Doxycycline and tooth discoloration update: the tooth behind the matter

Doxycycline and tooth discoloration update: the tooth behind the matter

Kelly Beneke, PharmD New Ulm Medical Center

Background: Tetracycline use and associated tooth discoloration in children was first reported in 1959. Doxycycline, brought to the market in 1967, was found to bind less readily to calcium than other medications in the class. Although there is limited evidence showing permanent tooth discoloration with doxycycline in young children, the use has been avoided in children  younger than eight years old. According to the package insert, the only FDA pediatric indication for doxycycline is post-exposure inhalational anthrax. A recent article by Stultz and Eiland reviews six studies and discusses the evidence of safety of doxycycline in children younger than eight years old and the new recommendations regarding its use moving forward. 

Evidence: From 1969 to 2017, six studies with approximately 338 patients were reviewed. Although methods between the studies varied for examining and evaluating the tooth discoloration, it primarily consisted of photography, direct examination, instruments, or scales. The children included in the studies were between four days and eight years old. Doxycycline doses ranged from 1 mg/kg/d to 10 mg/kg/d. Most of the medication regimens lasted less than 21 days with one 28 day course. Altogether, there were six potential tooth discoloration cases reported with three cases likely related to doxycycline. Of note, four out of the six patients were younger than two years old. These patients did not have matching controls nor were the adult teeth examined. 

Discussion: From the current research regarding doxycycline use in pediatric patients younger than eight years old, The American Academy of Pediatrics states in the Red Book, “doxycycline can be administered for short durations (i.e, 21 days or less) without regard to the patient’s age.” It should be noted that the tooth discoloration and weakened enamel warning still exists for other tetracyclines. 

Clinical Impact: The use of doxycycline can now be considered in pediatric patients with skin and soft tissue infections, atypical community-acquired pneumonia, and methicillin-susceptible Staphylococcus aureus. The new recommendation of doxycycline use in pediatrics younger than eight years old affords providers another oral, inexpensive treatment option for children without the risk of tooth discoloration and enamel weakening.  

Reference: 

  1. Stultz JS, Eiland LS. Doxycycline and tooth discoloration in children: changing of recommendations based on evidence of safety. Ann Pharmacother. 2019; doi: 10.1177/1060028019863796.

  2. Poyhonen H, Nurmi M, Peltola V, et al. Dental staining after doxycycline use in children. J Antimicrob Chemother. 2017;72:2887-2890. 

  3. Lochary ME, Lockhard PB, Williams WT Jr. Doxycycline and staining of permanent teeth. Pediatric Infect Dis J. 1998; 17(5):429-31. 

  4. Todd SR, Dahlgren FS, Traeger MS, et al. No visible dental staining in children treated with doxycycline for suspected rocky mountain spotted fever. J Pediatric. 2015;166:1246-51. 

  5. Antimicrobial agents and related therapy: tetracyclines. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, ed. Red Book: Report of the Committee of Infectious Disease. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:905-6.