Review Article
Antibiotics: Use and misuse in pediatric dentistry Peedikayil FC
Abstract Antibiotics are commonly used in dentistry for prophylactic as well as for therapeutic purposes. Most often antibiotics are used in unwarranted situations, which may give rise to resistant bacterial strains. Dentists want to make their patients well and to prevent unpleasant complications. These desires, coupled with the belief that many oral problems are infectious, stimulate the prescribing of antibiotics. Good knowledge about the indications of antibiotics is the need of the hour in prescribing antibiotics for dental conditions.
Key words Antibiotics, antibiotic resistance, antibiotic prophylaxis, pediatric antibiotics
Introduction Antibiotics are prescribed in dental practice for prophylactic and therapeutic reasons. Prophylactic antibiotics are prescribed to prevent diseases caused by members of the oral flora introduced to distant sites in a host at risk or introduced to a local compromised site in a host at risk.[1] In most cases, prophylaxis is used for prevention of endocarditis. Therapeutic antibiotics are prescribed, in most cases, to treat diseases of the hard and soft tissues in the oral cavity after local debridement has failed.[2] Antibiotics are prescribed for oral conditions related to endodontic, oral surgical, and periodontal manifestations. Unwarranted use of antibiotics are reported in children; [3] mostly for ear and dental infections. However, in children, increasing microbial resistance to antibiotics is a well-documented and is a serious global health concern.[3-5] Antibiotic resistance is due to inappropriate use of antibiotics by clinicians. One factor that may contribute is the inappropriate use of antibiotics in dentistry.[3] According to Dr. Thomas J. Pallasch,[6] antibiotic misuse in dentistry mainly involves prescribing them in ‘inappropriate situations’ or for too long, which includes - giving antibiotics after 282
Department of Pedodontics and Preventive Dentistry, Kannur Dental College, Kannur, Kerala State, India Correspondence: Dr. Faizal C P, Department of Pedodontics and Preventive Dentistry, Kannur Dental College, Anjarakandy, Kannur, Kerala, India 670612. E-mail:
[email protected] Access this article online Quick Response Code:
Website: www.jisppd.com DOI: 10.4103/0970-4388.86368 PMID: **********
a dental procedure is complete in an otherwise healthy patient to ‘prevent’ an infection, which in all likelihood will not occur • Using antibiotics as ‘analgesics,’ particularly in endodontics; — employing antibiotics for prophylaxis in patients not at risk for metastatic bacteremias • Using antimicrobials to treat chronic adult periodontitis, which is almost totally responsive to mechanical treatment • Using antimicrobial therapy in lieu of mechanical therapy for management of periodontitis • Using antibiotics and antimicrobials chronically in periodontitis • Using antibiotics instead of surgical incision and drainage of infections • Using antibiotics to ‘prevent’ claims of negligence The impression is that antibiotics continue to be prescribed by dentists as much or more as in the past, despite the scarcity of clinical trials demonstrating the need for antibiotics. Dentists want to make their patients well and to prevent unpleasant complications. These desires, coupled with the belief that many oral problems are infectious, stimulate the prescribing of antibiotics.[7] Textbooks, continuing education lectures, and dental school instructors have likely directed that
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Oct - Dec 2011 | Issue 4 | Vol 29 |
Peedikayil: Antibiotic use and misuse
antibiotics be used (albeit empirically). There is also the impression that patients get better when given antibiotics. The reality is that signs and symptoms are usually cyclical and will often improve spontaneously, then deteriorate later. The temporary improvement is likely in spite of and not because of the prescribed antibiotic.
• Antibiotics are rarely recommended for the treatment of mild traumatisms, although in cases involving important soft tissue or dentoalveolar lesions, antibiotic prophylaxis against infection is advisable • Good antibiotic coverage is required in children with dental avulsion programmed for reimplantation
The antibiotic prescribed most frequently is penicillin or an analog, especially amoxicillin.[8-10] However, other newer-generation antibiotics are becoming more widely used because of the belief that these are more effective, and they are more expensive. This belief may be based more on marketing than on the fact, as their effectiveness has not been demonstrated in clinical trials.[11]
Dental conditions and antibiotic therapy Pulpitis
Micr obiology of odontogenic infections The bacteria that cause odontogenic infections are generally saprophytes. The microbiology in this sense is varied, and multiple microorganisms with different characteristics can be involved. Anaerobes and aerobes are usually present, numerous aerobic species cause odontogenic infections — the most common being Streptococci.[12,13] In the course of dental caries, the bacteria that penetrate the dentinal tubules are mainly facultative anaerobes (i.e., Streptococci, Staphylococci, and Lactobacilli). When the pulp tissue suffers necrosis, the bacteria advance through the pulp canal, and the process evolves toward periapical inflammation — with a predominance of Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococci.[14,15]
Management considerations in odontogenic infections The following must be considered before deciding to administer antibiotics: [9,16,17] • The severity of the infection, when the child visits the dentist • The patient’s immune defense status • In the case of acute infection, if inflammation is moderate and the process has progressed rapidly, and in cases of diffuse cellulite with moderate-to-severe pain, or if the child has fever the existing evidence advises antibiotic prescription as well as treatment of the damaged tooth • Infection in a medically compromised child • Infection that has progressed to the extraoral facial spaces
In pulpitis, the tooth pulp is vital, but inflamed, and is occasionally accompanied by pain, which can sometimes be severe. The inflammation is confined and is not a true infection. Treatment is removal of the inflamed tissue; antibiotics should not be used.[18,19]
Endodontic diseases Endodontic diseases involve the dental pulp and related periradicular tissues. The dental pulp is the viable connective tissue within a tooth. Its major function is to form the tooth around itself. The bacteria may reach the pulp canal through a caries lesion, via direct pulp tissue exposure after trauma, or via iatrogenic mechanisms. Penetration takes place through the dentinal tubules, dentinal cracks, or defective dental restorations. If a patient presents evidence of acute pulpitis, the required dental management should be provided (pulp therapy or extraction). Antibiotic treatment is usually not indicated if the infectious process only reaches the pulp or the immediate adjacent tissues in the absence of signs of systemic infection (i.e., fever or facial swelling).[18-21] Whether this pulpal and periapical pathosis is a true infection (an invasion of tissues by pathogenic bacteria) is debatable, Most bacteria recovered from these lesions are common facultative and obligate anaerobic oral bacteria that are relatively nonpathogenic, which have not been shown to proliferate readily in the host tissues. Rather, they seem to be able to survive best in necrotic tissues. Therefore, the damage they cause may be secondary. Furthermore, there is good evidence that these lesions are actually caused by immune mechanisms reacting to toxins and histolytic enzymes produced by the bacteria.[22] Even if this condition were indeed an infective process, the effectiveness of antibiotic therapy would be questionable. As there is no circulation within the necrotic pulp or an abscess, it is unlikely that an antibiotic would reach the bacteria in the therapeutic concentrations.
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Peedikayil: Antibiotic use and misuse
Periapical abscess, localized
Endodontic flare-ups
These are the most common abscesses in the oral tissues. They begin in the bone at the tooth apex as inflammatory lesions, which progress to becoming abscesses. These abscesses may be confined to the bone, but often spread to the overlying soft tissues. The resulting swelling is predominantly within the oral cavity, but may be seen as a slight elevation of the cheek or lip. The abscess contains mixed bacteria with a predominance of anaerobes.[14,15]
Adverse reactions (known as flare-ups) occur infrequently. Antibiotics are frequently administered to prevent adverse post-treatment sequelae of root canal treatment and oral surgery. Controlled prospective clinical trials have demonstrated that antibiotics are not beneficial in treating symptoms after root canal treatment.[15,19,22]
Emergency treatment consists primarily and most importantly of removing the irritant (bacteria, bacterial by-products, inflammatory mediators) from within the tooth and relieving the pressure and purulence by incision and drainage. If the tooth is not salvageable, extraction accomplishes both removal of irritants and drainage.[19-21]
Acute apical abscess and cellulitis An infrequent occurrence, cellulitis is a more severe manifestation of the localized abscess, in which the abscess and the reaction to the abscess disseminates, often rapidly, into other tissues and spaces. The result is noticeable swelling and distortion of the facial features. If untreated, this infection can spread to vital structures, resulting in blindness, cerebral abscess, mediastinal involvement, and even death. Such serious sequelae are rare and tend to occur only in otherwise debilitated patients.[19] A child presenting with a facial swelling secondary to a dental infection should receive immediate dental attention.[21] Depending on the clinical findings, the treatment may consist of treating the tooth / teeth in question with antibiotic coverage or prescribing antibiotics to contain the spread of infection and then treating the involved tooth / teeth.[19,21] Many patients with facial cellulitis do not demonstrate systemic manifestations. Although they rarely have an elevated temperature or white cell count, it is hoped that administration of antibiotics will control the infection.[11] The choice of antibiotic is empirical, as no definitive information on the causative pathogenic microorganisms is available. The antibiotic of choice is penicillin, administered orally and with aggressive dosages.[16,17,21] Intravenous antibiotics are seldom used except for a patient who is hospitalized with a serious infection. At best, antibiotics are supplemental; without local treatment, they will not resolve the problem. In fact, serious sequelae have resulted from using antibiotics alone without the underlying problem being corrected.[16,17] 284
Management of dental trauma Tooth trauma is a risk factor for oral infection, particularly in the presence of direct pulp exposure and / or alteration of the periodontal space. The possibilities of infection increase when trauma to the hard dental or supporting tissues is in turn associated with open skin or mucosal membrane wounds.[13] In case of avulsion, 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, to inhibit external resorption and aid in pulpal revascularization. Systemic antibiotics have been recommended as an adjunctive therapy for avulsed permanent incisors with an open or closed apex. 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. [9] Penicillin V can be given as an alternative. The use of topical antibiotics to induce pulpal revascularization in immature non-vital traumatized teeth has been suggested. However, further randomized clinical trials are needed.[13,18,19]
Management of periodontal disease Systemic antibiotics do not appear to offer any benefit additional to mechanical therapy in patients with periodontitis. In refractory periodontitis, and possibly, rapidly progressing periodontitis, local delivery of antibiotics is of some value in managing the specific sites of recurrent disease.[13] Antibiotics, are at best an adjunctive and not a primary form of therapy. Removal of local irritants is the primary objective.[19,23] In periodontal disorders associated with neutropenia, such as the Papillon-Lefevre syndrome and leukocyte adhesion deficiencies, the immune system of children is unable to control the growth of periodontal pathogens. Antibiotic treatment is therefore needed in such cases.[23] Pericoronitis is inflammation of a flap (operculum) of the gingival tissue that overlies a partially impacted tooth, usually molar. Food debris and bacteria can
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Peedikayil: Antibiotic use and misuse
invade the space between the tooth and the tissue, which may then become traumatized by occlusion from an upper tooth. This damage results in a secondary infection with pain and swelling, usually on the inside of the mandible extending posteriorly toward the pharynx. Occasionally, the infection is severe with extensive swelling to the face, and the patient is febrile. Treatment of milder forms of pericoronitis is debridement (irrigation under the flap) or removal of the soft tissue, and more serious infections require more aggressive therapy, including antibiotics.[19,23] As the offending microorganisms are from the oral cavity, the antibiotic of choice is penicillin or its derivatives.
Systemic antibiotic prophylaxis Although the potential exists for oral microorganisms to seed and infect the distant tissues after oral procedures,[1,3] there is no substantiated evidence that this occurs. Consequently, the issue of when and for what conditions systemic prophylactic antibiotics are necessary is controversial.[24] The American Academy of Pediatric Dentistry (AAPD) endorses the American Heart Association’s (AHA) guideline on prevention of infective endocarditis.[25] The 2007, AHA guideline recommends infective endocarditis (IE) prophylaxis only for those whose underlying cardiac conditions are associated with the highest risk of an adverse outcome. Such conditions include prosthetic heart valves, previous history of IE, unrepaired cyanotic congenital heart disease (CHD), a completely repaired congenital heart defect, with prosthetic material or device during the first six months after the procedure, repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device, and cardiac transplantation recipients who develop valvulopathy. Consultation with the patient’s physician may be necessary to determine the susceptibility to bacteremia-induced infections. For patients with high-risk cardiac conditions, [Table 1] IE prophylaxis is recommended for all dental procedures that involve manipulation of the gingival tissue or periapical region of the teeth or perforation of the oral mucosa. Table 2 lists the suggested prophylaxis regimen.
Patients with compromised immunity Patients with a compromised immune system may not be able to tolerate a transient bacteremia following invasive dental procedures.[25,26] Therefore antibiotic prophylaxis may be given in following conditions;
1. Human immunodeficiency virus (HIV) 2. Severe combined immunodeficiency (SCIDS) 3. Neutropenia 4. Immunosuppression 5. Sickle cell anemia 6. Status post splenectomy 7. Chronic steroid usage 8. Lupus erythematosus 9. Diabetes 10. Status post organ transplantation
Patients with shunts, indwelling vascular catheters, or medical devices Bacteremia following an invasive dental procedure may lead to colonization of shunts or indwelling vascular catheters. Vascular catheters, such as those required by patients undergoing dialysis, chemotherapy, or frequent administration of blood products, are susceptible to bacterial infections. Ventriculoatrial (VA) or ventriculovenus (VV) shunts for hydrocephalus are at risk of bacteremia-induced infections, due to their vascular access. In contrast, ventriculoperitoneal (VP) shunts do not involve any vascular structures, and consequently, do not require antibiotic prophylaxis. The AAPD endorses the recommendations of the American Dental Association and the American Academy of Orthopedic Surgeons for the management of patients with prosthetic joints. Antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws, nor is it indicated routinely for most dental patients with total joint replacements.[25,27]
Antibiotic selection Oral antibiotics that are effective against odontogenic infections comprise of penicillin, clindamycin, erythromycin, cefadroxil, metronidazole, and the tetracyclines. [8,9,11] These antibiotics are effective against Streptococci and oral anaerobes. Penicillin V is the penicillin of choice in cases of odontogenic infection. It is a bactericidal, and although the spectrum of action is relatively limited, it is appropriate for the treatment of odontogenic infections. For the prophylaxis of endocarditis associated with dental treatments, amoxicillin is the antibiotic of choice. Amoxicillin with clavulanic acid (clavulanate) can be used in certain cases, as it offers the advantage of preserving activity against the betalactamases commonly produced by microorganisms associated with odontogenic infections.[13] Clindamycin is an alternative in the case of patients who are allergic to penicillins. The drug is bacteriostatic,
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Table 1: High risk cardiac conditions for which IE prohylaxis is recommended Prosthetic cardiac valve or prosthetic material used for cardiac valve repair Previous infective endocarditis Congenital heart disease (CHD) Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device Cardiac transplantation recipients who develop cardiac valvulopathy
Table 2: Antibiotic prophylaxis regimen for children Situation
Agent
Children
Oral
Amoxycillin
50mg/kg
Unable to take oral medication
Ampicillin or
50mg/kg IM /IV
Cefazolin / ceftriax
50mg/kg IM/IV
Cephalexin or
50mg/kg
Clindamycin or
20mg/kg
Allergic to penicillins oral
Azithromycin / clarithromycin
15mg/kg
Allergic to penicillin
Cefazolin or ceftriaxone
50 mg/kg IM or IV
or ampicillin
OR
and unable to take oral medication
Clindamycin
although bactericidal action is clinically achieved with the generally recommended dosage. The latest generation macrolides, clarithromycin, and azithromycin can also be used if a child is allergic to penicillin. Cephalosporin and cefadroxil are additional options when a broader spectrum of action is required. Metronidazole is usually used against anaerobes, and is characteristically reserved for situations in which only anaerobe bacteria are suspected. Tetracyclines are of very limited use in dental practice, as these drugs can cause alterations in tooth color, they must not be administered to children under eight years of age, or pregnant or nursing women.[17]
Duration of antibiotic therapy The ideal duration of antibiotic treatment is the shortest cycle capable of preventing both clinical and microbiological relapse. Most acute infections are resolved within three to seven days. When oral antibiotics are used, a high dose should be considered to secure faster therapeutic levels.[17,20]
Conclusions Appropriate and correct use of antibiotics is essential to ensure that effective and safe treatment is available. Practices that may enhance microbial resistance should be avoided. To improve standards of care, dentists need to be up-to-date in their knowledge of pharmacology in dental education, as well as in the continuing education, 286
20 mg/kg IM or IV
with a continuous assessment of dental practices, a better understanding of the pathogenesis of these infections, including the host immune response to bacteremia, along with prospective clinical trials, which will allow for more evidence-based decisions.
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11. Dailey YM, Martin MV. Are antibiotics being used appropriately for emergency dental treatment? Br Dent J 2001;191:391-3. 12. Peterson L. Principles of management and prevention of odontogenic infections. In: Peterson L, Ellis E, Hupp JR, Tucker MR, editors. Contemporary oral and maxillofacial surgery. 3rd ed. St. Louis, Missouri: Mosby-Year Book, Inc.; 1998. 13. Planells-del Pozo P, Barra-Soto MJ, Santa Eulalia-Troisfontaines E. Antibiotic prophylaxis in pediatric odontology. An update. Med Oral Patol Oral Cir Bucal 2006;11:E352-7. 14. Brook I. Microbiology and management of endodontic infections in children. J Pediatr Dent 2003;28:13-8. 15. Siqueira Junior JF. Aetiology of root canal treatment failure: Why well-treated teeth can fail. Int Endod J 2001;34:1-10. 16. Dodson TB, Perrott DH, Kaban LB. Pediatric maxillofacial infections: A retrospective study of 113 patients. J Oral Maxillofac Surg 1989;47:327-30. 17. Peterson L. Principles of management and prevention of odontogenic infections. In: Peterson L, Ellis E, Hupp JR, Tucker MR, editors. Contemporary oral and maxillofacial surgery. 3rd ed. St. Louis, Missouri: Mosby-Year Book, Inc.; 1998. 18. American Academy of Pediatric Dentistry. Guideline on use of antibiotic therapy for pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry; 2009. 19. Walton RE, Zerr M, Peterson L. Antibiotics in dentistry--a boon or bane? APUA Newsletter 1997;15:(1) 20. Johnson BS. Oral infection: Principles and practice of antibiotic therapy. Infect Dis Clin North Am 1999;134:851-70.
21. Maestre Vera JR. Treatment options in odontogenic infection. Med Oral Patol Oral Cir Bucal 2004;9(Suppl S):19-31 22. Dahlen G, Moller AJ. Microbiology of Endodontic Infections. In: Slots J, Taubman M, editors. Contemporary Oral Microbiology and Immunology. St. Louis, MO: Mosby; 1992. p. 458. 23. Delaney JE, Keels MA. Pediatric oral pathology: Soft tissue and periodontal conditions. Pediatr Clin North Am 2000;47:1125-47. 24. Bogle RG, Bajpai. Antibiotic Prophylaxis Against Infective Endocarditis: New Guidelines, New Controversy? Br J Cardiol 2008;15:279-80. 25. American Academy of Pediatric Dentistry (AAPD). Guideline on use of antibiotic therapy for patients at risk of infection: American Academy of Pediatric Dentistry (AAPD); 2007. 26. American Academy of Pediatric Dentistry. Clinical guideline on dental management of pediatric patients receivingchemotherapy, hematopoietic cell transplantation, and/or radiation. Pediatr Dent 2005;27(suppl):170-5. 27. American Dental Association, American Academy of Orthopaedic Surgeons. Advisory Statement: Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc 1997;128:1004-7. How to cite this article: Peedikayil FC. Antibiotics: Use and misuse in pediatric dentistry. J Indian Soc Pedod Prev Dent 2011;29:282-7. Source of Support: Nil, Conflict of Interest: None declared.
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