Download Common Medication prescribed in pediatric dentistry.

Common Medications prescribed in pediatric
dentistry.
• Introduction;
• Several categories of medications prescribed
by dentist to manage a variety of diseases and
conditions associated with oral cavity; i.e
Bacterial , fungal ,Viral , pain and caries
prevention.
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INTRODUCTION
• Body of the pediatric patient is not simply a
miniaturized version of his adult counter part.
child physiology and anatomy significantly
differ from those of adults.
• Pediatric dentist must consider this
differences when making therapeutic choices
about young patient.
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CONTNU..
• In pediatric patient administration of drugs is
complicated by the necessity to adjust the
dose to accommodate their lower weight and
body size. so the pediatric patient can not be
given adult dose. Therefore adjustment of the
dose in pediatric patient is necessary.
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Cont..
• PEDIATRIC DRUG DOSAGE
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Cont..
Drug (WHO definition)  Any substance or product
that is used or intended to be used to modify or explore
physiological system or pathological states for the benefit
of the recipient.
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Cont…
DRUG ;
-- ANY SUBSTANCE
USED TO DIAGNOSE
TREAT, RELEIVE, CURE OR PREVENT DISEASE
• --MAY ALSO BE USED TO ELIMINATE PAIN OR ALTER
MOOD OR BEHAVIOUR
• -- HAS THE POTENCY TO CHANGE ONE OR MORE
BODILY FUNCTIONS
•
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DRUG DOSAGE
DOSE ;..
IS THE AMOUNT OF DRUG THE PATIENT TAKES OVER A GIVEN
PERIOD OF TIME.
• FACTORS TO BE CONSIDERED WHEN DISPENSING A DRUG• AGE OF THE PATIENT,
• WEIGHT OF THE PATIENT, GENDER,
• TIME OF THE DAY THE DRUG IS TO BE TAKEN AND
• THE DRUG FORM
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Dosage forms:
Solid dosage forms--Powders, granules, tablets, capsules etc.
Liquid dosage forms
 Aqueous solution
Syrup, liquids, injection etc.
 Aqueous Suspensions
Mixtures, emulsions etc.
Dosage forms for external use:
Liniments, lotion, ointments, paste, gel aerosol, suppositories,
transdermal adhesive patch etc.
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Drug Dosage
Dose is the appropriate amount of a drug needed
to produce a certain degree of response in a patient.
Therapeutic dose
In clinical practice, the required amount of drug in
wt, volume, moles/international units, that is necessary
to provide a desired effect.
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Drug Dosage
Dose is the appropriate amount of a drug needed
to produce a certain degree of response in a patient.
Therapeutic dose
In clinical practice, the required amount of drug in
wt, volume, moles/international units, that is necessary
to provide a desired effect.
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Factors influencing drug dosage
Dosage literally means the method of dosing
and represents a decision about 4 variables:
a. The dosage form and the amount of the drug
to be administered at one time.
b. The route of administration
c. The interval between doses and
d. The duration
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Rules for drug dosage..
CALCULATION OF PEDIATRIC DOSE
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Rules of drug dosage..
• No rules guarantee the efficacy and safety of
the drugs in children.
• Dosage requirements constantly changes as a
function of the body organs and age.
• Dosage based on body weight, age, is practical
but not ideal concept
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Rules of drug dosage…
• Adjustment of dosage in pediatric patient
• Several rules exist to compute the dose for
drugs for child.
• Clark rule , which based on the typical adult
weight ( 70 KG, or 150 LB )
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Rules of drug dosage….
Child dose = child’s weight (kg) x adult dose
------------------------------------70kg( typical adult weight)
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Rules of drug dosage..
• child’dose = child’s weight(lb) x adult dose
----------------------------------------150(lb).typical adult weight
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Rules of drug dosage
• Young’s rule
This rule based on the age of the child
regardless of the weight.
It is to divide the age of the child by the age
of the child +12 and the resulting fraction is
multiplied by the adult dose.
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Rules of drug dosage
• Catzel’s rule
It offers a safe guide based on the surface area and
expressed as a percentage of adult dose for a
patient.
Age in years
% of adult dose
1
25
3
35
7
50
12
75
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• Use of safe recommended dose.
• Reco dose x child weight
• ---------------------------------• No. of time intervale.
• Rec safe dose,, from drug references
• i.e Ampicillin 25-50mg/kg/body wt
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Rules of drug dosage…
• EXAMPLE.,,
• Calculation dose of Ampicillin for a child
weighing 38 lb.
• The usual adult dose is 2000 mg in 4 divided
dose
• Clarks rule – weight of the child lb /150 x adult
dose.
• 38/150 x 2000= 500mg in 4 divided dose
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Rules of drug dosage
*
Prescription writing
for pediatric patients
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PRESCRIOION WRITING
• Prescription,
•
is an order from prescriber ,, doctors ,or
legally licensed person,, to the pharmacist for
particular medication for specific patient.
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Components of written prescription
All written prescription should contain
• Prescribers full name and address, telephone
number and register number.
• Patients full name , address, age and sex.
• Date of issuance
. Drug name, strength, dose, dosage form and
amount
• Direction for use
• Refill instruction
. prescriber signature
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PRESCRIPTION FORMAT
• Under no circumstance may a dental
assistant prescribe medication.
• Dispensing of medication may only be
completed with the explicit instruction
from the dentist
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Prescription format
•
•
•
•
•
•
•
Heading
Name and address of the Dentist
Name , address ,age, sex and of the patient
Date
Superscription Rx
Latin for Recipe
Gives the pharmacist permission to take the drug
listed and dispense the drug to the patient
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cont
• Inscription
Body of Rx includes name of the drug and
strength
• Subscription
• Number of tablet, capsule or the amount of liquid to be
dispensed.
• Signature
• ‘SIG’ means the specific instruction to the patient and
how the patient should take the drug.
• Signature of the dentist
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Cont…
• Refill
• The number of times that the dentist is
allowing to the patient to refill the
prescription
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Cont..
• Recording
• A record must be kept for each prescription
written or administered to patient.
• A duplicate or carbon copy may be used and
placed in the patient’s chart.
• The drug dispense is written in the patients
chart.
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Common medication…… cont
• Antimicrobials ,is
Drugs that suppress or kill the growth of
microbes.
i.e Bacteria , Viruses ,Fungi or parasites
• The most common antimicrobials used in
dentistry are;…
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1. ANTIBIOTIC AGENT
• Drugs., that produced by microbes or by
chemical methods
• antibiotics the second most prescribed group
of drugs in dentistry after local anesthesia
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Indication for prescription of
antibiotics
• 1. Oral wounds i.e
* soft tissue laceration
* gingivectomy
* avulsion
* sever ulceration,, etc…
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Cont…
• 2. Dental infection .i.e
* acute peri-apical abscess.
* acute gingivitis.
* tissue ulceration.. Trauma. etc
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Cont…
• 3. pediatric periodontal diseases. I.e..
•
* for management of ch.per. Diseases.
Especially in patient in immunodeficiency
diseases
•
* periodontal conditions. I.e.;
•
Neutrpenias, papilon lefevere
syndrome,.
• NOTE,.. Necessitate culture sensitivity
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Cont…
• 3. Viral diseases.
When there strong evidence of secondary
infection exist ,, SO, it targeted to bacteria not
viruses
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*Antibiotics
• * Can be narrow spectrum.
•
Effective against either gram- positive or
gram- negative.
• * can be broad spectrum, effective against
wide rang of bacteria.
• Efficacy of antibiotic is determine by culture
sensitivity
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Selected antibiotics
• Penicillin V.
•
* beta lactam.
•
* bactericidal.
• Dose;
•
* children < 12 years ,25-50mg/kg. in
divided dose every 6-8hrs.
•
* children > 12, years adult dose ,250500mg every 6hrs
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Cont…
• Penivillin V,
•
may given with meals … preferred
dosing is one hour or tow hours after meals
• Contra –ind. Hypersensitivity
• precaution,, with sever renal impairment.
• Supl,.as, 125 or 250mg/5ml solution or 250
and 500mg tablets
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cont
• Clindamycin.
• * it is broad spectrum and resistance to
beta- lactam enzyme
• * it is highly effective against almost all oral
pathogens.
• * presence of food does not significantly
impair absorption
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Cont..
• Cont –ind.,,
•
* hypersensitivity
• Precaution.--- with liver dysfunction
• Dose;. *children<12yrs 10-20mg/kg/day, divided in three
doses. For ten days.
•
*children > 12yrs , adult dose 600—1800mg/day.
Divided in three doses
• Supp…; 75mg/5ml solution or 150 ,300, 450,600,750,
900mg tablets
•
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Cont..
• Amoxicillin.
•
* more convenient dosing regimen
•
* absorption better
•
* it is not effective than penicillin v
• Cont- ind., hypersensitivity to amoxil or
penicillin.
• Percaution., with sever renal impairment
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Cont….
• Dose,.. Children,< 12yrs 20 – 40mg/kg
divided in 2 -3 dose daily for 10 days
•
children.> 12yrs , adult dose, 250 –
500mg three times a day.
• Supp.;; 125,200,250,400mg/5ml solution,
and250 or 500 capsules .
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Cont..
•
Augmentin, ( Amoxicillin+ Glavulanic acid)
• Belong to lactam group.
• Glavulanic acid ( beta lactamase enzyme
inhabitor). To reduce the development of drug
resistant bacteria and maintain the
effectiveness of augmentin
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Cont..
• Suppl,, tab.
•
•
250mg|125mg………375mg
•
500|125mg……….. 625mg
•
875|125mg……… 900mg
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Cont..
• Powder for oral susp,.
•
125mg|31.25mg|5ml
•
200mg|28.5mg|5ml
•
250mg|62.5mg|5ml
•
400mg|57.25mg|5ml
•
Reco, dose for child<40kg 20-40mg|kg|day.q8hrs
•
child>40kg ,250-500mgq8hrs or 875mgq12hrs
•
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Cont..
Augmentin, may be,
. taken without regard to meal
. Preferably to be taken at the start
of the meal.
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Cont..
•
•
•
•
•
Macrolide antibiotics
Erythromycin
Roxithromycin
Azythromycin
Clarithromycin
• These drugs act by inhibiting the bacterial
protein synthesis
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Erythromycin
Action  Binds to ribosomal subunits of susceptible
bacteria and suppresses protein synthesis.
Dosage & route  PO, 30-50 mg/kg drug in 4 divided
dose  6 hrly.
Available forms  Tabs 250 & 500 mg
Caps 250 & 500 mg
Suspension 125, 250 mg/5ml
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Cont..
• Azithromycin
• Anti microbial spectrum expanded as compared
to erythromycin.
• Effective against, hemophilus influenza, High
activity against respiratory
pathogens,mycobacterium avium complex in
AIDS patients
• Dosage- 500mg OD for adults. Children above 6
months10mg/kg for 3 days.
• available as 100mg kids tablet
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Ampicillin
Recommonded dose.
for children <12 years
Dosage & route  Per oral 50-100 mg/kg /day
drug in 4 divided dose  6 hrly.
Parenterally ---25-50mg/kg/day given in divided
dose
Available forms  Caps 250 mg, 500 mg
Powder for oral suspension
125mg/5ml, 250 mg/5ml
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Cont..
• Tetracyclins.
• Limited use in pediatric dentistry.
• They are active against a range of gram
positive and gram negative aerobic and
anaerobic bacteria
• Doxycycline better anaerobic activity than
tetracycline
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Cont…
• Dose—20-40mg/kg/day to be given 4 divided
dose.
• Adverse effects
• GIT disturbance are common with tetracycline
• Hypersensitivity reactions such as skin rashes
• The use of tetracycline in children under 13
years of age is contraindicated due to the risk
of permanent discoloration of teeth and
interference with bone devolepment
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Cont..
• Metronidazole
• Effective against penicillin resistant anaerobic
gram negative bacilli.e.g. for the treatment of
ANNUG
• In serious infections metronidazole is best used in
conjunction with penicillin to ensure coverage
against aerobic gram positive bacteria. Available
as tablets, suspension and injectable forms.
• Recommended pediatric dose is 20-30 mg/kg/day
orally in divided doses q8hrs.
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Cont..
2. Anti fungal agents
Nystatin
• Nystatin oral suspension contains
1,00,000units/ml, oral topical application is usually
done 4 times a day.
Children less than 1 year-1,00,000 units
8 hourly.
1-6 years—2,00,000 units 4 hourly
Above 6 years—4,00,000 units 4 hourly
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nystatin
• Nystatin oral suspension
• Infants. 2ml [200,000 units] 4times|day.
• Children and adult.2 to 4ml |400.000…
600,000units|,,4times\day.
• Each ml contain 100,000 units NYSTATIN.
• Suppl. Susp,in 60ml bottles, and 473ml
bottles.
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• Daktarin oral gel, ( Miconazole), antifungal
it contain 25 miconazole per ,ml.
It can be use to treat adult , children and
infant aged 4month and older.
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Cont…
• 3. Anti viral drugs
•
•
•
•
* Acyclovir,
Treatment of HSV infection in immuno
suppressed patients.
Recommended oral dose in adults is 200mg 3-5
times daily for the duration of immuno
suppression.
In children,-5ml elixir to be taken 5 times a day
for 5 days
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*ANALGESICS
• The agents used for relief of pain is called
analgesics.
• Analgesics act either in the peripheral tissues
or centrally in the brain or spinal chord.
• Narcotic analgesics are thought to act
primarily in the CNS
• Non narcotic analgesics thought to act in the
periphery at the nerve endings.
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Cont…
• Non narcotic analgesics differ from the
narcotics in their site of action, their lesser
degree of toxicity and side effects.
• The standard type drug in this class are
aspirin, acetaminophen, non steroidal anti
inflammatory drugs.
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NSIAD (Non Opioid Analgesics)
•
•
•
•
Essential for clinical dental practice
These drugs have common actions such as
Analgesic - pain relief
Anti pyretic - reduction of elevated body
temperature
• Ant inflammatory - suppression of
inflammatory mediators
• Anti platelet aggregatory activity
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Cont..
• NSIADs reset the hypothalamic thermal
regulation to lower temperature and cause
sweating which helps in reducing the body
temperature.
• Paracetamol should be used as the first line of
anti pyretic in children
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Cont…
• Salicylates.
• Eg. acetyl salicylic acid (aspirin)– has
• Analgesic, antipyretic, anti inflammatory and
antiplatelet aggregatory action.
• Adverse effects• It should be avoided in infants and children
below 12 years of age.
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Cont..
• Aspirin should be avoided in patients with
asthma.
• The gastro intestinal effects of aspirin are the
problems most commonly encountered and
may be modulated by administering the drug
with food.
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Cont..
• Serious and fatal complications like Rey’s
syndrome
• Peptic ulcers and Gastrointestinal hemorrhage
• Normal adult dose-- 30 to 65mg/kg/day in
divided dose at 4 hour intervals.
• Dosage recommended for children-10-15 mg/kg/day in divided dose given 4 hour
interval.
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Cont..
• Acetaminophen
• It is effective analgesic and antipyretic .
• Unlike aspirin , acetaminophen does not
inhibit platelet function, and it produces less
gastric upset.
• It has no anti inflammatory properties.
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Cont…
•
•
•
•
Recommended dosage for acetaminophen
For adults—300 to 650 mg every 4 -6 hours
Children-10-15mg/kg/dose every 6 hours.
Maximum dose for adults.- 1000mg every 6
hours.
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Cont..
• Paracetamol
• Analgesic and anti pyretic action but weak anti
inflammatory action.
• Analgesic of choice when salicylates and other
NSAIDs are contraindicated eg, asthmatic
patient, peptic ulcer patient and children.
• Available as tablets, suspensions,
suppositories and injections.
• Dosage--10mg/kg body wt every 4-6 hourly.
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Dose of paracetamol
3 months -1year
60-120mg
1 –5 years
120—250mg
6 --12 years
250 --500mg
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Cont..
• Diclofenac
• Potent anti inflammatory, analgesic and anti
pyretic action
• Available as sodium or potassium salts.
• Available in the form of tablets ,syrups and
injections.
• Dose for children over 1 year is 1-3 mg/kg/day
in divided doses.
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Cont..
•
•
•
•
Adverse effects
Perforation of gastric ulcer
Gastro intestinal hemorrhage
Blood dyscrasias.
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Cont…
• Ibuprofen
• Anti inflammatory, analgesic and anti pyretic
effect
• Available as tablets ,capsules and suspension.
• The recommended dose
• 10—15 mg/kg to be given every 4-6 hours.
• It should not be given children less than 7 kgs
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Cont…
•
•
•
•
•
Adverse effects
Hamatemesis.
Agranulocytosis
Gastro intestinal disturbances
thrombocytopenia
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Centrally acting analgesics
• Effective against acute pain ,administered
parenterally, are devoid of anti inflammatory
anti pyretic action.
Serious drug dependence and abuse liability
has limited their use in pediatric dentistry.
Eg. Morphine, codeine, pethidine,
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Cont..
• Codeine is given alone or in combination with
another analgesic.
• An example is Acetaminophen with Codiene.
• Recommended dosage• Children--0.5 -1 mg/kg dose at 4-6 hours as
needed.
• Adults –30-60 mg/dose given at 4-6 hours
intervals
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Recent Opioid analgesics
• Alfentanil. & Remifentanil—used for longer
neurosurgical procedures where rapid
emergance from anesthesia .
• Tramodol– used in mild to moderate pre and
post operative pain.
• Dosage—adults and adolescent over 14
years—single dose of 100mg
• Maximum daily dose—400mg .
• In children - 1-1.5mg/kg/wt
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Medication and dosage for oral
pediatric post operative management
medication
availability
dosage
40 lb child
80 lb child
Acetaminophe
n
Elixr165mg/5ml
Tablets 325mg
Chewable
tablets-160mg
10-15mg/kg
4-6hours
interval
160mg=1tsp
160mg
chewable
tablet
325mg=1
tablet
320mg—2
chewable
tablet
Ibuprofen
Suspension100mg/5ml
Tablets 200
300,400,600,
800mg
4-10mg/kg at
6-8 hours
interval
100mg=1tsp
200mg =2tsp
200mg=1
tablet
Tramodol
Tablets
50,100mg
1-2mg/kg
4-6 hours
interval
maximum
100mg
25 mg=1/2
tablet
50 mg= 1 tablet
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Cont…
Codine and
Acetaminophe
n
Suspension
12mg/5ml
0.5-1mg
12mg=1tsp
codine/kg dose
given at 4-6
hours interval
24mg=2tsp
Meperidine
syrup 50mg/ml
Tablets
50mg,100mg
1-2mg/kg/dose 25mg=1/2 tsp
given at 4-6
hours intervals
50mg=1tsp
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*Local Anesthetics - Definition
A substance which reversibly inhibits
nerve conduction when applied
directly to tissues at non-toxic
concentrations
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Local anesthetics - vasoconstrictors
Esters
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Local anesthetics - Formulation
Biologically active substances are frequently
administered as very dilute solutions which can
be expressed as parts of active drug per 100
parts of solution (grams percent)
Ex.: 2% solution =
_2 grams__ = _2000 mg_ = __20 mg__
100 cc’s
100 cc’s
1 cc
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Local Anesthetics - Allergy
• True allergy is very rare
• Most reactions are from ester class
• Patient reports of “allergy” are frequently due to
previous intravascular injections
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Local Anesthetics - Toxicity
Tissue toxicity – Rare
Systemic toxicity – Rare
• Can occur if administered
in high enough
concentrations (greater
than those used clinically)
• Usually related to
preservatives added to
solution
• Related to blood level of drug
secondary to absorption from
site of injection.
• Range from light headedness,
tinnitus to seizures and
CNS/cardiovascular collapse
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Local anesthetics - Duration
• Determined by rate of elimination of
agent from site injected
• Factors include lipid solubility, dose
given, blood flow at site, addition of
vasoconstrictors (does not reliably
prolong all agents)
• Some techniques allow multiple
injections over time to increase
duration, e.g. epidural catheter
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Local anesthetics - vasoconstrictors
Ratios
Epinephrine is added to local anesthetics in
extremely dilute concentrations, best expressed as a
ratio of grams of drug:total cc’s of solution.
Expressed numerically, a 1:1000 preparation of
epinephrine would be
1 gram epi
1000 cc’s solution
1000 mg epi
=
1000cc’s solution
prof s.m.omar
=
1 mg epi
1 cc
84
Local anesthetics - vasoconstrictors
Therefore, a 1 : 200,000 solution of epinephrine would be
1000 mg epi
1 gram epi
200,000 cc’s solution
=
200,000 cc’s solution
or
1 mg epi
200 cc solution
prof s.m.omar
=
0.005mg/
ml
85
Local anesthetics - vasoconstrictors
• Because of ;..
•
•
•
•
* high tissue perfusion
* high BMR.
*High cardiac output.
which lead to rapid clearance of local
anesthesia from the tissue into the circulation,
therefore, the L.A used for children should contain V.C
, to reduce the rapid clearance of L.A from the tissue,
and increase the duration of L.A , and reduce the level
of toxicity.
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Local anesthetics - vasoconstrictors
• Calculation of L.A for pediatric patients;
.The recommended dose for pediatric patient is;
4.4mg/ kg| BW. ( maximum dose)
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Local anesthetics - vasoconstrictors
• Example:..
Pt weighing 20kg, the maximum dose is
20kg x4.4mg L.A = 88mg local anesthetic
agent.
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Local anesthetics - vasoconstrictors
Amind group is the most commonly use L.A
agent in dentistry, i e Lidocaine.
because of
* high potency at low concentration.
* less allergic reaction.
* long duration.
NOTE,
CAUTION WITH PATIENTS WITH LIVE FUNCTION
IMPAIRMENT.
‘ END’
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Oral surgery –pediatric
dentistry
•
Minor Oral Surgery in Pediatric Dentistry
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Definitions
• Minor oral surgery
– Is the part of dentistry that deals with the diagnosis
and surgical treatment of diseases, injuries and
defects of the human teeth, jaws, oral cavity and
associated structures which, under normal
circumstances, can be performed under local
anaesthesia in an outpatient setting in most healthy
and normal patients.
– that can be performed under local anaesthesia with or
without sedation (normally inhalational) or day-stay
general anaesthesia in healthy children.
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Setting up practice
 Two important things
 Clinician must be adequately experienced in the
field
 Equipped with various tools of the trade that are
essential for the safe practice of the minor oral
surgery
 Surgical equipments
A. Non- disposable instruments
B. Disposable surgical instruments
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MOS – 3 sets of instruments
1.
2.
3.
Instruments for
access and clear
surgical field
Instruments for
manipulation or
removal of
surgical specimen
Instruments for
wound toilet and
repair
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Differences between primary and
permanent teeth
1. Size. - Primary teeth are smaller in every dimension
compared with their permanent counterparts.
2. Shape. - The crowns of primary teeth are more
bulbous than the crowns of permanent teeth. The
roots of primary molars are more splayed than the
roots of permanent molar teeth.
3. Physiology. - The roots of primary teeth resorb
naturally, whereas in the permanent dentition
resorption is normally a sign of pathology.
4. Support. - The bone of the alveolus is much more
elastic in the younger patient.
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Modifications To Extraction
Techniques In Children
• Forceps- The beaks and
handles are smaller.
• In addition, to
accommodate the more
bulbous crown, the
beaks are more curved
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Modifications To Extraction
Techniques In Children
• The wide splaying of primary molar roots
means that more expansion of the socket is
required
• Due to the relatively cervical position of the
bifurcation in primary molars it is injudicious
to use forceps with deeply plunging beaks
(such as the adult cowhorn design) as these
could damage the underlying permanent
successors.
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Differences between primary and
permanent teeth
• As primary roots are resorbed it is often preferable to
leave small fragments in situ if the root fractures.
• When part of a fractured root is visible then it should
be removed. Blind investigation of primary sockets
should not be performed as there is a danger of
damaging the underlying permanent successor.
• Similarly, blind investigation of the distal root socket of
first permanent molar teeth must not be carried out in
children with unerupted second molars, as
unintentional elevation of the second molar can occur.
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Extraction techniques
PATIENT POSITION
• Dental chair reclined
about 30° to the vertical
for extractions under
local anaesthesia.
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Extraction techniques
Operators position
Site
Upper
teeth
Operators
position
Front of the
patient
Lower left Front of the
teeth
patient
Lower right Behind the
patient
Straight back and the patient's
mouth at a level just below the
operator's shoulder
The patient's mouth is at a height
just below the operator's elbow
Chair as low as possible to allow
good vision
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The non-working hand
The 'non-working' hand also has important
roles to play
1. It retracts soft tissues to allow visibility and
access.
2. It protects the tissues if the instrument slips.
3. It provides resistance to the extraction force
on the mandible to prevent dislocation.
4. It provides 'feel' to the operator during the
extraction and gives information about
resistance to removal.
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•
UPPER PRIMARY AND PERMANENT
ANTERIORS
Normal position
– Removed by applying
the forceps beaks to the
root and then using
clockwise and
anticlockwise rotations
about the long axis
– In older children some
additional buccal
expansion may be
required for the removal
of the permanent upper
canine.
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UPPER PRIMARY AND PERMANENT
ANTERIORS
• Malpositioned permanent upper anteriors
– Labially placed upper lateral incisors and canines
have very little buccal support and are easily
removed, either by using straight forceps applied
mesially and distally and using a slight rotatory
movement
– Palatally positioned lateral incisors and canines
are usually not accessible with forceps and thus
elevators are used
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UPPER PRIMARY MOLARS
• Considerable expansion of the socket is required.
• The initial movement after application of the
forceps is palatal, to expand the socket in this
direction. The tooth is then subjected to a
continuous bucally directed force, which results
in delivery.
• Occasionally, buccal movement is not adequately
obtained due to gross caries on the palatal aspect
causing slippage of the forceps beak on the
palatal side during buccal expansion.
• This may be overcome by completing the
extraction by continued palatal expansion.
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UPPER PREMOLARS
• Removed by buccal expansion using upper
premolar forceps.
• The upper second premolar is often single
rooted and, can also be subjected to a
rotation about its long axis to effect delivery.
• Palatally displaced upper premolars are
difficult to remove with forceps. The use of
elevators in a manner similar to that described
for palatally placed canines is preferred.
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UPPER PERMANENT MOLARS
• These teeth are removed using left and right
upper molar forceps.
• Following application of the forceps to the
roots of the tooth (the pointed beak being
driven towards the buccal root bifurcation)
the tooth is delivered by expanding the socket
in a buccal direction.
• The use of palatal expansion is not as
successful in the removal of permanent
molars
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LOWER PRIMARY ANTERIORS
• These teeth are extracted in the same manner
as their upper counterparts, in that, rotation
about the long axis using lower primary
anterior or root forceps is employed.
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LOWER PERMANENT ANTERIORS
 Permanent lower incisors are not readily removed by
rotation as their roots are thin mesiodistally and rotation is
likely to cause root fracture.
 The most effective method of removal is to apply lower root
forceps and expand the socket labially.
 Permanent lower canines may be delivered by a rotatory
movement about the long axis or by buccal expansion.
 Labially displaced lower canines - Mesial and distal
application of forceps or straight elevators are used.
 The position of lingually placed lower anteriors normally
precludes the use of forceps and straight elevators applied
mesially and distally should be employed.
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LOWER PRIMARY MOLARS
 These teeth are removed by buccolingual
expansion of the socket.
 Lower primary molar forceps are similar in design
to the permanent molar forceps. They have two
pointed beaks which engage the bifurcation.
 Lower primary root forceps are used by applying
the beaks to the mesial root of the primary molar.
 Lower first primary molars are usually more easily
removed with lower primary root forceps. After
application of the forceps a small lingual
movement is followed by a continuous buccal
force, which delivers the tooth.
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LOWER PREMOLARS
 When these teeth are fully erupted in the arch of the young
patient y removed by a rotatory movement around the long
axis of the root using lower premolar forceps.
 Malpositioned lower second premolars are normally
lingually positioned
 When lingually placed, lower premolars may be extracted
using straight elevators applied mesially, lingually, and
distally.
 Alternatively, it is often possible to apply the beaks of upper
fine root forceps mesially and distally to the crown of the
lingually placed tooth when the forceps are directed from
the opposite side of the jaw. Gentle rotation of the tooth
with the forceps may then effect removal.
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LOWER PERMANENT MOLARS
• The lower molar forceps have two pointed beaks
that are applied in the region of the bifurcation
buccally and lingually.
• Once applied the forceps are used to move the
tooth in a buccal direction to expand the buccal
cortical plate.
• When buccal expansion is not sufficient to deliver
the tooth then the forceps should be moved in a
figure-of-eight fashion to expand the socket
lingually as well as buccally, and this is generally
successful.
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Post-operative instructions-for the
child
1. The child should not be dismissed until a blood clot is
2.
3.
4.
5.
6.
7.
formed
Blood soaked gauze when removed from mouth
should be disposed out of sight of the child
Gauze to be hold between the teeth for half an hour
Child is instucted not to bite his lip
Do not disturb the area where tooth was removed
Do not rinse mouth vigourosly for 24 hours after
extraction
Do not take juices with a straw for that day
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Post-operative instructions-for parent
1. Reinforce what has been told to the child
regarding the home care
2. A light meal with no hard food should be
recommended for that day
3. Analgesic is prescribed and antibiotic coverage is
done if the area was infected
4. Blood can appear on the pillow the next day.
This represents a slight oozing of blood from the
healing socket that gets mixed with saliva
5. Call the dental office if undue symptoms
develop
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Thank you
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