This document discusses the evaluation, diagnosis, and treatment of orofacial infections with an emphasis on antibiotic therapy and prophylaxis. It outlines how to assess infections through medical history, exam, and identifying signs of infection. Most oral infections involve both aerobic and anaerobic bacteria. Commonly used antibiotics include penicillin, cephalosporins, metronidazole, and clindamycin. Antibiotics should be used as an adjunct to drainage and are indicated for severe infections, inadequate drainage, or compromised hosts. Prophylactic antibiotics are recommended for high-risk dental procedures in certain patients.

1. Antibiotic Use in Orofacial
Dental Infection
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2. INTRODUCTION
 This presentation will review the
evaluation and management of orofacial
infections with emphasis on:
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■
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Antibiotic Therapy
Indications for Prophylaxis
Antifungal Agents
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3. ASSESSMENT
 Requires a complete medical history and exam of the
head and neck region with awareness to systemic
factors as part of a comprehensive dental
examination
 Identify local and/or systemic signs and
symptoms to support the diagnosis of infection:
< erythema, warmth, swelling, and pain >
< malaise, fever ( >38 c), chills >
 Loss of function
< dysphagia, trismus, dyspnea >
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4. DIAGNOSIS: Infection
 Determine etiology
> odontogenic
> trauma wound, animal bite
> TB, fungi, viral,
actinomycoses
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5. DIAGNOSIS (CON’T)
 Determine cellulitis versus abscess
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6. TREATMENT of INFECTION
 Remove the cause of infection, most important
of all, drain the pus by either spontaneously or
surgically
 Antibiotics are merely an adjunctive therapy.
Drainage
Host defense
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Antibiotics

7. INDICATION for ANTIBIOTICS
1. Severity of the infection
 Acute onset
 Diffuse swelling involves fascial spaces
2. Adequacy of removing the source of infection
 When drainage can’t be established immediately
3. The state of patients’ host defense
 When the patient is febrile
 Compromised host defenses
 For prophylaxis
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8. MICROBIOLOGY
 Most oral infections are mixed in origin
consisting of aerobic and anaerobic Gram
positive and Gram negative organisms
 Anaerobes predominant (75%)
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9. COMMONLY USED A/B
 Mechanism of the antibiotics

10. COMMONLY USED A/B
1. Groups of Penicillin
 First choice for odontogenic infection
 G(+) cocci and rod, spirochetes, anaerobes
 0.7~10% hypersensitivity
 Nature: penicillin G (IV), penicillin V (Oral)
 Penicillinase-resistant: oxacillin, dicloxacillin
 Extended spectrum: ampicillin, amoxicillin
 Combine β-lactamase inhibitor: augmentin
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11. 2. Cephalosporin
 More resistance to penicillinase
 G(+) cocci, many G(-) rods
 Third generation: Pseudomonas aeruginosa
 Second choice (less effect for anaerobes)
First generation
Cefazolin
U-SAVE-A
Tydine
Second generation
Keflor
Ucefaxim
Third generation
Claforan
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Forth generation
Cefepime

12. 3. Clindamycin
 G(+) cocci
 Bacteriostatic -> bactericidal
 Second-line drug: should be held in reserve to
treat those infections caused by anaerobes
resistant to other antibiotics
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13. 4. Aminoglycoside
 G(-) aerobes, some G(+) aerobes eg S. aureus
 Poorly absorbed from GI tract
 Adjustment of dosage in renal dysfunction
 Drugs: Gentamicin, Amikacin, Amikin
 Combined with penicillin or cephalosporin
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14. 5. Metronidazole*
 Only for obligate anaerobes
 Can cross blood-brain barrier
 To treat serious infections caused by anaerobic
bacteria, combined with β-lactam A/B
 Effective against Bacteroides species, esp. in
periodontal infections
 Drugs: Anegyn, Flagyne
 Avoid in pregnant women
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15. 6. Vancomycin
 G(+), most anaerobes, some G(-) cocci (Neisseria)
 Given intravenously, BP should be monitored
 Adjustment of dosage in renal dysfunction
 Use as a substitute for penicillin in the
prophylaxis of the heart valve patient
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16. 7. Chloramphenicol
 Wide spectrum, highly active against anaerobes
 Limited to severe odontogenic infection
threatening to the eye or brain
 Severe toxicity
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17. `
8. Erythromycin
 G(+) cocci, oral anaerobes
 Bacteriostatic
 Second choice for odontogenic infections
 Indication for out-patients with mild infection
 Drug resistence: 50% of S. aureus, Strep. viridans,
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18. 9. Tetracycline*
 Only against anaerobes
 Contraindications: pregnant women, children <12
 Limited usefulness in orofacial infection
 Use as adjunctive therapy for refractory
periodontitis
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19. SELECTION of A/B
 Use Empiric therapy routinely
 Use the narrowest spectrum antibiotics
 Use the antibiotics with the lowest toxicity and
side effects
 Use bactericidal antibiotics if possible
 Be aware of the cost of antibiotics
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20.  Empiric Antibiotics in Oro-Facial Infection
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First-line
Penicillin 3MU IVA q6h -> Cefazolin 1000mg q6h
Gentamycin 60-80mg IVA q8h-q12h
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Second line (3A)
Augmentin 1200mg q8h + Amikin 375mg q12h + Anegyn
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Mild infection
Amoxicillin 250mg #2 PO q8h
Clindamycin 300mg PO q6h
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21.  Side Effect of Commonly Used Antibiotics
1. Penicillin
hypersensitivity
2. Cephalosporin
hypersensitivity
3. Clindamycin
diarrhea, pseudomembrane colitis
4. Aminoglycoside
damage to kidney, 8th neurotoxicity
5. Metronidazole*
GI disturbance, seizures
6. Vancomycin
8th neurotoxicity, thrombophlebitis
7. Chloramphenicol bone marrow suppression
8. Erythromycin
mild GI disturbance
9. Tetracyclin*
tooth discoloration, photosensitivity
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22. PROPHYLAXIS
 Indications

23. PROPHYLAXIS (CON’T)
 Dental procedures recommended for prophylaxis

24. PROPHYLAXIS (CON’T)
 Regimen

25. ANTIFUNGAL AGENT
 Most of fungal infection are from candida
 Commonly used drugs:
(1) Nystatin (Mycostatin)= PO 4-600,000 U qid
(2) Amphotericin B= IV for severe systemic infec.
(3) Fluconazole, Ketoconazole
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26. Parmason Gargle
 0.2% Chlorhexidine gluconate
 Against G(+), G(-)
 Reduce pain and inflammation, enhance healing
 Indication: immunocompromised patient, C/T R/T
(prophylaxis mouthrinse reduce oral mucositis)
 Use: 2-3 times daily,10-20cc/ time, 20-30sec.

27. Anti-Virals used in dentistry
 Topical Acyclovir is useful for recurrent
herpetic infections, but must be started early in
the prodromal phase to have a worthwhile effect.
 Oral Acyclovir, Valacyclovir and Famciclovir
are efficacious and safe for the treatment of the
first episode and recurrent genital herpes
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28.  FOSCARNET - Class: Non-nucleoside DNA Polymerase
Inhibitors
Indications: "HSV, CMV
Treatment of acyclovir resistant HSV infections in AIDS
patients
Acyclovir resistant VZV
MOA/PCOL: Blocks the pyrophosphate binding site on
viral DNA polymerase
Adverse Effects/Other: "Not a purine or pyrimidine
analog, Phosphono formate analog
Toxic: renal impairment, CNS disturbance, leukopenia,
liver dysfunction
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