What should you consider as a first line of choice in dental infections?

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.

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)

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)

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)

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.

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.

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3. Al-Mubarak S, Al-Nowaiser A, Rass MA, et al. Antibiotic prescription and dental practice within Saudi Arabia; the need to reinforce guidelines and implement specialty needs. J Int Acad Periodontol.2004;6(2):47–55.

4. Dar-Odeh NS, Abu-Hammad OA, Khraisat AS, El Maaytah MA, Shehabi A. An analysis of therapeutic, adult antibiotic prescriptions issued by dental practitioners in Jordan. Chemotherapy. 2008;54(1):17–22.

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9. http://www.sdcep.org.uk/wp-content/uploads/2013/03/SDCEP-Drug-Prescribing-for-Dentistry-Update-Sept-2014.pdf

10. Martinez Lacasa J, Jimence J, Ferras VA. A double blind, placebo-controlled, randomised, comparative phase III clinical trial of pharmacokinetically enhanced amoxicillin-clavunate 2000-125, as prophylaxis or as treatment versus placebo for infectious and inflammatory morbidity after third mandibular removal. Program and Abstracts of the 43rd International Science Conference on Antimicrobial Agents and Chemotherapy, Chicago. American Society for Microbiology, Washington, DC

11. Thomas DW, Satterthwarte, Absi EG. Antibiotic prescription for acute dental infection conditions in the primary care setting. British Dent J 1996; 181: 401-404.

12. Whitten BH, Gardiner DL, Jeansonne BG, Lemon RR. Current trends in endodontic treatment report of a national survey. J the Am Dent Ass 1996; 127: 1333-1341

13. Fouad AF. Are antibiotics effective for endodontic pain-An evidence based review. Endodontic Topics 2002; 2: 52-66.

14. Rodriguez-Nunez A, Cisneros-Cabello R, Velasco-Ortega E, Llamas-Carreras JM, Torres-Lagares D, Segura-Egea JJ. Antibiotic use by members of the Spanish Endodontic Society. J Endod2009;35:1198-203.

15. Pinheiro ET, Gomes BP, Ferraz CC, Teixeira FB, Zaia AA, Souza Filho FJ. Evaluation of root canal microorganisms isolated from teeth with endodontic failure and their antimicrobial susceptibility. Oral Microbiol Immunol 2003;18:100-3.

16. Aminoshariae A, Kulild JC. Evidence-based recommendations for antibiotic usage to treat endodontic infections and pain: A systematic review of randomized controlled trials. J Am Dent Assoc 2016;147:186-91.

17. An analysis of bacteremias during dental extractions. A double-blind, placebo-controlled study of chlorhexidine.Lockhart PB Arch Intern Med. 1996 Mar 11; 156(5):513-20.

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.

19. Prevention of bacterial endocarditis: recommendations by the American Heart Association. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G Jr Clin Infect Dis. 1997 Dec; 25(6):1448-58.

20. Segura-Egea, J.J.; Gould, K.; Sen, B.H.; Jonasson, P.; Cotti, E.; Mazzoni, A.; Sunay, H.; Tjaderhane, L.; Dummer, P.M.H. European Society of Endodontology position statement: The use of antibiotics in endodontics. Int. Endod. J. 2018, 51, 20–25.

21. Asepsis during periodontal surgery involving oral implants and the usefulness of peri-operative antibiotics: a prospective, randomized, controlled clinical trial.Abu-Ta'a M, Quirynen M, Teughels W, van Steenberghe D J Clin Periodontol. 2008 Jan; 35(1):58-63.

22. Single-dose versus single-day antibiotic prophylaxis for orthognathic surgery: a prospective, randomized, double-blind clinical study. Danda AK, Wahab A, Narayanan V, Siddareddi AJ Oral Maxillofac Surg. 2010 Feb; 68(2):344-6

23. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications.

Esposito M, Worthington HV, Loli V, Coulthard P, Grusovin MG Cochrane Database Syst Rev. 2010 Jul 7; (7):CD004152.

24. Goel, D., Goel, G. K., Chaudhary, S., & Jain, D. (2020). Antibiotic prescriptions in pediatric dentistry: A review. Journal of family medicine and primary care, 9(2), 473–https://doi.org/10.4103/jfmpc.jfmpc_1097_19

25. Bakhsh, A.A.; Shabeeh, H.; Mannocci, F.; Niazi, S.A. A Review of Guidelines for Antibiotic Prophylaxis before Invasive Dental Treatments. Appl. Sci. 2021, 11, 311. https:// doi.org/10.3390/app11010311

26. Lockhart, P.B.; Tampi, M.P.; Abt, E.; Aminoshariae, A.; Durkin, M.J.; Fouad, A.F.; Gopal, P.; Hatten, B.W.; Kennedy, E.; Lang, M.S.et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association.

27. Colley D.P., J. Kay, and G.T. Gibson, "Amoxicillin and ampicillin: A study of Their Use in Pregnancy," Australian Journal of Pharmacy, vol. 64, pp. 207-111, 1983.

28. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019 Jan 15;321(2):188-199

29. Jeske AH. Mosby's Dental Drug Reference. 12th ed. St. Louis, Mo.: Elsevier, Inc.; 2018.

30. Lexicomp Online, Pediatric and Neonatal Lexi-Drugs Online. Hudson, Ohio: Wolters Kluver Clinical Drug Information, Inc.; 2020. Available at: "http://webstore.lexi.com/Pediatric-Lexi-Drugs". Accessed October 12, 2020.

31. Segura-Egea JJ, Velasco-Ortega E, Torres-Lagares D, Velasco-Ponferrada MC, Monsalve-Guil L, LlamasCarreras JM. Pattern of antibiotic prescription in the management of endodontic infections amongst Spanish oral surgeons. Int Endod J 2010;43:342-50.