Amoxycillin In Dentistry-A Trusted Solution To Orofacial Infections

Dental infections & their life-threatening sequels- Pain and swelling in the oral region are frequent local signs of dental infections. In a severe spread, systemic symptoms like pyrexia and inflammation are noted. (1)

These infections should be treated as soon as possible since they cause serious and irreversible complications such as osteomyelitis, brain abscess, airway blockage, carotid infection, sinusitis, septicemia, meningitis, cavernous sinus thrombosis, orbital abscess, vision loss. Despite advances in dental therapies, orofacial infections are still regarded as a worldwide issue. (1)

This review focuses on the role of antibiotics in dental infections while highlighting the unique position of Amoxycillin in managing the same.

Antibiotic indications in dentistry-(1)

• Antibiotics are not suggested for all odontogenic infections. They should not be used as an alternative to specific dental therapy that aims to remove the infection's cause (root canal therapy).
• In the event of infection, incision and drainage, debridement, and endodontic care are advised, followed by systemic antibiotic therapy.
• Furthermore, practitioners should remember that antibiotic prophylaxis is only suggested in a few specific circumstances. Immunocompromised patients, patients with a history of cancer, individuals with infective endocarditis, patients with metabolic disorders (such as diabetes and splenectomies), patients with prosthetic joints, in-dwelling catheters, neurosurgical shunts, valvular heart diseases, surgical pulmonary shunts, hypertrophic cardiomyopathy, mitral valve prolapsed, and prosthetic heart valves all require antibiotic prophylaxis.
• Some invasive procedures include dental extraction, surgical periodontal procedures, dental implant placement, tooth reimplantation, endodontic or endodontic surgeries, subgingival placement of antibiotic fibres or strips, and intraligamentary local anaesthetic injections, increase the risk of infection in susceptible patients-and warrant antibiotic use.
• Acute infection conditions such as necrotizing ulcerative gingivitis, stage III-grade C/incisor-molar pattern periodontitis (formerly known as localized aggressive periodontitis), acute periapical abscess, cellulitis, local or systemic spreading of infection in the periodontal abscess, pericoronitis, periimplantitis, infection of deep fascial layers of the head and neck, and fever and malaise warrant an antibiotic prescription.

Features that make amoxicillin "most -suited" for dental infections-According to research, Amoxicillin is the most commonly administered empirical antibiotic in dental practice, followed by the combination of Amoxicillin and clavulanic acid. (1)

• Range of antimicrobial activity-Research highlights that Gram-positive cocci cause around 65% of orofacial infections, whereas Gram-negative bacilli can be identified in 25% of patients. Since Amoxycillin provides a broad spectrum of action, including various gram-positive and gram-negative micro-organisms, this drug is suited to manage dental and orofacial infections. (1)
• Core-access antibiotic-Amoxycillin is a World Health Organization (WHO)-designated 'core access antibiotic.' (2)
• Better pharmacokinetics- The hydroxyl group that separates Amoxicillin from its predecessor, ampicillin- resulted in a more lipid-soluble medication, enhanced bioavailability and duration of action, and higher bactericidal efficacy in some pharmacodynamic investigations. (3)
• Narrow spectrum antibiotic-Acknowledging that antibiotic overuse can lead to various significant complications, including bacterial resistance, gastrointestinal and haematological issues, and bacterial microbiota diversion, the focus has shifted to the use of narrow-spectrum antibiotics. The American Academy of Pediatrics has identified Amoxicillin as a narrow-spectrum antibiotic recommended for acute infection with signs of systemic involvement in immunocompromised and high-risk patients. (4)
• Good safety and tolerability profile-Patients with impaired renal function do not generally require a reduction in dose unless the impairment is severe. Amoxicillin is a pregnancy category B drug under the old FDA classification system, meaning no studies have demonstrated clear risk. Amoxicillin is widely used in pregnant women. Based on available data, Amoxicillin is usually considered compatible during pregnancy. (3)
• Drug dosage adopted for adult and pediatric populations - Recommended dosage of Amoxicillin is 500-1000 mg thrice daily (PO or IV) in adults and 15-20 mg/kg twice daily oral, 30-35 mg/kg thrice daily IV in paediatrics (5)
• The recommended dosage of Amoxicillin as prophylaxis for high-risk dental procedures in high-risk patients is 50 mg/kg orally or IV 30-60 minutes before the procedure. (5)

Study testimonials: Amoxicillin standing the test of time for five decades:

• According to research, Amoxicillin has traditionally been the primary option for administration during endodontic root canal procedures (6).
• Studies show that taking 2 g of Amoxicillin orally 1 hour before surgery lowers dental implant failures considerably (7). Single-dose oral Amoxicillin (SDOAP) is very useful at preventing dental implant failure. (8)
• Amoxicillin 2000 mg at a reasonable dose and interval for five days helps to meet the therapeutic requirements following third molar surgery. (9)
• Amoxicillin is effective against Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis, proving its significance in treating gingival and periodontal diseases. (10)
• With studies repeatedly demonstrating that bacteremia and subsequent infective endocarditis is a common complication following a tooth extraction, the practice of advocating a standard regimen of 2 g of oral Amoxicillin for adults before the start of the dental procedure has been widely accepted and followed by dentists. According to research, 2g of Amoxicillin gives long hours of antibiotic coverage (9).

In the case of older individuals, the standard preventative regimen consists of 3g amoxicillin 1 hour before the dental operation, followed by 1.5g 6 hours later (11). Furthermore, British Society for Antimicrobial Chemotherapy (BSAC) guidelines recommend that in the case of certain high-risk cardiac patients who require antibiotic prophylaxis before dental procedures, such as those with a history of previous infective endocarditis, the presence of prosthetic valves or a surgically constructed systemic or pulmonary shunt, these patients should receive 3g of Amoxicillin before all dental procedures involving dental-gingival manipulation (12).

Key pointers

• In dentistry, antibiotics are commonly used as an adjunct to surgical procedures to treat odontogenic infections, nonodontogenic infections, local infections, focused infections, and prophylaxis. Patients with immunocompromised conditions, infective endocarditis, metabolic problems, and prosthetic joints are given antibiotic prophylaxis.
• Proper antibiotic therapy, administered at the appropriate time and dose, can help to alleviate tooth discomfort while reducing the risk of systemic spread.
• Amoxicillin, supported by considerable research and unrivalled efficacy, has been and will continue to be a reasonable antibiotic in successfully controlling dental infections.

References

1. Ahmadi H, Ebrahimi A, Ahmadi F. Antibiotic Therapy in Dentistry. Int J Dent. 2021;2021:6667624. Published 2021 Jan 28. doi:10.1155/2021/6667624

2. M. Sharland, C. Pulcini, S. Harbarth, M. Zeng, S. Gandra, S. Mathur, et al. Classifying antibiotics in the WHO essential medicines list for optimal use-be AWaRe Lancet Infect Dis, 18 (2018), pp. 18-20

3. Huttner, A., Bielicki, J., Clements, M., Frimodt-Møller, N., Muller, A., Paccaud, J., & Mouton, J. (2020). Oral amoxicillin and amoxicillin–clavulanic acid: properties, indications and usage. Clinical Microbiology and Infection, 26(7), 871-879. https://doi.org/10.1016/j.cmi.2019.11.028

4. Gerber JS, Ross RK, Bryan M, et al. Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections. JAMA. 2017;318(23):2325–2336. doi:10.1001/jama.2017.18715

5. Indian Council of Medical Research. Treatment Guidelines for Antimicrobial Use in Common Syndrome. 2022. https://amrtg.icmr.org.in/redirect.html. [Access 10 th January 2023]

6. Segura-Egea JJ, Gould K, Şen BH, Jonasson P, Cotti E, Mazzoni A, Sunay H, Tjäderhane L, Dummer PMH. European Society of Endodontology position statement: the use of antibiotics in endodontics. Int Endod J. 2018 Jan;51(1):20-25. doi: 10.1111/iej.12781. Epub 2017 Jun 14. PMID: 28436043.

7. Surapaneni, H., Yalamanchili, P. S., Basha, M. H., Potluri, S., Elisetti, N., & Kiran Kumar,M. V. (2016). Antibiotics in dental implants: A review of literature. Journal of pharmacy &bioallied sciences, 8(Suppl 1), S28–S31. https://doi.org/10.4103/0975-7406.191961

8. Rodríguez Sánchez F, Rodríguez Andrés C, Arteagoitia I. Which antibiotic regimen prevents implant failure or infection after dental implant surgery? A systematic review and meta-analysis. J Craniomaxillofac Surg. 2018 Apr;46(4):722-736. doi:10.1016/j.jcms.2018.02.004. Epub 2018 Feb 26. PMID: 29550218.

9. Ramu, C., & Padmanabhan, T. V. (2012). Indications of antibiotic prophylaxis in dental practice- review. Asian Pacific journal of tropical biomedicine, 2(9), 749–754. https://doi.org/10.1016/S2221-1691(12)60222-6 Mehrotra,N.Palle,A.R.,Gedela,R.K.,Vasudevan ,S.(2017).

10. Efficacy of Natural and Allopathic Antimicrobial Agents Incorporated onto Guided Tissue Regeneration Membrane Against Periodontal Pathogens: An In vitro Study,J Clin of Diagn Res. 11(1), ZC84-ZC87. https://www.doi.org/10.7860/JCDR/2017/23851/9227

11. Arthur H. Friedlander & Charles E. Marshall. Pathogenesis and Prevention of Native Valve Infective Endocarditis in Elderly Dental Patients. Drugs Aging (1994) 2012 Apr;4(4):325-30. DOI: 10.2165/00002512-199404040-00005.

12. Gould FK, Elliott TS, Foweraker J et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy J Antimicrob Chemother 2006 57: 1035-1042.