Antibiotics And Analgesics Ior Adults

A. Analgesics
In endodontic treatment, is usually required analgesic drugs as pain relievers. Analgesics
may be classiIied as Iollows:
a. Non-Opioid
Non-Steroid Anti-InIlammatory (NSAIDs) Nonsteroidal anti-inIlammatory drugs
(NSAIDs)
Acethaminophen
orticosteroid
a. Opioid
- pure agonist
- mixed agonist and antagonist
- pure antagonist
Here is the comparison to these two kinds oI analgesics:
opioid NON-opioid
ontaining Opium
Anti-InIlammatory with little
eIIect
It causes dependence
Only relieve pain, not relieve
Iever
ithout Opium
Anti-InIlammatory with large
eIIects (except Achetaminophen)
Does not cause dependence
liminate the pain and relieve
Iever (Anti Piretik)
a. Non-Opioid
1. Nonsteroid Anti Inflammatory Drugs ( NSAIDs)
It is a class oI drugs that are pharmacologically active compounds that work has
inhibited the production oI prostaglandins. The drug is used Ior pain in acute or chronic
inIlammatory. These drugs have the characteristics to relieve pain, Iever, and inIlammation.
NSAIDs are believed to have therapeutic eIIects through inhibition oI cyclooxygenase
enzyme that is an enzyme that aIIects the synthesis oI prostaglandins Irom arachidonic acid
and tromboxsan. So terjaid inhibition oI production oI proinIlammatory prostaglandins,
especially prostaglandin (PG). hen this has been discovered enzyme cyclooxygenase
(OX). Drugs that inhibit only the OX enzyme without inhibiting the enzyme
cyclooxygenase 1 (OX1) work more speciIically, the common side eIIects oI drugs oI this
class oI gastric irritation and ulceration can be prevented.
NSAID medicines are classiIied as Iollows:
a) arboxylic Acid
1) Acetic Acid
Phenylacetic acid derivative: DicloIenac, FenkloIenak
Asetat-inden/indol acid derivatives: Indomethacin, Sulindak, Tolmetin
) Acid Derivatives Salicylates: Aspirin, Benorilat, DiIlunisal, Salsalat
3) Propionic Acid Derivatives: Acid tiaproIenat, Fenbuten, FenoproIen,
FlurbiproIen, IbuproIen, KetoproIen, Naproksen
4) Acid Derivatives Fenamat: MeIenamic acid, MakloIenamat
b) Acid nolate
1) Derivatives Pirazolon: Azapropazon, Phenylbutazone, OksiIenbutazon
) Oksikam Derivatives: Piroxicam, Tenoksikam
Here is an explanation oI NSAID drugs are oIten used in dentistry:
1) Aspirin (acetyl salicylic acid)
O Pharmacokinetics: oI oral administration, aspirin is absorbed rapidly,absorption
partly Irom the stomach, a portion oI the upper small intestine. The highest
concentration oI approximately hours aIter administration. Absorbsinya speed
depends on several Iactors, mainly the speed oI tablet disintegration and dissolution, the
pH at the mucosal surIace and gastric emptying time. once absorbed, aspirin would be
spread throughout the body surIace and the Iluid between cells.
O Distribution: once absorbed, aspirin would be spread throughout the body surIace and
intercellular Iluid. 50-90 oI aspirin bound to plasma proteins, primarily albumin.
O BiotransIormation : biotransIormation oI aspirin occurs in many tissues, especially in a
system oI liver microsomes and mitochondria. excreted through the kidneys (at most)
in the Iorm metabollit.
O xcretion : excreted through the kidneys (at most) in the Iorm metabollit
O Pharmacodynamic : used to relieve mild to moderate pain, central (works on
hypothalamus) or peripheral (inhibit the Iormation oI prostaglandins in the
inIlammation and prevent the sensitization oI pain receptors to mechanical or chemical
stimuli.
O Dosage: 35-650 mg orally every 3-4 hours (adults) .Side eIIects: gastrointestinal
disorders such tools dyspepsia, nausea and vomiting. Aspirin allergy can cause skin
redness, edema oI the larynx, asthma, anaphylactic reactions. IIects on the NS in the
Iorm oI dizziness, blurred vision, a lot oI sweat, drowsiness, restlessness, vertigo, etc.
) Derivatives Pyrazolon
O Included in the pyrazolone: antipirin (Ienazone), aminopropin (amidopirin),
Ienilbutazone, and their derivatives.
O Pharmacodynamic: analgesic, antipyretic and anti-inIlammatory (stronger than aspirin).
Not interIere with acid-base balance .
O Pharmacokinetics: antipirin to measure the amount oI water in the body. Aminopirin
experiencing metabolism by enzymes in liver microsomes. Only 3 aminopirin
original Iorm excreted in urine
O Side eIIects: agranulotosis, aplastic anemia and thrombocytopenia, the drug is to Iorm
nitrosamines which are carcinogenic :0,3-1 g dose 3 times a day
) Fenoprofen
O Pharmacodynamic: anti-inIlammatory, analgesic, antipyretic
O Pharmacokinetics: rapidly absorbed through oral administration, the highest
concentration in plasma is reached within 90 minutes, tightly bound in plasma proteins,
excreted through urine
O Side eIIects: gastrointestinal disorders such as constipation, nausea, vomiting, stomach
bleeding.
O Dose: 600 mg 4 times daily, aIter satisIactory, the dose adjusted
) Ibuprofen
IIicacy and side eIIects similar to IenoproIen. Dose oI 400 mg 4 times daily.
ontraindicated in pregnant and lactating mothers
5) Mefenamic acid
O Pharmacodynamic: acute and chronic pain who are, are more tosik
O Side eIIects: irritation oI the stomach, intestinal colic and diarrhea.
O ontraindications: patients with peptic gastric disorders, diarrhea, pregnant women and
asthma
O Dose: 50 mg every 6 hours Ior no more than 7 days
O The used must be oriented on nonopioid oral, some such patients, small children or
patients who have intermaksilari Iixation aIter maxilloIacial surgery or trauma, can not
swallow tablets capsule atu. For these patients, liquid / liquid oI acetaminophen or
ibuproIen can be considered.
For rare cases, such patients can not receive medication by mouth Parenteral (ketorolac)
or rectal (acetaminophen, aspirin).
) Acethaminophen
O Acetaminophen is an antipyretic analgesic drug which is used as a substitute asprin out
because o stomach problems or other contraindications.
O Indications: Provides analgesic eIIects, the Iield oI dentistry is widely used aIter dental
surgical procedures, are also commonly used aIter extraction oI third molar teeth. These
drugs also provide anti-inIlammatory eIIects, although not sepoten aspirin.
Acetaminophen shows positive eIIects to bear the pain until pemakaina 1000 mg.
O Pharmacodynamic: similar to aspirin, relieve pain mild - moderate Acetaminophen has
analgesic and antipyretic eIIects are equivalent to aspirin. Just as with other NSAID
drugs, acetaminophen is also work by inhibiting prostaglandin synthesis. That
distinguishes only spectrum that diinhibit diIIerent OX enzymes. Acetaminophene
also been proven to work more actively than spirin in the NS, whereas the less active
peripheral works. It's just anti-inIlamasinya work was minimal, this is due perokside
produced by leukocytes in inIlamed tissue. Perokside highly reactive with
acetaminophen, so the work acetaminophenpun will be reduced.
O Pharmacokinetics: Absorbed rapidly and completely through the gastrointestinal tract.
High concentrations in plasma reached within hour. xperiencing metabolism in the
liver by enzin microsomes and secreted through the kidneys. These drugs can be easily
absorbed by the small intestine when given orally. ell distributed in body tissues and
Iluids tubuh.sedangkan through elimination occurs through the kidneys by glomerular
Iiltration and secretion in proximal tubule.
O Side eIIects: Side eIIects caused by this drug caused by its relationship with alcohol and
drug overdose. hen given an overdose oI acetaminophen poisoning will cause liver
and kidney damage. In some patients, allergic reactions can also occur, such as skin
ruption. Rare cases is neutropenia, thrombocytopenia, and pancytopenia. The
combination oI these drugs with alcohol consumption can cause liver disIunction
because berIiIat hepatotoksi. Side eIIects oI these drugs is lower than aspirin, does not
cause allergies and irritation oI the stomach.
O Dose: 300 mg-1 g per time with max dose oI 4 g per day Ior adults: 150-300 mg / dose
max times with 1. g / day Ior children aged 6-1 years

b. Opioid
Opioid analgesics are added to nonopioid to regulate painIul Ieel Irom medium to
severe or do not respond to nonopioid.
Limit dose used, based on side eIIects. Physical deIense and tolerance oI the body
can occur virtually in all patients using opioid analgesics in the long term. Opioid analgesics,
including both pure agonists (such as codeine and oxycodeine) and agonist / antagonist (such
as pentazocine and butorphanol) . Severe pain should be treated with a combination oI
nonopioid and opioid (such as morphine or hydromorphone) Adjuvants (substances added to
a drug to add the power oI component) agent (anticonvulsant: an agent that inhibits seizures,
or tricyclic antidepressan) can be added also in accordance with the indication). For patients
who can not swallow tablets or capsules in a liquid Iormulation can be useIul opioids
(codeine, hydrocodone, oxycodone). Opioids and phenothiazines (chlorpromazine) is known
to produce NS depression, including respiratory depression. Aspirin and NSAIDs are used
to reduce pain to pathological processes (pulpitis, dentoalveolar, abscess)
Opioids Ior dentistry:
1. Morphine and Opium Alkaloids
O Pharmacodynamic: is highly selective and not accompanied by loss oI Iunction snsorik.
UseIulness based on 3 Iactors: elevated pain threshold, aIIect the emotions, Iacilitate
sleep (increased pain threshold)
O Pharmacokinetics: morphine can not penetrate intact skin, but can penetrate the oral
mucosa. IIects oI oral administration is lower than parenteral administration.
Morphine excretion through the kidneys, a Iraction oI Iaeces and sweat
restlessness, rapid breathing, yawning, anorexia, etc.
O Side eIIects: addiction
. Meperidine
O Pharmacodynamic: same as morphine, Iaster and shorter tenure
O Pharmacokinetics: good absorption aIter oral administration, maximum plasma
concentrations achieved within 1- hours. Metabolism in the liver
O Side eIIects: dizziness, sweating, dry mouth, nausea and Ieeling weak
O Dose: 50 mg (tablets) oral administration
3. Methadone
O Pharmacodynamic: same as morphine
O Pharmacokinetics: oral administration to work 0-30 minutes. ell absorbed in the
intestine. Quick out dri blood and accumulate in the lungs, liver, kidney, spleen, and a
small entrance into the brain
O Dose: tablets 5, 7.5 and 10 mg (oral)
O Side eIIects: dizziness, drowsiness, sweating and vomiting

b. Corticosteroid
Function glucocorticosteroids : suppress pain because oI acute inIlammation by
pressing vasodilatation, OMN migration and phagocytosis, and inhibit the Iormation
arakidonik acid that Iunctions in the mechanism oI pain, especially when the pulp
exposure. Postoperative pain or Ilare-ups can be caused by inIlammation and inIection
that occurs in periapeks, as we have seen in response to irritants, inIlammatory mediators
such as prostaglandins, leukotrienes, bradykinin, pAF, substance-P, and others issued to
surrounding tissue, which can cause vasodilation and increased vascular permeability
that can cause edema.
Mechanism oI action: orticosteroids work by aIIecting the rate oI protein
synthesis. Hormone molecule enters the network through the plasma membrane by
passive diIIusion in the target tissue, and then react with a speciIic receptor protein in the
cell cytoplasm and Iorm a complex network oI receptor-steroid. These complex changes
conIormation, and then move toward the nucleus and binds to chromatin. These bond
synthesis stimulates the transcription oI RNA and speciIic proteins. Induction oI protein
synthesis is an intermediary Ior the physiological eIIects oI steroids. Some researchers
suggest that steroid hormones stimulate the synthesis oI proteins that are inhibiting or
toxic to lymphoid cells, it is possible that catabolic eIIect.

B. Antibiotics
Because bacteria are involved in endodontic cases with apical periodontitis, the incidence oI a
posttreatment inIection or Ilare-up is a concern to clinicians providing endodontic treatment.
Prescribing an antibiotic to prevent such an occurence might make sense, but the use oI
antibiotic is controversial Ior some reasos, such as:
1. Overprescribing antibiotics, especially when these drugs are not indicated, has led to
increased bacterial resistance and patient sensitization.
. Antibiotics have been mistakenly prescribed Ior patients with severe pain who have a
vital tooth (i.e., when bacteria are unlikely to be a causative Iactor in periradicular
pain).
3. ven when a bacteria are likely to present, data Irom uncontrolled clinical trials
provide little or no support Ior the hypothesis that antibiotics reduce pain.
A common error in antibiotic therapy is to prescribe too little or Ior too short oI a duration.
UnIortunetely such schedule will kill oII the weaker organisms, thus leaving more substrate
available Ior those with greater virulence to become entrenched. Most antibiotics are given at
least Iour times a day.
hen prescribing prophylactically to prevent an inIection, the dentist should speciIy a
minimum oI to 3 days Ior keeping up the therapy. hen dealing with an already present
inIection, therapy should be continued Ior at least 6 days or Ior a minimum oI days aIter the
inIection appears to be under control.
InsuIIicient dosage as insuIIicient time on the antimicrobial has killed oII the weaker
organisms and led to newer, stronger breeds oI bacteria. Due to this impetus, many antibiotics
that were available as a maximum in 50 mg Iorms are now standard in 500mg Iorms per
dose.
Types oI Penicillin Ior Use during ndodontic Therapy :
a. POTASSIUM PNIILLIN V
Dosage : 50 to 500mg 4 times/day
SpeciIically developed Ior oral administration; very high level oI penicillin
developed; has had extremely wide and successIul use Ior 0 years
b. AMINOPNIILLIN, AMPIILLIN
Dosage : 1 to 4 g divided and given every 6 hr
Not penicillinase resistant, but has a wider spectrum than potassium penicillin
V
c. AMOXIILLIN
Dosage : 50 to 500 mg every 8 hours
Advantage over K and V penicillin and ampicillin is that may be used in three
rather than Iour doses ang gives high blood levels Ior longer periods, replaces
other penicillin Iorms Ior SB prevention drug oI choice according to AHA
guidlines, and also come in liquid suspension Iorm
d. PNIILLINAS-RSISTANT PNIILINS
Dosage : 50 to 500 mg every 6 hours
IIective against penicillinase producing microorganisms, but weak against
others; only appropiate use is vs. Staphylococci penicillinase-producing
bacteria
e. BTA-LATAMAS INHIBITORS
Dosage : 50 mg every 8 hr
ide spectrum against gram-positive and gram negative anaerobs; also, due to
clavulanate portion, is eIIective against beta-lactamase-producing
microorganisms, which are usually resistant to penicillin and cephalosporin
Types oI Nonpenicillin Antibiotics Ior Use during ndodontic Therapy
a. RYTHROMYIN
Dosage : 50 to 500 mg 4 times/day
Depending on microorganism type and drug concentration, is either
bacteriocodal or bacteriostatic; good antibacterial spectrum; only serious
problem is that patients experience serious gastritis,even taken with empty
stomach; available in oral suspension
b. P (RYTHROMYIN PARTILS IN TABLTS)
Dosage : 333 mg every 8 hr
Due to special coating to inactive gastric activity, is absorbed in small
intestine and causes less stomach upset; although might be taken without
regards to meals, optimal blood leverls are obtained in Iasting state (halI to
hr beIore meals)
c. LINDAMYIN
Dosage : 150 to 300 mg every 6 hr
Broad-spectrum antibacterial with greater eIIectiveness against gram-negative
anaerobs including !70;490,than erythromycin; serious side eIIect is
pseudomembranous colitis with diarrhea
d. PHALOSPORIN
Dosage: 50 mg every 6 hr (1st generation)
There is a 10 to 15 crossover sensitivty to cephalosporin; as you go to the
newwer generations, gram-ngeative antibacterial eIIects increase , but gram-
positive antibacterial eIIect decrease; has eIIectiveness against bone
inIections, so good in endodontics
e. DOXYYLIN
Dosage : 100 mg every 1 hr Ior 1st day, 100mg/day thereaIter
Tetracycline with more convenient dosage Iorm; must adhere to dose regimen
or more side eIIects occur; more useIul in endodontic and periodontic
inIections
I. FLUOROQUINOLON IPROFLAXAIN
Dosage : 50 to 500 mg every 1 hr
Broad spectrum with convenient dosing schedule; very expensive, but works
well against many gram-positive and gram-negative species; do not use on
children,pregnant and nursing women
g. Metronidazole
Dosage : 500 mg every 6 hr, not to exceed 4g/day
Oral synthetic antiprotozoal and antibacterial agent with antibacterial spectrum
versus !70;490, species against many gram-positive and gram-negative
anaerobs; good drug to give along with penicillin Ior coverage against both
gram-positive and gram-negative bacteria; vomitting occurs when alcohol is
ingested while taking this medication
h. MAROLIDS
Dosage : 500 mg Iirst day dose, Iollowed by 50 daily Ior -5 days
Reversibly binds to P site oI the 50 S ribosomonal subunit; may inhibit RNA
dependent protein synthesis; can be bacteriostatic or bacteriocidal; should be
used with caution due to bacterial resistance; can be used as alternative Ior
penicillin-allergic patient.

Antibiotics and Analgesics Ior hildren
A. Antibiotics
Antibiotic prophylaxis is advised in the Iollowing situations:
a) Patients with cardiac problems associated with endocarditis: many patients are at risk oI
suIIering endocarditis Iollowing dental treatment, due to the prior existence oI heart problems
The American Academy oI Pediatric Dentistry (AAPD) approved the guide Ior the
prevention oI bacterial endocarditis developed by the American Heart Association. This
guide stresses that children with a history oI intravenous drug administration and children
with certain syndromes (e.g., Down or MarIan syndrome), may be at risk oI developing
bacterial endocarditis, due to the associated cardiac anomalies.
b) Immunocompromised patients: these patients do not tolerate transient bacteremia
Iollowing invasive dental management. ThereIore, patients subjected to chemotherapy
irradiation or bone marrow transplantation must be treated accordingly. This criterion also
applies to patients with the Iollowing conditions: human immunodeIiciency virus (HIV)
inIection, immune deIiciencies, neutropenia, immunosuppression, anemia, splenectomy,
habitual steroid use, lupus erythematosus, diabetes and organ transplants .
c) Patients with shunts, vascular catheters or prostheses: bacteremia Iollowing invasive
dental treatment can give rise to shunt or vascular catheter colonization. Patient subjected to
dialysis or chemotherapy, or who require Irequent blood transIusions, are very susceptible to
this problem.
- Antibiotic selection
Oral antibiotics that are eIIective against odontogenic inIections comprise penicillin,
clindamycin, erythromycin, ceIadroxil, metronidazole and the tetracycline. These antibiotics
are eIIective against streptococci and oral anaerobes. Penicillin V is the penicillin oI choice in
cases oI odontogenic inIection. It is bactericidal, and although the spectrum oI action is
relatively limited, it is appropriate Ior the treatment oI odontogenic inIections. For the
prophylaxis oI endocarditis, associated to dental treatments, amoxicillin is the antibiotic oI
choice. Amoxicillin with clavulanic acid (clavulanate) can be used in certain cases, since it
oIIers the advantage oI preserving activity against the betalactamases commonly produced by
microorganisms associated with odontogenic inIections.
lindamycin is an alternative in the case oI patients who are allergic to penicillins. The drug
is bacteriostatic, though bactericidal action is clinically achieved with the generally
recommended dosage. The latest generation macrolides, clarithromycin and azithromycin can
also be used iI the child is allergic to penicillin. ephalosporin ceIadroxil are additional
options when a broader spectrum oI action is required. Metronidazole is usually used against
anaerobes, and is characteristically reserved Ior situations in which only anaerobe bacteria are
suspected. Tetracyclines are oI very limited use in dental practice since these drugs can cause
alterations in tooth color, they must not be administered to children under 8 years oI age, or
pregnant or nursing women.

- Duration oI antibiotic therapy in odontogenic inIection
The ideal duration oI antibiotic treatment is the shortest cycle capable oI preventing both
clinical and microbiological relapse. Most acute inIections are resolved within 3-7 days.
hen oral antibiotics are used, a high dose should be considered to secure Iaster therapeutic
levels.

. Analgesics
However, almost any oI the drugs mentioned Ior adults may be used on children, but only
aIter appropiate change in dosage. The usual alteration in dosage may be computed by
Clark`s Rule. It states that the Iull dosage is calculated on the basis oI the child`s weight
ratio to a Iull dose.
hild`s weight Fraction oI adult dose to be given
150
Almost every antibiotic has excellent dosage Ior children. Tablets or capsules are available in
15-mg Irom, and many antibiotics are manuIactured so syrups may be compounded by the
pharmacist oI 15 mg per teaspoon.
xample:

Young`s Rule


Dosage ased on Weight


Sources:
ohen,s Pathways oI the pulp. Kenneth M. Hargreaves et all editor.011. Mosby lsevier.
Del Pozo PP, Soto MJB, TroisIontaines S. Antibiotic prophylaxis in pediatric odontology.
An update. Med Oral Patol Oral ir Bucal 006:11:35-7
eine,SF. ndodontic Therapy. 010
http://www.pharmacy-tech-study.com/dosecalculation.html (retrieved on 1
st
December 004)