Many individuals suffer from bacterial infections. However, after penicillin’s discovery in 1928, it became possible to prevent and treat bacterial infections by discovering and developing antibiotics[1]; due to bacteria’s bacteriostatic and bactericidal effects[2,3].

However, the indiscriminate use of antibiotics often results in antibiotic resistance[2,4]. Antibiotic-resistant bacteria weaken and incapacitate an individual’s immune system, causing social and economic losses[4-7]. The World Health Organization (WHO) has warned about this issue and urged countries to unite and improve their policies[8,9]. Studies have shown that approximately 25,000 people in Europe die yearly from antibiotic-resistant bacteria, and approximately 1.5 billion euros are paid for social expenses[6,7]. De Kraker et al.[10] reported that antibiotic-resistant bacteria could kill approximately 10 million people annually by 2050. According to data released by the Centers for Disease Control and Prevention (CDC) in 2019, approximately 2.8 million antibiotic-resistant infections occur annually in the United States alone, killing approximately 35,000 patients[11].

The misuse and overuse of antibiotics cause antibiotic resistance[7]. Antibiotic use in Korea decreased from 2016 to 2020[12]. Nevertheless, Korea is still one of the countries that use large amounts of antibiotics[5,12]. According to a survey by the Organization for Economic Cooperation and Development (OECD) member countries on antibiotic consumption, Korea ranked third from 2016 to 2019 and fourth in 2020[12]. Korea also had the second highest antibiotic consumption, according to a WHO survey of six countries in the West Pacific on antibiotic consumption from 2016 to 2018[5]. According to the WHO 2016 records, Korea consumed antibiotics at 27.68 Defined Daily Doses (DDD) per 1000 inhabitants per day. In contrast, the DDD per 1000 inhabitants of Canada, Germany, and Japan per day were 17.05, 11.49, and 14.19, respectively. Choe and Shin[13] reported that South Korea had considerably high antibiotic prescribing rates for children. Youngster et al.[14] also reported that South Korea had the highest prescription rate for children.

Antibiotics are the second most commonly used drugs after pain relievers in dentistry[2]. They are mainly used preoperatively to prevent endocarditis, infection after surgery, and to prevent or treat fascial space infection. However, some studies have shown that dentists prescribe antibiotics more frequently and for longer periods than medical doctors, and the rate of antibiotic prescription by dentists is increasing[15,16].

Studies in Korea have analyzed antibiotic prescription trends in dental institutions[2,17,18]. However, there were limitations, such as being studied in a single institution, studying only the antibiotics prescribed for specific illnesses, and studying adults only. To the best of our knowledge, no studies have previously investigated the trends in antibiotics prescribed for children by dental institutions in South Korea. Therefore, this study aimed to investigate and analyze antibiotic prescription trends and rates prescribed by domestic dental institutions for children and adolescents aged < 20 years between 2016 and 2020.

This study was approved by the Medical Ethics Committee of the Yonsei University Wonju College of Medicine (CR321380).

From 2016 to 2020, 207,024 patients were prescribed antibiotics by their dentists. There were 100,412 males (48.50%) and 106,612 females (51.50%), with a higher proportion of females than males (Table 1, p < 0.05). The number of patients aged 0 - 4, 5 - 9, 10 - 14, and 15 - 19 years was 19,127 (9.24%), 48,290 (23.33%), 24,450 (11.81%), and 115,157 (55.62%), respectively, and significant differences were found according to age (Table 1, Fig. 2, p < 0.05).

Between 2016 and 2020, 307,249 antibiotics were prescribed by dentists. The number of prescriptions at 0 - 4, 5 - 9, 10 - 14, and 15 - 19 years was 25,630 (8.34%), 64,630 (21.04%), 32,925 (10.72%), and 184,064 (59.90%), respectively, and significant differences were found according to age (Table 2, p < 0.05). A total of 147,239 were males (47.92%), and 160,010 were females (52.08%). According to insurance type, 10,957 were Medicaid recipients (3.57%) and 296,292 NIH subscribers (96.43%). The average number of yearly Medicaid recipients between 2016 and 2020 was 1,498,951, accounting for approximately 2.9% of the total population of South Korea[21]. However, the Medicaid recipients’ proportion of antibiotic prescriptions in this study was higher than 2.9%. By region, 219,067 patients were located in cities (71.30%), and 88,182 (28.70%) were in rural areas. The average yearly population of rural areas between 2016 and 2020 was 15,581,294, accounting for approximately 30% of the total population of South Korea[21]. However, in rural areas, the proportion of antibiotic prescriptions in this study was lower than 30%. Hospitals accounted for 41,798 (13.60%), and clinics accounted for 265,451 (86.40%) of antibiotic prescriptions, according to the classification of medical institutions. Significant differences were found in sex, type of insurance, region, and classification of medical institutions (Table 2, p < 0.05).

From 2016 to 2020, differences in antibiotic prescription rates were identified according to year, age, sex, insurance type, region, and classification of medical institutions (Table 3). It was confirmed that about 4.74% of the 6,486,921 dental treatments required antibiotics (Table 3). Females were prescribed more antibiotics than males, and the 15 - 19 age group had a higher antibiotic prescription rate than the other age groups. Medicaid recipients received more antibiotics than NIH subscribers. Rural areas had a higher antibiotic prescription rate than cities, and hospitals had a higher antibiotic prescription rate than clinics. There were significant differences in the antibiotic prescription rates according to year, age, sex, insurance, region, and classification of medical institutions (Table 3, p < 0.05).

As a result of investigating 307,249 dental antibiotic prescriptions from 2016 to 2020, the average number of days of antibiotic prescriptions was 3.13 (Table 4). The group aged 15 - 19 years had a longer antibiotic duration than the other age groups (Table 4, p < 0.05). NIH subscribers were prescribed antibiotics for longer than Medicaid recipients. Furthermore, antibiotics were prescribed for longer durations in cities than in rural areas and in hospitals compared to clinics. There were no significant differences in the number of days of antibiotic prescription according to sex. However, there were significant differences according to age, type of insurance, region, and classification of medical institutions (Table 4, p < 0.05).

An investigation of 307,249 antibiotic prescriptions received from dentists between 2016 and 2020 revealed that the most preferred antibiotic was amoxicillin, followed by cephalosporins (Table 5). Amoxicillin or cephalosporin antibiotics were used in 96.8% of the cases (Fig. 3). Amoxicillin was more frequently prescribed in younger age groups, and the proportion of cephalosporin antibiotics increased with age. Antibiotic preference significantly differed according to age (Table 5, p < 0.05).

The condition for which dentists prescribed antibiotics was investigated. Pulpitis, dental abscesses, and dental caries accounted for a high proportion of cases before the age of 10 years (Table 5). However, the rate of antibiotic prescriptions for impacted teeth and periodontal disease increased after 10 years of age. In addition, the proportion of antibiotic prescriptions due to trauma in the 0 - 4-years-old group was relatively higher than in the other age groups. There was a significant difference in the number of antibiotic-prescribed diseases according to age (Table 5, p < 0.05).

Antibiotics are used to prevent and treat infections. Antibiotics kill infectious microorganisms by inhibiting proliferation[2,3]. However, antibiotics can cause problems that render infectious microorganisms resistant to them[3]. This is a natural process by which infectious microorganisms adapt to antibiotics[3]. Antibiotic-resistant bacteria are more likely to develop after frequent antibiotic exposure[3]. Therefore, considering both antibiotics’ effects and side effects, their use is recommended only in appropriate situations. Several studies and guidelines for the prescription of antibiotics have been published[2,5,7,9,12-18,22-32]. This study researched antibiotics prescribed by dentists for children and adolescents aged 0 - 19 years in Korea, which has not previously been covered in the literature.

The antibiotic prescription rate was approximately 4.74% after dental procedures performed between 2016 and 2020; this was lower than 5.7%, as shown in a previous study on adults, and lower than 6.5 - 8.5%, in an earlier study conducted in the Czech Republic[2,16]. Significant differences in antibiotic prescription rates were confirmed according to year, age, sex, region, classification by medical institutions, and insurance type. Cities had lower antibiotic prescription rates than rural areas; this could be attributed to the fact that children and adolescents in cities with good dental access often receive preventive care or checkups; however, children and adolescents in rural areas received more restorations or surgical treatments because of poor dental access[33]. These results were consistent with a previous study in which children and adolescents in rural areas that lacked access to medical institutions and thus lacked preventive treatment were compared to those in cities[34]. Furthermore, a previous study showed that more antibiotics are desired and prescribed among older parents and parents with lower education[35]. Therefore, in rural areas with elderly guardians or low education, unnecessary antibiotic prescriptions may lead to higher prescription rates. Shin et al.[36] also reported that metropolitan regions had a lower antibiotic prescription rate than rural areas in South Korea.

Children and adolescents aged 5 - 9 years exhibited higher antibiotic prescription rates than those aged 0 - 4 years. Lim et al.[37] reported that oral health was worse in older pediatric patients, and they attributed this to the cumulative nature of dental caries. Therefore, the oral health of children aged 5 - 9 years could be worse than that of children aged 0 - 4 years before exfoliation of deciduous teeth. Consequently, more antibiotics could be prescribed for this age group. In addition, patients with NIH had a lower antibiotic prescription rate than Medicaid recipients. According to the Children’s Oral Health Survey announced by the Ministry of Health and Welfare in December 2019, the group marked “low” on the economic status item had more carious teeth[38]. In other words, the poorer the economic condition, the poorer the oral health, and the more aggressive dental treatments and antibiotic prescriptions were required. The antibiotic prescription rate also differed depending on the classification of the medical institutions. Dental hospitals had a higher antibiotic prescription rate than dental clinics, consistent with previous studies conducted on adults[17,18]. According to Korea’s medical system, treatment for mild diseases is carried out in clinics, whereas difficult diseases requiring specialized medical management are referred to hospitals. Therefore, hospitals may encounter more severe infections and situations requiring surgical treatment than do clinics, resulting in frequent antibiotic prescriptions. This is consistent with the findings of Choi et al.[39], which indicated that more surgical treatments were performed at dental hospitals than at dental clinics.

The average duration of antibiotic prescriptions was 3.13. In a previous study, Kim et al.[2] reported that the average duration of antibiotic prescription in dentistry is 3.40. However, their study was conducted at a single dental institution. In another study, Lee and Choi[18] reported that the average number of days of antibiotic prescription in dentistry was 3.06 for adults. There have been no previous dental studies on antibiotic prescriptions for children in Korea, but a medical study on antibiotics prescribed to children for acute upper respiratory tract infections was found, in which antibiotic prescriptions in pediatric adolescents averaged 3.08 days[40]. Moreover, as previously described, more antibiotics are desired and prescribed among older parents and parents with lower education[35]. As antibiotics were over-prescribed or prescribed unnecessarily to patients in rural areas and Medicaid recipients with elderly guardians or guardians with lower education, practitioners could prescribe antibiotics for a shorter duration. Thus, in this study, patients from rural areas and Medicaid recipients were prescribed antibiotics for shorter durations than were those from cities and NIH subscribers.

The most frequently prescribed antibiotics for children and adolescents in dental institutions in Korea were amoxicillin- and cephalosporin-based drugs. Amoxicillin accounted for approximately 73.2% of all antibiotic prescriptions, and cephalosporin-based antibiotics accounted for approximately 23.7% of all antibiotic prescriptions. In another study conducted on adults, Choi[17] reported that penicillin was the first choice, followed by metronidazole. Metronidazole is an antibiotic that acts on anaerobic bacteria. The International Association of Paediatric Dentistry (IAPD) announced that tooth extraction and root canal treatment could resolve most infections in children and adolescents. Removing the source of infection should be the first step, and antibiotic prescriptions are unnecessary, except in special cases[41]. This means that when infections were found, most were thought to be sufficient to be alleviated with amoxicillin-and cephalosporin-based antibiotics. Therefore, metronidazole was unnecessary for children and adolescents compared to adults, so its preference was low.

Orofacial infections are commonly attributed to bacteria such as gram-positive cocci and gram-negative bacilli. In appropriate conditions, antibiotics contribute to controlling the infection along with surgical intervention by killing or inhibiting the growth of bacteria[42]. When prescribing antibiotics for dental infections in children and adolescents, amoxicillin is the first-choice drug because it offers broad gram-positive bacteria coverage with a low incidence of adverse effects[42,43]. In addition, it offers greater gram-negative coverage than does penicillin[44]. Amoxicillin can also be absorbed from the gastrointestinal tract and provide high serum concentrations, demonstrating high effectiveness against oral flora[43,45]. Cephalosporin can be considered an alternative for the management of odontogenic infections in children who are allergic to penicillin/amoxicillin[46]. For antibiotic prescriptions, the American Academy of Pediatric Dentistry (AAPD) recommends that the duration of the drug regimen be five days beyond the point of substantial improvement, regardless of the disease[30]. However, Aidasani et al.[28] conducted a systemic review and reported that no consensus regarding the duration of antibiotic therapy or prophylaxis was found.

This study confirmed that antibiotics were commonly prescribed for dental trauma in children aged 0 - 4 years and for periodontal disease as they got older (Fig. 4). This result was consistent with previous studies, which reported that the younger the age, the higher the frequency of dental trauma, and the higher the age, the higher the frequency of periodontal disease[47,48]. Lam et al.[47] reported that children aged 0 - 4 years presented with the highest number of dental trauma injuries, and Kassebaum et al.[48] reported that people aged < 15 years were not at a risk of developing severe periodontitis.

When dentists prescribed antibiotics, the disease was investigated. Antibiotics were mostly prescribed for pulpitis, periodontal disease, impacted teeth, and dental abscesses. However, according to the antibiotic prescription guidelines revised in 2022 by AAPD, an antibiotic prescription is unnecessary for pediatric and adolescent patients most of time[30]. In case of pulpitis, apical periodontitis, draining sinus tract, and localized intraoral swelling, antibiotic therapy is not indicated or needed if the dental infection is confined to the pulpal tissue or the immediate surrounding tissue. However, oral wounds contaminated by extrinsic factors should be managed with systemic antibiotics. Antibiotics could be beneficial because they supplement the natural host resistance to killing bacteria. Acute facial swelling also needs antibiotics, which medical management with intravenous antibiotics could help cure more rapidly alongside surgical intervention; metronidazole could be considered for anaerobic coverage. Cases of tooth avulsion need antibiotics. Drugs such as amoxicillin are beneficial for avulsed permanent incisors due to their effectiveness against oral flora. Periodontitis commonly does not warrant antibiotics, but aggressive periodontitis does. Periodontal patients with systemic diseases should be given antibiotics because their immune systems are compromised and they cannot control the growth of periodontal pathogens. Antibiotics are not warranted for viral infections since these medications are only effective against bacteria. In the case of salivary gland infections, antibiotics are indicated. Amoxicillin/clavulanate is the drug of choice due to its extensive staphylococcal and streptococcal coverage, the most common etiologic agents[30].

The IAPD guidelines also report that oral infections in children and adolescents can commonly be resolved with tooth extraction and root canal treatment, and antibiotic prescriptions are unnecessary except in special cases[41]. Goel et al.[25] recommended prescribing only analgesic and anti-inflammatory drugs when no clear signs of infection progression, such as fever or facial swelling, were found. Therefore, further research is needed to confirm whether patients prescribed antibiotics for pulpitis, periodontitis, and dental abscesses in this study were prescribed appropriately.

This study had several limitations. The NHIS-NSC used in this study included only data on covered benefits and did not include medical treatment for non-covered benefits under the insurance plan, such as orthodontic extractions. In other words, prescriptions for noncovered benefits could not be explained by the results of this study. The inaccuracy of the investigated diseases is also a limitation of this study. This was because when dentists entered disease names after patient treatment, there were cases in which dentists arbitrarily or habitually entered disease names differently. Another limitation is that the study is confined to showing the trends of antibiotic prescriptions without verifying the overuse or misuse of antibiotics. The American Medical Association (AMA) defined the two terms as such: ‘overuse’ occurs when the potential for harm exceeds the possible benefit, whereas ‘misuse’ occurs when an appropriate service has been selected but a preventable complication occurs and the patient does not receive the service’s full potential benefit[49]. However, antibiotic resistance takes time to identify. Hence, this cross-sectional study was also unable to document if any harm or complications, such as antibiotic resistance, arose from the antibiotics prescribed. In addition, factors affecting antibiotic prescription, such as systemic disease and its severity, could not be identified and included in the study. Finally, the distinction between cities and rural areas was limited because the Review and Assessment Service data were based on the administrative district. Thus, it included cities such as Jinju and Changwon in Gyeongsangnam-do, but data on Jinju and Changwon could not be obtained as city data, and only data covering the entire Gyeongsangnam-do area could be obtained.

Despite these limitations, this study used NHIS-NSC data representing the entire Korean population to investigate antibiotics prescribed by dentists to children and adolescents. Therefore, these representative results can be used to establish national policies to reduce antibiotic use.

This study analyzed the dental prescription of antibiotics prescribed to children and adolescents between 2016 and 2020. A significant relationship was observed between socioeconomic factors and antibiotic prescription rates. In addition, this study highlighted the latest trends in antibiotic prescriptions and emphasized the need for close monitoring to ensure the appropriate use of antibiotics.