# **Antibiotics, Local Anaesthetics**
# **& Analgesics In Paediatric Dentistry**
DENT 5312
Paediatric Dentistry Module
**Dr Jilen Patel**
**Specialist Paediatric Dentist**
**Senior Lecturer, Clinical Dentistry**
**UWA Dental School**
<img src="logo.png" alt="The University of Western Australia logo with text 'THE UNIVERSITY OF WESTERN AUSTRALIA'">
#### Course Information
- **Module:** Paediatric Dentistry Module (DENT 5312)
- **Institution:** UWA Dental School, The University of Western Australia
#### Presenter Details
- **Dr Jilen Patel**
- Specialist Paediatric Dentist
- Senior Lecturer, Clinical Dentistry
![]()
The University of Western Australia logo, featuring a shield with a black swan and the text 'THE UNIVERSITY OF WESTERN AUSTRALIA' in blue and black.
# Prescription Writing
* MUST READ
* Oral and Dental Therapeutic Guidelines Version 3
* Chapter: Dental prescriptions and prescription-writing
* Chapter: Practical information on using drugs in dentistry
* Chapter: Acute odontogenic infections
#### Essential Therapeutic Guidelines
To ensure safe and effective clinical practice, practitioners must refer to the **Oral and Dental Therapeutic Guidelines (Version 3)**. Key chapters for review include:
- **Dental prescriptions and prescription-writing**: Fundamental protocols for issuing medication.
- **Practical information on using drugs in dentistry**: Clinical application and pharmacological considerations.
- **Acute odontogenic infections**: Management strategies and specific prescribing for dental infections.
![]()
A photograph of the 'Oral and Dental Therapeutic Guidelines Version 3' book cover, featuring a colorful illustration of two clown faces with exaggerated expressions. The book is placed on a surface with a purple toy car partially visible in the foreground.
# Prescription Writing
<img src="image1.png" alt="University of Western Australia logo">
* Must be legible
* Prescriber’s name, address, telephone number and qualifications
* Patient’s full name, address and date of birth, weight (especially for children)
* Date the prescription is written
* Drug name in full
* Drug strength (250mg, 500mg)
* Drug form (tablet, capsule, suspension)
* Quantity of drug to be administered
* Drug dose, route of administration, frequency and duration of treatment
* Clear instructions for the patient (NOT ‘take as directed)
* “for dental treatment only”
* Handwritten signature of prescriber
#### Essential Prescription Components
All prescriptions must be legible and contain the following information to meet legal and clinical standards:
- **Prescriber Information**
- Full name, practice address, and telephone number.
- Professional qualifications.
- Handwritten signature of the prescriber.
- **Patient Information**
- Full name and address.
- Date of birth.
- Patient weight (this is critical for pediatric dosing calculations).
- **Medication Details**
- Date the prescription is issued.
- Full drug name (avoid abbreviations).
- Drug strength (e.g., 250mg, 500mg).
- Drug form (e.g., tablet, capsule, suspension).
- Quantity of the drug to be dispensed.
- **Administration Instructions**
- Specific dose, route of administration, frequency, and duration of treatment.
- Clear instructions for the patient (avoid vague phrases such as "take as directed").
- The notation "for dental treatment only" must be included.
![]()
The University of Western Australia logo, featuring a shield with a swan and the institution's name in blue text.
<img src="image_description.png">
**Common Antibiotics**
**In**
**Paediatric Dentistry**
**THE UNIVERSITY OF**
**WESTERN AUSTRALIA**
This section outlines the common antibiotics utilized within the field of paediatric dentistry.
![]()
A photo of various colored antibiotic capsules and tablets scattered in the bottom left corner of the page, visually representing the topic of common antibiotics in paediatric dentistry.
# Common Antibiotics
<img src="https://i.imgur.com/1uG2jTf.png" alt="The University of Western Australia logo">
- **Phenoxymethylpenicillin (Penicillin V)**
- **Amoxycillin**
- **Cephalexin**
- **Clindamycin**
- **Metronidazole** (to be used in addition to one of the above antibiotics for spreading odontogenic infections)
The following antibiotics are commonly prescribed in paediatric dental practice:
- Phenoxymethylpenicillin (Penicillin V)
- Amoxycillin
- Cephalexin
- Clindamycin
- Metronidazole (to be used in addition to one of the above antibiotics for spreading odontogenic infections)
![]()
The University of Western Australia logo, featuring a shield with a swan and the institution's name in blue text, located in the top-right corner of the slide.
# Common Antibiotics
<img src="figure.png" alt="Logo of The University of Western Australia">
* **Phenoxymethylpencillin (Penicillin V)**
* narrow spectrum penicillin: Actinomyces, most Strep spp., Fusobacterium spp.
* inactivated by strains producing beta-lactamase enzymes
* drug of first choice in odontogenic infections due to its narrow (and appropriate) spectrum of activity
* has fewer gastrointestinal problems than amoxycillin and is less likely to cause a rash
#### Clinical Profile
- **Classification**: Narrow spectrum penicillin.
- **Activity**: Effective against *Actinomyces*, most *Strep* spp., and *Fusobacterium* spp.
- **Limitations**: Inactivated by strains producing beta-lactamase enzymes.
- **Indications**: Drug of first choice in odontogenic infections due to its narrow and appropriate spectrum of activity.
- **Tolerability**: Has fewer gastrointestinal problems than amoxycillin and is less likely to cause a rash.
![]()
The University of Western Australia logo, featuring a shield with a black swan and the institution's name in blue text.
# Common Antibiotics
* **Phenoxymethylpencillin (Penicillin V)**
* Dose:
* 12.5mg/kg up to 500mg orally
* taken 1 hour before meals or 2 hours after 6 hourly for 5 days
* compliance??
* 125mg/5ml; 150mg/5mL; 250mg/5ml
#### Dosage and Administration
- **Dose**: 12.5 mg/kg up to 500 mg orally.
- **Frequency**: Taken 6 hourly for 5 days.
- **Timing**: Administer 1 hour before meals or 2 hours after meals.
- **Compliance**: Consideration should be given to patient compliance with the 6-hourly regimen.
- **Available Preparations**:
- 125 mg/5 mL
- 150 mg/5 mL
- 250 mg/5 mL
# **Common Antibiotics**
<img src="image_description">
THE UNIVERSITY OF
**WESTERN**
**AUSTRALIA**
Australian Government
Department of Health
The
**PBS** **Pharmaceutical**
**Benefits Scheme**
A-Z Medicines FAQ Subscribe Search for general PBS information Q
Q phenoxymethylpenicillin PBS MEDICINE SEARCH
PBS Information Browse the PBS▾ For Health Professionals▾ For Industry▾ News▾ Publications & Downloads▾ Contacts
**PBS Schedule search for "phenoxymethylpenicillin"**
| Did you mean? | Brand Name | [Phenoxymethylpenicillin-aft] |
| :--- | :--- | :--- |
| | Drug Name | [Phenoxymethylpenicillin] |
**Refine search**
To refine your search select one of the options below.
| Body System | Antiinfectives For Systemic Use (21) |
| :--- | :--- |
| Schedule | General Schedule (21) |
| Prescriber | Dental Practitioners (9) , Medical Practitioners (12) , Nurse Practitioners (12) |
## **PHENOXYMETHYLPENICILLIN**
phenoxymethylpenicillin 500 mg capsule, 50
phenoxymethylpenicillin 500 mg tablet, 25
phenoxymethylpenicillin 125 mg/5 mL powder for oral liquid, 100 mL
phenoxymethylpenicillin 250 mg tablet, 25
phenoxymethylpenicillin 150 mg/5 mL oral liquid, 100 mL
phenoxymethylpenicillin 250 mg/5 mL powder for oral liquid, 100 mL
phenoxymethylpenicillin 250 mg capsule, 50
#### Pharmaceutical Benefits Scheme (PBS) Listings
Phenoxymethylpenicillin is available under the General Schedule for Dental Practitioners in various forms:
- **Capsules**: 250 mg (50), 500 mg (50)
- **Tablets**: 250 mg (25), 500 mg (25)
- **Oral Liquid/Powder**:
- 125 mg/5 mL powder for oral liquid (100 mL)
- 150 mg/5 mL oral liquid (100 mL)
- 250 mg/5 mL powder for oral liquid (100 mL)
![]()
A photo showing a spoon with white powder, a syringe, and various colored pills (red, blue, green, white) scattered on a white surface, illustrating medication forms.
**Common Antibiotics**
* **Amoxycillin**
* moderate spectrum penicillin
* not affected by food and requires fewer oral doses per day
* Dose
* 12.5mg/kg up to 500mg orally
* taken 8 hourly for 5 days
* 100mg/ml; 125mg/5mL; 250mg/5mL; 500mg/5mL
* Nb: amoxicillin + clavulanate has a limited role in treating odontogenic infections
#### Clinical Profile and Dosage
- **Classification**: Moderate spectrum penicillin.
- **Administration**: Not affected by food and requires fewer oral doses per day compared to Penicillin V.
- **Dose**: 12.5 mg/kg up to 500 mg orally.
- **Frequency**: Taken 8 hourly for 5 days.
- **Available Preparations**: 100 mg/mL; 125 mg/5 mL; 250 mg/5 mL; 500 mg/5 mL.
**Note**: Amoxicillin + clavulanate has a limited role in treating odontogenic infections.
# Common Antibiotics
@ The University of Western Australia logo
* **Cephalexin**
* moderate spectrum cephalosporins
* maybe an alternative to patients who are sensitive to penicillin (excluding immediate hypersensitivity)
* not appropriate for those on long-term penicillin or have taken a related penicillin more than once in the previous month
* Dose
* 12.5mg/kg up to 500mg orally, taken 8 hourly for 5 days
* 125mg/5mL; 250mg/5mL
#### Clinical Profile and Dosage
- **Classification**: Moderate spectrum cephalosporin.
- **Indications**: May be an alternative for patients sensitive to penicillin (excluding those with immediate hypersensitivity).
- **Contraindications**: Not appropriate for patients on long-term penicillin or those who have taken a related penicillin more than once in the previous month.
- **Dose**: 12.5 mg/kg up to 500 mg orally.
- **Frequency**: Taken 8 hourly for 5 days.
- **Available Preparations**: 125 mg/5 mL; 250 mg/5 mL.
# **Common Antibiotics**
<img src="Image of a university crest and text: THE UNIVERSITY OF WESTERN AUSTRALIA">
* **Clindamycin**
* first choice in penicillin allergic patients
* **Dose:**
* 7.5mg/kg up to 300mg orally taken 8 hourly for 5 days
* 150mg capsules
#### Clinical Profile and Dosage
- **Indications**: First choice in penicillin-allergic patients.
- **Dose**: 7.5 mg/kg up to 300 mg orally.
- **Frequency**: Taken 8 hourly for 5 days.
- **Available Preparations**: 150 mg capsules.
![]()
The University of Western Australia logo, featuring a shield with a swan and the text "THE UNIVERSITY OF WESTERN AUSTRALIA" in blue and yellow.
# **Common Antibiotics**
<img src="image1.png" width="500"/>
* **Penicillin Allergy**
* Clinical history: nature and severity of the reaction
* Childhood rash?
* most often caused by viral infections or drug-virus interaction rather than a true allergy
* patients can be rechallenged under specialist guidance for definitive assessment
* Can be immediate (IgE-mediated) or delayed (T-Cell mediated)
#### Clinical Assessment
- **Clinical History**: Evaluate the nature and severity of the reaction.
- **Childhood Rash**:
- Most often caused by viral infections or drug-virus interactions rather than a true allergy.
- Patients can be rechallenged under specialist guidance for definitive assessment.
- **Reaction Types**: Can be immediate (IgE-mediated) or delayed (T-Cell mediated).
# **Common Antibiotics**
* Penicillin Allergy: cross-reactivity between beta lactams
* R1 ($\text{6- position}$ for Penicillins, $\text{7- position}$ for Cephalosporins)
* R3 ($\text{3- position}$ for Cephalosporins)
* **Penicillins**: R-side chain ($\text{R-CONH-}$), $\text{B-Lactam Ring}$, $\text{Thiazolidine ring}$
* **Cephalosporins**: R-side chain ($\text{R-CONH-}$), $\text{B-Lactam Ring}$, $\text{Dihydrothiazine ring}$, $\text{R2-side chain}$
**Penicillins** **Cephalosporins**
#### Cross-Reactivity Between Beta-Lactams
Cross-reactivity is determined by the structural components of the antibiotics:
- **Penicillins**: Consist of an R-side chain (R-CONH-), Beta-Lactam Ring, and Thiazolidine ring (R1 at 6-position).
- **Cephalosporins**: Consist of an R-side chain (R-CONH-), Beta-Lactam Ring, Dihydrothiazine ring, and R2-side chain (R1 at 7-position; R3 at 3-position).
![]()
The image displays a comparative diagram of the chemical structures of penicillins and cephalosporins, highlighting key components such as the beta-lactam ring, R-side chains, and specific positions (6-position for penicillins, 7-position for cephalosporins). The diagram illustrates structural differences, including the thiazolidine ring in penicillins and the dihydrothiazine ring in cephalosporins, with labels for R1, R2, and R3 side chains.
Common Antibiotics
* **Penicillin Allergy**
**Penicillin Allergy**
**GUIDE FOR HEALTH PROFESSIONALS**
www.allergy.org.au
* **In severe penicillin allergy** (e.g. anaphylaxis, bronchospasm, urticaria, angioedema), **avoid ALL penicillins, cephalosporins and other beta-lactam antibiotics**
* **In non-severe penicillin allergy** (e.g. mild rash) use cephalosporins and carbapenems **with caution**
* Some reactions (e.g. nausea) are not considered allergies and do not warrant prohibiting penicillin use
| Recommendation | Description | Antibiotics/Classes |
| :--- | :--- | :--- |
| **Contraindicated** | At all times where reasonable evidence of penicillin allergy exists | Ampicillin |
| | | Amoxycillin |
| | | Amoxycillin/clavulanic acid (e.g. Augmentin®) |
| | | Benzathine penicillin |
| | | Benzylpenicillin (e.g. penicillin G) |
| | | Phenoxymethylpenicillin (e.g. penicillin V) |
| | | Dicloxacillin |
| | | Flucloxacillin |
| | | Piperacillin/tazobactam (e.g. Tazocin®) |
| | | Ticarcillin/clavulanic acid (e.g. Timentin®) |
| **Caution** | Avoid if severe penicillin allergy (e.g. anaphylaxis) | Cefaclor |
| | Use with caution if non-severe allergy (e.g. minor rash) | Cefepime |
| | Seek specialist advice | Cefotaxime |
| | | Cefoxitin |
| | | Ceftazidime |
| | | Ceftriaxone |
| | | Cefuroxime |
| | | Cephalexin |
| | | Cephazolin |
| | | Doripenem, ertapenem, imipenem, meropenem |
| **Considered Safe** | In the absence of other contraindications | Aztreonam |
| | | Azithromycin, erythromycin, roxithromycin, clarithromycin |
| | | Ciprofloxacin, norfloxacin, moxifloxacin |
| | | Clindamycin, lincomycin |
| | | Doxycycline, minocycline, tigecycline |
| | | Gentamicin, tobramycin, amikacin |
| | | Linezolid |
| | | Metronidazole |
| | | Trimethoprim/sulfamethoxazole |
| | | Vancomycin |
* **Record allergy alert in the patient health record allergy section**
* **Record details of allergy incident including drug name, description of reaction, severity, date, and name of the person making the report**
* **In hospitals contact ward pharmacist, infectious diseases physician or immunology consultant for any concerns/queries**
* **Immunology consultation for formal testing and/or desensitisation may be indicated**
© 2016 ASCIA ASCIA is the peak professional body of clinical immunology and allergy specialists in Australia and New Zealand
Adapted by ASCIA with permission from Pharmacy Department, Women's and Children's Hospital, Adelaide SA
Endorsed by SA Expert Group on Antimicrobial Resistance, Immunology Departments - RAH, WCH and SA Pathology
Acknowledgement: Counties Manukau District Health Board, Auckland, New Zealand
<img src="image_description">A logo for the Australasian Society of Clinical Immunology and Allergy (ASCIA) and "Penicillin Allergy GUIDE FOR HEALTH PROFESSIONALS" next to a logo for The University of Western Australia.</img>
#### Management Guidelines
1. **Severe Penicillin Allergy** (e.g., anaphylaxis, bronchospasm, urticaria, angioedema): Avoid ALL penicillins, cephalosporins, and other beta-lactam antibiotics.
2. **Non-Severe Penicillin Allergy** (e.g., mild rash): Use cephalosporins and carbapenems with caution.
3. **Non-Allergic Reactions**: Symptoms like nausea are not considered allergies and do not prohibit penicillin use.
#### Antibiotic Selection Table
| Recommendation | Antibiotics / Classes |
| :--- | :--- |
| **Contraindicated** (if allergy exists) | Ampicillin, Amoxycillin, Amoxycillin/clavulanic acid, Benzathine penicillin, Benzylpenicillin, Phenoxymethylpenicillin, Dicloxacillin, Flucloxacillin, Piperacillin/tazobactam, Ticarcillin/clavulanic acid |
| **Caution** (Avoid if severe; use with caution if non-severe) | Cefaclor, Cefepime, Cefotaxime, Cefoxitin, Ceftazidime, Ceftriaxone, Cefuroxime, Cephalexin, Cephazolin, Carbapenems (Doripenem, ertapenem, imipenem, meropenem) |
| **Considered Safe** | Aztreonam, Macrolides (Azithromycin, erythromycin, roxithromycin, clarithromycin), Quinolones (Ciprofloxacin, norfloxacin, moxifloxacin), Clindamycin, Lincomycin, Tetracyclines (Doxycycline, minocycline, tigecycline), Aminoglycosides (Gentamicin, tobramycin, amikacin), Linezolid, Metronidazole, Trimethoprim/sulfamethoxazole, Vancomycin |
#### Documentation and Follow-up
- Record allergy alerts in the patient health record allergy section.
- Include drug name, reaction description, severity, date, and reporter's name.
- Consult immunology for formal testing or desensitisation if indicated.
![]()
A flowchart diagram illustrating antibiotic recommendations for patients with penicillin allergy, categorized into three sections: 'Contraindicated' (red circle), 'Caution' (orange circle), and 'Considered Safe' (green circle). Each section lists specific antibiotics or classes of antibiotics, with arrows indicating the flow of decision-making based on allergy severity.
![]()
A logo for The University of Western Australia, featuring a shield with a black swan and the text 'THE UNIVERSITY OF WESTERN AUSTRALIA' in blue.
![]()
A logo for ASCIA (Australasian Society of Clinical Immunology and Allergy), featuring the acronym 'ascia' in white text on a black background, with the full name and website 'www.allergy.org.au' below.
# Common Antibiotics
* **Metronidazole**
* used as a supplement to penicillin or clindamycin in the case of an unresponsive or severe infection
* active against most anaerobic bacteria: *Peptoniphilus* spp, *P. gingivalis*, *P. oralis*
* Dose:
* 10mg/kg up to 400mg orally taken 12 hourly for 5 days
* 200mg/5mL
#### Clinical Profile and Dosage
- **Indications**: Used as a supplement to penicillin or clindamycin for unresponsive or severe infections.
- **Activity**: Active against most anaerobic bacteria, including *Peptoniphilus* spp, *P. gingivalis*, and *P. oralis*.
- **Dose**: 10 mg/kg up to 400 mg orally.
- **Frequency**: Taken 12 hourly for 5 days.
- **Available Preparations**: 200 mg/5 mL.
![]()
a photograph of a pink box of Flagyl 400mg metronidazole tablets, labeled as 'Antiamoebic and Anti-infective' with '200 Film Coated Tablets' indicated, placed on a white background.
# Common Antibiotics
<img src="data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAD8AAAA8CAYAAACg8L8EAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAACxMAAAALAwEB3D34AAAACklEQVR4nO3SsQ0AAADCoPVPbQhWoAAAANE/1wB7Y9P0v/vLAAAAAElFTkSuQmCC" alt="image"> | THE UNIVERSITY OF
WESTERN
AUSTRALIA
* **Metronidazole**
* side effects: nausea, vomiting, flushing, headache (Adults should avoid alcohol for atleast 24hrs after completing the course of metronidazole)
* interactions with several drugs e.g. Warfarin
**Common Antibiotics**
#### Side Effects and Interactions
- **Side Effects**: Nausea, vomiting, flushing, and headache.
- **Alcohol Warning**: Adults should avoid alcohol for at least 24 hours after completing the course.
- **Drug Interactions**: Interacts with several drugs, such as Warfarin.
![]()
The University of Western Australia logo, featuring a blue and yellow shield with a black swan and the text 'THE UNIVERSITY OF WESTERN AUSTRALIA' in blue.
<div align="center">
<h1><font color="#1f497d">Common Analgesics</font></h1>
<h1><font color="#1f497d">In</font></h1>
<h1><font color="#1f497d">Paediatric Dentistry</font></h1>
</div>
This section covers the selection and administration of analgesics within the context of paediatric dental care.
![]()
A photo of various colored capsules and tablets scattered in the bottom left corner, representing common analgesics used in paediatric dentistry.
# **Common Analgesics**
<img src="image_description.png">
* **Paracetamol (panadol)**
* **Ibuprofen (nurofen)**
* **Painstop?**
* **Aspirin?**
#### Overview of Analgesic Options
- Paracetamol (e.g., Panadol)
- Ibuprofen (e.g., Nurofen)
- Painstop (Historical/Review required)
- Aspirin (Historical/Review required)
![]()
The University of Western Australia logo, featuring a shield with a black swan, books, and a crown, along with the institution's name in blue text.
# Common Analgesics
<img src="image_description.png">
* **Paracetamol**
* Dose:
* $15 \text{mg}/\text{kg}$ orally
* 4 to 6 hourly (to a maximum daily dose of $4\text{g}/\text{day}$)
* $120 \text{mg} /5 \text{ml}$
* contra-indications: impaired renal or hepatic function
#### Dosage and Administration
- **Dose:** 15 mg/kg orally
- **Frequency:** 4 to 6 hourly
- **Maximum Daily Dose:** 4 g/day
- **Concentration:** 120 mg / 5 ml
#### Contraindications
- Impaired renal function
- Impaired hepatic function
# Common Analgesics
<img src="https://i.imgur.com/4S74h1y.png" width="500">
* **Ibuprofen**
* Dose:
* 5-10mg/kg orally
* 6 to 8 hourly (to a maximum daily dose of 2400mg/day)
* 100 mg / 5 ml
* contra-indications: hypersensitivity (asthma, rhinitis, urticaria) renal or cardiac impairment, gastroenterological pathology, anticoagulants/corticosteroids
* *use the lowest effective dose, no more than 3 days without review
#### Dosage and Administration
- **Dose:** 5-10 mg/kg orally
- **Frequency:** 6 to 8 hourly
- **Maximum Daily Dose:** 2400 mg/day
- **Concentration:** 100 mg / 5 ml
- **Usage Note:** Use the lowest effective dose for no more than 3 days without review.
#### Contraindications
- Hypersensitivity (e.g., asthma, rhinitis, urticaria)
- Renal or cardiac impairment
- Gastroenterological pathology
- Concurrent use of anticoagulants or corticosteroids
# **Common Analgesics**
* **Ibuprofen**
<img src="placeholder_image_description">
Kent, A.P. et al. J Am Coll Cardiol. 2018;72(3):255-67.
#### Clinical Considerations
Reference: Kent, A.P. et al. J Am Coll Cardiol. 2018;72(3):255-67.
![]()
A detailed diagram illustrating the mechanisms of action for nonselective NSAIDs and oral anticoagulants, showing their effects on platelets, gastric mucosa, and coagulation pathways. The diagram highlights potential side effects such as gastric ulcers, bleeding, thrombi in the left atrium, and increased risk of stroke and gastrointestinal bleeding when combining NSAIDs with anticoagulants.
Common Analgesics
* **Painstop?** *Paracetamol + codeine*
* Paracetamol 120mg per 5mL + Codeine Phosphate 5mg per 5mL (dosage on the bottle)
* for acute pain, 0.8 ml / kg 6h Painstop Night
* Paracetamol 120mg/5mL + Codeine Phosphate 5mg/5mL + Promethazine Hydrochloride 6.5mg/5mL + Ethanol 0.5mL/ 5mL (dosage on the bottle)
* acute pain + sedation, 0.5 ml /kg 6h
FOR HISTORICAL REFERENCE ONLY!
#### Historical Formulations (FOR HISTORICAL REFERENCE ONLY)
- **Painstop (Paracetamol + Codeine):**
- Composition: Paracetamol 120 mg/5 mL + Codeine Phosphate 5 mg/5 mL
- Historical dosage for acute pain: 0.8 ml/kg every 6 hours
- **Painstop Night:**
- Composition: Paracetamol 120 mg/5 mL + Codeine Phosphate 5 mg/5 mL + Promethazine Hydrochloride 6.5 mg/5 mL + Ethanol 0.5 mL/5 mL
- Historical dosage for acute pain and sedation: 0.5 ml/kg every 6 hours
# Common Analgesics
- **Painstop?** Paracetamol + codeine
<table>
<tr>
<td>
<img src="painstop_package.png" alt="Painstop for children Night-Time Pain Reliever packaging and bottle">
</td>
<td>
<table>
<tr>
<td>
EMNote
</td>
<td>
American Academy of Pediatrics
<br>
DEDICATED TO THE HEALTH OF ALL CHILDREN
</td>
</tr>
</table>
<h2>Codeine: Time To Say “No”</h2>
<p>Joseph D. Tobias, MD, Thomas P. Green, MD, Charles J. Coté, MD, SECTION ON ANESTHESIOLOGY AND PAIN MEDICINE, COMMITTEE ON DRUGS</p>
<table>
<tr>
<td colspan="2">Codeine</td>
<td>CYP2D6</td>
<td colspan="2">Morphine</td>
</tr>
<tr>
<td colspan="2">(Inactive prodrug)</td>
<td>(liver enzyme)</td>
<td colspan="2">(Active metabolite)</td>
</tr>
</table>
<ol>
<li>Codeine <span style="color:red">should not be prescribed</span> to children</li>
<li>Codeine may cause unanticipated respiratory depressions and deaths in children who are <span style="color:red">ultrarapid metabolizers</span></li>
</ol>
<p>Pediatrics. 2016;138(4):e20162396 @jackcfchong</p>
</td>
</tr>
</table>
**THE UNIVERSITY OF WESTERN AUSTRALIA**
#### Safety Warnings and Metabolism
According to the American Academy of Pediatrics (Section on Anesthesiology and Pain Medicine):
- **Metabolic Pathway:** Codeine is an inactive prodrug converted by the liver enzyme **CYP2D6** into its active metabolite, **Morphine**.
- **Key Recommendations:**
1. Codeine should not be prescribed to children.
2. Codeine may cause unanticipated respiratory depression and death in children who are **ultra-rapid metabolizers**.
Reference: Pediatrics. 2016;138(4):e20162396.
![]()
A photo of the Painstop for children Night-Time Pain Reliever packaging and bottle, labeled as a pharmacist-only medicine with antihistamine, highlighted with a red diagonal line across the image.
![]()
A diagram illustrating the metabolic pathway of codeine, showing it as an inactive prodrug converted by the CYP2D6 liver enzyme into the active metabolite morphine, with a warning that codeine should not be prescribed to children due to risks of respiratory depression in ultrarapid metabolizers.
# Common Analgesics
• **Painstop? Paracetamol + codeine**
<div style="text-align: right;">
<img src="logo_uwa.png" alt="University of Western Australia Logo">
</div>
<div style="border-top: 2px solid yellow; border-bottom: 2px solid blue;">
<div style="background-color: #003366; color: white; padding: 5px;">
<span style="padding: 0 10px; background-color: #006699;">Home</span>
<span style="padding: 0 10px;">Safety information</span>
<span style="padding: 0 10px;">Consumers</span>
<span style="padding: 0 10px;">Health professionals</span>
<span style="padding: 0 10px;">Industry</span>
<span style="padding: 0 10px;">About the TGA</span>
<span style="padding: 0 10px;">News room</span>
</div>
</div>
<div style="display: flex;">
<div style="width: 25%; background-color: #f0f0f0; padding: 10px;">
<div style="background-color: #004477; color: white; padding: 5px;">Safety information</div>
<ul>
<li><span style="color: #004477;">&rsaquo; Report a problem or side effect</span></li>
<li><span style="color: #004477;">&rsaquo; Alerts</span></li>
<li><span style="color: #004477;">&rsaquo; Recalls</span></li>
<li><span style="color: #004477;">&rsaquo; Early warning system</span></li>
<li><span style="color: #004477;">&rsaquo; Prescription opioids hub</span></li>
<li><span style="color: #004477;">&rsaquo; Black Triangle Scheme</span></li>
<li><span style="color: #004477;">&rsaquo; Medicine shortages</span></li>
<li style="background-color: #0077b3; color: white; padding: 5px 0;">Safety information & education
<ul>
<li style="background-color: #e0e0e0; color: black; padding: 2px 5px;">Medicines safety</li>
<li style="background-color: #e0e0e0; color: black; padding: 2px 5px;">Medical devices safety</li>
<li style="background-color: #e0e0e0; color: black; padding: 2px 5px;">Database of Adverse Event Notifications (DAEN)</li>
</ul>
</li>
</ul>
</div>
<div style="width: 75%; padding: 10px;">
<div style="text-align: right;">
<span style="float: left;">Home &raquo; Safety information &raquo; Safety information & education &raquo; Medicines safety</span>
A- A+ <img src="icon_print.png" alt="Print Icon"> Share
</div>
<h2>Safety review: Codeine use in children and ultra-rapid metabolisers</h2>
<p>22 November 2017</p>
<h3>Update - recommendations implemented</h3>
<p>Consumers and health professionals are advised that the recommendations of the safety review of codeine use in children and rapid metabolisers have now been implemented.</p>
<p>The Product Information (PI) documents for all prescription codeine products have been updated to reflect the findings of the TGA's safety review.</p>
<p>Specifically, codeine products should no longer be used in children under 12 years of age, or in children aged 12-18 years who have recently undergone surgery to remove their tonsils or adenoids.</p>
<p>Codeine should also not be used by breastfeeding mothers or in patients known to be ultra-rapid metabolisers.</p>
<p>Most PIs for over-the-counter codeine products now have warnings to not use these products in children aged under 12 years.</p>
<p>From 1 February 2018, all Schedule 2 (Pharmacy Medicine) and Schedule 3 (Pharmacist Only Medicine) codeine-containing products will be rescheduled to Schedule 4 (Prescription Only Medicine).</p>
<p>In the meantime, the TGA has identified a small number of over-the-counter codeine products, all of which are tablets, that are currently being marketed and still have dosage instructions for children aged 6-12 years. The sponsors of these products have written to pharmacists to inform them of the relevant safety information including that these products should not be used in children under 12 years of age.</p>
</div>
<div style="width: 25%; border-left: 1px solid #ccc; padding-left: 10px;">
<h4>Related information</h4>
<ul>
<li>Update of codeine safety and efficacy review</li>
<li>Scheduling delegate's final decision: codeine, December 2016</li>
<li>Update on the proposal for the rescheduling of codeine products</li>
</ul>
</div>
</div>
#### TGA Safety Review and Regulatory Changes
The Therapeutic Goods Administration (TGA) implemented the following recommendations regarding codeine use:
- **Age Restrictions:** Codeine products should no longer be used in children under 12 years of age.
- **Post-Surgical Restrictions:** Contraindicated in children aged 12-18 years who have recently undergone tonsillectomy or adenoidectomy.
- **Other Contraindications:** Should not be used by breastfeeding mothers or patients known to be ultra-rapid metabolizers.
- **Rescheduling:** As of 1 February 2018, all codeine-containing products were rescheduled from Schedule 2/3 to **Schedule 4 (Prescription Only Medicine)**.
![]()
The University of Western Australia logo, featuring a shield with a swan and the text 'THE UNIVERSITY OF WESTERN AUSTRALIA' in blue and white.
![]()
The Australian Government Department of Health Therapeutic Goods Administration logo, showing a crest with a kangaroo and emu, and the organization's name in white text on a dark blue background.
Common Analgesics
# Aspirin?
**[Severe Reye syndrome: report of 14 cases managed in a pediatric intensive care unit over 11 years].**
[Article in French]
Thabet F¹, Drug Saf. 2006;29(12):1111-21.
**Reye's syndrome: the case for a causal link with aspirin.**
Glasgow JF¹.
Drug Saf. 2002;25(4):225-31.
**Is aspirin a cause of Reye's syndrome? A case against.**
Orlowski JP¹, Hanhan UA, Fiallos MR.
Paediatr Drugs. 2007;9(3):195-204.
**Aspirin and Reye syndrome: a review of the evidence.**
Schrör K¹.
BMJ. 2002 Nov 2;325(7371):988.
**Aspirin use to be banned in under 16 year olds.**
Macdonald S.
PMID: 12411346 PMCID: PMC1169585 DOI: 10.1136/bmj.325.7371.988/c
#### Clinical Evidence and Restrictions
There is a documented causal link between aspirin use in children and the development of Reye Syndrome.
- **Age Restriction:** Aspirin use is banned in individuals under 16 years of age.
- **Key Literature:**
- *Reye's syndrome: the case for a causal link with aspirin.* Glasgow JF. Drug Saf. 2002.
- *Aspirin and Reye syndrome: a review of the evidence.* Schrör K. BMJ. 2002.
- *Aspirin use to be banned in under 16 year olds.* Macdonald S. BMJ. 2002.
<img src="image_description" />
**Local Anaesthesia**
**In**
**Paediatric Dentistry**
<img src="image_description" />
Local Anaesthesia in Paediatric Dentistry
![]()
A photo showing various dental anesthesia supplies, including syringes with different colored caps, a dental mirror, and a packaged dental instrument, arranged on a white surface.
![]()
A photo of a dental anesthesia device labeled 'STA System' by Miltex, featuring a control panel with buttons and a connected handpiece, designed for local anesthesia delivery in pediatric dentistry.
# **Local Anaesthetics**
<img src="image1.png">
* **Assumed knowledge:** mechanisms of action of LA, types of LA, indications/contraindications, duration on onset etc
<img src="image2.png">
#### Foundational Knowledge
- Assumed knowledge: mechanisms of action of LA, types of LA, indications/contraindications, duration of onset, etc.
![]()
A flowchart diagram illustrating the classification of local anaesthetic agents into ester and amide types, based on the difference in the chain that binds the hydrophobic and hydrophilic groups in a molecule. The diagram lists examples of ester-type agents (benzocaine, 2-chloroprocaine, procaine, tetracaine) and amide-type agents (articaine, bupivacaine, dibucaine, etidocaine, lidocaine, mepivacaine, prilocaine, S-ropivacaine).
# Local Anaesthetics
Logo:
* Assumed knowledge: mechanisms of action of LA, types of LA, indications/
contraindications, duration on onset etc
<br>
The image contains a flowchart detailing local anaesthetic agents based on mode of administration (Topical vs. Injectable) and potency/duration for injectables.
| Top Level | Branch 1 (Topical) | Branch 2 (Injectable) |
| :--- | :--- | :--- |
| **Local anaesthetic agents** | based on mode of administration | based on mode of administration |
| | **Topical** | **Injectable** |
| | based on formulation/composition | based on potency and duration of action |
| | aqueous, viscous, gel, cream, spray, or patch | low potency and short duration | moderate potency and duration | high potency and long duration |
| | **single agent** | **combination** | | | |
| | Benzocaine | Eutectic mixture of local anaesthetics | Procaine | Articaine | Tetracaine |
| | Lidocaine | Lidocaine + prilocaine; | 2-chloroprocaine | Lidocaine | Bupivacaine |
| | Tetracaine | Lidocaine + tetracaine; | | Mepivacaine | Etidocaine |
| | | Lidocaine + prilocaine + dibucaine | | Prilocaine | S-ropivacaine |
#### Classification of Local Anaesthetic Agents
Local anaesthetic agents are categorized based on their mode of administration and pharmacological properties:
1. **Topical Administration**
- Based on formulation/composition: aqueous, viscous, gel, cream, spray, or patch.
- **Single Agents:** Benzocaine, Lidocaine, Tetracaine.
- **Combinations (Eutectic mixtures):**
- Lidocaine + prilocaine
- Lidocaine + tetracaine
- Lidocaine + prilocaine + dibucaine
2. **Injectable Administration**
- Based on potency and duration of action:
- **Low potency / Short duration:** Procaine, 2-chloroprocaine.
- **Moderate potency / Duration:** Articaine, Lidocaine, Mepivacaine, Prilocaine.
- **High potency / Long duration:** Tetracaine, Bupivacaine, Etidocaine, S-ropivacaine.
![]()
A flowchart diagram classifying local anaesthetic agents based on mode of administration (Topical vs. Injectable). The Topical branch is further divided into single agents (benzocaine, lidocaine, tetracaine) and combinations (eutectic mixture of local anaesthetics, lidocaine + prilocaine, lidocaine + tetracaine, lidocaine + prilocaine + dibucaine). The Injectable branch is categorized by potency and duration into low (procaine, 2-chloroprocaine), moderate (articaine, lidocaine, mepivacaine, prilocaine), and high (tetracaine, bupivacaine, etidocaine, S-ropivacaine).
# **Local Anaesthetics**
The University of Western Australia logo is present.
* 2% Lignocaine with 1:80,000 Adrenaline
* Max dose: 7mg/kg
* 4% Articaine with Adrenaline 1:100,000
* Max dose: 7mg/kg
* 0.5% Bupivacaine with 1:200,000 Adrenaline
* Max dose: 2mg/kg
<img src="image.png" alt="Product images for Lignospan Special, Septanest 1:100,000, and Marcaine 0.5% with epinephrine 1:200,000 injection.">
#### Common Formulations and Maximum Dosages
- **2% Lignocaine with 1:80,000 Adrenaline**
- Max dose: 7mg/kg
- **4% Articaine with Adrenaline 1:100,000**
- Max dose: 7mg/kg
- **0.5% Bupivacaine with 1:200,000 Adrenaline**
- Max dose: 2mg/kg
![]()
Product image of Lignospan Special, a box of 10 vials of 2% lignocaine with 1:80,000 adrenaline, displayed next to its packaging.
![]()
Product image of Septanest 1:100,000, a box of 10 vials of 4% articaine with adrenaline, shown with its packaging.
![]()
Product image of Marcaine 0.5% with epinephrine 1:200,000, a box of 10 vials of 0.5% bupivacaine with adrenaline, displayed next to its packaging.
# Local Anaesthetics
• **Variations among countries/regions**
<img src="image_placeholder_for_local_anaesthetics_vials_and_logo.png">
#### Regional Variations
- Variations among countries/regions regarding available formulations and standards.
![]()
A photo displaying various local anesthetic vials with different labels and colors, illustrating variations among countries/regions. The vials include brands like Septanest, Scandonest, and Lignospan, each with distinct labeling and packaging.
# Local Anaesthetics
* Variations among countries/regions
Table 1. Local anaesthetic agent and concentration colors (Band 1)
| Product | Band color (PMS) | | | |
|---|---|---|---|---|
| Articaine - 4% | Gold 871 | Gold 872 | Gold 873 | Gold 874 | Gold 875 |
| Bupivacaine - 0.5% | Blue 300 | Blue 301 | | | |
| Lidocaine - 2% | Red 185 | Red 188 | Red 199 | Red 200 | |
| Lidocaine - 3% | Purple 266 | Purple 267 | | | |
| Mepivacaine - 2% | Brown 477 | Brown 478 | Brown 498 | Brown 499 | |
| Mepivacaine - 3% | Tan 406 | Tan 407 | Tan 408 | | |
| Prilocaine - 3% | Orange 136 | Orange 137 | | | |
Table 2. Vasoconstrictor and concentration colors (Band 2)
| Product | Band color (PMS) | | | | | |
|---|---|---|---|---|---|---|
| No vasoconstrictor | White | None | | | | |
| Epinephrine < 1:200 000 | Yellow 108 | Yellow 109 | Yellow 110 | Yellow 115 | Yellow 116 | |
| Epinephrine <1:100 000 to 1:200 000 | Orange 136 | Orange 137 | | | | |
| Epinephrine <1:50 000 to 1:100 000 | Brown 477 | Brown 478 | Brown 498 | Brown 499 | |
| Epinephrine 1:50 000 | Green 347 | Green 348 | Green 355 | Green 356 | | |
| Levonordefrin | Black | None | | | | |
| Nor-epinephrine 1:100 000 | Tan 406 | Tan 407 | Tan 408 | | | |
| Nor-epinephrine 1:25 000 | Purple 266 | Purple 267 | | | | |
| Octapressin (felypressin) | Blue 300 | Blue 301 | | | | |
Figure 1. Placement of colour coding bands on cartridge
$$\text{}$$
Dimensions in millimeters
Key
1: Band #1 for coding of concentration of anaesthetic agent
2: Band #2 for coding of concentration of vasoconstrictor
3: Cartridge plunger
4: Disc end
**The University of Western Australia**
**American Dental Association**
#### ISO/ADA Colour Coding Standards
Cartridges utilize colour-coded bands to identify the anaesthetic agent and the vasoconstrictor concentration.
**Table 1: Local Anaesthetic Agent and Concentration (Band 1)**
- Articaine 4%: Gold
- Bupivacaine 0.5%: Blue
- Lidocaine 2%: Red
- Lidocaine 3%: Purple
- Mepivacaine 2%: Brown
- Mepivacaine 3%: Tan
- Prilocaine 3%: Orange
**Table 2: Vasoconstrictor and Concentration (Band 2)**
- No vasoconstrictor: White
- Epinephrine < 1:200,000: Yellow
- Epinephrine 1:100,000 to 1:200,000: Orange
- Epinephrine 1:50,000 to 1:100,000: Brown
- Epinephrine 1:50,000: Green
- Levonordefrin: Black
- Nor-epinephrine 1:100,000: Tan
- Nor-epinephrine 1:25,000: Purple
- Octapressin (felypressin): Blue
**Cartridge Band Placement**
1. Band #1: Coding for concentration of anaesthetic agent.
2. Band #2: Coding for concentration of vasoconstrictor.
![]()
Table 2 displays the vasoconstrictor and concentration colors (Band 2) for various dental anesthetic products, using PMS color codes to indicate different concentrations and types of vasoconstrictors such as epinephrine, levonordefrin, and nor-epinephrine.
![]()
Table 1 shows the local anesthetic agent and concentration colors (Band 1), listing products like articaine, bupivacaine, and lidocaine with their corresponding PMS color codes for different concentrations.
![]()
Figure 1 illustrates the placement of color coding bands on a dental cartridge, showing the dimensions and positions of Band #1 for the anesthetic agent concentration and Band #2 for the vasoconstrictor concentration.
**Local Anaesthetics**
* Variations among countries/regions
<br>
#### International Standards
- Variations among countries/regions.
![]()
Three vials of Septanest 1:100,000 local anesthetic solution are displayed in ascending size order, with volumes of 1 ml, 1.7 ml, and 2.2 ml. The vials have gold caps and blue labels, and are presented against a white background, illustrating variations in packaging sizes.
**Local Anaesthetics**
<img src="image_description.png">
* Calculating dosage
**Option 1**
* 1% solution contains 1g in 100mL
* which is 10mg in 1mL
* 1mL of a 1% solution contains 10mg of LA base
* 2% lignocaine = 20mg/mL
* Each carpule:
* 2.2mL (x 20mg) = 44mg of lignocaine per carpule
* 1.8mL (x 20mg) = 36mg of lignocaine per carpule
* 1.7mL (x 20 mg) = 34mg of lignocaine per carpule
#### Dosage Calculation: Option 1
Calculation based on solution percentage:
- A 1% solution contains 1g in 100mL, which equals 10mg/mL.
- 2% Lignocaine = 20mg/mL.
**Content per Carpule (2% Lignocaine):**
- 2.2mL carpule: 44mg
- 1.8mL carpule: 36mg
- 1.7mL carpule: 34mg
**Local Anaesthetics**
<img src="logo.png" alt="University of Western Australia Logo">
* Calculating dosage
* *What is the maximum dose of 2% Lignocaine with adrenaline can you give a 25 kg child?*
* Max dose = 7mg/kg (ie. 7mg/kg x 25kg) = 175mg
* 2% Lignocaine ie 20mg/ml
* ie. 175mg/20mg = 8.75ml (which is 3.9 carpules) [8.75ml/2.2mL carpules]
#### Clinical Example: 25kg Child
**Question:** What is the maximum dose of 2% Lignocaine with adrenaline for a 25kg child?
1. **Calculate Maximum Dose in mg:**
- 7mg/kg × 25kg = 175mg
2. **Convert to Volume (mL):**
- 2% Lignocaine = 20mg/mL
- 175mg / 20mg/mL = 8.75mL
3. **Convert to Carpules:**
- 8.75mL / 2.2mL per carpule ≈ 3.9 carpules
**Local Anaesthetics**
$$\includegraphics[max width=\textwidth]{/mnt/data/image.png}$$
* Calculating dosage **Option 2**
* *What is the maximum dose of 2% Lignocaine with adrenaline can you give a 25 kg child?*
$$\text{Maximum dose (mg/kg)} \times \frac{\text{weight (kg)}}{10} \times \frac{1}{\text{concentration of LA}} = \text{Max dose (ml)}$$
$$7 \text{ (mg/kg)} \times \frac{25 \text{ (kg)}}{10} \times \frac{1}{2} = 8.75\text{ml}$$
#### Dosage Calculation: Option 2 (Formula Method)
To determine the maximum dose in milliliters (mL):
$$\text{Maximum dose (mg/kg)} \times \frac{\text{weight (kg)}}{10} \times \frac{1}{\text{concentration of LA}} = \text{Max dose (ml)}$$
**Example for 25kg child using 2% Lignocaine:**
$$7 \text{ (mg/kg)} \times \frac{25 \text{ (kg)}}{10} \times \frac{1}{2} = 8.75\text{ml}$$
![]()
A mathematical formula for calculating the maximum dose of local anaesthetic in milliliters, presented as a general equation and then applied to a specific case of a 25 kg child with 2% lignocaine. The formula includes variables for maximum dose per kilogram, weight, and concentration of the local anaesthetic.
# **Local Anaesthetics**
* **Documentation!**
* must include the type and dosage of local anaesthetic
* Dosage of vasoconstrictors, if any, must be noted
* e.g. 2% or 44 mg lignocaine with 1:100,000 epinephrine include the type of injection(s) given
* e.g. infiltration, block, intra-osseous
* needle selection, and patient’s reaction to the injection (eg. Beh: +)
* patients for whom the maximum dosage of local anaesthetic may be a concern, the weight should be documented preoperatively
Local Anaesthetics
#### Essential Record Keeping
Clinical documentation must be thorough and include:
- **Type and Dosage:** Specific local anaesthetic used and the total milligrams administered.
- **Vasoconstrictors:** Dosage and type (e.g., 44mg Lignocaine with 1:100,000 epinephrine).
- **Injection Details:** Type of technique used (e.g., infiltration, block, intra-osseous).
- **Equipment and Response:** Needle selection and the patient’s behavioral reaction (e.g., Behavior: +).
- **Patient Weight:** For patients where maximum dosage is a concern, weight must be documented preoperatively.
# **Local Anaesthetics**
<img src="image_placeholder.png" alt="Dental model showing needle placement for an Inferior Alveolar Nerve Block (IANB)">
* **Techniques: Inferior Alveolar Nerve Block**
**The IANB has the LOWEST success rate of all major nerve blocks in the human body - Malamed 2015**
#### Overview of Techniques
- Inferior Alveolar Nerve Block (IANB)
#### Success Rates
According to Malamed (2015), the IANB has the lowest success rate of all major nerve blocks in the human body.
![]()
A photographic image of a dental model demonstrating the Inferior Alveolar Nerve Block (IANB) technique, showing a needle being inserted into the mandibular ramus. The image is used to illustrate the procedure discussed in the context of local anaesthetics.
# **Local Anaesthetics**
* **Techniques: Inferior Alveolar Nerve Block**
#### Procedural Considerations
- Specific techniques for the Inferior Alveolar Nerve Block.
![]()
A detailed anatomical photo showing the inferior alveolar nerve block technique, with a dental syringe injecting local anesthetic into the mandibular region. The image displays a model of the lower jaw with teeth and the needle positioned near the mental foramen, illustrating the precise placement for effective anesthesia.
# **Local Anaesthetics**
<img src = "image_description"> The University of Western Australia logo
* **Techniques:** Inferior Alveolar Nerve Block
* **Differences between adult and children:**
* ramus shorter vertically
* narrower anterio-posteriorly
* consider using a short needle
* gauge 27 to 30
<img src="image_description"> Dental model illustrating an injection technique on the mandible.
#### Paediatric vs. Adult Anatomy
Key anatomical differences in children to consider for IANB:
- The ramus is shorter vertically.
- The ramus is narrower anterio-posteriorly.
- Needle selection: Consider using a short needle.
- Gauge: 27 to 30 gauge is typically used.
![]()
A photograph showing a dental model of the mandible with a needle inserted, illustrating an inferior alveolar nerve block technique. The model is used to demonstrate the injection site and needle placement.
![]()
A close-up photo of a dental model of the mandible, highlighting the anatomical structure relevant to local anaesthesia. The model shows the ramus and alveolar process, with a small hole indicating the injection site.
# **Local Anaesthetics**
* Techniques: Inferior Alveolar Nerve Block
* use precise technique
* practice aspiration technique
* use vasoconstrictors
* adhere to maximum dose
* use half carpule initially and then re-inject if inadequate or block is missed
* post-operative care!
#### Clinical Best Practices
- Use precise technique.
- Practice aspiration technique.
- Use vasoconstrictors to improve efficacy and safety.
- Strictly adhere to maximum calculated doses.
- **Staged Injection:** Use half a carpule initially; re-inject only if the block is inadequate or missed.
- Provide comprehensive post-operative care instructions.
# **Local Anaesthetics**
* **Use of Vasoconstrictors in children**
* high cardiac output
* greater tissue perfusion
* higher basal metabolic rate
* liver enzymes less mature than in adults so detoxifying of LA’s slower
* immature CNS and CVS so more susceptible to toxicity at low concentrations
<img src="image.png">
#### Paediatric Physiological Factors
Children have distinct physiological profiles that affect LA metabolism:
- High cardiac output and greater tissue perfusion.
- Higher basal metabolic rate.
- Immature liver enzymes: Detoxification of local anaesthetics is slower than in adults.
- Immature Central Nervous System (CNS) and Cardiovascular System (CVS): Increased susceptibility to toxicity at lower concentrations.
![]()
The University of Western Australia logo, featuring a shield with a swan and the institution's name in blue text, positioned in the top right corner of the slide.
# **Local Anaesthetics**
<img src="image.png">
* High doses of local anaesthetic
* CNS: depression, **sleepy**
* CVS: decreased contractile force, decreased cardiac output
* Pulmonary system: respiratory arrest - **DEATH**
* IV administration: analgesia, anxiety, restlessness, **GA**
#### Manifestations of Systemic Toxicity
**High Doses of Local Anaesthetic:**
- **CNS:** Depression, sleepiness.
- **CVS:** Decreased contractile force, decreased cardiac output.
- **Pulmonary System:** Respiratory arrest leading to death.
**Accidental Intravenous (IV) Administration:**
- Can cause analgesia, anxiety, restlessness, or symptoms mimicking General Anaesthesia (GA).
![]()
The image contains a logo of The University of Western Australia, featuring a shield with a swan and the university's name. This is a static graphic element, not a chart, diagram, photo, or table.
# **Local Anaesthetics**
<img src="https://example.com/university_logo.png" alt="The University of Western Australia logo">
* Delivery systems
<img src="https://example.com/sta_system_images.png" alt="Images of the STA injection system showing the main unit, a hand holding the handpiece, and a diagram labeling components like Foot Control, Computer Regulated Drive Unit, and Ergonomically Designed Handpiece.">
#### Computer-Regulated Delivery
Modern delivery systems, such as the STA (Single Tooth Anaesthesia) system, include:
- Computer-regulated drive unit.
- Ergonomically designed handpiece.
- Foot control for regulated flow.
![]()
A photograph of the STA System, a dental anesthesia delivery device, showing the main unit with its control panel and connected handpiece.
![]()
A photograph of a hand holding the STA handpiece, illustrating its use during a dental procedure.
![]()
A diagram labeling the components of the STA System, including the Computer Regulated Drive Unit, Ergonomically Designed Handpiece, and Foot Control, set against a blue background.
![]()
A promotional image for the DentalVibe device, showcasing a needle-free injection system with text that reads "SAY GOODBYE TO NEEDLE PAIN! YES, IT'S POSSIBLE WITH... DENTALVibe" and an image of the device.
![]()
A photo of a child receiving a dental procedure using a needle-free injector, with a butterfly graphic symbolizing pain-free treatment, and the text "Injection WITHOUT Needle" below.
![]()
A close-up photo of a dental procedure in progress, showing a patient with braces having a dental instrument applied to their mouth, with a gloved hand holding the tool.
![]()
A product advertisement for the Injex Needle Free Injector, featuring an image of the device with a butterfly graphic and the text "Injection WITHOUT Needle," highlighting its use for pain-free injections.
# Local Anaesthetics
* Delivery systems: camouflage
#### Psychological Management
- Delivery systems: Use of camouflage techniques to reduce patient anxiety.
![]()
A photo showing a dental syringe and a green alligator-shaped delivery device alongside a card with a cartoon alligator, illustrating camouflage delivery systems for local anaesthetics.
![]()
A photo of a child receiving a dental procedure using a green alligator-shaped delivery device, demonstrating the use of camouflage delivery systems for local anaesthetics.
<br>
**Thank You**
<br>
<img src="logo.png" alt="The University of Western Australia logo">
Thank You
![]()
The University of Western Australia logo, featuring a shield with a black swan, books, and a banner with the motto 'Fides et Sapientia', accompanied by the institution's name in blue text.
[^1]: Original PDF page 1: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=1|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.1]]
[^2]: Original PDF page 2: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=2|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.2]]
[^3]: Original PDF page 3: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=3|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.3]]
[^4]: Original PDF page 4: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=4|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.4]]
[^5]: Original PDF page 5: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=5|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.5]]
[^6]: Original PDF page 6: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=6|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.6]]
[^7]: Original PDF page 7: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=7|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.7]]
[^8]: Original PDF page 8: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=8|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.8]]
[^9]: Original PDF page 9: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=9|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.9]]
[^10]: Original PDF page 10: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=10|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.10]]
[^11]: Original PDF page 11: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=11|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.11]]
[^12]: Original PDF page 12: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=12|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.12]]
[^13]: Original PDF page 13: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=13|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.13]]
[^14]: Original PDF page 14: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=14|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.14]]
[^15]: Original PDF page 15: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=15|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.15]]
[^16]: Original PDF page 16: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=16|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.16]]
[^17]: Original PDF page 17: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=17|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.17]]
[^18]: Original PDF page 18: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=18|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.18]]
[^19]: Original PDF page 19: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=19|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.19]]
[^20]: Original PDF page 20: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=20|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.20]]
[^21]: Original PDF page 21: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=21|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.21]]
[^22]: Original PDF page 22: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=22|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.22]]
[^23]: Original PDF page 23: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=23|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.23]]
[^24]: Original PDF page 24: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=24|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.24]]
[^25]: Original PDF page 25: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=25|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.25]]
[^26]: Original PDF page 26: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=26|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.26]]
[^27]: Original PDF page 27: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=27|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.27]]
[^28]: Original PDF page 28: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=28|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.28]]
[^29]: Original PDF page 29: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=29|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.29]]
[^30]: Original PDF page 30: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=30|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.30]]
[^31]: Original PDF page 31: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=31|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.31]]
[^32]: Original PDF page 32: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=32|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.32]]
[^33]: Original PDF page 33: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=33|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.33]]
[^34]: Original PDF page 34: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=34|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.34]]
[^35]: Original PDF page 35: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=35|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.35]]
[^36]: Original PDF page 36: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=36|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.36]]
[^37]: Original PDF page 37: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=37|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.37]]
[^38]: Original PDF page 38: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=38|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.38]]
[^39]: Original PDF page 39: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=39|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.39]]
[^40]: Original PDF page 40: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=40|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.40]]
[^41]: Original PDF page 41: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=41|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.41]]
[^42]: Original PDF page 42: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=42|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.42]]
[^43]: Original PDF page 43: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=43|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.43]]
[^44]: Original PDF page 44: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=44|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.44]]
[^45]: Original PDF page 45: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=45|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.45]]
[^46]: Original PDF page 46: [[L6 -Antibiotics LA and Analgesics in Paediatric Dentistry.pdf#page=46|L6 -Antibiotics LA and Analgesics in Paediatric Dentistry, p.46]]