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284 CLINICAL GUIDELINES

REFERENCE MANUAL V 36 / NO 6 14 / 1 5

PurposeTe American Academy of Pediatric Dentistry (AAPD) recog-nizes the increasing prevalence of antibiotic-resistant micro-organisms. Tis guideline is intended to provide guidance inthe proper and judicious use of antibiotic therapy in thetreatment of oral conditions.1

MethodsTis guideline is an update of the previous document adoptedin 2001 and last revised in 2009. Te revision was based upona new systematic literature search of the PubMed electronicdatabase using the following parameters: erms: antibiotictherapy, antibacterial agents, antimicrobial agents, dentaltrauma, oral wound management, orofacial infections,

periodontal disease, viral disease, and oral contraception;Fields: all; Limits: within the last 10 years, humans, English,clinical trials, birth through age 18. One hundred sixty-fivearticles matched these criteria. Papers for review were chosenfrom this search and from hand searching. When data didnot appear sufficient or were inconclusive, recommendationswere based upon expert and/or consensus opinion by experi-enced researchers and clinicians.

BackgroundAntibiotics are beneficial in patient care when prescribed andadministered correctly for bacterial infections. However, the

widespread use of antibiotics has permitted common bacteriato develop resistance to drugs that once controlled them.1-3Drug resistance is prevalent throughout the world.3 Somemicroorganisms may develop resistance to a single anti-microbial agent, while others develop multidrug-resistantstrains.2,3 o diminish the rate at which resistance is increas-ing, health care providers must be prudent in the use ofantibiotics.1

RecommendationsConservative use of antibiotics is indicated to minimize therisk of developing resistance to current antibiotic regimens. 2,3Practitioners should adhere to the following general principleswhen prescribing antibiotics for the pediatric population.

Oral wound managementFactors related to host risk (eg, age, systemic illness, malnutri-tion) and type of wound (eg, laceration, puncture) must beevaluated when determining the risk for infection and subse-quent need for antibiotics. Wounds can be classified as clean,potentially contaminated, or contaminated/dirty. Faciallacerations may require topical antibiotic agents. 4Intraorallacerations that appear to have been contaminated by extrinsic

bacteria, open fractures, and joint injury have an increased riskof infection and should be covered with antibiotics.4 If it isdetermined that antibiotics would be beneficial to the healingprocess, the timing of the administration of antibiotics iscritical to supplement the natural host resistance in bacterialkilling. Te drug should be administered as soon as possible forthe best result. Te most effective route of drug administration(intravenous vs. intramuscular vs. oral) must be considered.Te clinical effectiveness of the drug must be monitored. Teminimal duration of drug therapy should be five days beyondthe point of substantial improvement or resolution of signsand symptoms; this is usually a five- to seven-day course of

treatment dependent upon the specific drug selected.5-7

Inlight of the growing problem of drug resistance, the clinicianshould consider altering or discontinuing antibiotics followingdetermination of either ineffectiveness or cure prior to com-pletion of a full course of therapy.8If the infection is not respon-sive to the initial drug selection, a culture and susceptibilitytesting of isolates from the infective site may be indicated.

Originating CouncilCouncil on Clinical Affairs

Review CouncilCouncil on Clinical Affairs

Adopted2001

Revised2005, 2009, 2014

Guideline on Use of Antibiotic Therapy forPediatric Dental Patients

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AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

CLINICAL GUIDELINES 285

Special conditionsPulpitis/apical periodontitis/draining sinus tract/localized intra-oral swellingBacteria can gain access to the pulpal tissue through caries,exposed pulp or dentinal tubules, cracks into the dentin, anddefective restorations. If a child presents with acute symptomsof pulpitis, treatment (ie, pulpotomy, pulpectomy, or extraction)

should be rendered. Antibiotic therapy usually is notindicated if the dental infection is contained within thepulpal tissue or the immediate surrounding tissue. In thiscase, the child will have no systemic signs of an infection(ie, no fever and no facial swelling).9,10

Consideration for use of antibiotics should be given in casesof advanced non-odontogenic bacterial infections such asstaphylococcal mucositis, tuberculosis, gonococcal stomatitis,and oral syphilis. If suspected, it is best to refer patients forculture, biopsy, or other laboratory tests for documentationand definitive treatment.

Acute facial swelling of dental originA child presenting with a facial swelling or facial cellulitis sec-ondary to an odontogenic infection should receive promptdental attention. In most situations, immediate surgical inter-vention is appropriate and contributes to a more rapid cure.12Te clinician should consider age, the ability to obtain adequateanesthesia (local vs. general), the severity of the infection, themedical status, and any social issues of the child.11,12 Signsof systemic involvement (ie, fever, asymmetry, facial swelling)warrant emergency treatment. Intravenous antibiotic therapyand/or referral for medical management may be indicated.9-11Penicillin remains the empirical choice for odontogenicinfections; however, consideration of additional adjunctive

antimicrobial therapy (ie, metronidazole) can be given wherethere is anaerobic bacterial involvement.8

Dental traumaSystemic antibiotics have been recommended as adjunc-tive therapy for avulsed permanent incisors with an open orclosed apex.14-17etracycline (doxycycline twice daily for sevendays) is the drug of choice, but consideration of the childsage must be exercised in the systemic use of tetracycline dueto the risk of discoloration in the developing permanentdentition.13,14 Penicillin V or amoxicillin can be given as analternative.14,15,17Te use of topical antibiotics to induce pulpal

revascularization in immature non-vital traumatized teethhas shown some potential.14,15,17,18 However, further random-ized clinical trials are needed.19-21 For luxation injuries in theprimary dentition, antibiotics generally are not indicated.22,23Antibiotics can be warranted in cases of concomitant softtissue injuries (see Oral wound management) and whendictated by the patients medical status.

Pediatric periodontal diseasesDental plaque-induced gingivitis does not require antibiotictherapy. Pediatric patients with aggressive periodontal diseases

may require adjunctive antimicrobial therapy in conjunctionwith localized treatment.24 In pediatric periodontal diseasesassociated with systemic disease (eg, severe congenital neutro-penia, Papillon-Lefvre syndrome, leukocyte adhesiondeficiency), the immune system is unable to control thegrowth of periodontal pathogens and, in some cases, treatmentmay involve antibiotic therapy.24,25 Te use of systemic anti-

biotics has been recommended as adjunctive treatment tomechanical debridement in patients with aggressive perio-dontal disease.24,25 In severe and refractory cases, extraction isindicated.24,25Culture and susceptibility testing of isolates fromthe involved sites are helpful in guiding the drug selection.24,25

Viral diseasesConditions of viral origin such as acute primary herpetic gin-givostomatitis should not be treated with antibiotic therapyunless there is strong evidence to indicate that a secondarybacterial infection exists.26

Salivary gland infectionsMany salivary gland infections, following confirmation ofbacterial etiology, will respond favorable to antibiotic therapy.Acute bacterial parotitis has two forms: hospital acquired andcommunity acquired.27 Both can be treated with antibiotics.Hospital acquired usually requires intravenous antibiotics; oralantibiotics are appropriate for community acquired. Chronicrecurrent juvenile parotitis generally occurs prior to puberty.Antibiotic therapy is recommended and has been successful.27For both acute bacterial submandibular sialadenitis and chro-nic recurrent submandibular sialadenitis, antibiotic therapy isincluded as part of the treatment.27

Oral contraceptive useWhenever an antibiotic is pre scribed to a female pat ienttaking oral contraceptives to prevent pregnancy, the patientmust be advised to use additional techniques of birth controlduring antibiotic therapy and for at least one week beyond thelast dose, as the antibiotic may render the oral contraceptiveineffective.28,29Rifampicin has been documented to decreasethe effectiveness of oral contraceptives.28,29Other antibiotics,particularly tetracycline and penicillin derivatives, have beenshown to cause significant decrease in the plasma concentra-tions of ethinyl estradiol, causing ovulation in some individualstaking oral contraceptives.28,29Caution is advised with the

concomitant use of antibiotics and oral contraceptives.28,29

References 1. Wilson W, aubert KA, Gevitz M, et al. Prevention of in-

fective endocarditis: Guidelines from the American HeartAssociationA Guideline From the American Heart As-sociation Rheumatic Fever, Endocarditis and KawasakiDisease Committee, Council on Cardiovascular Diseasein the Young, and the Council on Clinical Cardiology,Council on Cardiovascular Surgery and Anesthesia Anes-thesia, and the Quality of Care and Outcomes Research

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