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I/PREGNANCY

• CLASSIFICATION  : pregnancy is classically divided into three periods:

First trimester  : the most critical period in terms of fetal sensitivity, it corresponds to embryogenesis and organogenesis.

Second trimester  : maturation of organs

Third trimester  : end of organ maturation

• GENERAL REPERCUSSIONS TO TAKE INTO ACCOUNT:

• Mild anemia
• Thrombocytopenia in late pregnancy
• Gastroesophageal reflux disease
• Gestational diabetes
• Pregnancy-induced hypertension
• ORAL REPERCUSSIONS  :

• Increase in anaerobic oral flora
• Inflammatory gingival lesions (pregnancy gingivitis, epulis, etc.)
• Increased risk of caries
• Sialorrhea 
• Dentin hyperesthesia
• GENERAL PRECAUTIONS:

• Limit stress through short sessions and effective analgesia
• Favor a local anesthetic that does not cross the placental barrier very well
• Take precautions with certain medications
• Use a lead apron for x-rays (medico-legal aspect)
• precautions according to the stage of pregnancy

    -First quarter  

• Inform the patient about the role of good oral hygiene
• Only urgent care will be provided.

      – Second quarter 

• All treatments are possible while respecting general precautions.

      -Third quarter  

• All treatments are possible while respecting general precautions.
• Take into account at the end of this trimester the patient’s fatigue, a possible vena cava syndrome and the proximity of the term.
• Precautions regarding anesthesia:

• favor the use of articaine and bupivacaine 
• avoid mepivacaine 

•  transport of molecules 
•  immune defense 
•  coagulation ……
• PREGNANCY AND RADIOLOGY  : the average exposure of an individual to natural radioactivity is 2.4 mSv per year (2400 µ Sievert) 

An intraoral photo: 1 to 8 µSv 

         A panoramic X-ray: 4 to 30 µSv 

          A cephalometric study: 2 to 3 µSv 

Doses from dental X-rays remain well below recommended thresholds, even for pregnant women and the fetus.  

There are no contraindications to performing X-rays in these patients, regardless of the stage of pregnancy, as long as the examination is justified.

• PRECAUTIONS REGARDING COMMON PRESCRIPTIONS:
• ANTIBIOTICS
• ANTIBIOTICS INDICATED

                         Betalactams :

•   amoxicillin with or without clavulanic acid 
•   ampicillin
•   cephalosporins

                         Macrolides: Erythromycin / Clindamycin. 

• CONTRAINDICATED ANTIBIOTICS

Tetracyclines : may cause dental and bone malformations in the fetus and acute pancreatitis in the mother. 

Metronidazole : carcinogenic risk for the fetus 

Aminoglycosides (Neomycin, wound ointment): hearing problems 

 Doxycycline : dental staining in newborns and risk of liver toxicity in the mother. 

• ANALGESICS

Paracetamol is the analgesic of choice for pregnant women at a reasonable dosage over a short period. Codeine has teratogenic risks so it is contraindicated.

NSAIDs, including salicylates (Aspirin), are contraindicated in pregnant women. 

In pregnant women, they have the effect of inhibiting uterine contractions. 

Nonsteroidal anti-inflammatory drugs and Cox2 inhibitors are contraindicated throughout pregnancy: 

• Ibuprofen (Advil®…) 
• – Ketoprofen (Profenid® …) 
• ANXIOLYTICS 

Benzodiazepines can cause cleft palates in newborns. 

Valium and Xanax cause fetal respiratory depression and hypotonia. 

II/PATIENT AGE: SEE GERODONTOLOGY COURSE 

III/THE CHILD: The management of oral and dental conditions most often involves the performance of a therapeutic procedure. This procedure is sometimes accompanied by a drug prescription, once the diagnosis has been made and the therapy established. In pediatric dentistry, the dental doctor is required to prescribe antibiotics, analgesics, sedative premedication, antiemetics, fluoride or oral hygiene products (mouthwash, toothpaste, etc.). Thus, medications are used to prevent bacteriological risks, to treat infectious diseases, to treat or prevent pain or to premedicate anxious children. 

A- Routes of administration of medications (Dose form): The fate of the medication will be modified depending on the route of administration taken.

• Oral route: This is the route that we must favor in children over 06 years old. Some medications exist in pediatric forms, these have a pleasant taste, which is useful for taking the treatment, but are sometimes rich in sucrose and therefore cariogenic. Thus, we prefer tablets and capsules, as soon as the child is able to swallow them.
• Rectal route: This route will be interesting for us during vomiting or convulsions. However, rejection of the suppository is frequent, making the estimated dose received uncertain.
• Parenteral route: Being a source of pain, the choice of this route is exceptional in children. However, the almost immediate effectiveness of the intravenous route will justify its use in emergency situations. It is used in a hospital setting.
• Topical route: It is essential to consider here that children have a higher absorption than adults. Indeed, cutaneous resorption is increased due to the thinness of the skin and a high ratio between the skin surface and the body weight, hence a risk of too much passage of the drug and therefore of intoxication.

2. Dosage: There are three prescription groups:

•  newborns (up to 1 month), 
• infants (up to 02 years) 
• finally, children over 2 years old up to 15 years old.

In daily practice, it is advisable to prescribe according to weight, referring to Vidal® which provides a dosage per kg of weight and per 24 hours for pediatric forms.

• ANTIBIOTIC PRESCRIPTION: The prescription of antibiotics is only justified in clinical situations where its effectiveness has been proven. In the majority of cases our choice between this or that antibiotic will be based on the pathogenic bacteria supposedly present during the oral-dental infectious pathology as well as on the pharmacokinetics and the spectrum of antibacterial activity of the antibiotic. Two types of antibiotic therapy:

• prophylactic antibiotic therapy: to prevent the appearance of a local or distant infectious phenomenon
• curative antibiotic therapy used during a proven infection: we distinguish between 

• probabilistic antibiotic therapy taking into account the bacteria most present according to the type of infection 
• Antibiotic therapy documented by an antibiogram.
• First-line antibiotic therapy (mono antibiotic therapy)
• Second-line antibiotic therapy (combination antibiotic therapy) 

1. General rules for prescribing an antibiotic :

• Prescription if there is an indication 
• choosing an antibiotic with the narrowest possible spectrum 
• should not replace a surgical procedure
• its dosage must be well adapted (age and weight)
• its duration must be sufficient
• the administration interval adapted to the pharmacokinetics of the molecule
• should have the least side effects.

2. Different families of antibiotics:

• Betalactams
• Macrolides and related compounds
• Imidazoles
• Cyclines
• Synergistins
• Lincosamides
• BETALACTAMINS : in odontostomatology, aminopenicillins (penicillin A) are the most prescribed for: 

• Their bactericidal action 
• Their very broad spectrum of action
• Their stability in an acidic environment (easy administration per os)
• Half a life of an hour 
• Amoxicillin is the antibiotic of choice and used as first-line treatment.
• Comes in two forms:

             Oral solution with measuring spoons (250,500 mg)

             Scored and dispersible tablet 

• Second-line: amoxicillin + clavulanic acid.
• Cephalosporins may be indicated in severe infections.
• AMOXICILLINE

Capsules 500 mg

Powder for oral suspension: 125mg/5ml. 250mg/5ml. 500mg/5ml

Child < 30 months: 50 to 100 mg/kg/day in 3 doses spaced 8 hours apart/7 days 

Child > 30 months: 25 to 50 mg/kg/day in 3 doses spaced 8 hours apart/7 days

• Amoxicillin + clavulanic acid 

80 mg/kg/day in 3 doses/7 days 

Or more simply 1 dose weight /3 /day

For the prophylaxis of bacterial endocarditis  :

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• MACROLIDES  : 
• Dosage: 1.5 to 3 MUI / 10Kg in 2 to 3 doses.

    Syrup at 0.375 IU/5 ml/ 2 to 4 measuring spoons/ divided into 2 to 3 doses. (150 ml bottle).

• Spiramycin + Metronidazole (Rodogyl):

Film-coated tablets 125 mg metronidazole + 750,000 IU spiramycin / 30 mg/kg/24h: 

• IMIDAZOLES: 
• Dosage: 30 mg/kg/24H in 3 doses.
• SYNERGISTINS
• The leader is Pristinamycin  (currently not very recommended )
• LINCOSAMIDES

• The leader being clindamycin 
• Dosage: 20mg/kg 1 hour before the act
• Cyclines: use reserved for periodontology.

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• ANALGESIC PRESCRIPTION AND MANAGEMENT OF NON-OPIATIC AND NON-NSAID ANALGESICS:

Paracetamol 60 mg/kg/24 hours/4 doses.

• NSAIDs: 

Ibuprofen AMM > 03 months

Dosage (syrup): 10mg/kg X 3/day or 7.5mg/kg X 4/day

200 mg tablet for a child > 6 years old:

• 20 to 30 kg: 1 tablet every 6 to 8 hours (max. 600 mg/day)
• > 30 kg: 200 to 400 mg every 6 to 8 hours (max 1200 mg/day
• SEDATIVE PRESCRIPTION:  Sedation is especially useful for children with special needs. It prevents spontaneous movements and inspires cooperative behaviors.
• Antihistamines H1 / hydroxyzine (Atarax®): > or equal to 30 months / Syrup 1 to 2 mg / kg / 24 hours the day before and 1 hour 30 minutes before treatment.
• THE ANTIFUNGAL PRESCRIPTION:

•  indicated in the treatment of oral candidiasis.
• Available as oral gel / DAKTARIN 2% (Miconazole)
• Infants 4 to 24 months / 4 times a day after meals.
• Child (2 to 15 years) 4 times a day after meals.
• The usual duration of treatment is 7 to 15 days.
• Treatment should be continued for at least one week after symptoms have disappeared.
• ANTIEMETIC PRESCRIPTION: Nausea can be defined as a feeling of unease or discomfort that results in an urge to vomit. While vomiting corresponds to a mechanical reflex of defense of the body (protection against potentially toxic substances) that forces the expulsion of the contents of the stomach. These medications are taken, on average, half an hour to an hour before treatment.

• Metoclopramide (Primpéran®) Oral solution / Infants and children weighing 20 kg / 0.1 mg/kg (01 drop/kg) every 6 to 8 hours.
• Metopimazine (Vogalene® Vogalib®) / Infants and children aged 12 years and over / Oral solution, capsules, and suppositories / Children aged 6 to 12 years: 7.5 to 15 mg/day and under 6 years old / 1 mg/kg/day 
• FLUORIDE PRESCRIPTION: 

• This medicinal fluoride supplement is highly indicated in children with a significant risk of caries with oral administration. 
• The daily dose of fluoride/day is 0.05 mg from all sources. Do not exceed 1 mg/day
• It is recommended to administer small doses of Fluoride by twice-daily brushing with an age-appropriate fluoride toothpaste.
• It is important to understand it correctly in order to avoid the occurrence of dental fluorosis. In Algeria, the water is very rich in fluoride.

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 CONCLUSION: The management of oral diseases most often involves the performance of a therapeutic procedure. This procedure is sometimes accompanied by a drug prescription, once the diagnosis has been made and the therapy defined. Thus, drugs are used to prevent bacteriological risks, to treat infectious diseases, to treat or prevent pain or to premedicate anxious children. Drug prescription has become omnipresent in pediatric dentistry.

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XI/ BIBLIOGRAPHY

1. French Agency for the Safety of Health Products. Use of fluoride in the prevention of dental caries before the age of 18. 2008a. 

http://www.afssaps.fr/Safety-Info/Recommendations/Fluoride-and-prevention-of-dental-caries-Update

2.  French Agency for the Safety of Health Products. Coordination of Afssaps vigilance in 2008. Vigilances 2009a;45:1-4.
3. French Agency for the Safety of Health Products. Drug management of acute and chronic pain in children, 2009. http://www.afssaps.fr/infos-de-securite/recommandations/priseen-charge-medicamenteuse-de-la-douleur-aigue-et-chronique-chez-lenfant-recommandations-de-bonne-pratique
4. French Agency for the Safety of Health Products. Prescribing antibiotics in oral and dental practice, 2011a. http://www.afssaps.fr/infos-desecurite/recommandations/prescription-desbiotiques-en-pratiquebucco-dentaire-recommandations-de-bonne-pratique
5. French Agency for the Safety of Health Products. Anticholinergic Mydriatic Eye Drops in the Elderly and Children, 2011b. http://www.afssaps.fr/archives/surveillance-desmedicaments/medicaments-sous-surveillance-renforcee2/medicamentssous-surveillance-renforcee/collyres-mydriatiques-anticholinergiques-chezles-sujets-ages-et-les-enfants
6. French Agency for the Safety of Health Products. Thesaurus: National Reference Framework for Drug Interactions, 2011c.29 http://www.afssaps.fr/var/afssaps_site/storage/original/application/b02 0ad44063a 5cc737d44be59e3125e7.pdf

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  Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.
 

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