ANTIBIOTICS!! BANE OR BOON IN PEDIATRICS??

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.

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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:

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

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

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