term 'antibiosis', - Jean Paul Vuillemin 1877 renamed antibiotics - Selman Waksman,1942.1928 Alexander Fleming -named penicillin, -chemotherapy. Alexander Fleming first sulfonamide Gerhard Domaqk in 1932 in Germany,Domagk received the 1939 Noble Prize for medicine.In 1939, World War II, Rene Dubos- first naturally derived antibiotic, tyrothricin1941 penicillin was commercilly available, golden age of antibioticsFlorey and Chain succeeded in purifying the first penicillin,in 1942, e chemical structure of penicillin was determined by Dorothy Crowfoot Hodgkin in 1945. Clinical potential of microbial products as therapeutic agents in 1877 – Pasteur and JoubertChlortetracycline- introduced in 1948 [for rickettsial infections]
• It is important to understand the growth cycle and physiology of bacteria toappreciate how it influences antimicrobial action• Bacteria are all around us. Given good growing conditions, a bacteriumwill divide.• A new cell wall forms at the center and the "bug" splits into two daughtercells, both of which carry the same genetic information as the parent• If the environment is perfect, the two daughter cells can split into fourwithin 20 minutes• 1, 2, 4, 8, 16, 32, 64...• Typical bacterial growth cycle includes:Lag phaseExponential (log) phaseStationary phaseDeath phase
Gram-Negatives:1. Outer membrane entry through the:Porins: Hydrophilic ß-lactams tend to gain access into the periplasmicspace using these watery funnels (i.e., E. coli organism has about100,000 of these porins). Porins are transmembrane proteins. Theycomplex together to form water-filled channels through which lowmolecular weight (<600 daltons) hydrophilic substances readily diffuse.Such diffusion is passive and the concentration in the periplasmicspace can reach the level that prevails in the external environment aslong as there are no mechanisms to pump the drug back out or whichinactivate it.Phospholipids: This mode of entry is less common, but it seems toplay a significant part in the case of certain ß-lactams. Lipid bilayerssupport the diffusion of lipophilic compounds (certain ß-lactams arelipophilic). However, if the organism’s LPS (endotoxin) is branched(e.g., as in the case of Pseudomonas aeruginosa), such diffusion isblocked. This is called impermeability.2. Peptidoglycan entry3. Periplasmic space entry: ß-lactams may encounter ß-lactamases4. Cytoplasmic membrane PBP – boundNatural Resistance - Many Gram-negative organisms are naturally resistantto penicillin G and oxacillin because the drug is prevented from entering the cell by the LPS which blocks the porins.
Mode of actionTarget = Ribosome in cytoplasm1. Outer Membrane entry:Aminoglycosides are positively charged molecules which means theyrapidly enter bacteria (negatively charged) since the two charges attracteach other.The negative charge of bacteria is due to LPS in the outer membrane andthe peptidoglycan (notably the teichoic acid).2. Cytoplasmic Membrane entry:The drugs cross the cytoplasmic membrane via respiratory enzymes(involved in aerobic respiration).This is why bacteria without respiratory enzymes (strict anaerobes orfacultative anaerobes like streptococci) are naturally resistant toaminoglycosides.
Outer and Cytoplasmic Membrane Effect:positively charged molecules (cationic) which areattracted to the negatively charged bacteria.Cationic molecules attracted to the negatively charged bacteria.(LPS and peptidoglycan).
Anti-Metabolites• Called folate pathway inhibitors or anti-metabolitesFolic acid is essential for the synthesis of adenine and thymine, make up our genes, DNA and chromosomes.Humans do not synthesize folic acid. Good selective target.Sulfonamides• Bacteriostatic• Introduced in 1930’s – first effective systemic antimicrobial agent• Used for treatment of acute, uncomplicated UTI’sTrimethoprim/Sulfamethoxazole• TMP/SXT is bactericidal• Broad spectrum• Synergistic actionSulfonamides (sulfamethoxazole)-enzyme pteridinesynthetasetrimethoprim -enzyme dihydrofolic acid ReductaseTHFA is not produced by the bacteria. Sulfonamides, trimethoprim (alone/ combination) block folic acid -synthesis of adenine and thymidine -DNA, RNA. The combination SXT is synergistic bactericidal effect
Parkland's burn formula is most useful during the first twenty four hours of fluid resuscitation with second degree or greater burns. Ringers lactate is the fluid of choice and should be administered at 4 mL/kg of body weight per percentage of burn using total body surface area (TBSA) as a guide
A basic problem in diagnosing antibiotic allergy by immunological methods is the fact that most antibiotics are not complete antigens but rather haptenic metabolites of the parent drug coupled with a carrier tissue protein. With the exception of penicillin, immunoreactive drug metabolites have rarely been identified.The role of allergy testing is limited largely to immediate (IgE-mediated) hypersensitivity. The only validated skin testing approach involves the use of penicillin major and minor determinants (where available) in penicillin allergy. It is important to note that negative reactions may be seen if performed several months or years after the event. Amoxycillin side chain–specific immune reactions warrant specific amoxycillin skin testing. Intradermal skin testing is difficult to do in children under 10 years of age.Skin testing should only be performed by specialists due to the risk of anaphylaxis. Most nonpruriticmaculopapular rashes will not be predicted by skin testing.Blood allergy testing (ImmunoCAP) is available for penicillin G, penicillin V, amoxicillin and Cefaclor through commercial laboratories and is most accurate when measured close to the time of the event. Tryptase elevation on a sample collected within 1–4 hours after a reaction is consistent with mast cell degranulation. A blood count (looking for eosinophilia) and biochemistry (looking for raised liver enzymes) may also indicate that a reaction is related to drug administration. Eosinophilia and/or abnormal liver function tests are often due to T-cell/non-IgE-mediated reactions rather than IgE-mediated reactions.It is important to note that results of allergy testing may become negative with time from the event, and that testing may be negative even in patients who have current allergy. Thus a negative test in the presence of a convincing history does not guarantee safe administration.For IgE-mediated antibiotic allergy, antimicrobial introduction can be judiciously employed where skin and intradermal tests are negative, or in circumstances where history suggests a low risk and alternative drugs are clearly inferior. This should only be done under medical supervision, after consultation with a clinical immunology/allergy specialist. In these cases, the degree of suspicion surrounding possible life-threatening reactivity will dictate whether a desensitisation protocol (see Appendix 1) is preferable to oral challenge.
Components of the Penicillin Allergy TestPenicillin allergy testing involves the use of various skin testing techniques, including prick skin testingand intradermal skin testing, to penicillin and penicillin metabolites. Most allergy physicians perform skin testing with penicillin G (an injectable form of penicillin that is in liquid form), Pre-Pen (benzylpenicilloylpolylysine) - the major metabolite of penicillin after the body breaks down the drug, and a minor determinant mixture (MDM) containing other "minor" metabolites.MDM is not available commercially available at this time, although some allergists -- such as those working in university settings -- will make a "homemade" version. Penicillin testing that includes the use of MDM adds to the accuracy of the testing.Generally, prick skin testing is performed first, which is able to identify the most sensitive penicillin-allergic people. If prick skin testing is positive, then the person is considered to be allergic to penicillin, and no additional testing is done. If prick testing is negative, then intradermal skin testing is performed with the same materials. Intradermal skin testing identifies many more people with penicillin allergy, but is potentially dangerous in the most sensitive people. This is the reason why prick skin testing is performed first
NON OPIOID ANALGESICS
Vane and coworkers in 971, prostacyclin, thromboxane a2 cox 2 constitutional??? Macrophages MORE RECENTLY, IT HAS BEEN SHOWN TO BE UPREGULATED IN VARIOUS CARCINOMAS AND TO HAVE A CENTRAL ROLE IN TUMORIGENESIS.
Weaker analgesics except for inflammatory pain; but also on CNS to raise pain threshold.
1899, 1949,1963, heralded recognised for cyclooxygenase inhibition ,most are organic acid
In England 18th century- Reverend Freudman first described in a letter to the president of the Royal Society -cure of agues(Fever) The active ingredient in the willow bark was a bitter glycoside called Salicin, 1st isolated in a pure from in 1829 by Leroux, -antipyretic effect. Sodium salicylate was 1st used for the treatment of rheumatic fever and as an antipyretic in 1875 and discovery of its uricosuric effects and of its utility in the gout soon followed. Hoffman a chemist to prepare acetyl salicylic acid. 1899 introuduced by Dreses under the name aspirin.
Obtundin of peripheral ner, Prevention of sensitization of neve; subcortcal effect to inc pain thresh; sweatin n vasodil; hyperglycaemia at toxic doses;in large chronic doses- cholesterol levels reduced; negative nitrogen balace
Salicylic acid 3-5hours
Dizzziness vertigo tinitusexcitement n mental confusio n, electrolyte imbalance; hepqtic encephalopathy in children
Pediatric formulations banned in india
Miosis, bradycardia, vasodilatation decrese tone of blood vessels, hypothalanmic control on pit, constipation, contraction, sympathetic stimulation mild hyperglycaemia
Respiratory support, maintenance of bp, gastric lavage pot perm naloxone 0.4 to 0.8 mg till bp picks upevery2 tp 3mins
Good activity by oral route
Analgesic monotherapy has shown equivocal success in treating dental pain.Primary goal is to lower doses of component drugs,thereby increasing analgesia without increasing the side effects.
Journal of the American Dental Association (JADA). Feb2014, Vol. 145 Issue 2, p141-149.
One must remember that analgesics are a second best means of managing pain;the best means is to remove the source as quickly as possible. We have numerous analgesics at our disposal. Our goal should be to periodically assess patient’s pain & intervene as needed to adjust medications to balance analgesic efficacy against adverse effects. Rational prescribing will result in good pain management with minimal side effects.Antibiotics are basically given as an adjunct as not as the main cause of the treatment, undesirable use of antibiotics leads to its resistance and toxicity, so as dentist we should wisely prescribe antbiotics and analgesics as an adjunct and not as the sole treatment.
Antibiotics & analgesics dentistry
Department of Pedodontics and Preventive Dentistry
DEFINATION OF ANTIBIOTICS
CLASSIFICATION OF ANTIBIOTICS
MECHANISM OF ACTION
PRINICIPLE OF ANTIBIOTIC
AVOIDING RESISITENCE TO ANTIBIOTICS
THERAPEUTIC USE OF ANTIBIOTICS IN
PHARMACODYNAMIC RESPONSE OF
ANTIBIOTICS IN CHILDREN
CLASSIFICATION OF ANALGESICS
•Non opioid analgesics (NSAIDS)
OTHER DRUGS WITH ANALGESIC
PAIN MANAGEMENT STRATEGIES
REVIEW OF LITERATURE
•Prescribe mainly orofacial infections. ( originate from
•prescribing it is a important aspect of dental practice.
•7% and 11% of all common antibiotics (betalactams,
•National Center for Disease Control and Prevention
estimate that approximately one-third of all outpatient
antibiotic prescriptions are unnecessary
term 'antibiosis', - Jean Paul Vuillemin 1877
renamed antibiotics - Selman Waksman,1942.
1928 Alexander Fleming - penicillin, -chemotherapy.
Gerhard Domaqk in 1932 in Germany- first sulfonamide &
received Noble Prize the 1939.
penicillin was commercilly available-1941 golden age of
Florey and Chain purifying penicillin,in 1942,
Chemical structure of penicillin - Dorothy Crowfoot Hodgkin in
Chlortetracycline- introduced in 1948 [for rickettsial infections]
What is an Antibiotic?
Antibiotic is a chemical substance produced by a
microorganism that inhibits the growth of or kills
Antimicrobial agent is a chemical substance
derived from a biological source or produced
by chemical synthesis that kills or inhibits the
growth of microorganisms.
CLASSIFICATION BASED ON SUSCEPTIBILITY OF
I. Antibiotics effective against :
1) Gr +ve bacteria
Eg: penicillin , erythromycin
2) Gr -ve bacteria
3) Gr +ve & Gr –ve bacteria
Eg: ampicillin, amoxycillin, tetracycline,
4) Acid fast bacilli
Eg : Streptomycin
Eg : Nystatin
CLASSIFICATION OF ANTIBIOTICS
II) Based on mechanism of action
1. Inhibitors of cell wall synthesis -Eg: Penicillin, cephalosporins,
2. Inhibitors of protein synthesis
➢Affect the function of 30s or 50s (reversable inhibition of protien
synthesis)-Eg: Chloramphenicol, erythromycin,tetracyclin,
➢Bind to 30s and alter protein synthesis- Eg: Aminoglycosides
3. Inhibitors of membrane function
Eg:nystatin,ampohoteresin-B [polyene antifungals]
5. Inhibitors of nucleic acid synthesis
•initial empirical management of odontogenic infections
thiazolidine ring fused with a beta lactum ring.
• 6 amino-penicilanic acid- essential for the antibacterial
• 60% bound to plasma albumin.[ inactive form]
•bactericidal -bind to peptidoglycan
•absorbed- from duodenum.
•Food interferes absorption - oral 30 min before or 2-3 hr after
•Parenteral administration- longer compaired to plasma.
•High conc and eliminated -kidney
ON DURATION OF ACTION
• Short acting-Procain benzyl penicillin[1-3hr]
• Intermediate acting-Fortified Benzyl penicillin [12-24 hr]
• Long acting- Benzathine penicillin [12- 15 days]
Penicillin V –
•potassium phenoxyethyl penicilllin, azidocillin -
penicillinase resistent acid labile form
• Potassium salt form
• More rapidly absorbed
• Less active than benzyl penicillin
• Not used in management of severe infection.
Pencillin spectrum of activity
• penicillinase producing organism
• S. aureus are sensitive.
• Methicillin resistant staphyococci are resistant to all
NAFICILLIN - more active than methicillin
• but less active than benzyl penicillin
• 87%is plasma protein bound
• excreted by the liver
CLOXACILLIN-5-10 times more active than methicillin
• 90- 95 / is plasma protien bound
• diclozacilln-blood level is twice as that of cloxacillin
Flucloxacillin-simillar to dicloxacillin,Less protein bound
• Staphyloccal resistant - production of a new PBP
• antibacterial activity is simillar to benzyl penicillin
• More active against gram negative micro-organisms
• It is water soluble and acid resistant
• Food do not interfere absorption, but incompletely
absorbed excreated by kidney
• In infants and children excretion is delayed
• Parenteral solution deteriorates fast
•is a carboxylic ester of ampicillin
•Rapidly absorbed from gut
•Hydrolysed by tissue esterase in to active form.
•it is amio-p- hydroxy-benzyl penicillin
•Broad spectrum of activity similar to ampicillin
•Orally effective, and blood levels are twice as that of
•Absorption not affected by food
•Less protein bound
•excreate faster than ampicillin
•incidence of diarrhea is less than ampicillin.Amoxacillin spectrum of activity
•weaker antibacterial spectrum than
• Advantage - against all strains of proteus,
•It is penicillinase susceptable.
•It’s acid labile and must be given parentarilly.
•it is thienyle analogue of carbenicillin.
•antimicrobial activity is twice that of carbenicillin.
• it is betalactamase sensitive.
•broad spectrum activity against gram negative
•it is acid labile.
Clavulanic acid –
•it is well absorbed on oral administration.
•weak antibacterial activity.
•potent and irreversible inhibitor of many
• protect betalactum antibiotic from inactivation.
•Used in combination with amoxacillin and ticarcillin.
Third generation Forth generation
More active against
activity as that 0f
resistent to beta
•more active against klebicella, E.coli.
•Susceptable to staphylococcal beta lactamases.preffered for
surgical prophylaxis. T ½ - 2 hr.
•cephalexin- orally effective first generation cephalosporin.
•Has simillar spectrum of activity.T1/2- 1hr.
has good tissue penetration.
•Has sustained action at the site of infection.
produced by actinomycete.
•Highly resistant to beta lactamases (gram negative organisms)
•treatment of anaerobic infection, surgical infection.
• T ½- 2 hr.
Cefuroxim axetil- orally effective.
Cefotaxime- 3rd generation
•anaerobic & somegram positive bacteria
•meningitis (gram negative bacilli),
• life threatning /hospital aquired infections.
•septicaemias and infections in
• immunocompromised patients.
Cefpirome- serious and resistant hospital
•effective on all gram negative bacterias .
Monobactams- inhibits gram negative
•It is resistant to gram negative beta-
•hospital acquired infections.
• T1/2 1.8 hrs
Imipenem - it is extremely potent and
most broad spectrum beta-lactam
Imipenem spectrum of activity
2. Inhibitors of Protein Synthesis
•MLSK (Macrolides, Lincosamides, Streptogramins,
•Gram-positives, except Streptococus
•combine with aminoglycoside
(Gentamicin or Streptomycin) &
penicillin, ampicillin or vancomycin for
severe enterococcal infections
• In serious infection, with beta-lactams
•Gram-negative nosocomial infections
•severe systemic infections
•Broad spectrum of action
•Rapid bactericidal effect
• Inhibitors of Protein Synthesis
• Related in structure and function
• Drugs differ based on location of
radical groups attached to the 3 ring
•develops resistance quickly
•Hospital use only
• Nephrotoxic and toxic for ears
•Drug Dosage Adjustment:
•Control the serum level for peak -
ensure the bactericidal effect and
avoid side effects
Broad spectrum antibiotic.
Low absorption through git.
Rapid renal excretion,
Marked alteration of intestinal bacteria.
High plasma binding capacity.
Slower renal excretion.
Complete absorbtion from intestine.
High plasma binding.
T1/2- 18-24 hr.
Leaast alteration of intestinal flora.
Low toxixcity &metabolised in liver.
•anti bacterial spectrum – similar penicillin.
•against penicilin resistant staphylococci.
•partially destroyed by gastric juice, (enteric coated tablets)
•Various preparation- enteric coated tablets
Estolate form (most resistant by gastric
•drugs belonging to this group- olindomycin, Spiramycin
(Anti microbial -higher than erythromycin)
New macrolids- roxithromycin, clarithromycin
• Simillar spectrum of erythromycin
• More resistant to acid hydrolysis.
• Better tissue level are achieved.
Erythromycin (Macrolides )
• Chemically differ from the macrolide group -lactone ring
contains a nitrogen atom.
• simillar activity that of erythromycin.
• better tissue penetration.
• longer half life than erythromycin.
• Differ from erythromycin only in methylation of hydroxyl group.
• Rapidly absorbed from gut.
• Has longer half life and better tissue penetration.
(Newer macrolides [azalids] )
Is a lincosamide
•Widely distributed in tissue fluids and tissues, including bone.
•Avoid in the routine odontogenic infection
•An excellent alternative drug in penicillin-resistant anaerobic
•Used in Osteomyelitis of the jaws
•Antimicrobial activity in colon is for 5days.
•severe salmonella infection.
• Empiric treatment of meningitis,
• crosses BBB well.
•bone marrow aplasia
•Relatively small molecule, easily
enters Gram-positive and Gram-
•Spectrum of Action:Gram-positive
and Gram-negative bacteria,
Chlamydia, Mycoplasma and
•Target is Ribosome
•Binds to 50S subunit -inhibits
elongation step of protein synthesis
3. Inhibitors of Membrane
•Gram-negative UTI, blood, CSF and
•used in combination against very
resistant Pseudomonas, KPC.
• High toxicity – neurotoxic and
•Target =Membrane phospholipids,
LPS) & lipoproteins
• Outer and Cytoplasmic Membrane
•More permeable membrane. leakage
cellular molecules, inhibition of
respiration and increased water
uptake leading to cell death.
•Gram-positives are naturally
resistant (too thick to permit access)
4. Anti - Metabolites
• otitis media in children,
chronic bronchitis in adults,
•Enterococcus –poorly expressed
•Ps. aeruginosa (impermeability)
5. Inhibitors of Nucleic Acid
• Small and hydrophilic
• easily diffuse n reach Target =
• Rapid bactericidal activity
• 1st Generation Quinolones:
high concentrations -infection.
• Fluoroquinolones: Garenoxacin
Gram-negative and Gram-positive ( Anaerobes,
Atypicals, S.pneumoniae and Pseudomonas)
• Ciprofloxacin, Levofloxacin, Norfloxacin,
Ofloxacin - More effective (lower MIC values).
Spectrum -Staphylococci, Streptococci and
More widespread tissue distribution .
Ciprofloxacin and Ofloxacin -systemic
• Sparfloxacin, Gatifloxacin, Moxifloxacin
Trovafloxacin (removed cardiac arrhythmias,
liver destruction, phototoxicity.)
•Gatifloxacin (Tequin®) removed from market
final stage of
Pencillin binds to
proteins and inhibit
• Weekens the cell
• vulnerable to
damage by solutes in
• Inhibits cell wall
alanine terminus of
• Inhibits release of
the bulding block
unit from the carrier
high affinity for
• form a micropore in
the fungal wall
• Cell permiability is
through pores ions,
• passive diffusion
• Bind to 30s
• Prevent access to
aminoacyl t RNA to
the acceptor site on
• Inhibition of
• prevent the
binding of the
of the aminoacyl
accepor site on
• peptide bond
• interruption of
• Binds to 50s
acceptor site on
• Interruption of
• Binds to 50s
site as that of
• Diffuse by porin
• Crsses cytoplasmic
membrane by ETC
reduction of ph,
• bind to polysome
and interfears with
• misreading and
• aberrant protiens .
• altered permibility
and further drug
III) Classification based on spectrum of activity
➢Eg: Penicillin G
" Chloramphenicol" Vancomycin
" Clindamycin" Aminoglycosides
" Erythromycin" Cephalosporin(s)
" Tetracyclines" Penicillin(s)
" Bacteriostatic antibiotics" Bactericidal antibiotics
➢IV) Based on type of action
V) Based on the source of antibiotics
➢Fungi : Penicillin, Cephalosporin.
➢Bacteria : Polymyxin B, Bacitracin
➢Actinomycetes : Aminoglycosides, Tetracyclines
VI)Sources of Antibacterial Agents
• Natural - mainly fungal sources
• Semi-synthetic - chemically-altered natural
• Synthetic - chemically designed in the lab
• A. polyenes-
• Amphotricine B, nystatin, hamycin,natamycin
• B. heyerocyclic benzofuran-
• Natamycin- 15mg/kg 12 hourly, infants- [8-30 days older] 15 mg/kg 8 hourly,
children-10mg/kg 6 hourly, adult- 125- 250mg/kg 6 hourly.
• pseudomembranus colitis- orally
• Effective alternative for the treatment of endocarditis, in penicillin allergic
• Teicoplanin- used in osteomyelitis, endocarditis, methicillin resistant strains
• Can be given I.M
• Bacitracin- active against gram positive bacteria.
• Only topically used
• Used in opthalmical infection, infected ulcers, and in dressing of wound after
British journal of surgery 1980, vol 67
Nystatin- highly toxic
• Used for topically application.
• Not absorbed on oral administraton, can be used in monilial
diarrhoea [super infection]
Vancomycin- primarily active against gram positive bacteria.
• bacteriostatic drug, in combination with gentamycin or
tobramycin - bacteriocidal.
• Poorly absorbed after oral absorption, always given I.V.
• Half life 6 hr. Peak concentration is 60 micrograms/ml, higher
concentratio causes ototoxicity.
• Is not a first -line of antibiotic
• Causes potential toxicity- aplastic anemia,gray baby
• Indicated for life thratning conditions-bacterial
meningitis, rickettsial infections.
• Nitroimidazole antibiotic
•anerobic bacteria and protozoa
•antibiotic, amebicide, and antiprotozoal.[
moderate Cl.difficle infection
•MOA-taken up by diffusion, is
selectively absorbed by anerobic
bacteria & protoza.
•non-enzymatically reduced by reacting
with reduced ferredoxin, which is
generated by pyruvate oxido-reductase.
•sulfinamides and thioether linkages with
cysteine enzymes deactivate these
•anaerobes in intra-abdominal abscess,
(B.fragilis, spp, Fusobacterium
spp, Clostridium spp, Peptostreptococcus
spp, Prevotella spp )
• bone and joint infections, septicemia,
•endometritis, or endocarditis.
•Pseudomembranous colitis due
to Clostridium difficile
•Helicobacter pylori eradication therapy,
•MDR -peptic ulcer disease
•periapical abscess, periodontal abscess,
acute pericoronitis of impacted or partially
erupted teeth; often used in conjunction
•Nausea, diarrhea, metallic taste
•IV adminstration- Thrombophlebitis
•Infrequent adverse effects
include: Hypersensitivity reactions
(rash, itch, flushing, fever), headache,
dizziness, vomiting, glossitis, stomatitis,
dark urine, and/or paresthesia.
•High doses and/or long-term systemic
•Leukopenia, neutropenia, peripheral
• National Toxiology Program (NTP) -
• MIC = lowest concentration of antibiotic that inhibits growth
• Interpretation of quantitative susceptibility tests is based on:
relationship of the MIC to the achievable concentration of
antibiotic in body fluids with the dosage given
•For treatment purposes, the dosage of antibiotic given should
yield a peak body fluid concentration 3-5 times higher than the
MIC x 4 = dosage to obtain peak achievable concentration
• MBC = lowest concentration of antibiotic that
MBC – Minimum Bacterial Concentration
PRINCIPLES FOR CHOOSING THE APPROPRIATE
•Identify the causative organism
•70% infections- mixed flora
Indications for obtaining cultures
✓Patient who has received treatment for three days without
✓postoperative wound infection
✓actinomycosis is suspected
✓Osteomyelitis is present
➢Broth dilution susceptability test using a micro dilution plate-
determine quantitative result.
➢Disc diffusion method -qualitative susceptability result.
➢Gradient diffusion test [ E- test]- qualitative susceptability result.
DETERMINATION OF ANTIBIOTIC
1) Proper dose
2) Selection of antibiotic-
➢Disc diffusion method is employed.
➢Use of specific narrow spectrum antibiotic
➢Use of least toxic antibiotic.
3) Proper time interval
➢Plasma half-life (T ½)
➢Elimination and frequency of dosing
➢4) Proper route of administration
III) PRINCIPLES OF ANTIBIOTIC
BACTERICIDAL RATHER THAN A BACTERIOSTATIC
•Bactericidal - immunocompromosed conditions.
•Bacteriostatic- less chance of superinfection
USE OF SPECIFIC, NARROW-SPECTRUM ANTIBIOTIC
➢Decreases resistance, decreases superinfections
Child's BSA in M2
child's age in
x Adult DoseFried's Rule
child's age in years
child's age in years + 12 years
Clarks Rule Pediatric=
child's weight (x)= x
150 lbs 150
x Adult Dose
Fluid Requirements = TBSA burned (%) x Weight (kg) x
4 mL (RL)
Pediatric Dosage formulas
PEDIATRIC DOSAGES OF COMMONLY USED ANTIBIOTICS
Drug Daily dosage
Amoxicillin 20-25 mg/kg/day PO in 3 doses
Ampicillin 25-50 mg/kg/day PO, IM or Iv in 4 doses
Cephalothin 80-160 mg/kg/day PO, IM or IV in 6 doses
Cephalexin 25-50 mg/kg/day PO in 4 doses
Chloramphenicol 75-100 mg/kg/day IV in 4 doses
Clindamycin 10-20 mg/kg/day PO, IM, or IV in 3-4 doses
Cloxacillin 50-100 mg/kg/day PO in doses
Dicloxacillin 12.5-50 mg/kg/day PO in 2 doses
Doxycycline 5.0 mg/kg/day PO in 2 doses
Erythromycin 30-50 mg/kg/day PO in 4 doses
Gentamicin 6.0 mg/kg/day IM in 3 doses
Metronidazole 30-40 mg/kg/day PO
Minocycline 4.0 mg ist day, then 4.0 mg/kg/day in 2 doses
Penicillin G 100,000 U/kg day IM or IV in 3 doses
Penicillin V 50 mg/kg/day PO in 3-4 doses
Streptomycin 20-40 mg/kg/day IM in 3 doses
Tobramycin 3-5 mg/kg/day IM in 3 doses
Vancomycin 50 mg/kg/day IV in 4 doses
TOXIC EFFECTS OF ANTIBIOTIC
Some antibiotic kill / injure human cells
Renal urinary system
Erythromycin Pseudomembranous colitis
Myoclonic seizuresPenicillin and cephalosporin
Carbenicillin (and ticarcillin)
" PROBLEM" ANTIBIOTIC
Decreased platelet aggregation
Antibiotic-associated colitis (AAC)
➢Cramping abdominal pain, fever and leukocytosis
➢Treatment :To discontinue the causative antibiotic, restore fluid
and electrolyte balance and administer anti-clostridia antibiotics
like the usual choice is oral vancomycin, metronidazole
•Eg: overgrowth of Candida in the oral cavity
•broad-spectrum antibiotics results in decreased normal host flora
•Seen in the form of bacteremia, U T I, pneumonia owing to the over
growth of resistent micro-organisms- Klebicella, Aerobacter,
•Oral signs- stomatitis, glossitis, black hairy tongue.[staphylococci,
streptococci, bacteroids, candida] .
•More common In compromised host-
Leukemias,AIDS,Agranulocytosis ,Uncontrolled diabeties,
UNFAVORABLE DRUG INTERACTIONS
Antibiotic Other drug Effect
Aminglycoside Ethacrynic acid Increased ototoxicity
Cephaloridine Ethacrynic acid Nephrotoxicity
Tetracycline Coumarin Increased anticoagulation
Tetracycline Antacids Absorption inhibited
Bactericidal antibiotic Bacteriostatic antibiotic Decreased effectiveness
ampicillin Estrogen-containing birth
Decreased effectiveness of
birth control pills
PREGNANCY AND ANTIBIOTICS
Drugs contraindicated in children-
MONITORING THE PATIENT
➢Response to treatment :
➢The response begins by the second day, and initially it is a
subjective sense of feeling better.
➢From that time onward, objective signs of improvement occur
➢Duration of antibiotic therapy 2-3 days
CAUSES OF FAILURE IN TREATMENT OF INFECTION
➢Inadequate surgical treatment
➢Depressed host defenses
➢Presence of foreign body
▪ Drug not reaching infection
▪ Dose not adequate
▪ Wrong bacterial diagnosis
▪ Wrong antibiotic
Combination antibiotic therapy :
•increase the antibacterial spectrum in life-threatening sepsis of
•to increase the bactericidal effect against a specific organism.
•In the prevention of the rapid emergence of resistant bacteria
• Adjunctive treatment :
– Endodontic therapy or extraction
– Surgical drainage
– Many chronic dentoalveolar abscesses need
•Acute pericoronitis, if severe, may require antibiotic therapy.
•Treatment - debridement, drainage of the site,
penicillin 500 mg qid,
amoxacillin 500mg qid,
clindamycin 300mg qid
Dento Alveolar Abscess :Acute dentoalveolar abscess and cellulitis
Penicillin is the drug of choice
Therapeutic uses of antibiotics in maxillofacial
Soft tissue wounds
•open for six hours or more, (considered infected,)
•if primary closure is elected, a delayed primary closure is preffered
•delayed technique cannot be utilized,-antibiotic support is helpful.
•early primary closure -amoxicillin with clavulanic acid
Chronic inflammatory periodontal diseases-
•TOPICAL MEASURES - Tetracyclins, metronidazole 250mg tid, ,
penicillins500mg qid, cephalosporins
ANUG-Topical measures with systemic antibiotic penicillin,
•Identify the causative organisms
•antibiotics for a much longer period -soft tissue infections
•Jaws that require special therapy
•Actinomycosis ,Fungal infections
Antibiotic regimen for osteomyelitis
For hospitalalized/ when inta-venous therapy is indicated-
Aqueous penicillin, 2 million Units IV Q6h, metronidazole 500mg
q6h for 4 - 6 weeks
Ampicillin/sulbactum 1.5 to 3.0 gm IV q6h for 2 days then
amoxacillin/clavulanate (augmentin)875, 125.mg PO bd for 4 to 6
FOR OUT PATIENT TREATMENT
penicillin V 2gm + metronidazole 500mg q8h for 2 to 4 weeks after
last sequestrum removal and patient with out symptons.
cefoxitin 1 gm q8h IV OR IM
cephalexin 500mg q6h PO for 2 to 4 weeks
clindamycin 600, 900mg q6h IV then clindamycin 300, 450 mg PO.
Regimen for fracture
• therapeutic doses for 10 to 14 days
• should begin as early as possible after diagnosis
• penicillin 2 million units or cefazolin 0.5 gm-1.5 gm 12 hr [25-
• Penicillin 500mg 6 hr [30-40 mg /kg]
• Cephalexin 500mg 6 hr [25- 50 mg/kg]
• In suspected intra-cranial contamination-
• Pre-operatively- naficillin 2-6 gm 6hr+ gentamycin 3-5mg/kg
• Post-operatrively- cephalexin 500mg 6 hr[25-50 mg/kg]
Burke (1973) : “preventive antibiotics are indicated if there is a high
probability that a patient’s natural resistance to bacterial invasion will
not overcome the combined bacterial and physiological challenge of a
PROPHYLAXIS FOR WOUND INFECTION
IN ORAL AND MAXILLOFACIAL SURGERY
•Patient with normal defenses may require prophylaxis for some
•Long (over three hours)procedure requires the use of prophylactic.
•Bone graft procedures.
•implants of metal, plastic or other alloplastic material.
•cytotoxic cancer chemotherapy.
•immunosuppressive drugs such as glucocorticoids, azathioprine
(Imuran), or cyclosporine.
•For intraoral procedures, the drug of choice is penicillin given
parenterally, one or two million units preoperatively and an additional
dose every one and a half to two hours. The last dose is given after
•procedure has risk of significant bacterial contamination and a high
incidence of infection.
•organism & antibiotic susceptibility of the causative organism must
•To be effective and to minimize adverse effects, the antibiotic must
be in the tissue at the time of contamination (operation) and it must
be continued for no more than four hours after cessation of
•The drug must be given in dosages sufficient to reach four times the
MIC of the causative organisms.
Principles for the use of prophylactic
•Slower GI but faster IM absorption
•More body water vs lipid in early
•Limited protein binding in infants
•Larger liver/body weight ratio in
•Immature enzymes in neonates
•Larger brain/body weight ratio and
higher blood–brain barrier
•permeability in younger children
•Immature renal function in infants
Pharmacodynamics respone of
drugs in children
•Valproate hepatotoxicity increased
in young children (with learning
difﬁculties and receiving multiple
•Thalidomide only causes
phocomelia while the limb is forming
•Grey baby syndrome –
chloramphenicol in young children
•Tetracyclines only stain developing
Terence Stephenson,British Journal of Clinical Pharmacology,2005
THE AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
Antibiotic prophylactic regimens 2011
" Clindamycin 20mg/kg (maximum
600mg) IV or IM or cefazolin 25mg/kg
(maximum 1g) IV or IM within 30 min
before dental procedure
" Children allergic to penicillin and
unable to take oral medications
" Clindamycin 20mg/kg (maximum
600mg) orally 1 h prior to dental
" Children allergic to penicillin
Ampicillin 50mg /kg (maximum 2g)IV
or IM within 30 min before dental
Children not allergic to penicillin and
unable to take oral medications
Amoxicillin 50mg/kg (maximum 2g)
orally 1 hr prior to dental procedure
Children not allergic to penicillin
PROPHYLAXIS REGIMEN IN PATIENTS WITH
I) Standard Regimen
A) Preoperatively : 30 minutes before surgery
Ampicillin 1.0-2.0 g IM or IV and
Gentamicin 1.5 mg/kg IM or IV
Penicillin V 1.0 g PO 6 hours after initial dose or
Repeat preoperative regimen 8 hours after initial dose
II) Penicillin – allergic patient
•Preoperatively : 1.0 g by slow IV drip (over 6 hour period).
•1 hour before surgery
•Postoperatively : No repeat doses
III) Pediatric dosage
A) Standard regimen
•Ampicillin : 50 mg/kg per dose
•Gentamicin : 2.0 mg/kg per dose
•Penicillin V : 500 mg per dose
B) Penicillin Allergic patient
•Vancomycin 20 mg/kg per dose
• Amoxacillin 3 gm or clindamycin 600mg 1 hr pre- operatively and
amoxacillin 1gm after 6 hr
• Amoxacillin 0.5 gm IM after 6 hr or 3 gm 4 hr + 1 gm probensid post-
• Clarithromycin 500mg or azithromycin 2 gm 6 hr post- operatively.
• With previous history of infective endocarditis- Amox 1gm+ gentamycin
120mg IM and Amox 0.5 oral gm after 6 hr
• Vancomycin IV 1gm + gentamycin 120 mg 6 hr post- operatively.
Antibiotics in dentistry--a boon or bane? APUA Newsletter 15(1):1-5. Walton RE, Zerr M, 1997.
American Heart Association (AHA) -taking antibiotics for routine dental procedures
was no longer recommended.
Today antibiotics are only recommended for:
1. An artificial heart valve or who have had a heart valve repaired with artificial
2. A history of endocarditis.
3. Certain congenital heart defects.
4. A heart transplant with abnormal heart valve function.
dentistry is the medical discipline guilty of some of the most antibiotics abuse.
•several negative consequences happen.
•Overuse promotes natural mutation of common bacteria, resulting in newer
•Antibiotics -VERY useful to treat resistant bacterial infection, but remain effective if
urgent changes are made to curb the spread of antibiotic-resistant bacteria and
ANTIBIOTIC ALLERGY TESTS
•NO SINGLE TEST FOR ANTIBIOTIC ALLERGY.
•Except Penicillin, immunoreactive drug metabolites rarely identified.
• SKIN TESTING -
•Amoxycillin side chain–specific immune reactions warrant specific
amoxycillin skin testing.
•Intradermal skin testing is difficult to do in children under 10 years of
•Most nonpruritic maculopapular rashes will not be predicted by skin
ASCIA HPIP Antibiotic allergy 2014,351.38 KB
Principle of skin testing
•allergen is introduced into the skin
•contact with cutaneous mast cells
•Binding of the allergen occurs
•patient's mast cells are coated with IgE recognizing that specific allergen.
•then adjacent allergen-specific IgE -cross-linked on the mast cell surface & activated
•positive skin test,
•transient "wheal-and-flare" reaction (15 to 20 min)
•central area of superficial skin edema (wheal) surrounded by erythema (flare). pruritic
reaction represents the immediate phase.
•cutaneous mast cells are not activated, (no edema or erythema develo& the test is
• Falsely negative skin tests such as antihistamines
Penicillin skin testing , Solensky, Franklin Adkinson Jr, UpToDate, Feb 2014
•BLOOD ALLERGY TESTING (ImmunoCAP) is available for penicillin G,
penicillin V, amoxicillin and Cefaclor
•most accurate -close to the time of the event.
•Tryptase elevation collected within 1–4 hours after a reaction is consistent
with mast cell degranulation.
• blood count (looking for eosinophilia) and biochemistry (looking for raised
•Eosinophilia and/or abnormal liver function tests -T-cell/non-IgE-mediated
•results of allergy testing may become negative with time. Even in current
•For IgE-mediated antibiotic allergy, used where skin and intradermal tests are
negative, or H/O of low risk and alternative drugs are clearly inferior.
•under medical supervision (clinical immunology/allergy specialist)
ASCIA HPIP Antibiotic allergy 2014,351.38 KB
•Semi synthetic penicillins such as ticarcillin and piperacillin contain the same
nucleus as penicillin G.
•Cephalosporins share a common beta-lactam ring with the penicillins - cross-
reactivity is quite low.
•3-7% of those with penicillin allergy, may have allergic reactions to
cephalosporins as well.
•Monobactams such as aztreonam may be safely administered to penicillin
•carbapenems (imipenem) represent a significant risk to penicillin-allergic
ASCIA HPIP Antibiotic allergy 2014,351.38 KB
Suggested management of penicillin hypersensitivity
Clinical situation Possible course of action
A clear history of an immediate (IgE-mediated)
reaction to penicillin (NB1) OR
A vague history
and an urgent situation (NB1)
1. Do not administer penicillin, a cephalosporin or
2. Reconsider clinical necessity for antibiotic
3. If treatment is definitely required, administer an
alternative antibiotic. Penicillin is definitely
preferred, undertake desensitisation.
A vague history of an immediate (IgE-mediated)
reaction to penicillin and a non-urgent situation
Same as above
If a penicillin is definitely preferred, skin testing
should occur under the supervision of a clinical
immunology/allergy specialist. Negative-graded
challenge; if positive,- desensitisation program.
A clear history of a non-immediate reaction to
penicillin (NOT drug rash with eosinophilia and
systemic symptoms [DRESS], Stevens-Johnson
syndrome or variants)
1. Reconsider clinical necessity for antibiotic
2. If treatment is definitely required, administer an
alternative non-penicillin antibiotic (e.g.
cephalosporin, aztreonam or non–beta-lactam
antibiotic). If a penicillin is definitely indicated,
proceed with therapy, treating any mild reactions
A vague history of a non-immediate reaction to
penicillin (not DRESS, Stevens-Johnson
syndrome or variants)
Same as above
A clear or vague history of DRESS, Stevens- Same as above
Triple Antibiotic Paste
• metronidazole, ciprofloxacin, and minocycline
•combination would be needed -diverse flora in root canal
•metronidazole -at a high concentration, it cannot kill all the bacteria, indicating the
necessity for combination of other drugs
•TAP first tested by Sato et al.
• Metronidazole (nitroimidazole) -a broad spectrum against protozoa &anaerobic
•Minocycline (semisynthetic tetracycline) with a similar spectrum of activity.
• Ciprofloxacin, a synthetic fluoroquinolone, has a bactericidal mode of action
•increase in root thickness and length, resembling normal maturation of the root.
• the infected area requires a normal blood supply which is no longer in necrotic pulps.
•Therefore, local application of antibiotics most effective mode for delivering the drug.
•30% reduxtion in bacteria -2 weeks.
•successful treatment- sterilization of canals and healing of periapical pathology,
immature root development, necrotic pulps, and apical periodontitis
•managing non-vital young permanent tooth is based on the availability of viable stem
•drawbacks of this technique- Development of resistant bacterial strains and tooth
discoloration J Phrm Bioallied Science Aug 2012,4(suppl2) S230-233
PAIN CONTROL STRATEGY
• IV Sedation
• Nitrous Oxide
• Local Anesthesia
Algesia : It is defined as an ill defined,
unpleasant sensation, usually evoked by an
external or internal noxious stimuli.
Analgesic : A drug that selectively relieves
pain by acting in the CNS or peripheral pain
mechanism,without significantly altering the
• In England 18th century- Reverend Freudman first -
cure of agues(Fever)
• willow bark was a bitter glycoside -Salicin, 1st isolated
in 1829 by Leroux, -antipyretic effect.
• Sodium salicylate was 1st used for -rheumatic fever
• And as antipyretic in 1875 &
• its utility in the gout soon followed.
• Hoffman -prepared acetyl salicylic acid.
• 1899 introuduced by Dreses under the name aspirin.
NON-SELECTIVE COX INHIBITORs
• Acetyl salicylic acid.
• Rapidly converted in the body to salicylic acid which is
responsible for most of its action.
• Only drug amongst NSAIDs which irreversibly inhibit
PHARMACOLOGICAL ACTIONS OF SALICYLATES
• Analgesic: 600mg equivalent to 60mg codeine.
• Antipyretic: promotes heat loss, resets hypothalamic
• Anti-inflammatory: 3-6gm/day; quenching of free
• Respiration is stimulated; dose dependant.
• Metabolic: inflammatory doses; may decrease blood
sugar in diabetics.
• CVS: no direct effect in therapeutic doses.
• GIT: irritate gastric mucosa.
• Blood: irreversibly inhibits thromboxane synthesis.
• Absorption: Stomach and Small intestine.
• Poor water solubility.
• Solubility higher at high pH(alkaline medium)
• 80% plasma protein bound.
• Enters brain, crosses placenta.
• Excretion: Urine.
• T ½ 15-20min.
• Analgesic, Antipyretic, Anti inflammatory.
• Acute rheumatic fever.
• Rheumatoid arthritis.
• Postmyocardial infarction and post stroke
• Side effects: At analgesic dose(0.3-1.5
gm/day) causes nausea,vomiting,epigastric
pain,increased blood loss in stool.
• Idiosyncrasy and hypersensitivity: Infrequent
• Salicylism at antiinflammatory doses.
• Reye’s syndrome.
• Acute salicylate poisoning: fatal dose 15-
30g; serum >50mg/dl.
PRECAUTIONS & CONTRAINDICATION
Should be stopped 1 week before elective
surgery(Brennen et al. presented evidence
suggesting low-dose aspirin should be continued
during dental surgical procedures).
In Chronic liver diseases.
During pregnancy & avoided in breast feeding.
Avoided inG-6-PD deficient individuals.
Avoided in diabetics.
• Aminopyrine and antipyrine : agranulocytosis.
• Phenylbutazone and Oxyphenbutazone .
• Potent antiinflammatory drug,but poor analgesic and
• Banned: risk of bone marrow depression.
• Potent and promptly acting analgesic and antipyretic.
• Few cases of agranulocytosis reported.
• Similar to metamizol.
INDOLE DERIVATIVES (Indomethacin,
• Potent anti-inflammatory drug, comparable to
• Analgesic action is better than phenylbutazone, it
relieves only inflammatory or tissue injury related
• Highly potent inhibitor of PG synthesis and
suppresses neutrophil motility.
• Rectal absorption is slow but dependable.
• 90% bound to plasma proteins
• Partly metabolized in liver to inactive products and
excreted by kidney.
• Plasma t1/2 is 2-5 hours.
• High incidence of gastrointestinal & cardiovascular
• Frontal headache, leukopenia, increased risk of
• Pregnant women & children
• A prodrug that converts into an active sulfide
• Antiinflammatory action < Indomethacin.
• At lower doses, selectively inhibit extrarenal
Propionic acid derivatives
• Rated as the safest (SADR reporting system in U.K.)
• Better tolerated than aspirin.
• Anti- inflammatory,analgesic & antipyretic efficacy is
lower than high dose of aspirin.
• Most commonly used NSAID .
Dose: 400-800mg TD, Ibuprofen
250mg BD-TD, Naproxen
• Naproxen : more potent, but inhibits platelet
aggregation & prolong BT.
• 200mg Ibuprofen has same analgesic effect as
acetaminophen 650mg/ codeine 60mg
• 400mg and 600mg doses produced greater levels of
Hargreaves K,Abott PV; Aust Dent J 2005
• 90% plasma protein bound.
• Enter brain, synovial fluid, placenta.
• Liver – hydroxylation, glucoronide conjugation.
• Excreted in urine.
• Rheumatoid arthritis, ankylosing spondylitis who cannot
• Soft tissue injuries, fractures ,vasectomy, tooth
extraction, post partum and post operatively
• It is available as an `Over The Counter Drug’
• Gastric discomfort, nausea & vomiting.
• Occult blood loss are rare.
• Precipitate asthma.
• Not prescribed in pregnant women & should be avoided
in peptic ulcer patients.
Drug MOA Route Bioav
T ½ Uses AE
as well as
muscle pain, soft
tissue pain , joint
RA, OA, bursitis,
post traumatic, post
in liver by
Drug MOA Route Bioav
T ½ Uses AE
dental & acute
free of respiratory
orally 99% 2-5
short lasting painful
Sinusitis and other
ear, nose, throat
pain and OA.
PARA-AMINO PHENOL DERIVATIVES (Paracetamol )
• Introduced in 1887.
• Acetaminophen- deethylated active metabolite of
• CNS-raises pain threshold.
• negligible anti-inflammatory action.
• Poor inhibitor of PG synthesis in peripheral tissues, but
more active on COX in brain.
• Gastric irritation is insignificant –except in overdose
• Does not affect function or clotting factors and is not
ANALGESIC –ANTIPYRETICS WITH POOR
• 1/3 is protein bound in plasma .
• Excreted rapidly in urine.
• Plasma t l/2 is 2-3 hours.
• Effects after an oral dose last 3-5hrs.
•Nausea, rashes, leukopenia.
•Acute PCT poisoning – Dose >150 mg/kg or > 10g in
adult. Fatality >250mg/kg , jaundice starts after 2 days.
(In chronic alcoholics,even 5-6g/day taken for a
few days can result in hepatotoxicity)
N-acetylcysteine (150mg/kg iv) is the drug of choice.
• Musculoskeletal pain.
• Safe in gastric irritation, ulceration, bleeding,
pregnancy & lactating mother.
For Elderly Patients:
• Acetaminophen is the drug of choice.
• Selective COX-2 inhibitors are the second option.
Liver & Kidney Disases:
• Regular strength Acetaminophe(2-2.5 grams in divided
• Nimesulide is the drug of choice.
When additional pain control is
History of Opioids
• Mentioned in EBER’S papyrus 1500BC.
• THEOPHRATUS writings 300BC.
• GALEN 2nd century AD.
• Pharmacist – SERTURNER 1806 isolated
active component “morphine” from opium;
named after Greek god of dreams MORPHEUS.
CNS: interacts primarily with μ opiod
• Analgesia: strong analgesic; suppression
of pain is selective, without affecting other
sensations; degree increases with dose.
• Sedation: drowsiness, higher doses
induce sleep and coma.
• Mood & subjective effects: mental clouding, loss of
• Respiratory system: depresses RS in dose
• Cough centre: depressed.
• Temperature regulating centre: hypothermia occurs
in cold surroundings.
• Vasomotor centre:fall in BP at higher doses.
• CVS: vasodilatation due to direct action decreasing
tone of blood vessels
• Neuro endocrine: hypothalamic action on pituitary is
• GIT: constipation (direct action on intestines & in CNS)
• ANS: central sympathetic stimulation- causes mild
• First pass metabolism: high & variable.
• Concentrations in Liver, spleen, kidney>plasma.
• Crosses placenta.
• 30% ppb.
• Metabolised in Liver by glucoronide conjugation.
• T ½ 2-3hrs.
• Elimination complete by 24hrs.
• Side effects: sedation, mental clouding,
lethargy, dysphoria, blurring of vision.
• Idiosyncrasy and allergy: rare.
• Apnoea: in newborns if mother is on it during labor.
• Acute morphine poisoning: 50mg in non-tolerant adult.
Human lethal dose: 250mg.
• Tolerance and dependence: high.
• Infants more susceptible to resp depression.
• Respiratory disease.
• Head injury: intracranial tension
• Hypotensive and hypovolaemia: exaggerate fall in BP.
• Elderly male: chances of urinary retention.
• Liver, kidney disease.
•Codeine •Pethidine •Methadone •Tramadol
side effect at
to morphine in
•Not a cough
•T ½ 2-3hrs.
•Side effects –
•Binds to tissue
•T ½ 24-36hrs
intensity , short
•T ½ 3-5hrs.
•100mg IV =
•Not effective in
• NSAID-OPIOID COMBINATION
• NSAID-NSAID COMBINATION
1000mg paracetamol + 600mg ibuprofen
Two general methods for drug combination :
1. Alternating regimen consisting of an NSAID
followed by an acetaminophen-opioid
2. Single NSAID-opioid combination
e.g. Combunox (5mg oxycodone+400mg ibuprofen)
The potent antiinflammatory properties of
glucocorticoids were first appreciated &
utilized as an adjunct to endodontic therapy
more than 50years ago.
Used as an intracanal medicament &
systemically as a means to decrease pain &
inflammation in endodontic patients.
Ingle’s endodontics 6th Ed.
In the form of a paste mixed with antibiotics
• Dexamethasone solution.
• Kenacomb: Each gram contains 100 000 units
nystatin, 2.5 mg neomycin base (as sulphate), 0.25 mg
gramicidin, and 1.0 mg triamcinolone acetonide.
• Ledermix paste: triamcinolone 10mg, demeclocycline
• Very potent & highly selective glucocorticoid.
• Long acting.
• Pituitary depression.
• Used in inflammatory & allergic condition.
• Dose: 8mg loading dose,followed by 4 mg
every eight hours (upto max. 5 days).
• Considerations for Effective “Three-D” Pain
2. Definitive dental treatment
a. Pretreat with NSAIDs or acetaminophen when appropriate.
b. Use long-acting local anesthetics when indicated.
C. Use a flexible prescription plan.
d. Prescribe “by the clock” rather than as needed.
Cohen, 10th Ed.
Procedure/ condition Initial choice If more needed
1.Canal debridement Aspirin/ NSAID Analgesic with ½ gm
2.Canal debridement where
Analgesic +½ gm
Analgesic with 1gm
3.Canal fillings where
overfillings has occurred &
periapical tissue is normal
Analgesic +½ gm
Analgesic with 1gm
4.Root amputation without
surgery with minimal trauma
ASA,NSAID Analgesic with ½ gm
6.Extensive surgery with
Vicodin ,Lortab [steroids] Meperedine,
7.Call after office hours with
Analgesic with 1g of cod. Tradol, Vicodin
8. Call after office hours with Vicodin ,Lortab Demerol,Weine,6th Ed.
Antibiotic prophylaxis Infective endocarditis -updated by the American Heart
Association (AHA) and National Institute for Health (NIH) and Clinical
Excellence. Aim To determine the specific infective endocarditis antibiotic
prophylaxis prescribing practices of dentists in Singapore. Methods A
questionnaire survey was sent through an email link and by postal mail.
Statistical analysis was carried out using SPSS 19.0. Results Responses
were received from 458 dentists The accuracy of prescriptions for 13 cardiac
conditions and 12 dental procedures were evaluated.. The median number
of accurate answers for dental procedures was generally high, both for
dentists who followed the AHA 1999 guidelines (median = 10) and AHA
2007 (median = 9) guidelines. 82.8% felt that developing a local guideline
would be beneficial to the local dental community. Conclusion Dentists were
accurate in their prescriptions of antibiotic prophylaxis for dental procedures,
but not for cardiac conditions. It may be helpful to attain a consensus among
local cardiologists and dentists to unify the antibiotic prophylaxis prescription
practices in Singapore.
Antibiotic prophylaxis prescribing
practices of dentists in Singapore.
International Dental Journal. Apr2014, Vol. 64 Issue 2, p108-114. 7p
The purpose of this in vitro study was to compare the ability of triple antibiotic
paste (TAP) to calcium hydroxide (CH) in disinfecting dentinal tubules.
Sixty root blocks were obtained from extracted single-rooted human teeth. The
root canals were enlarged with Gates-Glidden drills up to size 3 and were
contaminated with (E. faecalis), and then left for 21 days. The contaminated
blocks were treated with saline (as negative control), CH or TAP. Dentin debris
was obtained at the end of first and 7th days, using Gates-Glidden drills sizes 4
and 5 from two different depths of 100 and 200 um. The vital bacterial load was
assessed by counting the number of colony forming units (CFUs). The data was
analyzed with the Kruskal-Wallis H and Dunn Post-Hoc tests & Wilcoxon
Signed Ranks test (P<0.05).
Results: TAP significantly decreased the number of CFUs in both depths and
time intervals (P<0.001), while the CH group showed a moderate antibacterial
Conclusion: TAP is more effective in disinfecting the canal against E. faecalis
compared to CH.
The Ability of Triple Antibiotic Paste and
Calcium Hydroxide in Disinfection of Dentinal
Iranian Endodontic Journal. 2014, Vol. 9 Issue 2, p123-126. 4p.
• The authors recruited parent-child pairs visiting the Pediatric Clinic at
the College of Dentistry at The University of Tennessee Health
Science Center, Memphis, and three private dental offices. They
made parents to measure 5 milliliters of liquid by using a medicine
cup with clear markings, a medicine cup with printed markings, a
cylindrical measuring spoon and an oral syringe,each device weighed
before and after the measuring exercise and compared the difference
in weight with 5 mL. Results-McNemar test revealed a significant
difference in parents' ability to measure accurate doses with the
• Conclusions- Medicine cups had a higher occurrence of dosing
errors when compared with the other devices.
• We improve pain management in pediatric patients by educating
parents about accurate measuring devices, weight-based dosing and
correct interpretation of medication dosing charts.
Parents' understanding of an accuracy in
using measuring devices to administer
liquid oral pain medication.
Journal of the American Dental Association (JADA). Feb2014, Vol. 145 Issue 2, p141-149.
• An 8-month-old boy underwent cleft palate repair and placement of
bilateral myringotomy tubes. His anesthetic course was uneventful,
consisting of maintenance with desflurane and fentanyl. He received
acetaminophen for routine postoperative pain management and was
tolerating liquids and discharged home on postoperative day 1.
• Day 3, child - profoundly lethargic with multiple episodes of emesis
,45-second tonic-clonic seizure in transport to the medical center, and
initial lab results - total bilirubin 3.1 mg/dL, and a serum
acetaminophen level -83 µg/mL. Aggressive measures -blood
products and periprocedural fresh frozen plasma,
peracillin/tazobactam, and intravenous infusions of N-acetylcysteine,
sodium phenylacetate and sodium benzoate, carnitine, and citrulline
were administered. metabolic acidosis and acute hepatitis began to
correct by day 4, and discharged on day 15.
• Conclusion: This report challenges existing guidelines for
acetaminophen administration and emphasizes the importance of
close follow-up and hydration after even relatively minor surgery.
Acute Liver Failure Following Cleft Palate Repair: A
Case of Therapeutic Acetaminophen Toxicity.
Cleft Palate-Craniofacial Journal. Nov2013, Vol. 50 Issue 6, p747-750. 4p.
•therapeutic transactions between physician and patient.
•The art of prescription writing is an ancient inheritance.
•most significant written communications of the human race.
• The ancient symbol, Rx, signifying the appeal, Latin was adopted,
•Present-day prescription contain single ingredient, written in English,
with doses given in the metric system.
•ancient "Rx" and the Latin "Signatura," abbreviated as "Sig.," are all
that remain of the ancient art of the prescription.
•Accurate diagnosis; proper selection of medication, dosage form and
route of administration; proper size and timing of dose; precise
dispensing; accurate labeling; and correct packaging all must be
•Form of the Written Prescription- Barest form- the superscription, the inscription, the
subscription, the signa, and the name of the prescriber - written within the confines of a
•Superscription- Date, the name, address and age of the patient; and the symbol Rx (an
abbreviation for "recipe," the Latin for "take thou."
•Inscription - body of the prescription, containing the name and amount or strength of
•Subscription - The directions to the pharmacist, usually consisting of a short sentence
such as: "make a solution," "mix and place into 10 capsules," or "dispense 10 tablets."
•Signatura- From the Latin "signa,“, contains the directions to the patient. written in
English; however, physicians continue Latin abbreviations, e.g. "1 cap t.i.d. pc. Since
the pharmacist always writes the label in English, the use of such abbreviations or
symbols should be discouraged.
•"take as directed”-avoided.
•directions to the patient - phrases as "for pain,for relief of headache, to relieve itching”
•Labeling- physician wants his patient to know the name of the drug, the box on
the prescription form marked "label" should be checked.
•Refills- The physician should designate the number of refills he wishes the
patient to have.
•Proprietary vs. Non-Proprietary ("Generic") Prescriptions- In recent years,
some hospitals and private physicians indicate willingness to pharmacist to
dispense a non-proprietary or "generic-named" preparation instead of the trade
name item written on the prescription. Some have a box on the prescription
designated "N.P.P." e pharmacist can sell a less expensive drug to the patient.
•The amount to be dispensed should be clearly stated and needed by the patient.
Excessive amounts should never be dispensed,
•It is far better to have several refills of a prescription than to have an excessive
amount prescribed at one time.
Table 1. Common Terms and Abbreviations
Term or Phrase Abbreviation Meaning
ad ad to, up to
ad libitum ad. lib. at pleasure
ana a.a. of each
ante cibos a.c. before meals
aqua aq. water
bis in die b.i.d. twice a day
collyrium collyr. eye lotion
cum c. with
cum aqua cum aq. with water
dentur tales doses d.t.d. give such doses
dispensa disp. dispense
et et and
gutta, guttae gtt. drop, drops
hora somni h.s. at bedtime
in vitro in vit. in glass
misce m. mix
non repetatur non. rep. do not repeat
oculus dexter o.d. right eye
oculus sinister o.s. left eye
omni die o.d. daily
omni mane o.m. every morning
omni nocte o.n. every night
per os p.o. by mouth
placebo placebo to please
post cibos p.c. after meals
pro re nata p.r.n. as the occasion arises
quantum sufficiat q.s. sufficient quantity
quater in die q.i.d. four times a day
recipe Rx take
semis ss _ one-half
sine s,s without
si opus sit s.o.s. if necessary
ter in die t.i.d. three times a day
trochiscus, torchisci troch. lozenge, lozenges
unguentum ungt. ointment
ut dictum ut dict. as directed
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