In pediatric dentistry, antibiotics are used to prevent and treat infections. They are commonly prescribed for dental trauma, pulpitis, apical periodontitis, draining sinus tracts, localized intraoral swelling, acute facial swelling of dental origin, periodontal disease, and salivary gland infections [1].

Antibiotics play a crucial role in treating bacterial infections. However, their use requires caution as they can inhibit bacterial growth and eliminate infections. They are fast acting, with some starting to work within a few hours. Antibiotics are easy to administer, as most are oral medications. They can successfully clear bacterial infections from the body, ease symptoms, help patients feel better, speed up recovery, stop the spread of infection to others, protect against serious illnesses or complications, and save lives [2,3].

The use of antibiotics in dentistry has increased dramatically over the past several decades [4]. Antibiotic use by dentists is estimated to account for approximately 7% ‒ 11% of total global antibiotic consumption [5]. The most commonly prescribed antibiotic is amoxicillin, followed by penicillin derivatives and clindamycin (clindamycin is prescribed in cases of penicillin allergy) [6]. Amoxicillin and cephalosporins are the most commonly prescribed antibiotics in dental clinics in Korea, accounting for approximately 96% of all antibiotic prescriptions [7].

Since the discovery of penicillin, the use of antibiotics has increased significantly, both among medical professionals and dentists, and this trend may pose the problem of antibiotic resistance [8]. Overuse of antibiotics can lead to antibiotic resistance, making them less effective. Prolonged antibiotic use may weaken the immune system. Some antibiotics can cause side effects, including digestive issues, bone damage, and photosensitivity [9].

Antibiotic use in the dental field, especially in pediatric dentistry, should be carefully considered, taking into account resistance and side effects. The American Dental Association and Centers for Disease Control and Prevention (CDC) are updating antibiotic therapy, dosage, and indications, and in pediatric dentistry, the American Academy of Pediatric Dentistry (AAPD) provides periodic updates. This review aims to provide a general overview of antibiotic use and dosage in pediatric dentistry.

The principles of antibiotic prescription follow the following key guidelines for effective treatment [10-13]:

- Selecting the right antibiotic: The right antibiotic should be selected for the causative agent of the infection. For this purpose, it is important to determine the optimal antibiotic through bacterial culture and antibiotic sensitivity testing.

- Appropriate dosage and duration of treatment: Antibiotics should be taken at the correct dosage for effective treatment to avoid overuse and minimize the duration of treatment when necessary. Long term use can increase the risk of developing resistant bacteria.

- Avoiding excessive antibiotic use: Unnecessary antibiotic use can promote the development of antibiotic-resistant bacteria. Therefore, antibiotics should not be used in cases of uncertain diagnoses or viral diseases.

- Prescribing according to the indication: Antibiotics are effective only for bacterial infections; therefore, they should not be used for viral infections, such as colds or flu. In addition, appropriate antibiotics should be selected according to the severity of the bacterial infection.

- Monitoring: The patient’s condition should be monitored while taking antibiotics so that side effects or allergic reactions can be detected early and adjusted if necessary.

- Preventing resistance: To prevent antibiotic resistance, antibiotic prescriptions should be minimized, and patients should be properly educated to take antibiotics for the correct duration.

The following are the precautions when prescribing antibiotics to children based on the latest guidelines (World Health Organization, CDC) [14-16]. Antibiotics should be prescribed to children when a bacterial infection is confirmed or strongly suspected. Primary antibiotics should be selected based on the main pathogen at each site of infection. In particular, ceftriaxone is associated with a risk of hyperbilirubinemia in newborns, and tetracyclines can cause tooth discoloration in children aged < 8 years. Fluoroquinolones should be used with restrictions owing to their effects on growth plates. Side effects, such as diarrhea, rash, and anaphylaxis, should be monitored, and the possibility of antibiotic-induced enteritis should be considered. The use of broad-spectrum antibiotics (3^rd ‒ 4^th generation, cephalosporins) should be prohibited [14-16].

The use of antibiotics in pediatric dentistry should be cautious and limited to treatment rather than infection prevention. As most dental infections can be resolved with local treatment (drainage, extraction, and root canal treatment), it is important to avoid unnecessary antibiotic prescriptions (Table 1) [1,17]. Facial lacerations and puncture wounds may necessitate the use of topical antibiotics [18]. Intraoral puncture wounds and lacerations that appear to be contaminated with extrinsic bacteria, debris and foreign bodies; open fractures; and joint injuries are at increased risk for infection and should be managed with systemic antibiotics [18]. Pediatric dentists should consider age, patient cooperation level, general anesthesia, severity of infection and medical status [19,20]. Non-localized progressive swelling and systemic symptoms (fever and dyspnea) of odontogenic infection require immediate surgical intervention and management with intravenous antibiotics to facilitate rapid recovery [21,22]. Systemic symptoms (fever, facial swelling, airway damage, dyspnea, tachycardia and dysphagia) and sepsis require emergency treatment [21,22]. Additional imaging techniques, such as radiography, and computed tomography, as well as reactive protein, bacterial culture, and susceptibility testing, may aid in the evaluation and diagnosis [19,20]. Systemic antibiotic administration is recommended as an adjunct therapy for replantation in cases of avulsed immature or mature permanent incisors. Amoxicillin or penicillin is recommended because of its effectiveness against oral flora and low incidence of side effects [23]. Doxycycline is recommended as an alternative to penicillin [23]. Doxycycline possesses antibacterial, anti-inflammatory, and anti-resorptive properties, making it effective in the management of dental trauma [23]. When acute symptoms of pulpitis appear, appropriate treatments such as pulpotomy, pulpectomy, or extraction should be performed [24]. When dental infection occurs within the pulp tissue or the tissues immediately surrounding it, systemic signs are not observed, and antibiotic treatment is not indicated [24]. Antibiotic therapy is recommended for treating acute bacterial syringomyelitis. If antibiotics alone do not result in any improvement in the patient’s condition within 24 ‒ 48 h, incision and drainage may be performed. Amoxicillin-clavulanate is used as an empirical therapy to treat both staphylococci and streptococci, as most bacterial infections of the salivary glands originate from the oral salivary glands [25].

Several types of antibiotics are used in dentistry to treat and prevent infections. The appropriate antibiotic is determined by the type of infection, the causative pathogen, and whether the patient had allergies [26]. The capacity was calculated with reference to the latest AAPD guidelines and is summarized in Table 2 [27].

In pediatric dentistry, antibiotic prophylaxis is recommended for children who are at a high risk of developing complications from bacteremia following invasive dental procedures. The primary purpose is to prevent infective endocarditis in susceptible individuals. Pediatric patients who are at a high risk of developing complications are shown in Table 3 [1].

For such high risk patients, the AAPD recommends a single dose of amoxicillin (50 mg/kg, up to a maximum of 2,000 mg) 30 ‒ 60 min before the dental procedure [1]. If the child is allergic to penicillin, alternative antibiotics (such as clindamycin or azithromycin) can be used with appropriate dosage adjustments. Because unnecessary antibiotic use can contribute to bacterial resistance and adverse effects, their administration should be carefully evaluated based on established guidelines. Proper consultation with the patient’s physician is essential before prescribing prophylactic antibiotics [1].

According to the literature, the use of antibiotics is increasing and is especially prevalent in dentistry. The misuse of antibiotics has become a major problem owing to the increase in antibiotic resistance. Rather than indiscriminate prescription, it is better to be familiar with the indications and select the appropriate antibiotic and dosage according to weight to minimize potential side effects. Periodic education and awareness are necessary, as the usage and dosage are updated periodically.