dentistry

1. Therapeutics in dentistry (antibiotics)
1. 1. Reminder Terms and Concepts1. Antimicrobial or anti-infective-drugs usedto
prevent or treat infections causedbypathogenic (disease-producing) microorganisms.
Include antibacterial, antiviral, and antifungal drugs.2. Antibacterial or antibiotic-
usually refer onlyto drugs used in bacterial infections.3. Antiviral- drugs used to treat
viral infections.4. Antifungal- drugs usedto treat fungal infections.5. Antiparasitic-
drugs used to treat parasite infections or infestations.
2. 2. Reminder6. BroadSpectrum- antibacterial drugs that are effective against several
groups of microorganisims.7. NarrowSpectrum- antibacterial drugs which are
effective against only a few groups of microorganisms.8. Bacteriocidal- actionof an
antibacterial drug in that it kills microorganisms.9. Bacteriostatic- actionof an
antibacterial drug in that it inhibits growth of the microorganism.10. Superinfection- a
new or secondaryinfectionthat occurs duringantimicrobial therapyof a primary
infection.
3. 3. Terms11. Antibiotic combinationtherapy- use 2 or more drugs in combinationto
treat infections knownor thought to be caused by multiple microorganisims, to get a
synergistic effect, to prevent emergence of drug-resistanceorganisims, or to treat
clients whose immune system is suppressedor client withbone marrow or organ
transplant.
4. 4. Mechanism of Action: 1. Inhibitionof Cell Wall Synthesis 2. Disruptionof Cell
Membrane 3. Inhibition of ProteinSynthesis 4. Interference withMetabolic Processes
NB: Bactericidal Bacteriostatic
5. 5. Table 1 Summary of some commonantibioticsBeta-lactams Broad-spectrum
antibiotics*. Flucloxacillinand co-(penicillins, cephalospor amoxiclavare effective
against some penicillin-ins)resistant organisms.Aminoglycosides Effective against
gram negative bacteriae.g.(streptomycin, gentami Pseudomonas. Reservedfor serious
infections e.g.cin, tobramycin) septicaemia, meningitis, hospital-acquired
pneumonia.Glycopeptides Effective against Staphylococci resistant to
other(vancomycin, drugs, including many strains of
MRSA**.teicoplanin)Tetracyclines Broad-spectrum
antibiotics(doxycycline,minocycline)
6. 6. Macrolides Broad-spectrum antibiotics, prescribedif patient is(erythromycin)
allergic to penicillins.MetronidazolePrescribedfor surgical prophylaxis, bacterial
vaginosis, pressure sores, legulcers.QuinolonesEffective against gram negative
bacteria,(ciprofloxacin) gonorrhoea, gastro-intestinal infections.Antitubercular drugs
Reservedfor treatment/ containment of(rifampicin, isoniazid,
tuberculosis(TB).rifabutin, streptomycin)sulphonamides (co- Co-trimoxazole is
reservedfor serious infectionstrimoxazole, associatedwithHIV/AIDS. Trimethoprin
istrimethoprin) prescribedfor urinarytract infections.* Broadspectrum antibiotics are
used when the infectious agent is unknown.Narrow spectrum antibiotics are
prescribedwhen the micro-organisms have been identifiedfromtissue samples.**
Many bacteriaproduce an enzyme which destroys betalactam antibiotics. In addition
to this,MRSA (methicilin-resistant Staphylococcus aureus) produces aninactivating
proteinwhichconfers resistanceto most otherantibiotics.

2. 7. 7. Indications for the use ofantibacterials(together withappropriate surgical drainage
orother measures) – Cervical fascial space infections; – Osteomyelitis and
osteoradionecrosis; – Odontogenic infections inill, toxic or susceptible patients (e.g.
immunocompromised); – Acute ulcerative gingivitis; – Some instances of: •
pericoronitis;• dental abscess;• dry socket;
8. 8. Prophylactic use of Antibacterials– infective endocarditis ;– incerebrospinal
rhinorrhoea;– incompound facial or skull fractures;– inmajor oral and maxillofacial
surgery(e.g. osteotomies or tumour resection);– Insurgeryin immunocompromised
or debilitatedpatients, or followingradiotherapyto the jaws.
9. 9. Drainage is essential if there ispus:antibacterials will not removepus;
10.10. Routes of administration• Oral preparations of antimicrobials are preferredin
most instances.• Topical antibacterials, shouldusually be avoided, as they may
produce sensitizationand may cause the emergence of resistant strains.
11.11. Routes of administration• Parenteral administrationof antibacterialsmaybe
indicatedwhere: – no oral preparationis available; – high bloodlevels are required
rapidly (e.g. serious infections); – the patient cannot or will not take oral medications
(e.g. unconscious patient); – the patient is to have a GA within the following4 h.
12.12. Which Antibacterial??• Anaerobes are implicatedin many odontogenic infections,
and these oftenrespondto penicillins or metronidazole• Odontogenic infections are
typically polymicrobial.• Most bacteriacausingodontogenic infections are penicillin-
sensitive. Oral phenoxymethyl penicillinis usually effective and is cheap.
13.13. • Amoxicillinis active orally(absorptionbetter thanampicillin).• Not resistant to
penicillinase.• Contraindicatedinpenicillinhypersensitivity• 500 mgPO q6-8hr
14.14. • Augmentin is a mixture of amoxicillinand potassium clavulanate – inhibits
some penicillinasesand therefore is active against most Staph. aureus; – inhibits some
lactamases and is thereforeactive against some Gram-negative and penicillin-resistant
bacteria• Contraindicatedin penicillinhypersensitivity.
15.15. • Metronidazole maybe preferredas an alternative to a penicillinif the patient is
allergic, or has had penicillinwith the previous month (resistant bacteria).•
Suppositories are effective. Contraindicatedinpregnancy.• 500 mgPO, q6-8hr• with
meals.• Use only for 7 days
16.16. • Erythromycinis an alternative for penicillin-resistant infections where a Beta-
lactamase producing organism is involved. However, many organisms are now
resistant to erythromycinor rapidlydevelop resistance andits use shouldtherefore be
limitedto short courses.• 250-500 mgPO QID
17.17. • Clindamycin is no more effective than penicillins against anaerobes• Should not
be used for routine treatment of odontogenicinfections.• Serious side-effects, mainly
antibiotic- associatedcolitis. So limiteduse.• Clindamycinis usedfor prophylaxis of
endocarditis inpatients allergic to penicillin• 150-450 mgPO q6-8hr
18.18. • Tetracyclines have a broad antibacterial spectrum, but of the many preparations
there is little to choosebetweenthem.• Use of Tetracyclines maypredispose to
candidiasis.• Useful in Acute ulcerative gingivitis.• 100 mg PO BID• Contraindicated
in pregnancy and childrenup to at least 7 years

3. 19.19. • Cephalosporins are broad-spectrum, expensive antibiotics withfew absolute
indications for their use indentistry,• Gentamicinis reservedfor use in pregnancy and
myasthenia gravis. Reduce dose in renal disease, 5 mg/kg daily.
20.20. Which Antibacterial??• Pus (as much as possible) shouldbe sent for culture and
sensitivities, but antimicrobials shouldbe startedimmediatelyfollowingsampling, if
they are indicated.
21.21. Antibacterial Teatrtment Failure• patient non-compliance• local factors (e.g.
foreignbody);• unusual type of infection;.
22.22. Antibacterial Teatrtment Failure• inadequacy of drainage of pus;•
inappropriateness of the drug or dose;• antimicrobial insensitivitiesof micro-
organism (staphylococci are nowfrequentlyresistant to penicillinand some show
multiple.
23.23. Antibacterial Teatrtment Failure• impairedhost defences (unusual and
opportunistic infections are increasinglyidentified, particularlyinthe
immunocompromisedpatient);• non-infective cause for the condition!• In serious or
unusual cases of infection, consult the clinical microbiologist.
24.24. • Candida Albicans• Local Factors• Systemic Factors• Antifungals are used to
treat oral or oropharyngeal fungal infections but underlying predisposingfactors
should first be considered.
25.25. • In immunocompromisedpatients, antifungals are usedfor prophylaxis,• In
immunocompromisedpatients antifungals are increasinglyadministratedsystemically
(azoles)
26.26. • Antifungal resistance is now a significant problem to immunocompromised
persons, especiallythosewitha severe immune defect, who may show Candida
species resistant to fluconazole and, sometimes, to other azoles.
27.27. • Antifungal resistance maysometimes be overcome byusing higher drug doses,
or changing the agent• Antifungals should be continuedfor at least 1 week following
resolutionof clinical manifestations.
28.28. • Nystatin is not active orally, very active ative topically.• Pastillestaste better
than lozenge.• Dose qid – 500 000 unit loz-enge, – 100 000 unit pastille or – 100 000
unit per mL of suspension.
29.29. • Amphotericinis close to Nystatincharacteristics• Topicallyapplied10 to100 mg
q6h
30.30. • Miconazole is active topicallyand orally.• Also has antibacterial activity.•
Interacts with terfenadine cisapride, astemizole andwarfarin.• Avoid in pregnancy,
porphyria• Dose – 250 mgtablet q6h – 25 mg/ml gel (Daktarin®) used as 5 mL q6h
for 14 days
31.31. • herpes viruses are associatedwithmost oral viral infections,• Also
(papillomaviruses, and enteroviruses).• HIVand other viruses may also cause
orofacial lesions.
32.32. • Management of viral infections is predominantlysupportive, as, at present, there
are few antiviral agents of proven efficacy.• Most antivirals will achieve maximum
benefit if given early in the disease.
33.33. • Systemic aciclovir shouldbe used with cautionin pregnancy and renal disease.
Aciclovir may cause liver enzymes, and urea, rashes and CNS effects.• Famciclovir

4. should also be usedwith cautionin pregnancy and renal disease. Famciclovir may
cause headache and nausea.• Topical Forms (cream) are preferredinoral medicine – 5
applicationby days
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