Teresa Joby, Safna C U, Anu Joy, Vipin Raj S V,Joby Peter, John Joseph Methippara, Ronin Sebastain

Department of Paediatric and Preventive Dentistry, Annoor Dental College and Hospital, Muvattupuzha,Kerala

Received: 11-01-2022

Revised: 01-02-2022

Accepted: 22-02-2022

Address for correspondence

John Joseph Methippara, Reader, Department of Pediatric and Preventive dentistry, Annoor Dental College and Hospital, Muvattupuzha, Kerala.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-Noncommercial ShareAlike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

How to cite this article: Joby T, Safna C U, Joy A, Raj V S V, Peter J, Methippara J J, Sebastain R. Antibiotics!! Bane or boon in pediatrics? J Oral Biomed Sci 2022;1:19-23.

 Abstract

Antibiotics are frequently used in dentistry, both prophylactically and therapeutically. Antibiotic overuse in children, particularly for dental and ear infections, is highly common. Antibiotics are frequently used to treat oral infections and prevent systemic bacteremia. Resistant bacterial strains arose as a result of a lack of understanding of antibiotic indications. For paediatric patients, prescribing the correct dosage of medicine is critical. The focus of this review paper is on the proper use and misuse of antibiotics in pediatric dentistry.

Keywords: Pediatric Dentistry, Antibiotics

Introduction

By the introduction of penicillin by Alexander Fleming marked the beginning of the so called ‘Golden Era’ of antibiotics. Antibiotics are mainly indicated for control of bacterial infections. The use of antibiotics by health care professionals has benefitted humankind to a great extent. Recent reports show an increasing trend of antibiotic prescriptions by dentists. At the same time antibiotic resistant bacteria survives and makes antibiotics ineffective¹.Treatment success depends on having a good understanding of how to prescribe antibiotics correctly. In dentistry, antibiotics are mostly used to treat endodontic, oral surgical, and periodontal symptoms. Antibiotic overuse has been reported in youngsters, mostly for dental infections².

History of antibiotics

Illness has been man’s heritage from the start of his existence, and therefore the search of remedies to combat it’s perhaps equally old. The invention of Penicillin, one among the world’s first antibiotics, marked a real turning point in human history when doctors finally had a tool that would completely cure their patients of deadly infectious diseases. Penicillin was discovered in London in September of 1928 by Alexander Fleming ³.

Gerhard Domagk (1895–1964), a German scientist, created Prontosil, the first Sulfa drug, in 1935. Streptomycin was discovered on October 19, 1943, in the laboratory of Selman Abraham Waksman at Rutgers University by Albert Schatz, a graduate student. Lloyd Conover patented tetracycline in 1955, and it quickly became the most often prescribed broad range antibiotic in the United States. Amoxicillin or amoxicillin/potassium clavulanate pills were patented by SmithKline Beecham, and the antibiotic was first released in 1998 under the trade names Amoxicillin, Amoxil and Trimox ⁴.

Physiological considerations in children

Children, unlike adults, are continually growing and developing. This fact should be considered anytime medications are administered to children, as there are significant disparities in body surface area, as well as hepatic and renal functions, depending on age. Therefore, route and rate of administration, dosage and duration of action and possible toxicity all are determined by the unique physiology of child ⁵. Physiologic considerations include absorption, distribution, metabolism and excretion ^6,7.

1. Absorption: host factors like existing surface area, gastric and duodenal PH, gastric emptying time, size of bile salt pool, bacterial colonization of gastrointestinal tract, presence and extent of underlying diseases influence the absorption rate.
2. Distribution: Factors like body fat, level of plasma proteins, blood brain permeability should also taken into account.
3. Metabolism: functioning of liver and kidney must be considered^.
4. Excretion: the development and maturation of glomerular filtration rate determines the dosage of the drug.

Factors to be considered while prescribing drugs for children ⁸

1. Host related factors: route of administration, age, renal and hepatic function
2. Pathogen related factors: antibiotic resistance rates and prevalence of particular pathogens
3. Drug factors: spectrum and type of activity, compliance by the patient, cost consideration

Drug dose calculation for children

Table 1: Different formulas for child dose calculation ⁹

Name	Formula
AGE BASE:
Young rules	Age in years / age + 12 × Adult dose
Dilling rules	Age in years / 20 × A. D
WEIGHT BASE:
Clark rules	Weight (kg)/ 70 × A. D
BSA BASE:
BSA formula	B S A (m2)/ 1.7 × A. D

*A. D= Adult Dose, B.S. A= Body Surface Area

Dosage and duration guidelines

For commonly used antibiotics in children ¹⁰:

Amoxicillin: Usual oral dosage for 1-3 Children >3 months: 125-250 mg every 8 hours.

For endocarditis prophylaxis 50mg/kg (maximum 2 g) can be given, 30-60 minutes before procedure.

Amoxicillin clavulanate potassium: Usual oral dosage, based on amoxicillin component, for children >3 months of age up to 40 kg: 25-45 mg/kg/day: doses divided every 12 hours (suspension or chewable tablet) for children >40 kg.

Azithromycin: Usual oral dosage, for Children >6 months up to 16 years: 5-12 mg/kg 1 time/day (maximum 500 mg/day) OR 30 mg/kg as a single dose (maximum 1500 mg).

As Endocarditis prophylaxis, 15 mg/kg (maximum 500 mg) 30-60 minutes before procedure is given.

Metranidazole: Usual oral dosage for children: 30mg/kg/day in divided doses every 6 hours.

Dental conditions that may / may not require antibiotic therapy in children ^11,12

Table 2: Clinical conditions in which antibiotics are used as an adjunct are summarized:

Pulpal/periapical/periodontal/conditions	Clinical signs and symptoms
Acute apical abscess with systemic involvement	Localized fluctuant swellings Elevated body temperature (>38°C) Malaise Lymphadenopathy Trismus
Cellulitis / Osteomyelitis	Rapid onset of severe infection (less than 24 hours) Cellulitis or a spreading infection Osteomyelitis
Acute necrotizing ulcerative gingivitis	Strong continuous pain and fetid odor. Generalized systemic manifestation including low grade fever, lymph adenopathy and malaise.
Aggressive periodontitis	Rapid loss of connective tissue attachment and alveolar bone.

 Table 3: Clinical conditions in which antibiotics are not used as an adjunct are:

Pulpal/periapical/periodontal/conditions	Clinical signs and symptoms
Irreversible pulpitis	Pain No other signs and symptoms of infection.
Pulpal necrosis	Nonvital teeth
Acute Apical periodontitis	Pain Pain to percussion and biting.Widening of periodontal space
Chronic apical abscess	Teeth with sinus tract Periapical radiolucency
Acute apical abscess with no systemic involvement	Localized fluctuant swellings
Eruption gingivitis	Gingival inflammation
Pubertal gingivitis	Swelling of interdental papilla with spontaneous gingival hemorrhage
Primary herpetic gingivostomatitis	Painful gingival inflammation and vesicles that are formed mainly on dorsum of the tongue, hard palate, and gingiva.

 Antibiotic therapy duration

The shortest antibiotic treatment cycle capable of preventing both clinical and microbiological recurrence is preferable. The majority of acute infections clear up in 3 to 7 days. When using oral antibiotics, a high dose should be considered in order to achieve quicker therapeutic levels ².

Antibiotic prophylaxis recommendations for children:

 Antibiotic prophylaxis is a necessary option in cases of immunosuppressed patients, history of cancer, infective endocarditis and metabolic disorders.

Table 4: Specific antibiotic regimen revised by the American Heart Association in 2014 ¹³

Regimen: Single dose 30 – 60 minutes before procedure
Situation	Agent	Children
Oral	Amoxicillin	50 mg /kg
Unable to take oral medication	Ampicillin	50 mg/kg IM or IV
	Cefazolin / Cephtrioxone	50 mg/kg IM or IV
Allergic to Penicillin or Ampicillin- Oral	Cephalexin	50 mg/kg
	Clindamycin	20 mg/kg
	Azithromycin / Clarithromycin	15 mg/ kg
Allergic to Penicillin or Ampicillin and Unable to take oral medication	Cefazolin / Ceftrioxone	50 mg/kg IM or IV
	Clindamycin	20 mg/kg IM or IV

Consequences of misuse of antibiotics in pediatric dentistry

Antibiotic misuse is a major health problem, especially leading to antibiotic resistance in children. This will make once compelling and less exorbitant therapy ineffectual expanding the therapy costs. The antibiotics are associated with several fatal complications if they are used improperly.

Problems associated with use of antibiotics include¹⁴:

• Hypersensitivity reaction
• Drug toxicity
• Nutritional deficiencies
• Antimicrobial drug resistance
• Super infection
• Masking of an infection.

According to Dr. Thomas J.pallasch ¹⁵, antibiotic misuse in dentistry mainly involves prescribing them in appropriate situations or for too long which includes:

• Giving an antibiotic after dental procedure in an otherwise healthy patient to prevent infection which in all likelihood will not occur.
• Using antibiotics as analgesics, especially in endodontics-employing antibiotics for prophylaxis in patients not at risk for metastatic bacteremia
• Using antimicrobials to treat chronic adult periodontitis, which is almost totally responsive to mechanical treatment
• Using antibiotics instead of surgical incision and drainage of infection
• Using antibiotics to prevent claims of negligence

So, antibiotics must be used correctly and appropriately to guarantee that effective and safe treatment is offered.

Conclusion

Antibiotic therapy is a double-edged sword, the misuse of which can be managed by its prudent use. Antibiotics should be prescribed in very judicious way. Dentist must know the ideal dosage of drugs. Antibiotics should be given or dosage calculation should be done according to weight and age of the child. An appropriate action today can assure an effective cure for tomorrow.

Conflict of interest: None

Financial support and sponsorship: Nil

References

1. Aidasani B, Solanki M, Khetarpal S, Ravi Pratap S. Antibiotics: their use and misuse in Paediatric dentistry. A systematic review. Eur J Paediatr Dent. 2019; 20:133-138.
2. Peedikayil FC. Antibiotics: Use and misuse in pediatric dentistry. J Indian Soc Pedod Prev Dent. 2011; 29:282-7.
3. Fleming A. On antibacterial action of culture of Penicillium, with special reference to their use in isolation of B. influenzae. Br J Exp Pathol 1929; 10:226- 236.
4. Griffin, MO, Fricovsky E, Ceballos G, Villarreal F. Tetracyclinesa pleitropic family of compounds with promising therapeutic properties. Review of the literature. Am J Physiol 2010; 299:539-548
5. Oberoi SS, Dhingra C, Sharma G, Sardana D. Antibiotics in dental practice: how justified are we. Int Dent J. 2015; 65:4-10
6. Wood M, Wood AJ. Changes in plasma drug binding and alpha 1-acid glycoprotein in mother and newborn infant. Clin Pharmacol Ther. 1981; 29:522-6.
7. Reed MD, Besunder JB. Developmental pharmacology: ontogenic basis of drug disposition. Pediatric Clinics of North America. 1989; 36:1053-1074.
8. Katharine Smart, Jean-Francois Lemay, James D Kellner. Antibiotic choices by paediatric residents and recently graduated paediatricians for typical infectious disease problems in children. Paediatr Child Health. 2006: 11:647-649.
9. Agarwal A, Panat SR, Anshul, Gurtu A, Aggarwal A. Antibiotic Usage in Pediatric Dentistry: A Comprehensive Review. J Dent Sci Oral Rehab 2014;5: 125-132.
10. Kumar KP, Kaushik M, Kumar PU, Reddy MS, Prashar N. Antibiotic prescribing habits of dental surgeons in Hyderabad city, India, for pulpal and periapical pathologies: a survey. Adv Pharmacol Sci. 2013:537-385.
11. Ramasamy A. A review of use of antibiotics in dentistry and recommendations for rational antibiotic usage by dentists? Int Arabic J Antimicrob Agents. 2014;20;4
12. Muppa R, Nallanchakrava S, Chinta M, Manthena RT. Nonsyndromic localized aggressive periodontitis of primary dentition: A rare case report. Contemp Clin Dent. 2016; 7:262-4.
13. American Academy of Pediatric Dentistry. Guideline on use of antibiotic therapy for pediatric dental patients. Chicago (IL): J Dent Child, 2014, 287-292.
14. Antibiotic side effects. Medscape News. Pharmacists.www.medscape.com /viewarticle/410873_1.
15. Pallasch TJ. Global antibiotic resistance and its impact on the dental community. Calif Dent Assn J 2000; 28:215- 33.