Antibiotic Use in Pediatric Dentistry
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Trans Abstract
Antibiotic use in the dental field, especially in pediatric dentistry, should be carefully considered, taking into account resistance and side effects. This review aims to provide a general overview of antibiotic use and dosage in pediatric dentistry. Indications for antibiotic prescription include symptoms of systemic infection such as fever (≥ 38°C), lymphadenitis (cervical lymph node swelling and tenderness), facial swelling (especially spreading around the eyes), cellulitis, soft tissue infections (risk of deep infection and sepsis), severe localized infection or high risk of infection after invasive dental procedures such as acute pulpitis, severe periapical abscess spreading to soft tissues, persistent or worsening infection despite drainage, and prophylactic antibiotic use in immunocompromised patients. Antibiotic use for simple dental caries, no signs of infection after root canal treatment, prophylactic use after simple tooth extraction, and viral infections is unnecessary. The first-choice antibiotic in dentistry is amoxicillin; its dosage should be adjusted according to the infection symptoms and body weight in children. Furthermore, amoxicillin-clavulanate, clindamycin, metronidazole and azithromycin can be prescribed depending on the type of infection and the patient’s allergies. Excessive and inappropriate antibiotic use can contribute to antibiotic resistance. Pediatric dentists should receive continuous education and stay updated on periodic revisions to antibiotic use and dosage guidelines.
Introduction
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.
Principles of antibiotic prescription
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 (3rd ‒ 4th 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].
Types of Antibiotics Used in Dentistry
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].
Amoxicillin
Amoxicillin (a penicillin antibiotic) is a β-lactam antibiotic that interferes with the synthesis of peptidoglycan, which constitutes the bacterial cell wall. This weakens the bacterial cell wall and eventually destroys the cells. Amoxicillin is widely used to treat and prevent infections in various clinical fields, including dentistry. It is metabolized in the kidneys and has bactericidal properties against streptococci and anaerobic bacteria that are frequently detected in oral and maxillofacial infections. It has almost no toxicity or side-effects; however, allergic reactions can occur [28,29]. If the patient recognizes that he or she has side effects from penicillin, an alternative antibiotic is prescribed after the penicillin skin test. If the test result is positive, cephalosporin can be considered as an alternative antibiotic; however, it can cause hypersensitivity, as it is also a beta-lactam. In such cases, it can be replaced with clindamycin [30]. The oral dose of amoxicillin is prescribed differently depending on the patient’s age and weight. For infants and children aged > 3 months and those weighing < 40 kg, 20 ‒ 40 mg/kg per day is administered in divided doses every 8 h, with a maximum single dose of 500 mg [27,31,32]. Alternatively, 25 ‒ 45 mg/kg per day can be administered in divided doses every 12 h, with a maximum single dose of 875 mg. For adolescents and adults weighing ≥ 40 kg, 250 ‒ 500 mg every 8 h or 500 ‒ 875 mg every 12 h can be administered [27,31,32].
Amoxicillin-Clavulanate
Amoxicillin-clavulanate is an antibiotic that combines amoxicillin, a β-lactam antibiotic, and clavulanate, a β -lactamase inhibitor. It enhances the antibacterial effect against β-lactamase-producing bacteria that are resistant to amoxicillin alone. Clavulanate inhibits β-lactamase, allowing amoxicillin to continue to be effective without being decomposed by the bacteria. In dentistry, amoxicillin-clavulanate is used to treat severe infections or when amoxicillin alone is ineffective. It is particularly effective for treating abscesses, cellulitis, extensive soft tissue infections, and infections in immunocompromised patients [31-33]. The oral dosage varies depending on the severity of the infection and is administered at two divided doses of 25 ‒ 45 mg/kg per day. The maximum single dose is 875 mg, which can be administered intravenously if necessary. For adolescents and adults weighing ≥ 40 kg, 500 ‒ 875 mg can be administered every 12 h [27,31,32]. Amoxicillin-clavulanic acid has a broad spectrum of antibacterial effects and is effective against penicillin-resistant bacteria; however, clavulanic acid may increase the risk of diarrhea, gastrointestinal upset, and liver toxicity and may be more expensive than regular amoxicillin. Therefore, it should be used appropriately, considering the range of infections that require treatment. It is contraindicated in patients with penicillin allergy, and the dose should be adjusted in patients with impaired renal function [31-33].
Clindamycin
Clindamycin is prescribed as an alternative antibiotic when adverse effects are observed with amoxicillin and cephalosporin [31]. Clindamycin belongs to the lincosamide series of antibiotics and is a bacteriostatic antibiotic that inhibits bacterial protein synthesis. Clindamycin is a relatively effective antibiotic, but caution is required, as it may increase the risk of pseudomembranous colitis caused by Clostridioides difficile infection when used long term. In addition, because digestive side effects (diarrhea, abdominal pain, and nausea) may commonly occur, it is recommended to drink plenty of fluids and take the drug after meals to reduce gastrointestinal disorders [33]. For infants and children, 20 ‒ 30 mg/kg/day is administered at divided doses every 8 h, with a maximum single dose of 450 mg [27].
Metronidazole
Metronidazole is a nitroimidazole antibiotic with strong antibacterial effects against anaerobic bacteria and some protozoa. It kills bacteria by inducing DNA damage. It is often used in combination with amoxicillin or clindamycin to enhance its therapeutic effects. The oral dose for children and adolescents allergic to penicillin is 10 mg/kg/dose every 8 h for 7 days, with a maximum single dose of 250 mg. Metronidazole is a relatively well-tolerated antibiotic, but some patients may experience gastrointestinal problems, such as nausea, vomiting, metallic taste, and abdominal pain. There is a risk of long-term neurotoxicity (e.g., peripheral neuropathy); therefore, it should be used cautiously when necessary.
Azithromycin
Azithromycin, a macrolide antibiotic, exerts antibacterial effects by inhibiting bacterial protein synthesis. It is effective against Staphylococcus, Streptococcus, and some Gram-negative bacteria (such as Haemophilus influenzae) and can be used as an alternative antibiotic, especially for patients allergic to penicillin. It is prescribed as an alternative antibiotic for patients allergic to penicillin who cannot use clindamycin. The oral dose for children is usually 10 ‒ 12 mg/kg as a single dose on the 1st day, followed by 5 ‒ 6 mg/kg daily from the 2nd to 5th day (5-day regimen). Azithromycin is generally a well-tolerated antibiotic, but some patients may experience gastrointestinal side effects, such as nausea, vomiting, abdominal pain, and diarrhea, and in rare cases, there may be a risk of cardiac arrhythmia owing to QT prolongation; therefore, caution should be taken in patients with a history of cardiac disease.
Prophylactic antibiotics
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].
Conclusion
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.
Notes
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.