The document discusses pain management and use of analgesics in pediatric dentistry. It begins by stating that the most common situations requiring drug therapy in children are pain and infection. It then classifies analgesics and describes their uses, dosages, and side effects. Centrally-acting narcotic analgesics are generally the most effective for acute pain but have more adverse effects. Peripherally-acting non-narcotic analgesics have less effectiveness but also less adverse effects. Topical analgesics can help reduce soft tissue pain. Combinations of analgesics may provide enhanced pain relief. Antibiotics are also discussed, along with their appropriate use and dosing in pediatric patients.

1. -BY MAHAK RALLI
ROL NO. 41
THIRD YEAR BDS

2.  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.

3.  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

4.  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.

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

6.  Analgesics can be broadly classified into-
I. Centrally acting (narcotic) analgesics
eg. Morphine, codeine, pethidine.
II. Peripherally acting (non-narcotic) analgesics
eg. Diclofenac, paracetamol.
III. Topical analgesics
eg. Ethyl aminobenzoate

7.  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.

8.  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

9.  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)

10. 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 clotting
Supplied as • suspension, oral drops: 40 mg/ml
• suspension, oral : 100mg/5ml
• Tab, chewable : 50mg, 100mg contains
phenlyanaline
• Tab : 200mg, 400mg, 600mg

12.  Dosage : single dose every 4-6 hours
max. dosage- 1.2g
AGE (year) DOSE (mg)
Under 1 60
1-6 60-120
6-12 150-300

13. Precautions The drug should not be administered for more than 10
days, as it is available without prescription
Side effects 1. causes renal injury
2. 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

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

16. Dosage Children : 5-10mg/kg/dose, every 8-12 hours
Adult : 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/ml
Tablets- 250mg, 375mg, 500mg.

18. Dosage 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 properties
Side effects Allergic reaction in patients with pre-existing asthma,
atopy and nasal polyp
Development of Reye Syndrome
Gastric ulcers
Last choice of drug in children
Supplied as Chewable tablets – 81mg
Caplets, tablets- 325mg, 500mg
Suppository, rectal- 300mg, 600mg

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

20.  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 paracetamol
2. diclofenac sodium and paracetamol
3. nimesulide and paracetamol
4. mefenamic acid and paracetamol

21. Dosage Children </= 44kg-oral :
Codiene- 0.5to 1mg/kg/dose every 4-6hrs
Acetaminophen- 10 to 15mg/kg/dose every 4-6hrds up
to 2.6g/day
Children >/= 44kg-oral :
Codeine-30 to 60mg/dose every 4-6 hours
Acetaminophen-325mg to 650mg/dose every 4-6
hours, up to 4g daily.
Advantage 1. Codeine acts at central site of pain
2. Acetaminophen acts at the peripheral site for
enhanced analgesia

22. Side effects Codeine can cause nausea, vomiting, sedation,
constipation and dependency
Acetaminophen may cause liver damage in overdose
Supplied as Suspension : acetaminophen 120mg and codeine
phosphate 12mg/5ml
Tablets : acetaminophen 300mg and codeine phosphate
60mg

23.  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.

25. • 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. Staphlyococcus
3. Actinomyces
4. Veillonella
5. Lactobacilli
6. Nocardia
7. Fusobacterium

26.  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.

27.  Antibiotics act through specific mechanisms
dictated by the site of action-
1. Cell membrane
2. Cell wall loss of integrity rupture
bactericidal
3. Nucleic acid content interferes with
ribosomal function replication, protein
synthesis and information transfer is
disrupted
4. Intermediary metabolism metabolic
pathways interrupted suppression of
growth

28. 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.

29.  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 rule
2. Young’s rule

30.  Clark’s rule
child’s weight in lb X adult dose = child dose
150
 Young’s rule
Age of child X adult dose = Child’s dose
age + 12
 Anders in 1992
 Administration of drug based on infants weight
is seldom appropriate.
dose p = dose a X weight pd
weight ad

31.  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.

34.  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.

35.  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.

36.  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 A
2. Regimen B

37. Regimen A Regimen B
1. 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 :
A. Penicillin V – 2g orally 30-60mins
prior to dental procedure, then
500mg every 6 hours for 8 doses.
B. 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

38. Antibiotics Generic Names Brand Names
Penicillins Oral penicillin G
Penicillin V
Pentids, Pizerpen,
Ledercillin VK,
Veracillin, V-cillin-K
Cephalosporins Cephalexin
Cephradine
Keflex, Anspor, Velosef
Erythromycin Erythromycin base
Erythromycin succinate
Erythromycin stearate
Erythromycin estolate
E-mycin, erythrocin,
Pedia mycin, eryhtrocin
ilosone
Lincosamides Lincomycin
Clindamycin
Lincocin
Cleocin

39.  Amoxicillin
 Amoxicillin + Clavulanate potassium
 Amoxicillin + cloxacillin
 Ampicillin
 Cephalexin
 Cotrimoxazole
 Erythromycin
 Metronidazole

40. 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, 500mg
Tablet-125mg, 250mg
Powder for suspension- 50mg/ml
Side effects Increased thirst, nausea, vomiting, diarrhoea, pruritis,
urticaria, angioneurotic oedema, bronchospasm,
anaphylaxis.

43. 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, 500mg
Chewable tablets 125mg and 250mg
Powder 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

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

45. 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 500mg
Capsule 250 and 500mg
Powder for oral suspension 125mg, 150mg/15ml
Side effects Increased thirst, Nausea, Vomitting, Hyperkalemia,
Pruritis, Urticaria, Bronchospasm, Anaphylaxis
Contra indications Hypersensitivity to penicillin

46. 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 500mg
Powder 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

47. Capsule Roscillin, Biocillin,
Ampilin
Syrup Amipilin 125mg/5ml

48. 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, 500mg
Tablet 250mg, 500mg
Oral 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.

52. 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 SMZ
Suspension 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

55. 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, 500mg
Suspension 250mg/5dl
Side effects Candidiasis, rash, urticaria, pruritis, hypersensitivity,
NVD, hepatotoxicity, abdominal pain,
pseudomembranous tnnitus
Contra indications Hypersensitivity to pre existing hepatic disease

57. 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/TID
Available forms Tab 200mg, 400mg
Suspension 200mg/5ml
Side 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)

59.  Paediatric drug therapy and immunization by
RK Suneja.
 Textbook of paediatric dentistry by Braham
and Morris.
 Text book of paediatric dentistry by Shobha
Tandon.