What should you consider as a first line of choice in dental infections?
Written By : SATABDI SAHA
Medically Reviewed By : Dr. Kamal Kant Kohli
Published On 2021-05-08 05:31 GMT | Update On 2023-04-26 06:56 GMT
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Judicious use of antibiotics along with appropriate dental therapy forms the backbone of successful dental treatment. Mainly indicated when clinical signs or chances of infection are evident, antibiotics have revolutionized the way dentists approach orofacial infections today.
The era of antibiotics started with the discovery of Penicillin. In dental practice, the most commonly used derivatives of penicillin are amoxicillin (1,2,3,4). Extensively documented as the first-line drug for orofacial infections(5,6), this drug, alone as well in combinations, continues to hold its position in modern dental treatment.
Spectrum/ Mechanism of action-
The oral cavity, home to a varied flora of transient and resident microorganisms, is a frequent site of focal infection. To combat such infections, amoxicillin warrants coverage against a wide spectrum of gram-positive and gram-negative microorganisms, highlighting high efficacy in oral infections.
Addressing the issue of antibiotic resistance, Swift et al. (7) indicated that despite the recent introduction of many new antimicrobials, none have demonstrated significant benefit justifying their replacement of amoxicillin in application to orofacial infections.
Owing to such a wide spectrum of action, it has been advocated that invasive dental procedures if performed on high-risk patients ( infective endocarditis, immunocompromised conditions, patient with implants, poorly controlled diabetes), should be preceded with antibiotic prophylaxis. (8)
This article focuses on the clinical implications of amoxicillin in various dental conditions while reinforcing its importance in ensuring the success of dental treatment.
Role of amoxicillin in various dental infections-
1. Odontogenic infections- Amoxicillin is used to treat a variety of bacterial infections like dental abscesses, sinusitis, and Acute Necrotising Ulcerative Gingivitis, and pericoronitis. (9). Studies have indicated that Amoxicillin 2,000 mg for five days at a suitable dose and interval helps to reduce chances of bacteremia after third molar surgery(10)
2. Use in endodontics-Endodontics is the field of choice where antibiotics are used extensively (11,12). The inflammatory process results in endodontic pain, which is most commonly related to microbial irritation but can also be related to mechanical or chemical factors(13).
Amoxicillin is the first line of antibiotics chosen as adjunct therapeutic agents in endodontics in the United States of America and Europe (14) . A study aimed to evaluate the microbiota of 30 root-filled teeth with persisting periapical lesions and to test the antibiotic susceptibility of the most prevalent species highlighted that the micro-organisms, being predominantly facultative anaerobes and gram-positive species , exhibited remarkable susceptibility to amoxicillin . Thus, amoxicillin is highly effective against isolates from infected root canal systems. (15). Previous studies have pointed out that amoxicillin should be used in cases with evidence of systemic involvement (fever, malaise, cellulitis, and/or lymphadenopathies) following adequate endodontic disinfection and abscess drainage. (16)
1. As a prophylactic antibiotic- Previous studies byLockhart reported more incidence of infective endocarditis following dental extraction and periodontal surgery(17), whereas, Ottentet al reported that bacteremia was associated with 74% of patients following tooth extraction. (18)In such cases a 2 g of oral amoxicillin dose before the dental procedure commencement is the recommended dose by AHA.(19)
The European Society of Endodontology (ESE) published a position statement on antibiotics in endodontics where they reaffirmed that along with cardiac conditions, impaired immunologic function, prosthetic joint replacement, high-dose irradiation of jaws, and intravenous bisphosphonates need prophylactic antibiotics for patients having certain treatment procedures. (20)
1. Prophylaxis to treat local infection and systemic spread- Abu-Taaet al compared the benefits of pre-and post-operative antibiotics in patients undergoing periodontal surgery, highlighting a remarkable reduction in post-operative discomfort. (21) In yet another study, Dandaet al evaluated the prophylactic value of single-dose antibiotic prophylaxis on postoperative infection in patients undergoing orthognathic surgery with results showing a significant reduction in infection rates. (22)It is well documented that 2 g of amoxicillin given orally 1 hour preoperatively significantly reduces failures of dental implants. (23)
2. Specific use in children- Empirical use of age-appropriate doses of amoxicillin has been considered as the standard for common clinical pathologies in children like acute facial swelling of dental origin/facial cellulitis, aggressive periodontitis, and Salivary gland infections. (24)
What do guidelines say?
A notable review in 2021, on the existing Guidelines for Antibiotic Prophylaxis before Invasive Dental Treatments, has highlighted that the American Heart Association (AHA), European Society of Cardiology (ESC), and the Belgian Health Care Knowledge Centre (KCE) recommend on the prescription of antibiotic prophylaxis to minimize the possibility of developing infective endocarditis before any dental procedure involving the handling of the gingiva as well as the periapical region of teeth and in cases of perforation of the oral mucosa in all patients with a high risk of developing infective endocarditis. (25)
American Dental Association (ADA) states that if dental treatment is not feasible and patients' symptoms get worse, a prescription for amoxicillin administered orally for patients diagnosed with pulp necrosis and symptomatic apical periodontitis is recommended. (26)Further, they advised prescription of antibiotics along with urgent dental treatment in immunocompromised patients diagnosed with pulp necrosis and acute apical abscess with systemic involvement.
Approved by FDA as a category B drug, amoxicillin, to date, has not demonstrated any clear risk in pregnant women. (27) The drug is documented to be very safe, though it is essential to get a proper history of allergy before prescribing the medication. (28)
Recommended routes and dosages of amoxicillin, in adults and children-
Amoxicillin is most effective when given orally in a "time-dependent" manner. It comes in immediate-release or extended-release tablets. Chewable tablets or suspensions, specifically for children, are also available. For pediatric doses, the suspension may be mixed and administered with formula, milk, water, fruit juice, ginger ale, or other cold drinks.
The current dosages of amoxicillin recommended by AAPD are-for Infants >3 months, children, and adolescents <40 kg: 20-40 mg/kg/day in divided doses every 8 hours (maximum 500 mg/dose) OR 25-45 mg/kg/day in divided doses every 12 hours (maximum 875 mg/dose).For Adolescents and adults, it is 250-500 mg every 8 hours OR 500-875 mg every 12 hours. (29, 30). Most practitioners usually prescribe antibiotics in courses of 3 to 7 days. (31)
Key pointers-
Dentists are positioned to prescribe antibiotics based on updated knowledge and individual opinions.
• Amoxicillin is the standard antibiotic therapy for oral infections, either of odontogenic or nonodontogenic origin.
• In the absence of a common global consensus guideline on the use of antibiotics in dental infections, logical use of amoxicillin as an adjunct to primary dental therapy is needed to optimize success rates of dental therapy while avoiding over-prescription of antibiotics.
• Combining amoxicillin with other drugs can improve its efficacy and should be considered based on individual cases if indicated.
Conclusion-
Appropriate dental therapy along with rational use of antibiotics is essential to ensure the success of dental treatment. Amoxicillin, used at the standard dosage and appropriate regimen, forms the mainstay antibiotic acting on most aerobic and anaerobic strains of microorganisms in the oral infectious processes.
Owing to its safety profile, a wide range of action and time-tested supremacy in managing oral infections, this drug has cemented its position as the gold standard antibiotic among dental surgeons worldwide.
References
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18. Anaerobic bacteremia following tooth extraction and removal of osteosynthesis plates. Otten JE, Pelz K, Christmann G J Oral Maxillofac Surg. 1987 Jun; 45(6):477-80.
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