Pharmacology in pediatric dentistry: Local anesthetics, analgesics, and antibacterial agents, part 2

Part II of II

The principles of adult pharmacotherapeutics are not easily extrapolated to "fit" the profile and needs of children. As such, pediatric patients may be our most vulnerable patients when it comes to potential drug interactions, adverse reactions, toxicity, and contraindications. Medications frequently used in dentistry may cause significant adverse events and toxicity in children. We, as dental practitioners, must be aware of the pharmacokinetic and pharmacodynamic differences associated with pediatric patients, and not simply treat them as "small adults."

In this second installment on pediatric dental pharmacology, learn more about analgesics and antibacterial agents. Read the first installment, Pharmacology in pediatric dentistry: Local anesthetics, analgesics, and antibacterial agents.

A first consideration

While there are generally no specific guidelines in antibacterial pharmacotherapy for pediatric patients versus adult patients, the first consideration may be whether to prescribe at all. Odontogenic infections are among the most common infections of the oral cavity.^1,2 The penicillins remain the gold standard for the treatment of odontogenic infection; however, their efficacy has decreased due to increasing bacterial resistance. In terms of antibacterial stewardship, dental practitioners must be cautious to prescribe antibacterial agents to pediatric patients only when the use of such agents is truly warranted. For example, pediatric patients presenting with acute symptoms of localized infections may not be prescribed antibacterial agents in lieu of other definitive measures for managing such infection. However, pediatric patients presenting with symptoms of soft-tissue infection that is secondary to an odontogenic infection and/or systemic involvement will likely be treated with antibacterial agents as soon as possible.³

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Penicillins are the most common

It is certainly no secret to any dental hygienist that the most commonly prescribed antibacterial agents in dentistry are the penicillins, especially amoxicillin. The penicillins are “acid-labile” drugs. This means that they are easily destroyed in the acidic environment of the stomach. As a result, penicillins may be dosed in adults to account for some of this “loss.” But since pediatric patients produce less stomach acid than adults do, penicillins are absorbed more readily in children than in adults. So pediatric patients may be more likely to experience exaggerated antibacterial adverse effects and their doses may need to be adjusted accordingly.⁴

In those instances when a pediatric patient is allergic to penicillin, clindamycin remains the most commonly prescribed alternative since it is quite effective against organisms responsible for causing odontogenic infections. While there has been much concern recently about the continued use of clindamycin in dentistry due to its potential for causing pseudomembranous colitis, this adverse effect is less frequently encountered in pediatric patients than in adult patients.⁵

If you’ve been in practice for any length of time as a dental hygienist, you know that the most commonly prescribed analgesics for dental pain are ibuprofen and acetaminophen. The potential for adverse effects and toxicity resulting from the use of these analgesics is much lower in children than adults.^6,7 Although there has been a recent increase in the use of aspirin as a “natural” analgesic by consumers, it is important to educate our patients and advise them that aspirin is contraindicated in pediatric patients, since its use may result in Reye's syndrome.^8,9

Acetaminophen: The analgesic of choice

Acetaminophen is indicated for the management of mild to moderate acute dental pain and is considered the analgesic of choice in pediatric patients.⁸ Although its exact mechanism of action is still unknown, acetaminophen has demonstrated both analgesic and antipyretic activity with very few side effects. While instances of acetaminophen toxicity secondary to acute overdose have been reported in pediatric patients, acetaminophen is generally considered very safe and effective if administered at appropriate therapeutic doses.⁶

However, in instances of moderate to severe pain, acetaminophen may be used in combination with ibuprofen. Since dental pain may be classified as acute inflammatory pain, the use of nonsteroidal anti-inflammatory agents (NSAIDs) such as ibuprofen may be considered advantageous, but they may also increase the risk of adverse effects and drug interactions, especially in pediatric patients.

Stay away from opioids

The use of opioid analgesics in the management of severe postoperative dental pain in pediatric patients should be avoided. Opioids produce significant adverse effects, including nausea and vomiting, constipation, and CNS and respiratory depression.¹⁰ Since it is sometimes common practice to perform minimal conscious sedation on pediatric patients with nitrous oxide and oxygen and a benzodiazepine, additive CNS and respiratory depression may occur when opioid analgesics and sedative agents are used together in pediatric patients.¹¹

Editor's note: This article appeared in the March 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

Bali RK, Sharma P, Gaba S, et al. A review of complications of odontogenic infections. Natl J Maxillofac Surg. 2015;6(2):136-143.

Sandor GK, Low DE, Judd PL, Davidson RJ. Antimicrobial treatment options in the management of odontogenic infections. J Can Dent Assoc. 1998;64(7):508-514.

American Academy of Pediatric Dentistry. Use of antibiotic therapy for pediatric dental patients. The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2021:461-464.

Fernandez E, Perez R, Hernandez A, et al. Factors and mechanisms for pharmacokinetic differences between pediatric population and adults. Pharm. 2011;3(1):53-72.

Brook I. Pseudomembranous colitis in children. J Gastroenterol Hepatol. 2005;20(2):182-186.

American Academy of Pediatrics. Committee on Drugs. Acetaminophen toxicity in children. Pediatr. 2001;108(4):1020-1024.

Lesko SM, Mitchell AA. The safety of acetaminophen and ibuprofen among children younger than two years old. Pediatr. 1999;104(4):e39.

Haas DA. An update on analgesics for the management of acute postoperative dental pain. J Can Dent Assoc. 2002;68(8):476-482.

Ong KS, Seymour RA. Maximizing the safety of nonsteroidal anti-inflammatory drug use for postoperative dental pain: an evidence-based approach. Anesth Prog. 2003;50(2):62-74.

Jitpakdee T, Mandee S. Strategies for preventing side effects of systemic opioid in postoperative pediatric patients. Paediatr Anaesth. 2014;24(6):561-568.