Antibiotic Therapy in Dentistry: A Comprehensive Guide

CONTENTS
1. Introduction
2. History of antibiotics
3. Fundamental concepts of antibiotic therapy
4. Choice of antibiotics
5. Types of antibiotics

Antibiotics are the susbstances produced by the microorganisms, which suppress
the growth or kill other microorganism at very low concentration without causing
any harm to the host.
Antibiotics are among the most frequently prescribed medication for the
treatment as well as prevention of bacterial infection in modern medicine.
The word antibiotic came from the word “antibiosis” a term coined in 1889
by Louis Pasteur which means a process by which life could be used to
destroy life.
INTRODUCTION

Proper use of antibiotics depends upon careful diagnosis of the
patient’s oral disease, adequate knowledge of the patient’s systemic
condition, and complete understanding of antibiotic therapy.
Unwarranted use of antibiotics are reported in children; mostly for
ear and dental infections leading to increased microbial resistance to
antibiotics.

 Antibiotics are used in dentistry for two major reasons:
to control oral
infection,
to prevent bacteremia
precipitated by dental
manipulations from
causing severe systemic
sequelae.

Children have different susceptibilities to oral and systemic diseases
than adults, and that the metabolism of drugs is often vastly
different in the pediatric patient.
Young children tend to lack medical antecedents suggesting the
possibility of drug allergies or adverse reactions.
The greater proportion of water in the tissues of children, and their
increased bone sponginess facilitate faster diffusion of infection.
Hence they require adequate dose adjustment of the prescribed
medication
The deficient oral hygiene found in most children and the
consumption of sugar-rich foods contribute to increase the presence
of microorganisms thereby increasing the risk of bacteremia
following oral treatment

HISTORY OF ANTIBIOTICS
🠶 The discovery of Penicillin, one of the world’s first antibiotics, marked a true
turning point in human history when doctors finally had a tool that could
completely cure their patients of deadly infectious diseases.
🠶 Penicillin was discovered in London in September of 1928 by Alexander
Flemming.

1928 Penicillin-Fleming
1932 Sulphonamides-Erlich
1948 Cephalosporins-
G.Brotzu
1952 Erythyromycin-Mc
Guire
1956
V
ancomycin-
M.H.Cormick
1962 Quinolone
1970 Linezolide
1998
Amoxicillin, Trade
name- Smithkline
Beecham
2000 Fluoroquinolones

FUNDAMENTAL CONCEPTS OF ANTIBIOTIC THERAPY
• Identify the causative organism
• Most effective narrow spectrum
antibiotics to be used.
• A bacteriostatic drug should not be used
with bactericidal antibiotic.
• Proper route,dose,duration of the
antibiotic should be managed.
• Combination therapy.
PRINCIPLES OF
ANTIBIOTIC
ADMINISTRA
TION
PROPER TIME
INTERVAL
PROPER ROUTE OF
ADMINISTRATION
CONSISTENCY IN
ROUTE OF
ADMINISTRA
TION
COMBINA
TION
ANTIBIOTIC
THERAPY
PROPER DOSE

CHOICE OF AN ANTIBIOTIC
🠶The choice of an antibiotic depends on the following factors:
🠶A. Host related factors: Age, Renal and hepatic function, Local factors
🠶 B. Pathogen related factors
🠶 C. Drug factors: Spectrum of activity, Type of activity, Compliance by
the patient, Cost consideration

Based on Spectrum
• Broad-spectrum antibiotics : use of one or more antimicrobial agents with the specific intent
of broadening the range of potential pathogens covered, to ensure adequate antimicrobial
coverage
• Narrow spectrum : targets only one type of pathogen and do not cause resistance in other
infections as a result of selection pressure.
Based on Anti Bacterial activity
• Bacteriostatic medications stop bacterial growth and multiplication, limiting the spread of
illness.
• Bactericidal medications kill cells without relying on the immune system of the host. The
bacterium eventually dies following appropriate medication exposure.
CLASSIFICATION OF ANTIBIOTIC

1. Sulfonamides and related drugs: Sulfadiazine and others, Sulfones— Dapsone (DDS), Paraaminosalicylic
acid (PAS).
2. Diaminopyrimidines: Trimethoprim, Pyrimethamine.
3. Quinolones: Nalidixic acid, Norfloxacin, Ciprofloxacin, Moxifloxacin, etc.
4. β-lactam antibiotics: Penicillins, Cephalosporins, Monobactams, Carbapenems.
5. Tetracyclines: Oxytetracycline, Doxycycline, etc.
6. Glycylcycline: Tigecycline.
7. Nitrobenzene derivative: Chloramphenicol.
8. Aminoglycosides: Streptomycin, Gentamicin, Neomycin, etc.
9. Macrolide antibiotics: Erythromycin, Clarithromycin, Azithromycin, etc.
BASED ON CHEMICAL STRUCTURE

10. Lincosamide antibiotics: Lincomycin, Clindamycin.
11. Polypeptide antibiotics: Polymyxin-B, Colistin, Bacitracin, Tyrothricin.
12. Glycopeptides: Vancomycin, Teicoplanin
13. Oxazolidinone: Linezolid.
14. Nitrofuran derivatives: Nitrofurantoin, Furazolidone.
15. Nitroimidazoles: Metronidazole, Tinidazole.
16. Nicotinic acid derivatives: Isoniazid, Pyrazinamide, Ethionamide.
17. Polyene antimicrobials: Nystatin, Amphotericin-B, Hamycin.
18. Azole derivatives: Miconazole, Clotrimazole, Ketoconazole, Fluconazole.
19. Others: Rifampin, Spectinomycin, Sod. fusidate, Cycloserine, Viomycin, Ethambutol, Thiacetazone,
Clofazimine, Griseofulvin.

Beta-lactam antibiotics are useful and frequently prescribed antimicrobial agents
that share a common structure and mechanism of action of inhibiting the
synthesis of the bacterial peptidoglycan cell wall.
Examples of Beta-lactam antibiotics include Penicillins, Cephalosporins,
Carbapenems and Imipenems.
Beta-lactam Antibiotics

AMOXICILLIN
Amoxicillin is an extended spectrum Penicillin group of antibiotics. It became first
available in 1972.
It is on the World Health Organization’s list of Essential Medicines, the most important
medication needed in a basic health system.
It is one of the most commonly prescribed antibiotics in children.

Amoxicillin is active against many gram positive and gram negative bacteria.
In general, Streptococcus, Enterococcus, Haemophilus, Helicobacter, and
Morexella are susceptible to amoxicillin, whereas Citrobacter, Klebsiella, and
Pseudomonas aeruginosa are resistant to it.
Some E.coli and most clinical isolates of Staphylococcus aureus have
developed resistance to Amoxicillin to varying degrees.

Dental prophylaxis in patients at risk of endocarditis (single dose)
For the treatment of pulpal, periapical and periodontal infection.
Upper respiratory tract infection due to Streptococci, Pneumococci H.
influenza
Infection of skin and soft tissues due to streptococci and susceptible
staphylococci.
THERAPEUTIC USES:

CONTRAINDICATION
Penicillin allergy
Hypersensitivity reaction (anaphylaxis or Steven Johnson syndrome)
Kidney disease
Phenylketonuria
Intestinal colitis

Below 10 years > 40 kgs Below 10 years < 40 kgs Infants < 3 months old
125– 250 mg every 8 hours. 20 – 40 mg/kg daily every 8
hours
30 mg/kg daily
Maximum dosage : 2 g/day.
Pediatric dosage:

CEPHALOSPORINS
Cephalosporins were discovered in 1945 by the Italian pharmacologist Giuseppe Brotzu
and were first sold in 1964.
They are indicated for the prophylaxis and treatment of infections for children who are
allergic to penicillin group of drugs.
 First generation cephalosporins are active predominantly against gram positive bacteria,
and successive generations have increased activity against gram negative bacteria

Cephalexin: Pediatric Dosage: 25-100 mg/kg/ day every 6-8 hours.
Available forms: Tablet 125mg, 250 mg and 500mg, Capsule
250 mg, 500 mg and 750 mg, Oral Suspension 125 mg/5ml and 250 mg/5ml.
Cefadroxil Pediatric Dosage: 30-40 mg/kg/day in 2 doses
Available forms: Tablet 1g, Capsule 500 mg, Oral suspension 250 mg/5 ml and 500 mg/5 ml
Cefixime Pediatric Dosage:
8 mg/kg/day in 2 divided doses for children weighing <50 kgs or < 12 years.
Available forms: T
ablet 400 mg, Chewable Tablet 100 mg and 200 mg and
Oral suspension 100 mg/5 ml, 200 mg/5 ml and 500 mg/5 ml.

🠶The history of Nitroimidazole as agents for clinical disease began with the recognition in
1953 that vaginitis was caused by the protozoan Trichomonas vaginalis.
🠶This led to the intensive search for a drug that would provide an effective treatment.
🠶Among 5 nitroimidazoles, metronidazole, imidazole and ornidazole are in widespread
clinical use in dentistry.
🠶 It is a potent inhibitor of obligate anaerobic bacteria and protozoa, but not of any
organism that is aerobic or incapable of anaerobic metabolism.
NITROIMIDAZOLE

METRONIDAZOLE
Metronidazole was introduced in 1959 and is one of the mainstay drugs
the treatment of anaerobic and certain parasitic infection.
Metronidazole is a 5-nitroimidazole available for oral administration or as
suppository; also formulated as hydrochloride for intravenous use, and as benzoate
in an oral suspension and also a dental gel.

THERAPEUTIC USES:
Acute necrotizing ulcerative gingivitis (Vincent’s Stomatitis)
Pericoronitis and pericoronal abscess
Chronic aggressive periodontitis
Periapical and periodontal abscess
Dentoalveolar abscess
Cellulitis and Space infections Osteomyelitis
Infected sockets
Gastro-duodenal ulcers caused by Helicobacter pylori
Surgical prophylaxis

Age 7 - 10 years: Age 3 – 7 years Age 1 – 3 years
300 mg in three doses. 200 mg in three doses 150 mg in three doses
Maximum dosage for Children: 2 g/day
Children: Adolescents and adults:
30/mg/kg/day every 6 hours
(maximum 4 g/24 hours)
7.5 mg/kg every 6 hours
(maximum 4 g/24 hours)
Pediatric dosage
For anaerobic skin and bone infection
CONTRAINDICATIONS:
Hypersensitivity to metronidazole and alcohol consumption.

Azithromycin
• This medication is a penicillin or cephalosporin replacement for people who
have a Type I penicillin or cephalosporin allergy and is effective against H.
influenza, as well as a few anaerobes as Peptostreptococcus and Clostridia
• Due to its anti-inflammatory properties as well as its ability to concentrate in
neutrophils, macrophages, and fibroblasts it can help in resolution of periodontal
diseases by suppressing periodontopathogens.
AZITHROMYCIN

Adverse effects
• Mild gastric upset, abdominal pain (less than erythromycin, headache, and dizziness
Contraindications
• Cardiac arrhythmias in patients with pre-existing cardiac conditions, macrolide
hypersensitivity.

Pediatric Dosage: 6 months-16
years
Endocarditis prophylaxis Penicillin allergic
patient with periodontal
diseases (3 days):
5-12 mg/kg on day 1, single
dose, (maximum 500 mg/day),
followed by 5-6 mg/kg once
daily for remainder of treatment
(2-5 days).
15 mg/kg (maximum 500 mg)
30-60 minutes before procedure.
10 mg/kg daily.

 Doxycycline is a second generation semi-synthetic . It is a Broad spectrum antibiotic.
 Doxycycline reversibly binds to the 30s subunit at the Acceptor site in m-RNA,
preventing aminoacyl t-RNA from binding to m-RNA, thus inhibiting the translation
process by preventing the addition of new amino acids to the developing peptide
chain.
 They also inhibit Rickettsiae, Chlamydiae, Mycoplasma, Actinomyces, E. histolytica
and Plasmodia
DOXYCYCLINE

Adverse effects
• Hepatotoxicity, hypersensitivity reactions, phototoxicity, gastrointestinal irritation, nausea,
vomiting and diarrhoea, renal toxicity, metabolites of outdated tetracyclines and are
teratogenic.
Contraindications
• This drug can cause enamel hypoplasia in developing teeth, and hyperpigmentation of the
soft tissues

Children >8 years <45 kg Children >8 years who weigh >45 kg and adults
Mild to moderate
infections
Severe infections Mild to moderate
infections
Severe infections
2.2 mg/kg every 12
hours on day 1, then
2.2 mg/kg once/day
2.2 mg/kg every 12
hours until infection
resolves
100 mg every 12 hours
on day 1, then 100 mg
once/day
100 mg every 12 hours
until infection resolves.
Pediatric dosage:

ANTIBIOTIC COMBINATIONS
Antibiotic combinations have long been used to provide antibacterial activity against
multiple potential pathogens for initial empirical treatment for critically ill patients.
The simultaneous use of two or more antimicrobial agents is recommended
in specifically defined situations based on pharmacological rationale.

However, selection of an appropriate combination requires an
understanding of the potential for interaction between the antimicrobial agents.
Antimicrobial agents acting at different targets may enhance or impair the overall
antimicrobial activity.
A combination of drugs also may have additive or super additive toxicities.

AMOXICILLIN AND CLAVULANIC ACID
Amoxicillin/Clavulanic acid combination was introduced in United in 1984 as an
antimicrobial agent that would enhance the activity of Amoxicillin by the addition of the
beta-lactamase inhibitor Clavulanic acid.
During the past 30 years this combination is being used for a variety pediatric infectious
diseases.
It is an oral antibacterial combination consisting of the semisynthetic antibiotic
Amoxicillin and Clavulanic acid is produced by the fermentation of Streptomyces
clavuligerus.

It is a β-lactam structurally related to the penicillins and possesses the
ability to inactivate a wide variety of β lactamases by blocking the
active sites of these enzymes.
Clavulanic acid is particularly active against the clinically important
plasmid mediated β-lactamases frequently responsible for transferred
drug resistance to Penicillins and Cephalosporins.

For Severe infections For less severe infections
45mg/kg/day every 12 hours
OR
40 mg/kg/day every 8 hours.
25 mg/kg/day every 12 hours
OR
20 mg/kg/day every 8 hours.
Maximum Dosage: 1000-2800 mg Amoxicillin/143-400 mg Clavulanic acid
PEDIATRIC DOSE

TRIPLE ANTIBIOTIC PASTE
 The infection of the root canal system is considered be a polymicrobial infection,
consisting of both aerobic and anaerobic bacteria.
Because of the complexity of the root canal infection, it is unlikely that any single
antibiotic could result in effective sterilization of the canal.
More likely, a combination would be needed to address the diverse flora encountered.
The combination that appears to be most promising consists of Metronidazole,
Ciprofloxacin, and Minocycline.

Contraindications
• Sensitivity to ciprofloxacin, minocycline, or metronidazole, or allergic reactions
to these antibiotics
• Perforation of the pulpal floor
• Excessive interior or exterior root resorption as determined by radiography
• Excessive bone loss in the furcation area with underlying tooth germ involvement
• Exfoliation of the primary tooth is nearing.

Either a 1:5 MP: 3mix (creamy consistency) or 1:7 MP: 3mix
(standard mix) can be prepared.
The antibiotic paste should be left in the tooth for a period of 4 weeks
to allow complete disinfection of any necrotic tissue. After this period
the tooth is re-entered for further treatment.
Ciprofloxacin(200mg),metronidazole(400mg),minocycline(100 mg).
The powdered drugs were mixed in a ratio of 1:3:3. The drug mixture was
then mixed with propylene glycol or canal sealer, producing a paste-like
consistency.

Pediatric restorative dentistry has evolved and got revolutionized over the years.
The addition of antibiotics to Glass ionomer cement (GIC) has recently been
recommended for the treatment of carious lesions aiming to reduce the total number of
viable bacteria, while preserving dentin tissue and pulpal vitality.
A combination of Ciprofloxacin, Metronidazole and Minocycline has been showed
to be successful in sterilizing carious lesion samples.
Staining of dentin, however has been reported with the use of Minocycline in the
antibiotic mixture, hence mixtures were suggested where Minocycline was left out of
the combination (i.e) Bi antibiotic paste containing Metronidazole and Ciprofloxacin
has been suggested.
ANTIBIOTIC COMBINATIONS IN PEDIATRIC RESTORATIVE DENTISTRY

Most oro-facial infections are odontogenic in origin, and are of self-limiting nature
characterized by spontaneous drainage.
 The causal bacteria are generally saprophytes.
Bacteremia is anticipated in the blood following invasive dental treatment
INFECTIVE ENDOCARDITIS (IE) is an uncommon but a life threatening complication
resulting from bacteremia .
The vast majority of cases of IE caused by oral microflora can result from bacteremia
associated with routine daily activities such as tooth brushing, and chewing.
 Antibiotic prophylaxis is recommended with certain procedures.
ANTIBIOTIC PROPHYLAXIS

RECOMMENDATIONS:
The conservative use of antibiotics is indicated to minimize the risk of developing
resistance to current antibiotic regimen.
Antibiotic prophylaxis is given prior to dental procedures in children having
the following conditions.
Patients with cardiac conditions
Patients with compromised immunity
Patients with shunts, indwelling vascular catheters, or medical devices
Patients with prosthetic joints

REFERENCES
1. Betal SK, Ahuja V. Antibiotic usage in pediatricdentistry: A review. J Dent Panacea 2022;4(2):64-
69.
2. Goel D, Goel GK, Chaudhary S, Jain D. Antibiotic prescriptions in pediatric dentistry: A review. J
Family Med Prim Care 2020;9:473-80.
3. Inchara R, Ganapathy D, Kiran P.(2019). Preference of antibiotics in pediatric dentistry. Drug
Invention Today. 11. 1495-1498.
4. Jayakaran TG, Rekha CV, Annamalai S, Baghkomeh PN. Antibiotics and its use in pediatric
dentistry: A review. Int J Appl Dent Sci. 2018;4(2):310-14.
5. Tripathi, K. D. (2018). Essentials of medical pharmacology (8th ed.).
6. Al Hamazani AD, AlNukhaysh S, AlGethami SMM, AlMathkuri WM, Asiri MM, AlShamrani YSA,
et al. Prescription of Antibiotics and Its Overuse among Pediatric Dental Patients: A Systematic
Review. Pharmacophore. 2022;13(5):86-92

 Physiological changes in Pediatric patients
 Selection of antibiotics
The decision to use antibiotics-status of infection
 Adjustment of dosages in Pediatric patients
Conditions that may necessitate the prescription of antibiotics in Pediatric patients
 Duration of antibiotic therapy
 Misuse of antibiotics
Golden rules to use antibiotics
 Conclusion
References

PHYSIOLOGICAL CHANGES IN PEDIATRIC PATIENTS
🠶Unlike adults, children are constantly growing and
developing. This fact should be taken into account
whenever any drugs are given to children.
🠶 There is a large differences in body surface area as well as hepatic
and renal function depending on age.

surface area,gastric and
duodenal pH, gastric
emptying time, size of bile
salt pool, bacterial
colonization,underlying
diseases influences drug
absorption.
DISTRIBUTION
ABSORPTIO
N

🠶MET
ABOLISM –
🠶Most important organ is liver
.
🠶 Liver cells are involved in 2 types of enzymes reaction for the
biotransformation of drugs.

Phase I- A non synthetic process and
includes oxidation, reduction,
hydrolysis and hydroxylation for
functional preparation of drugs.
Phase II - A synthetic process andincludes
conjugation with glycine, glucuronide
and sulfate for the enhancement of
drug excretion.
•The enzymes involved in reactions differ
between children and adults and there
exists high inter individual variability.

🠶Excretion- The amount of drug filtered by glomeruli depends on
glomerular function, renal blood flow and drug protein binding. Renal
tubular function matures at about 30 weeks of age and glomerular rate between 3 and 5
months.
Thus, the development and maturation of the glomerular filtration rate is
important in determining the appropriate drug dosage.
These peculiarities result in differences in therapeutic efficacy and
toxicity of of various antibiotics used in children.

🠶 Other Factors to be Considered in the Pediatric Age Group
🠶 Growth and Development Because childhood is a period of continuous
growth and development, administration of antibiotics in children may cause
peculiar neurologic an physical abnormalities.

🠶 It may not be immediately evident but if becomes obvious after long term
administration.
🠶 Especially since the central nervous system is continuously developing,
antibiotics may cause severe neuro developmental dysfunction.

Enamel dysplasia,hypoplasia,discoloration of teeth,dysfuction in bone growth.
Quinolones are reported to cause reversible arthralgia

DRUG ADMINISTRA
TION
🠶 The oral route is preferred for pediatric patients.
🠶An important factor to be considered for oral administration is in relation to meals.
For antibiotics such as penicillin G, ampicillin, cloxacillin,
lincomycin, drug absorption is significantly decreased when
given with food.

🠶The best known adverse drug influence on physical
development would be that of tetracycline, it forms tetracycline—calcium orthophosphate
complex.
🠶 Tetracycline should not be given with milk, dairy products or food
containing calcium and magnesium, which interfere with absorption of drug. A liquid form is
available for most preparations and should be used, if the young patient is unable to swallow the
tablet or capsule.

🠶Intravenously administered drug seem to reach the site of action quickly. It depends
of intravenous fluid infusion, the dead space of infusion set and and volume of fluid in
which drug is diluted.
🠶 Since, most intravenous infusion sets are manufactured for adult use, they have a
large dead space and since the rate of infusion in children is slow.
🠶 Intramuscular injection may be used when there is no accessible
venous route, but the site of injection should be chosen cautiously. There are a number of
factors influence the rate and amount of drug absorption when the intramuscular route is
used.

THE DECISION TO USE ANTIBIOTICS-STATUS OF
INFECTION
🠶The evaluation of the following signs and symptoms may assist in
determining the status of an infection.
1. Patient’s health:

3. Extent of soft tissue inflammation:
-If an intraoral swelling is localized, the infection may be managed by surgical
drainage.
-However, if the swelling spreads into extra oral musculofascial spaces or impedes
breathing or swallowing, the patient should immediately be referred for
care.
-A large, diffuse swelling may require antibiotics as well as surgical drainage.

4. Benefits vs risks:
🠶An antibiotic allergic reaction may present as a minor rash or
significant life-threatening anaphylaxis.
🠶Patients may also develop adverse side effects, such as
gastrointestinal problems and secondary infections. Pregnant women
should be evaluated with extra care due to a developing fetus.

ADJUSTMENT OF DOSAGES IN PEDIATRIC PATIENTS
🠶In general, pediatric patients cannot be given adult dosages of drug. The primary
reason for this is the difference in body size .
🠶 Several rules exist to compute the dosage of a drug for a child; the most
common is the Clark’s rule and the Young’s formula. Current dosage
recommendation are usually based on the basal metabolism of the child.

Based on body weight (Clark’s formula)
Adult dose×(weight ÷70)=child dose
Based on age (Y
oung’
s formula)= age of
child/age + 12 × adult dose
Based on age in months(Fried’s
rule)=Child’s age in
months/150×adult dose

CONDITIONSTHATMAYNECESSITATETHE
PRESCRIPTIONOFANTIBIOTICSIN
PEDIATRIC PATIENTS
ODONTOGENIC INFECTIONS
Most orofacial infections are of odontogenic origin.
Dental pulp infection, as a result of caries, is the leading cause odontogenic infection.
 Antibiotics are useless in eliminating bacteria during pulpitis because they cannot
reach the area due to a lack of blood circulation in the root canal.
However, if signs and symptoms are present, amoxicillin or amoxicillin and
clavulanic acid combinations may be prescribed.
During abscess or oro-facial swelling of dental origin, antibiotics of choice include
amoxicillin, metronidazole, or azithromycin.

OROFACIALLACERA
TIONS
🠶 There is a high incidence of perioral and intraoral lacerations
throughout childhood.
🠶 In most instances, intraoral wounds, although contaminated by the
oral flora, will heal well without the developing infection,
provided the wound is clean, no foreign bodies are left within the
cut surfaces, and sutures placed to approximate the tissues where
needed.
🠶However, wounds involving the skin surface, particularly those
with skin to oral mucosa communication, are most likely to
develop infection.

TRAUMA OF TEETH
• Systemic antibiotics have been recommended as an adjuvant therapy for
avulsed permanent incisors with an open or closed apex.
• Tetracyclines are used sparingly in dentistry as it enhances the
vascularisation of the pulp and reduces root resorption.
• Since they can stain teeth, they should not be given to children under the age
of eight. Antibiotics are not advised for primary dentition luxation injuries.
• Antibiotic coverage is essential in children who have dental avulsions that
can be re-implanted.

ACUTE PRIMARY HERPES INFECTION
🠶This acute infectious disease occurs most often in young children who may
become extremely debilitated with high fever and malaise.
🠶It is important that fluid intake be continued to avoid dehydration.
🠶 The etiologic agent in this condition is a virus, and antibiotics have no role in
treatment of the primary disease.
🠶 Penicillin is definitely contraindicated, as it will fix the virus and prolong the
disease.
🠶 McDonald and Avery report that topical application of tetracyclines to
ulcerated areas will aid in the control of secondary (bacterial) infection.

ACUTE NECROTIZING ULCERA
TIVE GINGIVITIS (ANUG)
🠶 Spirochetal organisms have been isolated from the involved gingivae of patients with
ANUG.
🠶This disease may occur in young children but the highest incidence is in late
adolescence and early adulthood.
🠶 Bear and Benjamin state that only with massive necrosis or systemic effects is,
systemic antibiotic therapy indicated conservative measures of removing local
irritants, improving oral hygiene, and using oxidizing mouthwashes
FEVER MALAISE
LYMPHADENOPATHY

🠶TREATMENTOF ANUG:-
The use of metronidazole (a
nitroimidazole antimicrobial which is
cidal against anaerobic microorganisms).
However, penicillin is the drug of
choice, Erythromycin if patient allergic
to penicillin.

ERUPTION AND EXFOLIATION OF TEETH
🠶Although it is a common belief that children present systemic
symptomatology during the ‘teething’ period, studies have not
correlated fever or elevated white cell counts with normal tooth
eruption.
🠶 If fever and other systemic disturbances are present at the time of
eruption, the source of the infection should be investigated.
🠶There is no evidence of need of antibiotic coverage during eruption or
exfoliation of teeth even in child susceptible to subacute bacterial
endocarditis.

🠶 In periodontal disorders associated with neutropenia, 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.
🠶Cultures and susceptibility testing are useful for selecting the most
appropriate drug in each case. Prolonged antibiotherapy is indicated
for the management of chronic periodontal disease.
PEDIATRIC PERIODONTAL DISEASE

PEDIATRIC PERIODONTAL DISEASES
• Antibiotics should be avoided as most of the gingival and periodontal conditions can be treated
with appropriate local therapeutic interventions.
• Patients with severe periodontal disease may require antibiotic medication in addition to targeted
treatment.
• Aggressive periodontitis- Amoxicillin or Metronidazole; Allergy to Amoxicillin-
Azithromycin/Metronidazole.
• In pediatric periodontal disorders associated to systemic disease, the immune system is unable to
control the growth of periodontal bacteria, and antibiotic therapy may be required in some cases. In
severe and refractory cases, extraction is advised.

🠶 In the absence of an adequate host immune system, patients are at increased risk for
developing bacteremia progressing to septicemia.
🠶Immunosuppression can be the direct result of a disease process and/or the result of the
treatment for the specific condition.
PATIENTS WITH COMPROMISED IMMUNE SYSTEM

🠶 The use of antibiotic prophylaxis or coverage must be considered on an
individual case basis in the following conditions:
Neutropenia, HIV infection,
organ transplantation, long
term immunosuppression
(e.g. corticosteroid use).

PROTOCOL FOR ANTIBIOTIC PROPHYLAXIS
In recent years several changes were made to the most widely used protocols. These
can be summarized as follows:
Intravenous
administration has
been replaced by oral
administration
The oral dose has been
reduced from
3 to 2 gm of amoxicillin
The follow up dose has been
discontinued and erythromycin
has been substituted by other
antibiotics as alternatives for
penicillin.
Whenever possible, sugar free
preparations should be used when
liquid medicines are prescribed in
order to prevent the development of
dental decay.

THE CHOICE OF ANTIBIOTIC AND THE DURATION OF ANTIBIOTIC COVERAGE.
Antibiotic coverage is required in
patients with reduced neutrophil
counts because these individuals are
at risk of bacterial infection. When
neutrophils are less than one
thousand cells per ml, antibiotic
coverage is mandatory.
Children who have deficiency in humoral
or T-cell mediated immunity, such as
children who receive immunosuppressive
medication that they take for prevention
of graft rejection or for an autoimmune
disease need antibiotic coverage.
Children infected with the
human immunodeficiency
virus (HIV) and AIDS need
antibiotics if the neutrophil
counts are low.
Children undergoing
chemotherapeutic treatment
are in need of antibiotic
coverage when dental
extractions or deep periodontal
scaling are necessary.

🠶 Children with diabetes (especially the
insulin-dependent type) often exhibit
some degree of leukocyte dysfunction.
Therefore antibiotic coverage is usually
recommended for invasive dental
procedures when their condition is
poorly controlled or uncontrolled.
There is still much debate
regarding the need for antibiotic
coverage in chronic intravenous
drug abusers and after
splenectomy.

DURATIONOF ANTIBIOTIC THERAPY
🠶The most acute infections resolve within 3-7 days.
🠶The ideal duration of antibiotic treatment is the shortest cycle capable of preventing both
clinical and microbiological relapse.
🠶 When oral antibiotics are used, a high dose should be considered to secure faster
therapeutic levels.

MISUSE OF ANTIBIOTICS
🠶Resistance is an inevitable consequence of antibiotic use.
🠶It is considered that the benefits of antibiotic use to society are so great that some
level of evolved resistance is both tolerable and accepted as a social cost.
🠶 The concern lies with the rate at which resistant strains of bacteria are emerging, and with
the human behaviors that foster faster resistance.

🠶Antibiotic resistance driven mainly from the over use of antibiotics, particularly in
children, is increasingly becoming a major public health problem globally.
🠶In other words; the once effective and inexpensive treatment for infections will soon
become increasingly ineffective; consequently increasing morbidity, mortality and
healthcare costs.
🠶According to Dr Thomas J Pallasch antibiotic misuse in dentistry mainly involves
prescribing them in ‘inappropriate situations’ or for too long, which includes,
giving antibiotics after 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.

GOLDEN RULES FOR ANTIBIOTIC USAGE
🠶Don’t use antibiotics uneccessarily.
🠶Avoid broad spectrum antibiotics as far as possible.
🠶Don’t prolong the antibiotic therapy unnecessarily.
🠶In case of chronic infections like Tuberculosis,Leprosy,etc employ multiple drug
regime.

CONCLUSION
The decision to use or not use antibiotics, and the potential to misuse these drugs, is a routine
issue in dental practice.
 Complications associated with bacterial resistance to antibiotics dictate that clinicians do
not prescribe antibiotics unless they are clearly indicated.
 Selection of proper antibiotic agent and its judicious use is the need of the hour to avoid the
risk of bacterial resistance.
Utmost care is required when dealing with the pediatric population as negligence or slightest
ignorance can affect their productive and disease free future as an adult.

Antibiotic Therapy in Dentistry: A Comprehensive Guide

Antibiotic Therapy in Dentistry: A Comprehensive Guide

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