Understanding the role of Amoxicillin in Tooth extractions

Tooth extraction is one of the most frequent oral surgical procedures performed by dentists routinely. The success of a tooth extraction relies not only on surgical expertise but also on the prevention of post-operative complications faced by the patient. Owing to the highly diverse oral microflora within the oral cavity and the invasive nature of the extraction procedures, chances of developing an infection following extraction remain high.

It has been scientifically affirmed that post-surgical bacteremia is a common complication after extraction (1, 2), with an incidence rate as high as 100 % (3). When left untreated, bacteremia may further spread via anatomic spaces, disseminate to local and distant sites and lead to serious complications, pain, inflammation, and even death. (4, 5)

Rationale of use

Providing antibiotic coverage:

To prevent such a situation, proper antibiotic coverage, either before the procedure or just after the procedure, as a prophylactic measure, has been widely advocated by dentists. While some studies have affirmed the protective effect of preoperative doses of antibiotics (6), yet others have supported the rationale of post-operative antibiotic usage. (7)

Several studies and reviews have highlighted amoxicillin as the first choice antibiotic (8, 9) used by dentists after extraction. Prophylactic use of amoxicillin has shown to reduce chances of infection drastically, (10,11) a fact that has been resonated, over and again, by the Committee for the Prevention of Infective Endocarditis of the American Heart Association. (12). A major study by Vergis et al have reported a decrease of almost 80% in the prevalence of post-extraction bacteremia after prophylaxis with amoxicillin (3 g).(13)

Amoxicillin, a penicillin derivative, ensures high efficacy against a wide range of gram-positive and gram-negative oral micro-organisms, both transient and resident. Considered a beta-lactam bactericidal antimicrobial, amoxicillin, works by preventing cross-linkages among microbial cell walls, ultimately causing cell lysis. (14)

Recent supporting studies by Cohen et al have highlighted that empirical peri-operative therapy with amoxicillin can reach a 3–4-fold higher concentration than the minimal inhibitory concentrations (MICs) and help in preventing bacteremia or local bacterial contaminations. (15)

Why amoxicillin is the most prescribed antibiotic among dentists-

Its wide spectrum of action, better absorption, high plasmatic concentrations, high rate of tolerability, an established safety profile with very few adverse effects and cost-effectiveness has made amoxicillin irreplaceable in modern dentistry (16,17). Being one of the most thoroughly studied drugs in tooth extraction, its benefits, when used in tooth extraction procedures, have been extensively documented throughout the literature.

Clinical uses of amoxicillin during tooth extraction

Third molar surgery-The risk of infection from a third molar extraction in healthy young people can range from 18–85%; it may rise to 25% in patients with co-morbidities and compromised immunity (18). Infectious complications in such cases can include swelling, pain, abscess, fever, and dry socket (19). Evidence shows that for wisdom tooth extraction, amoxicillin administered before and/or after surgery is proven to reduce the risk of dry socket by 38%(18).

Impacted tooth extraction- It is considered a 'high risk' surgical procedure involving mucoperiosteal flap retraction, deep soft tissue incisions, and bone cutting. The extreme invasiveness and complex nature of the surgery call for judicious amoxicillin coverage to eliminate chances of post-surgical bacteremia.

A study by Sancho-Puchades et al aimed to analyze antibiotic prophylaxis prescribed by Spanish Oral Surgeons after impacted tooth removal has reported that 87% to 100% of the operating dentists prescribed antibiotic prophylaxis. (20)

Trans alveolar extraction - Graded as a Class II surgery (clean-contaminated surgery) based on its level of difficulty, the expected infection rate in trans alveolar extractions ranges from 10%–15%. (21).

In a study by Natarajan B, aimed to assess the efficacy of amoxicillin in postsurgical management of trans alveolar extraction, the authors noted that amoxicillin was the antibiotic of the first choice among dentists with a prescription rate of 45.7%, further elaborating that a single dose of amoxicillin preoperatively is sufficient to prevent wound infection. (21) For longer procedures, intraoperative doses are given as necessary, followed by the final dose in the postoperative day 1 and 2, is sufficient for maximum infection control. (21)

Managing post-operative infection, inflammation, and pain - Post-extraction pain at the site of surgery is a common indicator of strong inflammatory response to the surgical procedure itself, which can progress to lymphadenopathy, local tension of tissues, fever >38◦C, malaise, and trismus within 48 to 72 hours, if left untreated. (22)

Previous studies have unanimously recognized the need for amoxicillin prophylaxis to modulate the microbial load, divert potential inflammatory pathways, thus promoting atraumatic healing of the surgical site.(23,24) It is well documented that complex extractions involving the surgery of long duration, surgical flaps with osteotomy, when treated with antibiotics, there was a reduction, from 2.7% to 16%, in postsurgical infections, suppuration, pain, swelling, trismus, and dry socket. (25)

Amoxicillin as a prophylactic in 'high-risk groups-

The high-risk population refers to medically compromised patients with medical risk-related histories which include patients at high risk of infective endocarditis and immunocompromised patients suffering from (leukemia, AIDS, end-line nephropathies, uncontrolled diabetes, dialysis, immunosuppressive therapies, or chemotherapies. (22)

Antibiotic prophylaxis for the prevention of bacterial endocarditis secondary to dental procedures has been strongly recommended since 1955 (26). The Committee for the Prevention of Infective Endocarditis of the American Heart Association (AHA) recommends that prophylaxis be considered for patients with a prosthetic valve or prosthetic material, patients with previous infective endocarditis, and patients with congenital heart disease undergoing oral procedures.(27) Further, the American Academy of Orthopaedic Surgeons and American Dental Association recommend antibiotic prophylaxis for invasive dental procedures executed during the first 3 months after the orthopedic intervention. (22)

Updated guidelines –

To minimize the possibility of developing infective endocarditis before any dental procedure, the American Heart Association (AHA), European Society of Cardiology (ESC), and the Belgian Health Care Knowledge Centre (KCE) recommend the prescription of antibiotic prophylaxis before operating for any invasive dental procedures. (28) The SDCEP recommends that cardiac patients from the "special considerations subgroup" require antibiotic prophylaxis for non-routine dental management and this should be assessed in consultation with their cardiologists. The AHA, ESC, and KCE support antibiotic prophylaxis for their enlisted high-risk cardiac patients. (28)

Key pointers-

• Dentists are positioned to prescribe antibiotics based on empirical therapy and individualized need
• Rational use of amoxicillin to prevent post-extraction complications is recommended and widely accepted.
• To date, amoxicillin holds a supreme position for managing extraction-related complications.
• Checkpoints like duration and difficulty levels of the surgical procedure, patient-related co- morbidities, presence of concomitant infections, penicillin allergy should be individually assessed before starting with antibiotic therapy.

Conclusion- Judicious use of amoxicillin is highly recommended for extraction procedures, more so for surgeries of high technical difficulty and tissue manipulation. Years of use, backed up by decades of evidence supporting the benefits of using amoxicillin for perioperative prophylaxis in tooth removal, this drug has established an irrevocable position among the dental fraternity.

References

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