___________________________________ DCA06DT Dental Treatment of Pediatric and Adolescent Patients
ANTIBIOTICS Oral infections that develop from grossly carious teeth require prompt antibiotic treatment before definitive treatment is com- pleted. The rise of resistant bacteria mandates that a conserva- tive approach for the use of antibiotics is used. The extent of the infection, the immunocompetence of the patient, and the age of the patient should be considered before any antibiotic is prescribed. Dental infections contained within the pulpal or gingival tissues immediately adjacent to the tooth and fis- tulous tracts without signs of systemic involvement generally do not require antibiotic therapy; more extensive involvement and symptomatic presentations do [37]. Dental infections can advance rapidly among pediatric patients, especially younger children, and those who present with signs of systemic involve- ment should be referred to a pedodontist, oral surgeon, or an emergency department, as intravenous antibiotics and surgical drainage may be required. Penicillin VK remains the empiric antibiotic of choice for the treatment of odontogenic infections [37]. It is effective against the gram-positive anaerobes commonly associated with these infections. Amoxicillin-clavulanate, a derivative of penicillin VK, is absorbed more rapidly and is more effective against gram-negative bacteria [38; 75]. Both medications are available in suspension formulations, with amoxicillin also available as a chewable tablet. Clindamycin is the alternative antibiotic of choice when a patient is allergic to penicillin VK or amoxicil- lin, but the development of pseudomembranous colitis is a potential risk when this agent is used. Consultation with the patient’s pediatrician is recommended prior to prescribing this medication. Cephalosporins should be considered, par- ticularly if the patient has had a previous course of penicillin or amoxicillin [37]. LOCAL ANESTHETICS Adequate pain control during restorative or surgical procedures is essential for patient comfort and for the ability to complete the procedure. Many adults have fears or phobias about dental treatment that originate from the pain they experienced dur- ing a childhood dental procedure during which pain control was inadequate. Therefore, prevention of pain should be an utmost concern. Supraperiosteal infiltration with a local anesthetic provides successful anesthesia for maxillary deciduous and permanent teeth. This technique is also successful for all mandibular deciduous teeth but decreases for mandibular molars, as bone density increases with age. An inferior alveolar nerve block (IANB) may be required to provide successful anesthesia for the deciduous mandibular molars in older children and will be required to successfully anesthetize permanent molars. The mandibular bicuspids may be anesthetized by an IANB or by infiltration of the mental nerve.
An excess use of acetaminophen can lead to hepatic toxic- ity and even liver failure. The smallest dose for the shortest duration to provide adequate analgesia should be used. Acet- aminophen may be combined with other over-the-counter medications (e.g., antihistamines) to provide relief from pain or symptoms of colds, influenza, or sinus congestion. These combinations increase the risk for hepatic toxicity. Parents should be aware that although acetaminophen is an over-the- counter medication, it can be dangerous if used inappropriately in children and adolescents. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen may also be used to relieve pain of odontogenic origin. NSAIDs have analgesic, antipyretic, and anti-inflammatory properties. The mechanism of action is twofold, as they decrease prostaglandin synthesis peripherally and decrease the accompanying inflammatory response. In the central nervous system, NSAIDs decrease the synthesis of pros- taglandins in the critical pain processing regions and inhibit the ability for pain impulses to be transmitted or received. The half-life of naproxen is 12 to 15 hours, which allows for it to be taken twice daily. The two- to four-hour half-life of ibuprofen requires that it be administered more frequently [35]. The gastrointestinal side effects that can occur with NSAIDs are decreased if they are taken with food; however, this practice will decrease their systemic absorption. To facilitate easier administration in the pediatric population, ibuprofen is available as infant drops, suspension, or chewable tablet, and naproxen is available as a suspension. Patients who have experienced an aspirin-induced asthma attack should avoid the use of NSAIDs, as there is a high potential for cross-sensitivity [36]. This group of medications inhibits platelet aggregation and should not be used in patients with a bleeding disorder. NSAIDs are also contraindicated in patients who have gastrointestinal diseases such as inflamma- tory bowel disease or peptic ulcer. Codeine, an opioid analgesic, has been the most commonly prescribed medication for moderate-to-severe pain in pediatric patients [33]. It may be given alone, but it is usually given in combination with acetaminophen. The recommended pedi- atric dose of codeine is 0.5–1 mg/kg (maximum of 60 mg in adolescents) every four to six hours [33]. The maximum dose of acetaminophen with codeine is based on the acetaminophen dose. Respiratory depression is a serious complication; other common side effects include constipation, nausea, sedation, dizziness, and pruritus. In 2024, the American Academy of Pediatrics and the Ameri- can Dental Association released guidelines regarding the treat- ment of acute pain in children and adolescents that strongly recommend against prescribing opioids. The American Acad- emy of Pediatrics suggests that if codeine is prescribed, parents should also purchase naloxone in case of accidental overdose [85]. The American Dental Association recommends the use of NSAIDs (e.g., ibuprofen, naproxen) alone or in combina- tion with acetaminophen for managing acute dental pain [86].
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