Article Type : Review Article
Authors : Garg D and Karthik S
Keywords : Antibiotics; Dentistry; Prophylaxis; Penicillin
Antibiotics are used in dentistry as an adjunct to dental treatment and also for prophylaxis. They can either give benefit with appropriate usage or can be misused. The most commonly used antibiotic is penicillin. They are commonly used in dentistry for prophylaxis in case of immunocompromised patients, odontogenic and non-odontogenic infections. This review focuses on the antibiotic usage and benefits in dentistry.
Antibiotics was introduced in the mid-twentieth
century in the form of sulfa drugs as an etiological and curative agent. Antibiotic treatment helps in identification
of new pathogens, antibiotic resistance and the consolidation of new diseases
[1-3]. Antibiotics are used in dentistry as an adjunct for dental intervention
and as prophylaxis in immunocompromised patients, signs of systemic infection
[4,5]. Now, antibiotics are chemically modified (semi synthetic) to improve
their pharmacokinetic properties and its use is based on selective toxicity
which can severely damage microorganisms but does not have any effect on
eukaryotic cell [6].
The human oral cavity consists of a wide number and a
broad range of microorganisms and saprophytes are the general causative factors
for odontogenic infections. The most commonly isolated species is
Streptococcus. Peri-apical infection due to necrosis of pulp caused by the
advancement of bacteria through the pulp canal warrants the use of systemic
antibiotic administration [7,8]. Prophylactic antibiotics have been used to
reduce the likelihood of postoperative local complications, like infection, dry
socket, or systemic complications like infective endocarditis [9].
Indications
for Antibiotic Use in Dentistry
Antibiotics are prescribed in dentistry for the
following conditions
·
treatment of acute and
chronic infections of odontogenic and non-odontogenic origins (b) prophylactic
treatment to prevent focal infection in immunocompromised patients (c)
prevention of local infection and systemic spread among patients undergoing
surgical oral or dental treatment Oberoi [10].
Contraindications
for Antibiotic Use in Dentistry
·
Antibiotics that are
eliminated through the kidneys may cause impaired renal function in patients
with renal failure.
·
Patients with liver
failure
·
Pregnant and lactating
women
·
Hypersensitivity
·
Patients with liver,
kidney failure and pregnant women require reduction of the drug dose to avoid
excessively elevated plasma drug concentrations that could lead to toxicity.
Patients with hypersensitivity to a certain antibiotic require alternative
prescription.
Principles
for Usage of Antibiotics
The appropriate usage of antibiotics is defined by the
term antibiotic stewardship as “the optimal selection, dosage, and duration of
antimicrobial treatment that results in the best clinical outcome for the
treatment or prevention of infection, with minimal toxicity to the patient and
minimal impact on subsequent resistance”. The 4 “Ds” of antibiotic usage was
elucidated by Joseph and Rodovold which comprised of right Drug, right Dose,
De-escalation to pathogen-directed therapy and right Duration of therapy
[11,12].
Principles
of choosing the appropriate antibiotic
Identification of the
causative organism: The antibiotic therapy
will be either initial (empirical) or definitive based on the identification of
the organism in the laboratory. The conditions in which culture should be
performed to identify the causative organism are:
·
If the patient has
received appropriate treatment for 3 days without improvement
·
If the infection is a
post-operative wound infection
·
If the infection is
recurrent
·
If actinomycosis is
suspected
·
If osteomyelitis is
present.
Determination
of antibiotic sensitivity: The causative agent and
antibiotic sensitivity must be precisely identified in infections before
prescription of antibiotics in cases that have not responded to initial
antibiotic therapy or postoperative wound infection.
Use
of specific and narrow spectrum antibiotic: Antibiotic
with the narrowest antibacterial spectrum should be prescribed which reduces
the chance of development of bacterial resistance, super infections and allows
larger proportions of the host flora to be maintained.
Use
of the least toxic antibiotic: Antibiotics
prescribed should be the least toxic from among those that are effective. Since
chloramphenicol is known to be very toxic causing bone marrow depression,
penicillin should be the used instead even though chloramphenicol is slightly
more effective than penicillin.
Patient
drug history: Patient’s drug history, allergic
reactions and toxic reactions should be noted since antibiotics may prolong,
enhance, or interfere with the other medication that the patient is taking.
Use
of bactericidal rather than a bacteriostatic drug: Bactericidal
antibiotics are less reliant on host resistance, have the property of killing
of the bacteria by the antibiotic itself, faster results than with
bacteriostatic drugs and has greater flexibility with dosage intervals.
Bacteriostatic antibiotics play a more important role in the eradication of the
bacteria.
Use
of the antibiotic with a proven history of success: Clinical
effectiveness of the drug penicillin over a prolonged period for treating oral
infections has shown that it is very effective with a low incidence of adverse
reactions. Newer antibiotics may be more active at lower concentration,
reducing the cost and dose related toxicity reactions and have fewer toxic
effects than the older antibiotic. Therefore, the newer antibiotics should be
used only when they offer clear advantages over the older ones.
Cost
of the antibiotic: Cost of the antibiotic
prescribed should also be considered. At times there may be a substantial
difference in price for drugs of equal efficacy
Ensure
that patient completes the antibiotic course: Patients
may fail to take the medication in the way in which it was prescribed and few
studies have indicated that the patient compliance decreases with increasing
number of pills per day. Therefore, antibiotics prescribed fewest times daily
to improve patient compliance.
Principles
of Antibiotic Administration
Administer
proper dose
The goal of any drug therapy should be to prescribe or
administer sufficient amounts to achieve the desired therapeutic effect but not
enough to cause injury to the host. The minimal inhibitory concentration (MIC)
of an antibiotic for a specific bacterium has to be used. The dosage prescribed
must be capable of establishing a concentration of antibiotics that is 3 to 4
times the MIC. The usual recommended dose of an antibiotic is usually
sufficient to provide a threshold MIC concentration against the common
susceptible organisms. Therapeutic levels greater than 3 to 4 times the MIC generally
do not improve the therapeutic results.
Proper
time interval
The frequency of dosing is also of importance in
administration of antibiotics as every antibiotic has an established plasma
half Life. The usual dosage interval for the therapeutic use of antibiotics is
4 times the plasma half Life.
Proper
route of Administration
The oral route of administration of antibiotics
results in the most variable absorption. However, in some infections only
parenteral administration produces the necessary serum level of antibiotic.
When long term parenteral administration is necessary use of the intravenous
route can be considered
Consistency
in route of Administration
Maintenance of peak blood levels of antibiotic for an
adequate period is important to achieve maximum tissue penetration effective
bacterial killing. Bacteria usually are not educated until the antibiotic has
been given for 5 to 6 days. If the infection is mild enough, the blood levels
achievable with oral therapy are sufficient.
Combination
Antibiotic Therapy
Recombination antibiotic therapy should be used only
when it is clearly indicated as in cases where it is necessary to increase the
antibacterial spectrum in patients with life-threatening sepsis of unknown
cause. It can also be used in increased bactericidal effect against a specific
organism is desired, in cases which demands the use of combined antibiotic
therapy is in the prevention of the Rapid emergence of resistant bacteria and
in the temperate treatment of certain odontogenic infection. Parenteral
penicillin G and parenteral metronidazole can be used. This combination therapy
provides rapid bactericidal activity against both streptococci and anaerobes
[13].
Uses of
Antibiotics in Dentistry
Dental
caries
Dental caries is the most common oral infectious
disease from early childhood to old age. Early in the prevention or treatment
of dental caries, systemic antibiotics like penicillin, tetracycline, and
metronidazole have showed potential efficacy. The use of probiotics has
excellent potential to reshape the oral microbial community in dental caries
[14-17].
Odontogenic
infections
Antibiotics for odontogenic infections are used for
acute periapical infection, dry socket and pulpitis. Facial cellulitis, which
may or may not be associated with dysphagia, must be treated with antibiotics
because of the possibility of spread of infection through lymph and blood
circulation, with the development of septicaemia [18]. Treatment of lateral
periodontal abscess involves the drainage and irrigation of the abscess with
antiseptic mouthwash (0.2% Chlorhexidine) and antibiotic therapy is rarely
required. In acute dent alveolar abscesses, antibiotic therapy selection can be
specific, since the bacteria involved are known. Penicillin is the most common
antibiotic to use. For patients with hypersensitive reactions to penicillin,
erythromycin can be used instead [19].
Non
odontogenic infections
Non-odontogenic infections like tuberculosis (TB),
syphilis, leprosy and non-specific infections of the mucosal membranes, muscles
and fascia, salivary glands and bone require prolonged treatment. Newer
antibiotics, such as fluoroquinolones, are the drug of choice for management of
non-odontogenic infections. In primary
oral tubercular lesion, an empirical treatment given for TB can cure the oral
tubercular lesion. For specific infections caused by mycobacteria antibiotics
for long periods of time (6 months to 2 years) should be used this includes the
prescription of dapsone, clofazimine and rifampicin for leprosy, and
associations of ethambutol, isoniazid, rifampicin, pyrazinamide and
streptomycin for TB [20].
Prophylaxis
Prophylactic antibiotics, taken before a number of
dental procedures, have been advocated to reduce the risk of postoperative
local complications (such as infections or
dry socket) or serious systemic complications (such as infective
endocarditis), in surgical excision of benign tumours and in immunocompromised
patients. According to new recommendations from the National Institution for
Health and Care Excellence (NICE), antibiotic prophylaxis should not be offered
for all patients at risk of infective endocarditis due to the ever-increasing
antibiotic resistance [21,22]. Amoxicillin, or ampicillin, is used before the
procedure. Cefalexin is recommended for patients hypersensitive to penicillin,
unless they have a history of immediate hypersensitivity in which case
clindamycin is use [23-25].
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