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Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients

Review Council
Council on Clinical Affairs

Adopted
2001

Revised
2005, 2009

Purpose
The American Academy of Pediatric Dentistry recognizes the increasing prevalence of antibiotic-resistant micro-organisms. This guideline is intended to provide guidance in the proper and judicious use of antibiotic therapy in the treatment of oral conditions.1

Methods
This revision was based upon a new systematic literature search of the MEDLINE/Pubmed electronic database using the following parameters: Terms: antibiotic therapy, antibacterial agents in children, antimicrobial agents in children, dental trauma, oral wound management, orofacial infections, periodontal disease, viral disease, and oral contraception; Field: All fields; Limits: within the last 10 years, humans, English, clinical trials, birth through age 18. Papers for review were chosen from this search and from hand searching. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians.

Background
The widespread use of antibiotics has permitted common bacteria to develop resistance to drugs that once controlled them.2-4 At present, there are no antibiotics to which resistance has not appeared.2,5 To diminish the rate at which resistance is increasing, health care providers must be prudent in the use of antibiotics. 1

Oral wound management Factors related to host risk (eg, age, systemic illness, malnutrition) and type of wound (eg, laceration, puncture) must be evaluated when determining the risk for infection and subsequent need for antibiotics. Wounds can be classified as clean, potentially contaminated, or contaminated/dirty. Facial lacerations may require topical antibiotic agents.12 Intraoral lacerations that appear to have been contaminated by extrinsic bacteria, open fractures, and joint injury have an increased risk of infection and should be covered with antibiotics.12 If it is determined that antibiotics would be beneficial to the healing process, the timing of the administration of antibiotics is critical to supplement the natural host resistance in bacterial killing. The drug should be administered as soon as possible for the best result. The most effective route of drug administration (intravenous vs intramuscular vs oral) must be considered. The clinical effectiveness of the drug must be monitored. If the infection is not responsive to the initial drug selection, a culture and susceptibility testing of isolates from the infective site may be indicated. The minimal duration of drug therapy should be limited to 5 days beyond the point of substantial improvement or resolution of signs and symptoms; this is usually a 5- to 7-day course of treatment dependent upon the specific drug selected.13-18 The importance of completing a full course of antibiotic must be emphasized. If the patient discontinues the antibiotic prematurely, the surviving bacteria can restart an infection that may be resistant to the original antibiotic. Special conditions Pulpitis/apical periodontitis/draining sinus tract/localized intraoral swelling Bacteria can gain access to the pulpal tissue through caries, exposed pulp or dentinal tubules, cracks into the dentin, and defective restorations. If a child presents with acute symptoms of pulpitis, treatment (ie, pulpotomy, pulpectomy, or extraction) should be rendered. Antibiotic therapy usually is not indicated

Recommendations
Conservative use of antibiotics is indicated to minimize the risk of developing resistance to current antibiotic regimens.2-11 The following general principles should be adhered to when prescribing antibiotics for the pediatric population.

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if the dental infection is contained within the pulpal tissue or the immediately surrounding tissue. In this case, the child will have no systemic signs of an infection (ie, no fever and no facial swelling).14,16-18 Acute facial swelling of dental origin A child presenting with a facial swelling secondary to a dental infection should receive immediate dental attention. Depending on clinical findings, treatment may consist of treating or extracting the tooth/teeth in question with antibiotic coverage or prescribing antibiotics for several days to contain the spread of infection and then treating the involved tooth/teeth. The clinician should consider the ability to obtain adequate anesthesia, the severity of the infection, and the medical status of the child. Intravenous antibiotic therapy and/or referral for medical management may be indicated.16,17 Dental trauma Local application of an antibiotic to the root surface of an avulsed tooth with an open apex and less than 60 minutes extraoral dry time has been recommended, if available, to inhibit external resorption and aid in pulpal revascularization. 20-26 Systemic antibiotics have been recommended as adjunctive therapy for avulsed permanent incisors with an open or closed apex.20, 22-25,27 Tetracycline is the drug of choice, but consideration must be exercised in the systemic use of tetracycline due to the risk of discoloration in the developing permanent dentition.20 Penicillin V can be given as an alternative.24,25,27 The use of topical antibiotics to induce pulpal revascularization in immature non-vital traumatized teeth has been suggested.28-31 However, further randomized clinical trials are needed. Pediatric periodontal diseases In pediatric periodontal diseases (eg, neutropenias, PapillonLeFevre syndrome, leukocyte adhesion deficiency), the immune system is unable to control the growth of periodontal pathogens and, in some cases, treatment may involve antibiotic therapy. Culture and susceptibility testing of isolates from the involved sites are helpful in guiding the drug selection.32 Viral diseases Conditions such as acute primary herpetic gingivostomatitis should not be treated with antibiotic therapy unless there is strong evidence to indicate that a secondary bacterial infection exists.33 Oral contraceptive use Whenever an antibiotic is prescribed to a female patient taking oral contraceptives to prevent pregnancy, the patient must be advised to use additional techniques of birth control during antibiotic therapy and for at least 1 week beyond the last dose, as the antibiotic may render the oral contraceptive ineffective.34,35 Rifampicin has been documented to decrease the effectiveness of oral contraceptives.36 Other antibiotics, particularly tetracycline and penicillin derivatives, have been

shown to cause significant decrease in the plasma concentrations of ethinyl estradiol, causing ovulation in some individuals taking oral contraceptives.36 Caution is advised with the concomitant use of antibiotics and oral contraceptives.36

References
1. Wilson W, Taubert KA, Gevitz P, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association. J American Dent Assoc 2008;139(1):3S-24S. 2. Levy SB. Multidrug resistance: A sign of the times. N Engl J Med 1998;338(19):1376-8. 3. Neu HC. The crisis in antibiotic resistance. Science 1992; 257(5073):1064-73. 4. Tenover FC, Hughes JM. The challenges of emerging infectious diseases. JAMA 1996;275(4):300-4. 5. American Academy of Pediatrics, CDC, American Society for Microbiology. Your child and antibiotics: Unnecessary antibiotics can be harmful. Atlanta, Ga: CDC; 1997. 6. CDC, Food and Drug Administration, National Institutes of Health. Action plan to combat antimicrobial resistance 1999. Available at: http://www.cdc.gov/drugresistance/ actionplan/index.htm. Accessed November 5, 2008. 7. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infectious. Pediatrics 1998;101:163-5. 8. Finkelstein JA, Metlay JP, Davis RL, Rifas-Shiman SL, Dowell SF, Platt R. Antimicrobial use in defined populations of infants and young children. Arch Pediatr Adolesc Med 2000;154(4):395-400. 9. OBrien KL, Dowell SF, Schwartz B, Marcy M, Phillips WR, Gerber MA. Acute sinusitis: Principles of judicious use of antimicrobial agents. Pediatrics 1998;101:174-7. 10. Schwartz B, Bell DM, Hughes JM. Preventing the emergence of antimicrobial resistance: A call to action by clinicians, public health officials, and patients. JAMA 1997;278(11):944-5. 11. Williams RJ, Heymann DL. Containment of antibiotic resistance. Science 1998;279(5354):1153-4. 12. Nakamura Y, Daya M. Use of appropriate antimicrobials in wound management. Emerg Med Clin North Am 2007;25(1)159-76. 13. Wickersham RM, Novak KK, Schweain SL, et al. Systemic anti-infectives. In: Drug Facts and Comparisons. St. Louis, Mo: Facts and Comparisons; 2004:1217-336. 14. Johnson BS. Oral infection: Principles and practice of antibiotic therapy. Infect Dis Clin North Am 1999;13 (4):851-70. 15. Kuriyama T, Karasawa T, Nakagawa K, Saiki Y, Yamamoto E, Nakamura S. Bacteriological features and antimicrobial susceptibility in isolates from orofacial odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90(5):600-8.

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16. Peterson LJ. Antibiotics for oral and maxillofacial infections. In: Newman MG, Kornman KS, eds. Antibiotic/ Antimicrobial Use in Dental Practice. St. Louis, Mo: Mosby; 1990:159-71. 17. Maestre Vera Jr. Treatment options in odontogenic infection. Med Oral Patol Oral Cir Bucal 2004;9(suppl S): 19-31. 18. Keenan JV, Farman AG, Fedorowicz Z, Newton JT. A Cochrane system review finds no evidence to support the use of antibiotics for pain relief in irreversible pulpitis. J Endod 2006;32(2):87-92. 19. Prieto-Prieto J, Calvo A. Microbiological basis of oral infections and sensitivity to antibiotics. Med Oral Patol Oral Cir Bucal 2004;9(suppl S):11-8. 20. Andreasen JO, Andreasen FM. Avulsions. In: Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4th ed. Copenhagen, Denmark: Blackwell Munksgaard; 2007: 461, 478-88. 21. Cvek M, Cleaton-Jones P, Austin J, Kling M, Lownie J, Fatti O. Effect of topical application of doxycycline on pulp revascularization and periodontal healing in reimplanted monkey incisors. Endod Dent Traumatol 1990;6 (4):170-6. 22. Lee JY, Vann WF, Sigurdson AS. Management of avulsed permanent incisors: A decision analysis based on changing concepts. Pediatr Dent 2001;23(4):357-60. 23. Trope M. Treatment of the avulsed tooth. Pediatr Dent 2000;22(2):145-7. 24. Flores MT, Andersson L, Andreasen JO, et al. Guidelines for the management of traumatic dental injuries II. Avulsion of permanent teeth. Dental Traumatol 2007;23 (3)130-6. 25. McIntyre JD, Lee JY, Tropte M, Vann WF Jr. Management of avulsed permanent incisors: A comprehensive update. Pediatr Dent 2007;29(1):56-63.

26. Yanpiset K, Trope M. Pulp revascularization of replanted immature dog teeth after different treatment methods. Endod Dent Traumatol 2000;16(5):211-7. 27. Sae-Lim V, Wand CY, Trope M. Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs teeth. Endod Dent Traumatol 1998;14 (5):216-20. 28. Iwaya S, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dent Traumatol 2001;17(4):185-7. 29. Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: Case report and review of the literature. Pediatr Dent 2007;29(1):47-50. 30. Thibodeau B, Teixeira F, Yamauchi M, Caplan DJ, Trope M. Pulp revascularization of immature dog teeth with apecial periodontitis. J Endod 2007;36(6):680-9. 31. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: New treatment protocol? J Endod 2004;30(4):196-200. 32. Delaney JE, Keels MA. Pediatric oral pathology: Soft tissue and periodontal conditions. Pediatr Clin North Am 2000;47(5):1125-47. 33. American Academy of Pediatrics. Herpes simplex. In: Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2003:344-53. 34. DeRossi SS, Hersh EV. Antibiotics and oral contraceptives. Pediatr Clin North Am 2002;46(4):653-64. 35. Burroughs KE, Chambliss ML. Antibiotics and oral contraceptive failure. Arch Fam Med 2000;9(1):81-2. 36. Dickinson BD, Altman RD, Nielsen NH, Sterling ML. Drug interactions between oral contraceptives and antibiotics. Obstet Gynecol 2001;98(5Pt1):853-60.

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