1. Antibiotics & ANALGESICS in DENTISTRY
Dr. Hala Helmi A. Hazzaa
Assistant professor of Oral Medicine, Diagnosis, Priodontology & Radiology.
Faculty of Dentistry(Al-Azhar University)

2. Outline: Terminology Indications Classification
Types, uses & side effects
Guidelines
Recommendations
Dr.Hala Helmi Hazzaa

3. Chemotherapeutic Agent: Antibiotic: Antiseptic: Disinfectant:
They are antimicrobial agents (subcategory of antiseptics) generally applied to inanimate surfaces to destroy MO.
It is a chemical antimicrobial agent applied topically or sub-gingivally to mucous membranes, wounds, or intact dermal surfaces to destroy MO & inhibit their multiplication or metabolism.
It is a naturally occurring, semisynthetic or synthetic type of anti-infective agent that destroys or inhibits the growth of selective micro-organisms (MO), generally at low concentrations.
It is a general term for a chemical substance that provides a clinical therapeutic benefit, either through antimicrobial actions or increasing host’s resistance).
Dr.Hala Helmi Hazzaa

4. Antibiotic ??? Antibiotics:
They are a type of antimicrobial drugs used in the treatment & prevention of bacterial infections.
They may either kill or inhibit the growth of bacteria.
A limited number of antibiotics also possess antiprotozoal activity.
Antibiotics are not effective against viruses.
Dr.Hala Helmi Hazzaa

5. Antibiotic ???
Antibiotics revolutionized medicine in the 20th century, and have together with vaccination led to the near eradication of diseases such as tuberculosis (T.B.) in the developed world.
Their effectiveness and easy access led to overuse, prompting bacteria to develop resistance.
This has led to the most common widespread problem known as antibiotic resistance.
Dr.Hala Helmi Hazzaa

6. Antibacterial versus antibiotic ???
To distinguish;
Antibacterials are used in soaps & cleaners
Antibiotics are used as medicine
No difference
Triclosan?
Microflora?
FDA
Dr.Hala Helmi Hazzaa

7. Indications ???
Dr.Hala Helmi Hazzaa

8. Therapeutic Prophylaxis. Host modulation.
In certain conditions, to treat & stop the spread of infection.
Prophylaxis.
To avoid bacteremia, that is anticipated following invasive dental procedures.
Host modulation.
To modulate (control) some immunologic aspects in the host.
Dr.Hala Helmi Hazzaa

9. Classification ???
Dr.Hala Helmi Hazzaa

10. I) According to the route of administration:
Systemic
Topical
Different routes:
Oral (Tablets & Syrup)
Injection (IV or IM)
Advantages:
Rapid action.
Wide spectrum.
Availability.
Affordable cost.
Disadvantages:
The undesirable side effects are the main obstacle????
Rationale:
A more safe route for antibiotics to avoid their undesirable side effects.
Controlled release device:
It is a system designed to prolong the retention of chemotherapeutics in periodontal pockets with a regular & steady release of the agent at therapeutic level.
However, these members are expensive, sometimes difficult in application & not easily available.
Dr.Hala Helmi Hazzaa

11. II) According to the mode of action:
Bactericidal:
(penicillins, cephalosporins, metronidazole, high concentration of macrolides).
Bacteriostatic:
(tetracycline, chloramphenicol, low concentration of macrolides).
Dr.Hala Helmi Hazzaa

12. Systemic Antibiotics
Dr.Hala Helmi Hazzaa

13. Therapeutic indications of antibiotics:
Continued periodontal disease activity as measured by continuing attachment loss, purulent exudate, and bleeding on probing. Non responding cases to treatment (refractory periodontitis).
Aggressive periodontitis.
NUG or NUP.
Acute gingival or periodontal abscess.
Oro-dental infections in medically compromised patients (e.g.; DM).
Severe acute peri-apical infections.
A rapidly spreading or persistent infection.
Dr.Hala Helmi Hazzaa

14. Avoid using antibiotics in the following;
Abscess needs drainage to bacteria
Pain needs analgesics for relief
Viral infection
It needs antiviral therapy
Dr.Hala Helmi Hazzaa

15. Table (1): Orofacial painful/inflammatory conditions that may be encountered in dental practice and their important features
Dar-Odeh et al., 2010
Dr.Hala Helmi Hazzaa

16. Indications for antibiotic administration in prophylaxis:
Notice that:
Utilization of antibiotic prophylaxis for patients at risk does not provide absolute prevention of infection. Post-procedural symptoms of acute infection may indicate antibiotic failure and need for further evaluation.
Indications:
Patients with cardiac conditions ???.
Patients with shunts, or medical devices.
Patients with compromised immunity.
Patients with prosthetic joints.
1. Immunosuppression secondary to:
A. human immunodeficiency virus (HIV).
B. severe combined immunodeficiency.
C. neutropenia.
D. cancer chemotherapy.
E. hematopoietic stem cell or solid organ transplantation.
2. Head & neck radiotherapy.
3. Autoimmune disease (e.g. SLE).
4. Sickle cell anemia.
5. Asplenism or status post splenectomy.
6. Chronic steroid usage.
7. DM.
Dental practitioners should consider prophylactic measures to minimize the risk of IE in patients with underlying cardiac conditions.
Antibiotic prophylaxis is not indicated for dental patients with pins, plates, screws, or other hardware that is not within a synovial joint.
It is indicated routinely for most dental patients with total joint replacements.
Antibiotics may be considered when high-risk dental procedures are performed for patients within 2 years following implant surgery, immuno-compromised patients with total joint arthroplasty, or patients who have had previous joint infections.
These non-cardiac factors can place a patient with compromised immunity at risk for distant-site infection from a dental procedure. This category includes, but is not limited to, patients with the following medical conditions:
Dr.Hala Helmi Hazzaa

17. Viridans streptococci have the unique ability to synthesize dextrans from glucose, which allows them to adhere to fibrin-platelet aggregates at damaged heart valves. This mechanism underlies their ability to cause subacute valvular heart disease following their introduction into the bloodstream (e.g., following dental extraction)
Dr.Hala Helmi Hazzaa

18. We should stay friends forever
Dr.Hala Helmi Hazzaa

19. Host modulation
This term refers to the use of some drugs in a way to modulate the host response in the management of periodontal diseases.
Non-steroidal anti-inflammatory drugs (NSAIDs):
Sub-antimicrobial dose of doxycycline (periostat):
Bisphosphonates:
They are chemical analogues of pyrophsphate known to inhibit bone resorption (in periodontitis & following periodontal surgery).
Tetracycline in low dose inhibit tissue destruction by its anti-collagenase (that of PNLs) effect i.e. decrease rate of collagen break down.
Tetracycline is able to chelate metal ions. Collagenases are Ca++ dependent enzymes.
They decrease bone loss by modifying host inflammatory response to bacteria.
NSAIDs interfere with arachidonic acid metabolism & inhibits the inflammatory process.
Some NSAIDs affect response of PNLs to inflammation.

20. Periostat
It is a proprietary product which is composed of a very low dose of doxycycline.
It is taken several times a day & is used principally for its inhibition effect on collagenase since the dose is too low to effectively act as an antibiotic (i.e. to kill germs). 

21. Guidelines in systemic administration of antibiotics
Antibiotic is a necessary therapeutic adjunct in controlling bacterial infection because bacteria can invade the tissues, making mechanical therapy alone sometimes ineffective.
Antibiotics should be used as adjunct to dental treatment and never used alone as the first line of care.
Make proper diagnosis & consider using narrow spectrum antibiotic to minimize disturbing the normal flora and keep the broad spectrum antibiotic to more complex infections.
Dr.Hala Helmi Hazzaa

22. Guidelines in systemic administration of antibiotics
Currently, no ideal antibiotic for treatment of peri-apical or periodontal disease, as no single antibiotic at its achieved conc. in body fluid can inhibit all the involved pathogens. Thus, combination therapy may be necessary (avoid bactericidal with bacteriostatic).
Antibiotics are indicated when systemic signs, that possibly indicate spread of infection, are evident e.g.; fever, lymphadenopathy, truisms ...etc…
Keep in mind the drug interactions and the side effects of the prescribed type.
Dr.Hala Helmi Hazzaa

23. Guidelines in systemic administration of antibiotics
An effective antibiotic regimen should be directed against the most likely infecting organism, with antibiotics administered shortly after the procedure.
The conservative use of antibiotics is indicated to minimize the risk of developing resistance to current antibiotic regimens.
The duration of antibiotics???. Ideally antibiotics are prescribed for 3-5 days + sufficient loading dose (stress on the full course of therapy) for proper treatment and avoiding the infection relapse.
Dr.Hala Helmi Hazzaa

24. Guidelines in systemic administration of antibiotics
When procedures involve infected tissues or are performed in a patient with a compromised host response, additional doses of antibiotics may be necessary.
Avoid the sub-therapeutic doses or long duration to avoid resistance.
On treating a patient with hepatitis, Penicillin, Clindamycin, Metronidazole are the safest antibiotics, while Tetracycline & Erythromycin should be avoided.
Dr.Hala Helmi Hazzaa

25. Guidelines in systemic administration of antibiotics
With renal patients, avoid nephrotoxic drugs (Tetracycline, aspirin, NSAIDs) & adjust the dosage of drugs metabolized by the kidney (e.g.; lidocaine, penicillin V, cephalexin & metronidazole).
Aggressive management of infections (culture, sensitivity test & antibiotics).
Hospitalization is indicated for severe infection or major procedures as sepsis & febrile illness can lead to fatal acidosis.
Dr.Hala Helmi Hazzaa

26. Penicillins Q-What about safety with pregnancy….? Side effects:
Allergy (anaphylactic shock ???)
Bacterial resistance.
Q- How can we overcome this problem?
Unasyn
Augmentin
Curam
Notice that: B-Lactamase are enzymes secreted by some bacteria e.g. Staphylococci, leading to inactivation of B-lactam antibiotics → resistance to these drugs.
They are bactericidal broad spectrum antibiotics (inhibit bacterial cell wall synthesis) containing a B-lactam ring e.g. amoxicillin.
They are considered among the safest antibiotics.
Dr.Hala Helmi Hazzaa

27. Ampicillin It is safe in lactation & pregnancy, but weak.
Adult dose
mg/ 6-8 hours.
The available capsule either 250 or 500 mg.
The available vial either 250, 500 or 1000 mg.
Other market names: Epicocillin.
Children dose
mg/ kg / 3 times /day.
The available form is:
mg/ 5 ml. susp.
Other market names: Epicocillin.
Dr.Hala Helmi Hazzaa

28. Notice that: Ampiflux (Ampicillin + Dicloxacillin):
Certain added preparations are used to increase the effectiveness of the drug by resisting the action of B- lactamase enzyme:
Ampiflux (Ampicillin + Dicloxacillin):
Available dose is; 250 mg (either capsule or suspension).
Cloxapen: as 250 or 500 mg capsules,
250 mg syrup.
Dr.Hala Helmi Hazzaa

29. Amoxycillin Adults or children over 10 years: 3 × 500 mg daily.
Children years: 3 × 250 mg daily.
Children 2-5 years: 3 × 125 mg daily.
0 - 2 years: 3 × 100 mg daily.
E-Mox
125 – 250 mg (suspension).
500 mg (capsule).
500 – 1000 (vial).
Amoxycillin
125 – 250 mg (suspension).
250 – 500 mg (capsule).
Amoxil
125 – 250 mg (suspension).
500 mg (capsule).
250 – 500 (vial).
Dr.Hala Helmi Hazzaa

30. Notice that: Flumox (Amoxycillin + Flucloxacillin):
Certain added preparations are used to increase the effectiveness of the drug by resisting the action of B- lactamase enzyme:
Flumox (Amoxycillin + Flucloxacillin):
Available dose is; 250 mg (suspension) or 500 mg (capsule).
Dr.Hala Helmi Hazzaa

31. Ampicillin + Sulbactam Amoxicillin + Clavulinic acid
Names: Unasyn, Sulbin, Ampictam.
Available as:
375 mg tablets, or: mg vials.
Augmentin, available as:
( mg tablets,
156 mg suspension,
mg vials)
Curam , available as:
( mg tablets,
mg suspension).
Although they are more effective formulas, safety with pregnancy may be questionable.
Dr.Hala Helmi Hazzaa

32. Cephalosporins Side effects:
Urticarial rashes, fever & GIT disturbance.
There’s cross-allergy & cross-resistance with penicillin.
- Clinically, they’re not used to treat dental infections (Why?)
- As the penicillins are more superior in their range of action against dental / periodontal pathogenic bacteria.
Notice that, 1ST generation Cephalosporins may be used clinically with some benefits e.g. DURICEF, CURISAFE, VELOSEF (against G+ve & some G-ve).
They are B-lactam antibiotics similar to penicillins in their mode of action, but are more resistant to B-lactamase.
Dr.Hala Helmi Hazzaa

33. Dr.Hala Helmi Hazzaa

34. Duricef It is available as: Clinical use: 125 – 250 - 500 mg syrup.
500 mg capsule.
1 gm tablet.
Clinical use:
In adult it can be used 500 mg – 1 gm (twice daily),
1 - 6 years: 250 mg (twice daily),
Under 1 year: 25 mg / kg (twice daily).
Dr.Hala Helmi Hazzaa

35. Metronidazole Market names:
Flagyl, Amrizole, Anazole.
Dosage:
250 or 500 mg tablets.
250 mg suspension.
It offers some benefit in the treatment of refractory periodontitis,
particularly when combined with amoxicillin.
It can be as a monotherapy or combined, with root planing or with other antibiotics.
Side effects:
Ant-abuse effect when alcohol is ingested.
Drug interactions (with oral anticoagulants & oral hypoglycemic drugs).
Metallic taste, sometimes CNS-manifestations & rash.
Several trials have suggested an increased risk for preterm birth among women given metronidazole during pregnancy. However, the current scientific evidence accepted its clinical use at the recommended doses, without an elevated risk of birth defects.
It is a bactericidal … (How?)
It disrupts (the bacterial DNA) of anaerobic MO e.g. P. gingivalis & P. intermedia.
Dr.Hala Helmi Hazzaa

36. Tetracyclines Side effects:
Gastric irritation & pain
Containdicted in pregnancy, lactation & less than 8 years (it causes bone & teeth discoloration).
Hepatotoxicity & phototoxicity.
Its conc. in GCF is 2-10 times that in serum.
It also binds to the tooth surface from where they can release (substantivity).
They exert an anticollagenase effect (esp. against host neutrophil collagenases which is more dangerous), when used in a subantimicrobial dose,
Thus it can inhibit tissue destruction & aid in bone regeneration (arrest bone loss).
They are bacteriostatic i.e effective against rapidly multiplying bacteria.
They act against A. actinomycetemcomitans, being good adjuncts in treatment of LAP.
Dr.Hala Helmi Hazzaa

37. Q- What are the different members of tetracyclines?
Doxycycline
100 mg twice daily in 1st day then, 100 mg once daily (i.e pt. is more compliant), the same spectrum as Minocycline & not affected by antacids.
Its use with surgery for 2 weeks in refractory periodontitis, with significant reduction of A.a. up to 12 months as well as PD reduction & CAL gain.
Minocycline
100 mg twice daily for 1 week, as half life is hr., thus it facilitates compliance.
It’s a broad spectrum & suppress spirochetes up to 3 months posoperatively.
It can be used with less renal toxicity (Why?)… As it’s excreted in feces.
Tetracycline
250 mg (4 t/day), the half life is 6-10 hr.
It shouldn’t be given for patients with impaired renal function, (excreted in urine).
Absorption is reduced with milk & antacids (GIT absorption).
Dr.Hala Helmi Hazzaa

38. Macrolides I)Erythromycin
They can be bacteriostatic or bactericidal, depending on the concentration of the drug & the nature of MO.
They inhibit protein synthesis at ribosomal level (bind to bacterial but not to human ribosomes).
Their spectrum is similar but not identical to penicillin, useful for patients allergic to penicillin.
Orally, mg/8 h. in adults (20-50 mg/kg/day).
It’s not effective against most periodontal putative pathogens (PPP) & doesn’t concentrate in GCF, so, it’s not indicated as an adjunct to periodontal therapy.
Side effects:
Mild GIT upset: nausea, vomiting & diarrhea.
Reversible hepatotoxicitytatic in form of cholestatic jaundice with eosinophilia (contraindicated in liver diseases).
Dr.Hala Helmi Hazzaa

39. II)Azithromycin It is effective against anaerobes & G-ve bacilli.
It penetrates fibroblasts & phagocytes (actively transporting the drug to the sites of inflammation to be directly released when they ruptured) in concentration times > extracellular compartment.
Long t ½, allowing once-daily dosing . After an oral dose of 500 mg for 3 days, significant level of azithromycin can be detected in most tissues for 7 – 10 days.
Dr.Hala Helmi Hazzaa

40. III)Clindamycin
It’s used specifically against anaerobic infections & effective in situations in which the patient allergic to penicillin.
Dose: 150 & 300 mg capsules.
Side effects:
Skin rash, diarrhea & liver dysfunction.
Pseudomembraneous colitis. (How?) (it kills intestinal Flora→ flourishment of colistridium dificile & its toxins→colitis).
Dr.Hala Helmi Hazzaa

41. Quinolones Ciprofloxacin:
It is bactericidal (inhibits DNA synthesis).
Active against G-ve rods (including all facultative & some anaerobic PPP).
It is the only antibiotic in periodontal therapy to which, all strains of A. actinomycetemcomitans are susceptible.
It enhances the effect of warfarin & other anticoagulants. In addition to, nausea, headache & metallic taste.
They’re contraindicated in pregnancy, lactation & patients less than 18 years (may lead to arthropathy).
Dr.Hala Helmi Hazzaa

42. Recommendations Don’t forget that:
Given the increasing number of organisms that have developed resistance to current antibiotic regimens, as well as the potential for an adverse anaphylactic reaction to the drug administered, it is best to be judicious in the use of antibiotics for the prevention of IE and other distant-site infections.
Dr.Hala Helmi Hazzaa

43. The decision making-tree in the different causes of oral problems
Pulpal
Periodontal
**Periodontal
abscess
*Reversible pulpitis
**Gingival abscess
Miscellaneous
*Irreversible pulpitis
**Pericoronitis
*Periapical periodontitis
**Osteomyelitis
*Plaque induced gingivitis
*Cysts
*localized dento-alveolar abscess
*Dry socket
**Non-plaque induced gingivitis
**Infected socket
**Facial cellulitis
*Chronic periodontitis
*Tumors
*Operative intervention is needed, e.g.; filling, root canal treatment, local irrigation, incisional drainage, removal & oral hygiene measures.
**Antibiotic prescribing is needed as an initial treatment. Operative intervention(s) may be initiated on the same visit or later. Oral hygiene measures are mandatory.
Care should be taken with immuno-comporomized patients.
**Aggressive periodontitis
**NUG/P/S
Dr.Hala Helmi Hazzaa

44. Antibiotic recommendations in implant dentistry
Although the use of prophylactic antibiotics in implant dentistry is controversial,
Antibiotics are generally considered beneficial for reducing failure of dental implants placed in ordinary conditions to minimize infections, (2 g or 3 g of amoxicillin given orally, as a single administration, one hour preoperatively significantly reduces failure of dental implants).
The use of postoperative antibiotics is still controversial. (Esposito et al., 2013)
However, special attention should be paid to immediate implant placement especially on replacing peri-apically infected teeth.
Dr.Hala Helmi Hazzaa

45. Analgesics
Dr.Hala Helmi Hazzaa

46. Non Steroidal Anti-inflammatory Drugs (NSAIDs).
There are two main types of NSAIDs, nonselective & selective.
The terms nonselective and selective refer to different NSAIDs’ ability to inhibit specific types of cyclo-oxygenase (COX) enzymes.
Nonselective NSAIDs:
They inhibit both COX-1 and COX-2 enzymes to a significant degree.
Selective NSAIDs:
They inhibit COX-2, an enzyme found at sites of inflammation, more than the type that is normally found in the stomach, blood platelets, and blood vessels (COX-1).
Dr.Hala Helmi Hazzaa

47. Mechanism of action:
Their general mechanism of action: The inhibition of prostaglandin synthesis (Cyclo-oxygenase Enzyme inhibitors).
Dr.Hala Helmi Hazzaa

48. Dr.Hala Helmi Hazzaa

49. Figure (2)
Dr.Hala Helmi Hazzaa

50. Side Effects of NSAIDs Blood pressure may rise with use of NSAIDs.
If NSAIDs are required, they should be used at the lowest effective dose and for the shortest duration necessary for the given indication.
If chronic use of NSAIDs is anticipated, control of treated hypertension may be adversely affected.
Therefore, changes in blood pressure medications may be required.
Anyone who is at risk for or who has cardiovascular disease (coronary artery disease) may have a further increase in risk of heart attacks when taking an NSAIDs (especially with COX2-inhibitors).
Dr.Hala Helmi Hazzaa

51. Side Effects of NSAIDs
Short-term use of NSAIDs can cause stomach upset.
Long-term use of NSAIDs, especially at high doses, can lead to peptic ulcer disease and bleeding from the stomach.
Inhibitor of stomach acid production:
High doses of antacid histamine blockers, such as famotidine (Pepcid®), can reduce the risk of developing an ulcer (related to use of an NSAID).
People with platelet disorders, such as von Willebrand disease, with abnormal platelet function from uremia, and with a low platelet count (thrombocytopenia) are advised to avoid NSAIDs.
Dr.Hala Helmi Hazzaa

52. Side Effects of NSAIDs
Most clinicians recommend stopping all NSAIDs approximately one week before elective surgery (e.g. tooth extraction) to decrease the risk of excessive bleeding. This usually includes aspirin, ibuprofen, naproxen.
Use of NSAIDs, even for a short period of time, can harm the kidneys, in people with underlying kidney disease (???).
salts that block further chemical activity for the rest of the life of that platelet (7-14 days).
Dr.Hala Helmi Hazzaa

53. Dr.Hala Helmi Hazzaa

54. Dr.Hala Helmi Hazzaa

55. Selective NSAIDs have less potential to cause ulcers or gastrointestinal bleeding.
Selective NSAIDs are sometimes recommended for people who have had a peptic ulcer, gastrointestinal bleeding, or gastrointestinal upset when taking nonselective NSAIDs.
Dr.Hala Helmi Hazzaa

56. Precautions with selective NSAIDs
Rofecoxib (Vioxx®) & valdecoxib (Bextra®) were taken off the market in 2004 when it was discovered that people who took these medications had a slightly increased risk of heart attack and stroke.
People with known coronary artery disease (e.g.; past history of heart attack, angina [chest pain due to narrowed heart arteries], history of a stroke, or narrowed arteries to the brain) should avoid using COX-2 inhibitors.
Of the nonselective NSAIDs, naproxen may be the safest for people with coronary artery disease, but a clinician should be consulted before use of this or any other NSAID.
Dr.Hala Helmi Hazzaa

57. Interaction with other medications
People using anticoagulant medications such as warfarin or heparin should generally not take NSAIDs or aspirin because of an increased risk of bleeding when both classes of drugs are used (Both will increase the prothrombin time & INR).
Taking an NSAID & phenytoin (Dilantin) can increase the phenytoin level. As a result, people who take phenytoin should have a blood test to monitor the phenytoin level when starting or increasing the dose of an NSAID.
Dr.Hala Helmi Hazzaa

58. People who take cyclosporine (e. g
People who take cyclosporine (e.g.; to prevent rejection after an organ transplant or for a rheumatic disease, such as rheumatoid arthritis) should take particular care when taking an NSAID ……………… Why??
There is a theoretical risk of kidney damage when cyclosporine and NSAIDs are taken together. To monitor for this complication, blood testing may be recommended.
People taking one NSAID should not take a second NSAID at the same time because of the increased risk of side effects.
Dr.Hala Helmi Hazzaa

59. People with medical conditions that require diuretics, including heart failure, liver disease, and kidney damage, are at increased risk of developing kidney damage while taking NSAIDs.
NSAIDs can worsen kidney function in people whose kidneys are not functioning normally. Therefore, most people with chronic kidney disease are advised to avoid all types of NSAIDs.
Dr.Hala Helmi Hazzaa

60. Fetal exposure to a NSAIDs was confirmed by meconium analysis
Safety with pregnancy
NSAIDS are not generally recommended for pregnant women during the third trimester due to an increased risk of complications in the newborn (persistent pulmonary hypertension of the newborn).
NSAIDs are safe for use during breastfeeding.
Fetal exposure to a NSAIDs was confirmed by meconium analysis
Dr.Hala Helmi Hazzaa

61. Meconium analysis
Meconium drug testing is a sensitive method for identifying infants who have been exposed to drugs in utero. Meconium represents the first series of green stools, which the infant excretes after birth.
The concept was based on initial research in animals, which showed, that a high concentration of the drugs, which the pregnant animal was exposed to, were present in the meconium of their fetuses. Drugs, which the fetus is exposed to during pregnancy, are metabolized by its liver into water-soluble metabolites and excreted into the bile or urine.
It is postulated that drug deposition in meconium occurs either through bile secretion or through swallowing by the fetus of its urine via the amniotic fluid.
Dr.Hala Helmi Hazzaa

62. Recently, analysis of the infant's hair for drugs has been used
Recently, analysis of the infant's hair for drugs has been used. Technical problems in the analysis and sample collection make this method not practical in the neonate.
Dr.Hala Helmi Hazzaa

63. Unfortunately, the drug-exposed neonate is not easy to recognize
Unfortunately, the drug-exposed neonate is not easy to recognize. Many of the drugs which the fetus was exposed to do not produce immediate, recognizable effects.
Even with maternal cooperation, information on the type and/or extent of drug usage is often inaccurate.
One alternative is to test the infant's urine for drugs, but this procedure has its limitations since the successful detection of drug metabolites in the infant's urine is dependent on time of the last drug intake by the mother or when after birth the infant's urine was collected.
The high rate of false negative urine test often arises from the mother's abstention from the use of the drug a few days before she delivers or to the inability to obtain a sample of the infant's urine soon after birth.
Dr.Hala Helmi Hazzaa

64. Dr.Hala Helmi Hazzaa

65. The most common types
Ketoprofen
It is an analgesic, antipyretic & anti-inflammatory NSAID.
75, 100 or 150 mg tab…… (Biprofenid).
25 mg tab. or 50, 75, 200 mg cap…..(Ketofan).
150 mg supp……..(Ketofan).
Ibuprofen
It is an analgesic, antipyretic & anti-inflammatory NSAID.
200, 400 or 600 mg tab…… (Brufen).
Diclofenac Potassium
It is an analgesic & anti-inflammatory NSAID.
25 or 50 mg tab…… (Cataflam).
75 mg amps……. (Cataflam, Dolphin-K).
Its use is safe with hypertension, with avoidance of gastric side effect.
Diclofenac Sodium
It is an analgesic & anti-inflammatory NSAID.
25 mg supp… (Baby relief or Dolphin).
25 or 50 mg tab…… (Declofenac).
75 mg amps……. (Epifenac).
Contra-indicated with hypertension.
Dr.Hala Helmi Hazzaa

66. Cyclo-oxygenase-2 inhibitors
Meloxicam
It is a NSAIDs, acting selectively to inhibit COX2 , not COX1.
It is contraindicated in case of hepatic impairment, bleeding disorders or renal failure.
Tablets : 7.5 or 15 mg.
Celecoxib
It is a NSAIDs, acting selectively to inhibit COX2 , not COX1.
It is contraindicated in case of patients with ischemic heart & cerebrovascular diseases.
capsules : mg.
Dr.Hala Helmi Hazzaa

67. Paracetamol Paracetamol, also known as acetaminophen.
Paracetamol is generally safe at recommended doses.
It is on the WHO Model List of Essential Medicines, the most important medications needed in a basic health system.
Paracetamol is available as a generic medication with trade names including Panadol with low cost.
Safe with pregnancy, lactation, children, hepatitis and kidney affected patients.
Dr.Hala Helmi Hazzaa

68. Paracetamol Disadvantages
In contrast to aspirin, paracetamol does not prevent blood from clotting (it is not an antithrombotic).
It does not cause gastric irritation.
Paracetamol is generally considered safe for children, as it is not associated with a risk of Reye's syndrome in children with viral illnesses.
Compared to ibuprofen, paracetamol has fewer adverse gastrointestinal effects.
Disadvantages
If paracetamol is taken with opioids, there is weak evidence that it may cause hearing loss.
Paracetamol does not help reduce inflammation, while aspirin does.
Although it is well tolerated and safe for use in patients with hepatic disease, acute overdoses of paracetamol can cause potentially fatal liver damage.
Serious skin rashes can rarely occur.
Dr.Hala Helmi Hazzaa

69. THANKS & GOOD LUCK
Dr.Hala Helmi Hazzaa