Pharmaceutical Prescribing and Primary Dental Care
Pharmaceutical Prescribing for Children
Part 3. Antibiotic Prescribing for Children
With Odontogenic Infections
Nikolaus OA Palmer
Key words: Antibiotic Prescribing, Dentists, Odontogenic Infections, Children
This paper is the third in a series on the prescribing of medicines for children by dentists working in primary care. It deals with
antibiotics, which may be prescribed for infections arising from teeth, and reviews current best practice.
In recent years, guidance has been issued
to practitioners aimed at reducing the
use of antibiotics for therapeutic and
prophylactic purposes. This has been due
to the worldwide increase in microor-
ganisms’ resistance to antimicrobials.1-3
Microbial resistance is a major health
problem and contributes significantly
to nosocomial septicaemia (serious
hospital-based infections such as meth-
icillin-resistant Staphylococcus aureus or
MRSA). The indiscr iminate use of
antimicrobials is a major cause of re-
sistance to such antibiotics by micro-
organisms. Antimicrobials can also lead
to selection and proliferation of resistant
organisms, which in turn can increase
the incidence of resistance through the
transfer of genetic material from resistant
strains to antibiotic-sensitive micro-
organisms.
Serious drug interactions and side
effects can occur with antimicrobial
agents. When other drugs are being taken
at the same time it is always important to
Series Editor:
Nikolaus OA Palmer PhD, BDS, MFDP(UK).
Research Associate, Postgraduate Medical
and Dental Education and Training,
Mersey Deanery, Liverpool, UK.
NOA Palmer PhD, BDS, MFDP(UK). Research Associate, Postgraduate Medical and Dental Education and Training, Mersey Deanery, Liverpool, UK.
check an authoritative source, such as the
British National Formulary (BNF), before
prescribing antibiotics. Information re-
garding drug therapy can be obtained
from local hospital medicines infor-
mation services and from the national
dental medicines information service
(Tel: 0151 794 8206).
Despite the paucity of scientific evi-
dence, there is some consensus among
experts on the use of antibiotics in
dentistry.4,5
The following represent the inappro-
priate use of antibiotics:
◗ Use in unwarranted clinical situa-
tions, for example dental pain in the
absence of infection.
◗ Incor rect dosage, frequency and
duration.
◗ Wrong choice of antimicrobial.
In dentistry antibiotics are used mainly:
◗ As an adjunct to the management of
orofacial infections.
◗ For the definitive management of
active infectious disease.
◗ For the prevention of metastatic in-
fection such as infective endocarditis.
There is no scientific evidence on the
use of antibiotics in the management of
acute infections arising in the primary
dentition. A systematic review of the
literature6 has provided clear, evidence-
© Primary Dental Care 2006;13(1):31-35
based guidelines for dentists on the
management of odontogenic infections
arising from the permanent dentition.7
These guidelines form the basis of the
following recommendations.
Antibiotics as Adjuncts
to Treatment of
Orofacial Infections
The initial assessment of an infection is
important. The clinician should decide
whether or not treatment can be pro-
vided in practice, or whether referral is
necessary. Referral is indicated if there
is or are:
◗ Signs of septicaemia (grossly elevated
temperature, lethargy, tachycardia).
◗ Spreading cellulitis.
◗ Swellings that may compromise the
airway, cause closure of the eye or
create difficulty in swallowing.
◗ Dehydration.
◗ Failure to respond to treatment.
◗ An uncooperative patient.
Nature of orofacial infections in children
Most acute orofacial infections in child-
ren are of odontogenic origin and the
majority of them are self limiting once
the cause (tooth) is removed.8 It must
Primary Dental Care • January 2006
31
 Pharmaceutical Prescribing for Children
Management of acute odontogenic infections.
Acute
dentoalveolar
abscess
Raised axillary
temperature or
diffuse swelling
Remove cause,
establish drainage,
and prescribe
antimicrobials
Review 2-3 days
Resolution of
swelling and
temperature
Failure of
resolution: check
drainage OR refer
Figure 1
also be remembered that some may drain
spontaneously.
Early recognition and management of
acute orofacial infection and careful fol-
low-up of the resolution of the infection
are critical because paediatric patients
may become systemically ill within a
short time.9,10 If untreated, local infec-
tions may lead to spread of infection
which may give rise to serious sequelae
such as airway obstruction.
Treatment
◗ Identify the cause.
◗ Define the extent of the infection.
◗ Record temperature (normal axillary
temperature 36.5º C).
◗ Establish drainage, remove cause.6
◗ Ensure fluid balance is maintained.
The algorithm in Figure 1, which dem-
onstrates the aim of establishing drainage
and resolution of the infection, should be
followed.
Failure of resolution is usually caused
by:
Primary Dental Care • January 2006
32
Defined swelling
apyrexial
Remove cause,
establish drainage.
No antibiotics
required
Review 2-3 days
Resolution
◗ Failure to establish adequate
drainage.
◗ Poor host resistance.
◗ Poor patient compliance.
◗ Incorrect diagnosis.
The use of antimicrobials should be as an
adjunct to treatment and aimed at:
◗ Limiting the spread of infection.
◗ Preventing metastatic spread.
The use of antibiotics in the manage-
ment of localised dental infections
over and above establishing drainage
of an abscess is not recommended.6
(Grade B level of evidence)*
* Grade B is defined as evidence based on well con-
ducted clinical studies but there are no randomised
clinical trials on the topic.11
Microbiology of odontogenic bacteria
The bacteria that cause odontogenic
infections are usually part of the normal
oral flora. The microbiology is mixed
with multiple organisms with different
characteristics.12 They include:
◗ Facultative anaerobic Gram-positive
cocci.
◗ Str ictly anaerobic Gram-positive
cocci.
◗ Strictly anaerobic Gram-negative
bacilli.
Antibiotic Choice
First choice
A penicillin such as amoxicillin has been
shown to be effective in the treatment of
infections in children.13 Phenoxymethyl-
penicillin is also recommended for dental
infections.14
Second choice
Metronidazole.
Third choice
Erythromycin.
There is no scientific evidence to rec-
ommend one antibiotic over another
for the management of odontogenic
infections with systemic spread.6
(Grade A level of evidence)**
** Grade A is defined as evidence based on at least one
randomised controlled trial as part of a body of
literature of overall good quality and consistency
addressing the recommendations on this topic.11
Amoxicillin
Amoxicillin is a broad-spectrum peni-
cillin with the following characteristics.
Spectrum
Kills Gram-positive facultative bacteria,
some Gram-negative bacilli, and anaer-
obes. Its effectiveness can be inhibited
by bacterial penicillinases.
Side effects
Gastrointestinal reactions are most com-
mon including nausea, abdominal cramps
and diarrhoea. Hypersensitivity reactions
present as a skin rash or urticaria in 1-7%
of patients. Severe anaphylactic reactions
are rare occurring in 0.005-0.05% of
patients treated.
Pharmacokinetic properties
Is rapidly and almost completely ab-
sorbed following oral administration.

Bioavailability (ie, high concentrations at
the site of the infection) is reported as
75-92%.15
Peak levels occur one-two hours after
an oral dose. The plasma half-life is
approximately one hour. There are no
indications for loading doses in dental
infections as the minimum inhibitory
concentration for oral pathogens is ex-
ceeded at normal doses.
Absorption is unaffected by food.
Dose for children
◗ Less than 12 months old: 62.5 mg tds.
◗ 1-5 years old: 125 mg tds.
◗ 6-12 years old: 250 mg tds.
Duration
Two-three days, with a maximum of five
days.
Presentation
◗ Capsule 250 mg.
◗ Oral suspension 125 mg in 5 ml, 250
mg in 5 ml. NB Some brands in-
clude sucrose: avoid these where
possible by specifying ‘sugar-free’
on the prescription.
◗ Syrup 125 mg in 5 ml and 250 mg in
5 ml.
Licensed status
Licensed for all ages.
Phenoxymethylpenicillin
Phenoxymethylpenicillin is an acid-sta-
ble penicillin with the following charac-
teristics.
Spectrum
Kills Gram-positive facultative bacteria
and some anaerobes. Its effectiveness is
inhibited by bacterial penicillinases.
Side effects
Gastrointestinal reactions are most com-
mon including nausea, vomiting, abdo-
minal cramps and diarrhoea. Hypersen-
sitivity reactions—including urticaria,
rashes, fever, joint pains, angioedema and
anaphylaxis—occur rarely.
Pharmacokinetic properties
Absorption, although rapid, is variable
with about 60% of oral dose being
absorbed. Presence of food may affect
absorption. It is best taken on an empty
stomach either one hour before or two
hours after food. Peak plasma levels occur
after approximately one hour. Plasma
half-life is 30-60 minutes. Loading doses
may be required.
Dose for children
◗ Less than 12 months old: 62.5 mg qds.
◗ 1-5 years old: 125 mg qds.
◗ 6-12 years old: 250 mg qds (in severe
infections ensure at least 12.5 mg/kg
qds).
Duration
Two-three days, with a maximum of five
days.
Presentation
◗ Tablet 250 mg.
◗ Oral solution 125 mg in 5 ml, 250
mg in 5 ml. NB Includes sucrose,
no sugar-free alternative available.
Licensed status
Licensed for all ages.
Metronidazole
Metronidazole is a nitroimidazole anti-
microbial agent with the following
characteristics.
Spectrum
Effective against anaerobic bacteria and
some protozoa.
Side effects
These are commonly nausea, vomiting,
unpleasant taste and gastrointestinal dis-
turbances. Drowsiness, dizziness, head-
ache may occur rarely.
Pharmacokinetic properties
Metronidazole has excellent bio-avail-
ability with over 80% absorption. It is
not significantly affected by food and is
widely distributed into most body tis-
sues, with tissue levels approaching serum
levels. Loading doses not normally
required. Peak plasma levels occur
between 20 minutes and three hours.
Plasma half-life is six-eight hours.
N Palmer
Dose for children
◗ 1-3 years of age: 50 mg tds.
◗ 3-7 years of age: 100 mg bd.
◗ 7-10 years of age: 100 mg tds.
◗ Over 10 years of age: 200 mg tds
(adult dose).
Duration
Three days.
Presentation
◗ As a suspension (as benzoate) 200 mg
in 5 ml. NB Includes sucrose, no
sugar-free alternative available.
◗ As tablets 200 mg.
Licensed status
Licensed for all ages except neonates (less
than one month).
Erythromycin
Erythromycin is a macrolide antibiotic. It
is useful for patients allergic to penicillin
and has the following characteristics.
Spectrum
It is active against a broad spectrum
of Gram-positive and Gram-negative
organisms. It inhibits bacterial growth
(bacteriostatic).
Side effects
These are most commonly nausea, diar-
rhoea, vomiting, and abdominal pain,
which are dose-related. Rashes are rare.
NB Children exper ience adverse
reactions more readily.16
Pharmacokinetic properties
Variable absorption can be poor with
bioavailability of between 30-65%.
Widely distributed throughout the body.
Peak plasma level occurs after two-three
hours with a plasma half-life of one-two
hours.
Dose for children
◗ From one month to two years of age:
125 mg qds.
◗ 2-12 years of age: 250 mg qds.
Duration
Two-three days with a maximum of five
days.
Primary Dental Care • January 2006
33
 Pharmaceutical Prescribing for Children

Dose for children

◗ 6 months-3 years: 10 mg/kg od.
Removing the cause of the infection.
◗ 3-7 years: 200 mg od.
◗ 8-11 years: 300 mg od.
Chronic ◗ 12-14 years: 400 mg od.
infection ◗ Over 14 years: 500 mg od (adult
dose).

Duration
Identify cause Two-three days only.

Diffuse swelling, Presentation

Defined swelling pyrexic or risk of Oral suspension 200 mg in 5 ml. NB
apyrexial local or systemic
spread Includes sucrose, no sugar-free alter-
native available.

Remove cause,
establish drainage—
Licensed status
antibiotics Licensed for children over six months
required
of age.

Remove cause,
Review 2-3 days
establish drainage
Resolution
Resolution
Discontinue
antibiotics
Figure 2
Presentation against Gram-positive organisms and
◗ Tablets 250 mg (as stearate), 250 mg more active against Gram-negative or-
(as ethylsuccinate). ganisms.
◗ Oral suspension 125 mg in 5 ml, 250
mg in 5 ml, 500 mg in 5 ml. NB Side effects
Some brands include sucrose: Well tolerated with fewer side effects
avoid where possible by specifying than erythromycin. Most commonly,
‘sugar-free’ on the prescription. gastrointestinal effects including nau-
sea, diarrhoea, vomiting and abdominal
Licensed status pain.
Licensed for all ages.
Pharmacokinetic properties
Azithromycin Bioavailability of around 37% but it is
widely distributed in the body. Tissue
Azithomycin is a macrolide antibiotic concentrations exceed plasma concentra-
with the following characteristics. tions. Time to peak plasma level occurs
in two-three hours.The plasma and tissue
Spectrum half-life is two-four days.
Similar to erythromycin but is less active
Management of Chronic
Odontogenic Infections
Chronic odontogenic infections can
occur in association with decayed and
restored deciduous teeth. They com-
monly present as a minor well localised
abscess, sometimes with a discharging
sinus and rarely require antimicrobial
therapy unless:
◗ There is an acute flare-up and there is
evidence of gross local spread.
◗ There is systemic involvement shown
by elevation of temperature or malaise.
◗ The patient is medically compro-
mised.
The principles of treatment are:
◗ Drainage of infection.
◗ Removal of cause.
The algorithm in Figure 2, which is
aimed at removing the cause of the in-
fection, should be followed. Antibiotic
choice is as for acute dentoalveolar in-
fections.
Conclusions
This paper has given recommendations
on the appropriate use of antibiotics in
the management of bacterial infections
of odontogenic origin in children only.
The next paper in the series will describe
the presentation and pharmacological
treatment of oral fungal and viral infec-
tions in children.

Primary Dental Care • January 2006

34
 N Palmer

References
1. Wise R, Hart T, Cars O, Streulens M, Helmuth R, Huovinen
P, et al. Antimicrobial resistance is a major threat to
public health. BMJ. 1998;317:609-10.
2. Standing Medical Advisory Committee. The Path of Least
Resistance. London: Department of Health; 1998.
3. House of Lords Select Committee on Science and Tech-
nology. Seventh Report. Resistance to Antibiotics and Other
Antimicrobial Agents. London:The Stationery Office; 1998.
4. Martin MV, Longman LP, Palmer NAO. Adult Antimicrobial
Prescribing in Primary Care for General Dental Practitioners.
London: Faculty of General Dental Practitioners (UK); 2000.
5. Cawson RA, Spector RG. Clinical Pharmacology in Dentistry.
5th ed. London: Churchill Livingstone; 1989.
6. Matthews DC, Sutherland S, Basrani B. Emergency manage-
ment of acute apical abscesses in the permanent dentition:
a systematic review of the literature. J Can Dent Assoc.
2003;69:660.
7. Glenny AM, Simpson T. The CCCD guidelines. Evid Based
Dent. 2004;5:9-11.
8. Cohen S, Burns RC. Pathways of the Pulp. 8th ed. St Louis,
MO: Mosby; 2002.
9. Dodson TB, Perrott DH, Kaban LB. Pediatric maxillofacial
infections: a retrospective study of 113 patients. J Oral
Maxillofac Surg. 1989;47:327-30.
10. Sandor GK, Low DE, Judd PL, Davidson RJ. Antimicrobial
treatment options in the management of odontogenic
infections. J Can Dent Assoc. 1998;64:508-14.
11. Acute Pain Management: Operative or Medical Procedures and
Trauma. AHCPR Pub. No. 92-0038. Rockville, MD: Agency
for Health Care Policy and Research, Public Health Service,
US Department of Health and Human Services; 1992.
12. Lewis MA, MacFarlane TW, McGowan DA. A microbiologi-
cal and clinical review of the acute dentoalveolar abscess.
Br J Oral Maxillofac Surg. 1990;28:359-66.
13. Paterson SA, Curzon ME. The effect of amoxycillin versus
penicillin V in the treatment of acutely abscessed primary
teeth. Br Dent J. 1993;174:443-9.
14. British Medical Association and Royal Pharmaceutical
Society of Great Britain. Dental Practitioners’ Formulary.
British National Formulary 49, March 2005. London: Pharma-
ceutical Press; 2005.
15. Boon RJ, Beale AS, Comber KR, Pierce CV, Sutherland R.
Distribution of amoxicillin and clavulanic acid in infected
animals and efficacy against experimental infections.
Antimicrob Agents Chemother. 1982;22:369-75.
16. The Royal College of Paediatrics and Child Health and the
Neonatal and Paediatric Pharmacists Group. Medicines for
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Correspondence: N Palmer,
4 Dowhills Road, Blundellsands,
Liverpool L23 8SN.
E-mail: Nikolaus.Palmer@btinternet.com

supporting general practice skills. This would provide good reminders

Periodontal Management of
Children, Adolescents and Young
Adults
Clerehugh,Valerie;Tugnait, Aradhna; and Chapple Iain LC
New Malden: Quintessence Publishing; 2004
£28.00; Hardcover; 187 pp; 135 col illus.
ISBN: 1 85097 071 8
The brief title of this book, sixth in the Quintessentials of Dental
Practice series (edited by Nairn HF Wilson), focused me to read it for
an update on the advances to periodontal approaches for chil-
dren since the change, a few years ago, from the long established clas-
sification of ‘juvenile diseases’. If that is your continuing professional
development goal, then that information is certainly all here, and very
readable, but the book has an added bonus of an excellent mini-atlas
guide to gingival and periodontal lesions in chapters 6 and 7. This
is certainly a very valuable addition in the surgery reference book
area. Additionally, if you have not enjoyed recent, or any, training in
communication with children, then the last chapters will stimulate
some new thoughts for your clinical practices and you may also be
better appreciated by your own siblings and young relatives!
The authors, however, take you first through a fundamental revi-
sion of your knowledge of the healthy periodontium, the classification
of diseases and the associated defects in biological processes, and risk
assessment considerations. The text is generally concise, with good
and clear diagrams, flow charts and appropriate photographs; how-
ever, switching between the lists on a page of text, and then to boxes
with lists on adjacent pages and back again, did not work comfortably
for me. To find that Box 4-1 was a heading for the next five pages
further added to the distraction in these early chapters. Never-
theless, this is excellent and concise revision material for any general
dental practitioner (GDP) feeling a need to update, and ideal for a
student dentist or hygienist. The book has a very educationally
correct approach, and the authors err on the side of covering not
just the periodontal basics, but also including details of a number of
to young, independent practitioners of radiographic film views, ion-
ising radiation regulations, social history recording, informed consent,
etc, but this may cause more experienced practitioners to jump
forward through more relevant text. As this is one book of a series,
it is not clear which experience group this is aimed at and because
the full periodontal examination details are in an earlier book, this
may put some readers of this volume at a disadvantage.
The classifications of gingival and periodontal lesions, with excel-
lent illustrations and tightly edited text, cover just 35 pages. This is a
very well presented section with the characteristics and management
of lesions outlined clearly and in appropriate detail for reference by
the GDP.
Non-surgical therapy is simply but effectively discussed in chap-
ter 8, Principles and Phases of Treatment. It would be good to see
here a repeat of figure 2-9 which illustrates this so well through the
fundamental, but poorly understood progress from numerous, initial
pockets through to a few residual sites and, then, the maintenance
phase. General advice on adjunctive treatments is outlined but, quite
properly, the author does not get involved, in depth, with surgical
options and regeneration. Equally, there is limited comment on the
management and outcomes of severe disease, of occlusion etc, and
as these issues normally fall into the adult phase, there are other
books to cover this. However, the implications of orthodontic care
are covered, although the suggestion of anticipating the excessive
proclination of lower incisors with a pre-orthodontic keratinised
labial gingival graft for an area of recession might raise some contro-
versy, particularly as the post-graft illustration appears to show the
tooth more upright and lingual, within the bone envelope position.
I enjoyed the scientific update, not at a genotype distribution level,
to my relief but at a level of ‘cellular traffic controllers’! More text-
annotated references would have been useful for follow-up informa-
tion, but this book should attract a wide readership.
DERRICK ALLEN BDS, MSC , MGDS.
SPECIALIST IN PERIODONTICS, WARWICK.

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