Antibiotic in dental infections

Odontogenic Conditions
Odonto- (from ancient Greek odous - "tooth") & -genic (from Greek genos - "birth“)

Common odontogenic conditions
Am Fam Physician. 2008;77(5):797-802, 806
Pulpitis
Pericoronitis
Periodontitis
Gingivitis
Dry Socket

Prevalence of common odontogenic infections
 Periapical abscess1  25%
 Pericoronitis1  11%
 Periodontal abscess1  7%
 Gingivitis2
 Frequency in school aged children 40-60% & 50% in adult
 Dry socket3: up to 30%
1. Int J Dent. 2015;2015:472470.
2. Dent Clin N Am 61 (2017) 217–233
3. Int J Dent. 2014; 2014: 796102.

Important features of common odontogenic conditions &
management

Acute Apical Abscess
 Acute inflammation of the soft tissues immediately surrounding the
tip of the root of a tooth, often caused by tooth decay and
subsequent death of the pulp tissue
Sign & Symptoms
1. Pain & Fever
2. Swelling of the gingiva, face or neck (due to abscess)
3. Listlessness, lethargy, loss of appetite for children younger than 16 years old
SDCEP: Scottish Dental Clinical Effectiveness Programme. Management of acute dental problems. Guidance for healthcare professionals. Available at: http://www.sdcep.org.uk/wp-
content/uploads/2013/03/SDCEP+MADP+Guidance+March+2013.pdf. Last accessed: 23/04/2018

Acute Pericoronitis
 Infection under the operculum, i.e. the gingiva (gum) tissue
covering a partially erupted tooth
 Pain associated with erupting teeth in children (both primary and
permanent teeth)
Sign & Symptoms
1. Pain, fever, nausea, fatigue
2. Swelling of the gingiva around partially erupted tooth
3. Discomfort with swallowing
4. Limited mouth opening
5. Unpleasant taste or odour

Management of Acute Apical Abscess & Acute Pericoronitis
Analgesic treatment (NSAIDs)
Antibiotics if there are signs of spreading infection (e.g. facial or neck swelling),
systemic infection
Acute Apical Abscess Acute Pericoronitis
 Relieving occlusion on the affected
tooth
 Extracting the tooth
 NSAIDs to control post-operative pain
 Mouth rinsing with chlorhexidine
 Extract the tooth if there are repeated
episodes of Pericoronitis associated
with the same tooth

Acute Periodontal Conditions
 Necrotising gingivitis and necrotising
periodontitis
 Severe inflammatory conditions of the gingiva (gum)
caused by pathogenic bacteria (Fusiform bacteria and
Spirochetes)
 Necrotising gingivitis  lesions limited to
gingival tissue
 Necrotising periodontitis  loss of attachment
Sign & Symptoms
Pain
Swelling
Bleeding
Halitosis
Ulcerated gingival tissue
Loss of attachment
Malaise
Fever
SDCEP: Scottish Dental Clinical Effectiveness Programme. Management of acute dental problems. Guidance for healthcare professionals.
Available at: http://www.sdcep.org.uk/wp-content/uploads/2013/03/SDCEP+MADP+Guidance+March+2013.pdf. Last accessed:
23/04/2018

Periodontal abscess Perio-endo abscesses
(endodontic and periodontal lesions)
 Periodontal breakdown occurs whilst
there is marginal closure of deep
periodontal pocket occluding
drainage (Abscesses develop in deep
periodontal pockets)
 Affect a single tooth leading to
abscess formation
Sign & Symptoms
1. Pain & tenderness swelling of gingival
tissue
2. Increased tooth mobility
3. Fever & swollen or lymph nodes
4. Suppuration from gingiva
Sign & Symptoms
1. Localized pain
2. Swelling with or without suppuration
on palpation
3. Deep pocketing to root apex with
bleeding on probing
23/04/2018

Management
Pain management  NSAIDs
Antibiotics  signs of spreading infection, systemic infection, or for an
immunocompromised patient if there are signs of necrotizing disease
Acute periodontal
conditions
Necrotising
periodontal disease
Periodontal abscess Perio-endo lesions
Scaling teeth as
effectively as
symptoms allow
Prescribing chemical
plaque control
Oral hygiene
instruction &
smoking cessation
Scaling & irrigating
periodontal pocket &
Extraction
Root canal treatment
or retreatment
23/04/2018

Alveolar Osteitis (Dry Socket)
 Osteitis (inflammation) of a socket after a tooth is extracted, most
common after molar extraction
Sign & Symptoms Management
1. Pain
2. Swelling
3. Unpleasant taste
or odour
 Analgesic treatment (NSAIDs)
 Irrigating with saline
 Applying a suitable material to dress the socket, e.g. Alvogy
 Antibiotics  if there are signs of spreading infection (e.g.
facial, limited mouth opening), systemic infection
23/04/2018

Antibiotics in odontogenic infections

Antibiotics: An empirical therapy in dental infections
 Microorganism culture are not commonly preferred to identify
infection
 Based on clinical & bacterial epidemiological data the types of pathogen
responsible for infection are suspected
 Treatment is dependant on
 Presumptive
 Fundamental
 Probabilistic
Int Dent J. 2015 Feb;65(1):4-10.

Common odontogenic pathogens
36.40%
27.30%
18.20%
9.10%
4.54% 4.54%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Streptococcus
Viridans
Klebsiella P. Aeruginosa Co-agulase & -
ve
Staphylococci
Enterobacter
Spp
Neisseria
Aerobic Pathogens
Int J Med and Dent Sci 2014; 3(1):303-313

Common odontogenic pathogens
59.00%
41%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Peptococci Peptostreptococcus
Anaerobic

Rationale for antibiotic usage
1. Human oral cavity contains >500 different species
2. Bacteria generally cause odontogenic infection are ‘Saprophytes’
(microorganism that lives on dead or decaying organic matter)
Involves
 Multiple microorganism with different characteristics
 Presence of anaerobic & aerobic species
3. Dental caries  bacteria penetrates in dentinal tubules
 Mainly facultative anaerobes (Streptococcus spp., staph spp.,
lactobacillus spp.)
4. Necrosed pulp  bacteria advance through pulp canal 
periapical inflammation
 Warrants antibiotic
Int Dent J. 2015 Feb;65(1):4-10.

Prophylactic use of antibiotic
 To reduce the likelihood of postoperative
 Local complication: Infection or dry socket
 Serious complication: Infective endocarditis
 In surgical excision of benign tumors
 In immunocompromised patients
Risk of infection after extracting wisdom teeth from healthy young
people  10%
25% in patients with sickness or low immunity
1. Do the drugs work? Cochrane evidence on antibiotics in dentistry. Posted on 11/14/2017. Available at: https://cochraneohg.wordpress.com/2017/11/14/do-the-
drugs-work-cochrane-evidence-on-antibiotics-in-dentistry/#more-1558. last accessed: 19/04/2018

Indications for performing culture & Sensitivity tests
 No improvement in symptoms despite adequate local debridement
& antibiotic coverage
 Possible causes
 Unusual species of virulent bacteria, multidrug resistant bacteria or fungal
infection
 Immune deficiency
 Uncontrolled diabetes
 Penicillin allergy or history of C. difficile infection
2017 AAE Guidance on the Use of Systemic Antibiotics in Endodontics. AAE Position Statement. Available at: www.aae.org. last accessed: 19/04/2018

Indications for performing culture & Sensitivity tests

Most commonly used antibiotic
Int Dent J. 2015 Feb;65(1):4-10

Antibiotics in odontogenic infections
 Benefits
 Prevention of infection
 Resolution of infection
 Prevention of spread of disease
 Minimization of serious complications
 Risk
 GI disturbance: Nausea, vomiting, diarrhea & stomach cramps
 Resistance

Efficacy of commonly used antibiotic
ENDODONTICS: Colleagues for Excellence by American Association of Endodontists. Antiobiotics and the treatment of endodontic infection. 2006. Available at:
https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/07/summer06ecfe.pdf. last accessed: 23/04/2018

Unlike others Amoxicillin/clavulanate sensitive to all common
pathogens
Odontoestomatol 2006; 22-1: 69-94

Sensitivity antibiotic to common odontogenic pathogen
Antibiotic Aerobic (%) Anaerobic (%)
Amoxicillin/Clavulanic acid 80.3 92.3
Azetreonam 4.5 -
Ampicillin 13.6 -
Cephalothin 53 100
Cephalexin 53 100
Ciprofloxacin 0 7.7
Gentamycin 19.7 15.4
Clindamycin 37.8 100
Erythromycin 53 100
Linezolid 53 100
Methicillin 42.4 15.4
Ticarcillin/Clavulanic acid 57.5 25.6
Pipercillin/Tazobactam 53 100
Vancomycin 47.1 100

80.3
4.5
13.6
53
53
0
19.7
42.4
57.5
53
47.1
37.8
53
53
92.3
0
0
100
100
7.7
15.4
15.4
25.6
100
100
100
100
100
0 20 40 60 80 100 120
Amoxicillin/Clavulanic acid
Azetreonam
Ampicillin
Cephalothin
Cephalexin
Ciprofloxacin
Gentamycin
Methicillin
Ticarcillin/Clavulanic acid
Pipercillin/Tazobactam
Vancomycin
Clindamycin
Erythromycin
Linezolid
Anaerobes
Aerobes

First line agent for odontogenic infections
 Penicillin such as amoxicillin is the first-line drug for odontogenic
infections
Amoxicillin
 Most common semi synthetic penicillin is drug of choice in treating
dental infections
 In penicillin resistant cases beta-lactamase-stable antibiotics like
amoxicillin with clavulanic acid should be prescribed
As per American Heart Association (AHA) amoxicillin is first choice for prophylaxis
against Endocarditis and prosthetic joint replacement therapy associated with
dental procedures
J Antimicro.2016. 2: 117

WHO: Antibiotic resistance: Enormous threat worldwide
 Antibiotic resistance 500 000 people worldwide
 Resistant to at least one commonly used antibiotic in different
country is 0-82%
 Penicillin up to 51%
 Ciprofloxacin 8-85%
Common strains exhibiting resistance
 Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus,
& Streptococcus pneumoniae, followed by Salmonella spp
WHO. High levels of antibiotic resistance found worldwide, new data shows. January 2018. Available at: http://www.who.int/mediacentre/news/releases/2018/antibiotic-
resistance-found/en/. Last accessed: 20/04/2018

An elevated cefaclor resistance rate
of 12.8%, for 240 isolates of H.
influenzae
Determined through SENTRY surveillance
program Antimicrobial Agents and
Chemotherapy 1999
Observed hrough susceptibility surveillance
observed Antimicrobial Agents and
Chemotherapy 1999
An ever increasing resistance to
Penecillin with 60% S. pneumoniae
isolates resistant
Confirmed through J. Antimicrob
Chemotherapy 2005 global surveillance
study
Cefuroxime resistance of 46%, for
1,113 Streptococcus pneumoniae
isolates
1) Journal of Antimicrobial Chemotherapy (2005) 56, S2, ii3-ii21 2) Antimicrobial Agents and Chemotherapy, September 1999, 3(9); 2236-
2239 3) Antimicrobial Agents and Chemotherapy, February 1999, 43(2); 357-359
Penicillin
60%
resistance
Cefaclor
12.8%
resistance
Cefuroxime
46%
resistance
Antibiotic resistance

ß-Lactamases  Cause of bacterial resistance
Curr Issues Mol Biol. 2015;17:11-21

Mechanism of antibiotic resistance
Antibiotic
Pathogen
Antibiotic inactivation
Loss of antimicrobial action
Bacterial Resistance

Combining β-lactam antibiotic with β-lactamase inhibitor
“Combination of -lactam Antibiotic + -lactamases Inhibitor  most successful
strategy to combat -lactamases-induced bacterial resistance”
Drugs 2003;63:1511-1524

Clavulanic Acid-superior to other β-lactamases inhibitors
3.FEMS Microbial Lett 1999;176:11-5 4.Antimicrobial Agents Chemother 1994;38:767-72

Choice of antibiotic
 Should be broad spectrum
 Wide clinical spectrum, to cover greatest number of dental
procedures
 Adequate pharmacokinetics and pharmacodynamics to allow use in
 wide dosing intervals in preventive, short-term treatment
 Adequate safety profile, including in paediatric & elderly
populations

Dental procedures & antibiotic recommendations

Efficacy of Amox/Clav in odontogenic condition

Amoxicillin/Clavulanic Acid for Treatment of Odontogenic Infections: A
Randomized Study Comparing Efficacy and Tolerability versus Clindamycin
 n = 471
 Intervention: Amox/Clav (875/125 mg) BID & Clindamycin 150 QID
 d = 5 - 7 days
 Condition: Acute odontogenic infections
 Periapical abscess, acute periodontitis, & pericoronitis
 Assessment: % of subjects achieving clinical success
 Composite measure of pain, swelling, fever & additional antimicrobial
therapy required
Int J Dent. 2015;2015:472470.

Clinical Success
77.00%
69%
64.00%
66.00%
68.00%
70.00%
72.00%
74.00%
76.00%
78.00%
Day 5
ClinicalSuccess
Amox/Clav Clinda
50%
44%46%
40%
0%
10%
20%
30%
40%
50%
60%
Reduction in pain Reduction in Swelling%reductioninVAS
Amox/Clav Clinda
Compared to clindamycin efficacy of Amox/Clav was higher at day 5 & comparable at day 7
Safety
Diarrhea: 8% in Amox/Clav & 12% in Clindamycin
Headache: 3% in Amox/Clav vs. 6% in Clindamycin
Int J Dent. 2015;2015:472470.

 Number of subjects: 47
 Condition: Dental infections
 Dry socket
 Pericoronitis
 Cellulitis
 Periapical abscess
 Intervention: Amoxicillin + Clavulanic acid 1g BID
 Duration: 1 week
J Med J 2010; 44 (3):305- 312

Clinical cure rate
J Med J 2010; 44 (3):305- 312

Before
After
Periapical abscess Pericoronitis Dry socket
Resolution of infection by Amox/Clav
J Med J 2010; 44 (3):305- 312

Sensitivity to both aerobes & anaerobes
J Med J 2010; 44 (3):305- 312
Conclusions
 Overall cure rate (87%); cure rate was (94%) in acute infections and (86%) in
chronic ones
 Amox/Clav is effective against most of isolated dental microbes

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:E11-8
Parameters Details
No. of Patients 494
Intervention Amoxicillin + Clavulanic acid 500/125 TID & Placebo
Duration of intervention 4 days postoperatively
Follow up 8 weeks

No. of Patients with postopertive infectious & inflammatory
complications significantly less in Amox/Clav group
2%
13%
0% 2% 4% 6% 8% 10% 12% 14%
Amox/Clav
Placebo
Conclusion:
Amoxicillin/clavulanic acid is efficacious in reducing the incidence of IC following
third molar extraction
Postoperative infectious & inflammatory complications are between 2.9 & 19.9 times
more frequent if antibiotics are not taken (OR 7.6; CI 2.9-19.9; P < 0.001)
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:E11-8

n = 150
Azithromycin
500 mg
OD
n = 153
Amox/Clav
500+125
TID
J Int Med Res. 1998 Oct-Nov;26(5):257-65.

Clinical Success: More in Amox/Clav than Azithromycin
96%
64%
32%
4%
91%
53%
38%
9%
0%
20%
40%
60%
80%
100%
120%
Overall Cured Improvement Failure
%ofpatients
Amox/Clav Azithro

Subjects with absence or mild symptoms
97%
96%
97%
96%
91%
94%
93%
94%
88%
89%
90%
91%
92%
93%
94%
95%
96%
97%
98%
Percussion Pain Masticatory Pain Redness Swelling
%ofpatient
Amox/Clav Azithro

Role of NSAIDs in Odontogenic infections

Conclusion
Combination of amoxicillin & clavulanic has proven to be significantly more effective than
amoxicillin after oral-surgical interventions
Combination of amoxicillin and clavulanic acid is recommended for use in further practice
Parameters Details
No. of subjects 102
Condition Removal of impacted wisdom teeth, apicoectomy or complicated extractions,
and odontogenic abscesses
Intervention Amox/Clav 500/125 mg TID (5-10 days) & Amoxicillin 500 mg QID (8-10 days)
Results  Efficacy appeared to be significantly more in combination group
 Pain & swelling significantly less in combination group

The ‘3-D’s’ principle: Pain management in dentistry
 Diagnosis
 Diagnosis of condition causing pain & identifying what caused that condition
 Dental treatment
 To remove cause of condition for rapid resolution of symptoms
 Drugs
 As an adjunct to dental treatment
 Eg. Non Narcotic analgesic (NSAIDs, Paracetamol etc mostly used); Narcotic
analgesic (Opioids: due to potential side effects, reserved for severe pain
only)
Australian Dental Journal Medications Supplement 2005;50:4: S14-S22

Non Steroidal Anti-inflammatory Drugs
Non-Selective COX-II
inhibitors
Selective COX-II inhibitors Preferential COX-II
inhibitors
Diclofenac, Ibuprofen,
Naproxen, Piroxicam,
indomethacin
Celecoxib, Etoricoxib Aceclofenac, Etodolac
Efficacy
Comparable Comparable Comparable or slightly
superior
Safety
High risk of GI & CV side
effects
High risk of CV side effects
but low GI side effects than
Non-Selective
Low GI & CV side effects

Subjects: 966611 + 23 million
Drug Saf. 2012 Dec 1;35(12):1127-46.

The risk of Upper GI complication: Lowest with Aceclofenac

Cardiac arrest risk was greatest with non-selective NSAIDs
Use of diclofenac (odds ratio [OR], 1.50 [95% CI 1.23–1.82]) & ibuprofen [OR, 1.31
(95% CI 1.14–1.51)] was associated with a significantly increased risk of Cardiac Arrest
Eur Heart J Cardiovasc Pharmacother. 2017 Apr 1;3(2):100-107.

BMJ. 2016 Sep 28;354:i4857.
Current use of individual NSAI Ds and risk of hospital admission for heart failure, compared with past use of any NSAID

82.44
62.92
38.48
9.16
81.64
64.28
64.96
40.36
0
10
20
30
40
50
60
70
80
90
Baseline 15 Min 30 Min 45 Min
VAS
n= 50: Reduction in Pain
Aceclofenac
Ibuprofen

50 subjects, (18-60 years)
Surgical removal of impacted mandibular third molars
Intervention
Aceclofenac 100 mg BID
Diclofenac 50 mg TID

Aceclofenac exerts superior efficacy & safety than diclofenac
Onset of Analgesia
Aceclofenac
30.6 minutes
Diclofenac
73 minutes

Aceclofenac + Paracetamol – Synergistic Combination
Parameters Aceclofenac Paracetamol
MOA
Preferential COX-
II inhibitor
COX-III
inhibitor
tmax 1.25-3 hours 0.7 hour
Onset of action 30 minutes 15 minutes
Analgesic action Yes Yes
Anti-inflammatory Action Yes No
Antipyretic Mild Yes
Paracetamol
Central action
Aceclofenac
Peripheral action

50 Subjects
25
Zerodol P BID
(Aceclofenac + Paracetamol)
25
Ketorolac
Thrice a day
Intervention

Aceclofenac + Paracetamol more effective than Ketorolac
Intervention
Pain intensity at
3 h 8 h 19 h
Zerodol P Lowest 3 & highest 6.5 Lowest 2 & highest 5.5 Lowest 1 & highest 3.5
Ketorolac Lowest 3.5 & highest 6.5 Lowest 2.5 & highest 5 Lowest 2 & highest 3.5
Oral Zerodol P shows better pain relief than Ketorolac

Antibiotic in dental infections

Antibiotic in dental infections

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