but also
in CNS to raise the pain threshold

Opioids
Dark brown resionous material obtained from
Papaver somniferum
Classification:
Natural opioids
Morphine, Codeine

Semisynthetic
Heroine, Pholcodeine

Synthetic
Pethidine, Fentanyl, Tramadol, Methadone

Uses in dentistry

Morphine
Pethidine (Meperidine)
Codeine
Mechanism of Action:
They act directly on the receptor site in the CNS i.e, ,,
to inhibit the release of excitatory transmittors from the
primary afferent carrying pain impulses
They also increase the pain perception threshold

Morphine
Strong analgesic
dull., poorly localized visceral pain is relieved better
than the sharply defined somatic pain
Degree of analgesia is directly proportional to the dose
Adverse effects:
Sedation, Lethargy, Vomiting, Constipation, Respiratory
depression,
Antidote : Naloxone , Nalorphine

Uses:
Indicated in case of severe pain
Especially in traumatic, visceral, ischemic (myocardial
infection), post operative, burn and cancer pain

Morphine
Dosage:
Children : 0.1 0.2 mg/kg

Precautions
It is a drug of emergency, care has to be taken in
Infants who are more susceptible to respiratory depression
Patient with bronchial asthma
Morphine is contraindicated in patients with head injury

Pethidine

Synthesized as an atropine substitute in 1939

Chemically unrelated to morphine
Mechanism of action is similar to that of morphine
Differences are
Analgesic efficacy is little lower than morphine, but higher
than codeine
Onset of action is more rapid
Safer in asthmatics
Constipation and miosis are less marked

Dosage:0.5- 2 mg/kg
Uses:
Mostly used in post operative pain relief
Also as a preanesthetic medication

Codeine

It is a methyl morphine
Partly converted in the body to morphine
Less potent than morphine and also less efficacious
More effective in oral route
Codeine is usually given in combination with nonnarcotic analgesics, because the narcotic acts at a
central site and the non-narcotic analgesic at a
peripheral site providing enhanced analgesic activity.
Dosage: 0.5-1mg codeine/kg/dose every 4-6 hours
Side effects: constipation, drowsiness, nausea,
vomiting, miosis, depression, and pardoxical
coughing

NSAIDS
They are nonsteroidal, anti-inflammatory cyclooxygenase inhibitors
Prostaglandins are the substances produced from the
Arachidonic acid(derived from membrane
phospholipids at the injury site) by the enzyme Cyclooxygenase(COX)
Prostaglandins play a part in formation of erythema,
edema, and fever associated with inflammation and
generates pain
By the direct action of PGs
Sensitizing the pain receptors and reduces the pain
threshold
By release of substances such as bradykinin and histamine

Cyclo- oxygenases
There are two types of COX
COX 1
Constitutive form present in blood vessels, GIT and kidney

COX 2
Inducible form at the site of inflammation

General principles
AAPD guidelines
recognize and assess pain, documenting in the patients chart;
use non-pharmacologic and pharmacologic strategies to reduce pain
experience pre-operatively;
be familiar with the patients medical history to avoid prescribing a
drug that would be otherwise contra- indicated;
comprehend the consequences, morbidities, and toxi- cities associated
with the use of specific therapeutics;
consider non-opioid analgesics as first line agents for post-operative
pain management;
utilize drug formularies in order to accurately pre- scribe medications
for the management of postopera- tive pain;
consider combining NSAIDs with acetaminophen to provide a greater
analgesic effect than the single agent alone; and
combine opioid analgesics with NSAIDs for post- operative treatment
of moderate to severe pain in children and adolescents.

Classification

Most commonly used NSAIDS

Aspirin
Ibuprofen
Diclofenac
Piroxicam
Ketorolac
Paracetamol

Aspirin

It is developed by Bayer in 1899

It is an Acetyl Salicylic acid
It irreversibly inhibits both COX 1 and COX 2
Uses:

As an analgesic in doses of 0.3 0.6 gm, 6-8 hourly

As an antipyretic
In acute rheumatic fever in the dose of 75-100 mg/kg/day
Also in cases of rheumatoid arthiritis, osteoarthritis
In low doses of 100 300 mg, it inhibits platelet aggregation and
is used in post myocardial infarction patients

Dosage:
Analgesic and antipyretic: Oral, rectal: 10-15mg/kg dose every 46 hours up to a total of 4 g/day

Aspirin
Adverse reactions:

Peptic ulceration
Precipitation of asthma
Hemorrhage
Reyes syndrome:
Use of Aspirin in children below 12 years with viral infections
cause life threatening condition characterized by

Vomiting
Lethargy
Coma
Even death
If patient survives, causes irreversible brain damage

So, use of aspirin in children is prohibited in India

Ibuprofen
Its a propionic acid derivative
Action: analgesic, antipyretic and anti inflammatory
Dosage:
4-10mg/kg/dose every 6-8 hours (maximum daily dose
40mg/kg/day)

Adverse effects:
Less than that of aspirin
Gastric discomfort, nausea, vomiting, headache, dizziness,
dyspepsia, abdominal pain, heart burn, diarrhoea, epigastric pain

Available as;
Tablets (200, 400, 600 mg)
Brufen, Ibuprofen, Emflam

Suspension (100mg/5ml)
Ibugesic, Ibrumac, Gesic

Diclofenac
Its an aryl acetic acid derivative
Dosage:
Children: 2 to 3 mg/kg/day orally in divided doses 2 to 4 times daily
Maximum dose: 200 mg daily.

Adverse reactions:
GI disturbances; headache, dizziness, rash; GI bleeding, peptic
ulceration; abnormalities of kidney function. Pain and tissue
damage at inj site (IM)

Available as:
Tablets (50, 100 mg)
Agile, Dan, Diclofen

Dispersed tablets
Agile, Diclonac, Diclotal, Zobid - D

Injections (IM)
Voveran, Osteoflam, Oxalgin

Piroxicam
Its an oxicam derivative
Dosage:
0.2 to 0.3 mg/kg orally once a day. Maximum daily dose is 15 mg

Adverse effects:
GI disturbances, peptic ulcer, GI bleeding, headache, dizziness,
blurred vision, tinnitus, skin rashes and pruritus. Haematological
changes and photosensitivity
Piroxicam is contraindicated for the treatment of perioperative pain
in patients undergoing coronary artery bypass graft (CABG) surgery.
Patients with the "triad" of asthma, nasal polyps, and aspirin or other
NSAID hypersensitivity (i.e. angioedema, bronchospasm, urticaria,
rhinitis) may be cross-sensitive to piroxicam

Available as:
Tablets (10, 20 mg)
Pirox, Dolonex, Doloswift

Ketorolac
Its a pyrrolo-pyrrole derivative
A novel NSAID with potent analgesic and modest
antiinflammatory activity
In post operative pain it has equalled the efficacy of
Morphine, without interacting with opioid receptors
Dosage:
Children 0.5 mg/kg

Uses:
Frequently in post operative pain
Acute musculoskeletal pain

Adverse effects:
Abdominal pain, dyspepsia, ulceration, loose stools,
drowsiness, nervousness, pain at the injection site

Paracetamol
It is de-ethylated active metabolite of Phenacetin
It has analgesic and antipyretic action but no anti
inflammatory action
Paracetamol exhibits analgesic action by peripheral blockage of
pain impulse generation.
It produces antipyresis by inhibiting the hypothalamic heatregulating centre.
Its weak anti-inflammatory activity is related to poor inhibition
of prostaglandin synthesis

Adverse reactions:
Nausea, skin rashes, acute renal tubular necrosis

Dosage:
10 to 15 mg/kg/dose every 4 to 6 hours as needed (Maximum: 5
doses in 24 hours)

Choice of NSAIDS
Choice of drug is empirical
Factors
Nature of the problem(acute/chronic, inflammation, severity)
Consideration of risk factors in individual patients

Mild to moderate pain Paracetamol / Low dose

Ibuprofen
Acute pain associated with inflammation high dose of
Ibuprofen, Diclofenac
Postoperative pain Ketorolac
Gastric intolerance to conventional NSAIDs Rofecoxib
Exacerbation of pain Piroxicam
Patients with history of Asthma or anaphylactoid reactions
Nimesulide

CLINICAL
CONSIDERATION
S

Bacterial resistance
Along with the dramatic benefits of systemic antibiotics,
there has also been an explosion in the number of
bacteria that have become resistant to a variety of these
drugs. The problem is not the antibiotics themselves.
Instead, the problem is in the way the drugs are used.
The inappropriate overuse of antibiotics has resulted in a
crisis situation due to bacterial mutations developing
resistant strains.
Many worldwide strains of Staphylococcus aureus
exhibit resistance to all medically important antibacterial
drugs, including vancomycin, and methicillin-resistant S.
aureus has become one of the most frequent nosocomial,
or hospital-acquired,pathogens.

A Glimmer of Hope.
A report from Aker University in Oslo, Norway,
strongly suggests that bacterial resistance to
antibacterial agents can be reversed
Dr. John Haug, infectious disease specialist says We
dont throw antibiotics at every person with a fever.
We tell them to hang on, wait and see, and we give
them a Tylenol to feel better"

Myths
Evaluating the following eight misconceptions or
myths may help to establish general guidelines to
aid us in making clinical decisions regarding the use
of antibiotic therapy, thereby leading to optimum use
and therapeutic success.

Myths
Myth #1: Antibiotics cure patients.
Myth #2: Antibiotics are substitutes for surgical intervention
Myth #3: The most important decision is which antibiotic to
use
Myth #4: Antibiotics increase the hosts defense to infection
Myth #5: Multiple antibiotics are superior to a single
antibiotic
Myth #6: Bactericidal agents are always superior to
bacteriostatic agents
Myth #7: Antibiotic dosages, dosing intervals and duration
of therapy are established for most infections
Myth #8: Bacterial infections require a complete course
of antibiotic therapy

 Baumgartner and Xia published a report of the susceptibility of

bacteria recovered from acute apical abscesses to five commonly
used antibiotics in dentistry, led to the following conclusions:
Pen-V-K is the antibiotic of choice for endodontic infections due to its
effectiveness in polymicrobial infections, its relative narrow spectrum of
activity against bacteria most commonly found in endodontic infections,
its low toxicity and low cost.
Clindamycin is the antibiotic of choice for patients allergic to
penicillins
While amoxicillin and augmentin (amoxicillin plus clavulanate)
demonstrated a higher antibacterial effectiveness than Pen-V-K, due to
the broader antibacterial spectrum of amoxicillin and the increased cost
of augmentin, the authors recommended that amoxicillin/augmentin be
reserved for unresolved infections and patients who are
immunocompromised.
Metronidazole demonstrated the greatest amount of bacterial resistance
and is only effective against anaerobes.Therefore, it should not be used
alone for the treatment of endodontic infections

Endodontic infections that

requires antibiotics
1st category irreversible pulpitis with moderate/ severe
symptoms
2nd category irrversible pulpitis with an acute apical
periodontitis
3rd category necrotic pulp, chronic apical periodontitis,
no swelling and no/mild symptoms
4th category necrotic pulp, acute apical periodontitis, no
swelling and moderate to severe symptoms
5th category necrotic pulp, chronic apical periodontitis
and cases with sinus tracts
6th category necrotic pulp, abscess with swelling and
moderate to severe symptoms of infection

Conclusion
Since their discovery eight decades ago, safe systemic
antibiotics have revolutionized the treatment of
infections, transforming once deadly diseases into
manageable health problems. However, the growing
phenomenon of bacterial resistance, caused by the use
and abuse of antibiotics, is now threatening to take us
back to the pre-antibiotic era.
A fundamentally changed view of antibiotics is
needed. They must be looked on as a common good,
where individuals must be aware that their choice to
use an antibiotic will affect the possibility of
effectively treating bacterial infections in other
people.

References
Goodman & Gilman's The Pharmacological Basis of
Therapeutics
K.D.Tripathis Essential of medical pharmacology
Katzungs Basic and Clinical pharmacology
Shoabha Tandons Textbook of Pedodontics
Ghoms Textbook of oral medicine
Damles Textbook of pediatric dentistry
Antibiotics: Use and misuse in pediatric dentistry, Journal
of Indian Society of Pedodontics and Preventive Dentistry:
Vol. 29, No. 4, October-December, 2011, pp. 282-287
Use of systemic antibiotics in endodontic infections A
review, Journal of Indian academy of dental specialist
researches,vol 1 issue 2:jul-sep2012

 AAPD reference manual: Vol 33/No 6

Baumgartner JC and Xia T. Antibiotic susceptibility
of bacteria associated with endodontic abscesses. J
Endod 2003;29(1):44-47
PallaschTJ. Global antibiotic resistance and its impact
on the dental community. J Cal Dent Association
2000;28:215-233

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