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A review of use of antibiotics in dentistry and recommendations for rational

antibiotic usage by dentists

Article  in  International Arabic Journal of Antimicrobial Agents · September 2014

DOI: 10.3823/748

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iMedPub Journals THE INTERNATIONAL ARABIC JOURNAL 2014
http://journals.imedpub.com Vol. 4 No. 2:1
OF ANTIMICROBIAL AGENTS
doi: 10.3823/748

A review of use of antibiotics in Dr. Akilesh Ramasamy

dentistry and recommendations

Department of Oral and Maxillofacial
for rational antibiotic usage by Surgery Government Dental College &
Hospital, Aurangabad, Maharashtra, India

dentists* Corresponding author:

 akident@gmail.com

Abstract
Dentists commonly prescribe antibiotics for controlling and treating
dental infections. But there is a widespread abuse of antibiotics in
medical and dental field. The inappropriate use of antibiotics results
in increased treatment costs, increased risk of adverse events related
to the antibiotic used and most importantly development and propa-
gation of antimicrobial resistance. The definitive indications for use of
antibiotics in dentistry are limited and specific. This review discusses
the various principles and rationale behind antibiotic therapy in differ-
ent fields of dentistry with stress on rational antibiotic use in dentistry

Introduction
Dentistry is a comprehensive speciality devoted to resolving dental
infections or restoring and rehabilitating tooth structure lost to such
bacterial processes. The use of antibiotics is an integral part of den-
tistry and prescribing antibiotics is a privilege that must not be abused.
Irrational use of antibiotics will lead to an increased burden on the
patient and the society by increasing treatment costs, adverse events
and also the risk of development of resistant bacterial species. Anti-
biotic abuse has already been considered as a pandemic community
issue by World Health Organization (WHO) [1], whilst the abuse of
antibiotics by dentists is worldwide as shown by many reports [2–5].

The oral cavity is a complex biological ecosystem with very large num-
ber of organisms living in a biofilm [6]. The interaction of the organisms
are complex and the change from health to disease state is associ-

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ated with a change in the balance of the ecosystem result in prompt relief of pain as well as the infec-
usually from the resident facultative anaerobes to tion. Antibiotics do not contribute to pain relief as
obligate anaerobes for most pulpal and periodontal they have no action on the inflammatory process
diseases [7]. Even though only a few of the micro- that causes the pain [9–11]. With appropriate mea-
organisms cause odontogenic infections, in disease sures to remove the foci of infection, antibiotics are
state, many other non pathogenic bacterial species not necessary in most cases. An old surgical credo
contribute by maintaining an ecosystem favourable is “pus cannot be cured by penicillin”.
for survival and growth of the pathogenic species.
The onset of disease is due to a shift in microbial
flora. Understanding this ecological principle is im- Principles of antibiotic usage
portant while treating oral and dental infections.
Micro-organisms in a biofilm are consistently more In recent times, antimicrobial stewardship has been
resistant to usual dosage of antibiotics by 1000- given lots of importance at the patient level and at
1500 fold [8]. the community level. Antimicrobial stewardship is
defined as “the optimal selection, dosage, and du-
Management of odontogenic infections involves ration of antimicrobial treatment that results in the
three phases; diagnosis, infection control and re- best clinical outcome for the treatment or preven-
habilitation/restoration. Antibiotics are useful in the tion of infection, with minimal toxicity to the patient
infection control phase. Based on the data collected and minimal impact on subsequent resistance.” Jo-
and interpreted in the diagnostic phase, infection seph and Rodvold [12] summarised the 4 D's of an-
control phase involves removal of the infectious foci timicrobial therapy which is given in Table 1. An
and resolving the infection. This will include use important consideration in starting antimicrobial
of antibiotics/antiseptic agents as well as surgical therapy is to assess if the infection is localized and
methods to resolve the infection. Until resolution of if the patient has an adequate immune response to
the infection, the response to the treatment should control the bacteria if supported surgically. These
be assessed often. considerations are summarised in Table 2.

Most dental pain is the result of infection induced In the presence of purulence, signs of inflamma-
inflammatory process in a closed compartment as tion, abscess or draining sinus tracts, the lesion/
in the pulp and the apical periodontal region or in infection responds to local debridement measures
sensitive and highly innervated soft tissue like the in a healthy patient [12,13]. In an otherwise healthy
periosteum space, gingiva and periodontium. The patient, infections that have not crossed the dento-
general principle of management of all infectious alveolar regions are amenable to treatment without
processes is the removal of the foci of infection.
Control of dental infections is by mechanical re-
moval of the foci of infection. It can be achieved Table 1. 4 D’s of antimicrobial therapy [12].
by removal of the infected pulp, scaling and root
planning and drainage of the pus by incision when right Drug
the soft tissue spaces are involved. Usually a com- right Dose
bination of one or more of these techniques are
De-escalation to pathogen-directed therapy,
utilised for maximum benefit. This, when supported
by appropriate use of anti-inflammatory agents can right Duration of therapy

2 Received 18 July 2014; accepted 22 August 2014 This article is available from: www.iajaa.org
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Table 2. Considerations for antimicrobial therapy [13]

Indicated clinical conditions Non-indicated clinical conditions for antimicrobial

for antimicrobial therapy therapy
1. P yrexia within last 24 hours – indicates a systemic
1. Pain – (Analgesics/ Anti-inflammatory drugs are indicated)
response to the infection
2. S ystemic symptoms like malaise, fatigue, weakness,
dizziness, rapid respiration and local tender 2. Oedema – (Anti-inflammatory drugs indicated)
lymphadenopathy – indicate an impending sepsis
3. Trismus – indicates spread to perimandibular spaces and
can extend to secondary spaces that can be potentially
3. Redness/heat (Anti-inflammatory drugs indicated)
dangerous. Also trismus makes intraoral procedures
difficult, which must wait until the trismus is relieved.

4. A
 s a prophylaxis in patients with systemic conditions like
rheumatic heart disease, endocarditis, heart / orthopaedic 4. Purulence – (Resolved by drainage of pus / debridement)
prosthesis.

5. In patients with any kind of immunocompromise – AIDS,

cancer, autoimmune diseases, corticosteroid therapy,
5. Abscess – localized (e.g., alveolar abscesses, periodontal
patients with immune compromised diseases like cyclic
abscesses) – (Resolves by incision and drainage)
neutropenia, pancytopenia, uncontrolled diabetes to
name a few common ones.

6. Draining sinus tract. (Removal of foci of infection resolves

6. A
 fter solid Organ transplant/grafts (cardiac/renal/bone
drainage and sinus tract may heal on its own or may have
marrow/liver/osseous implants)
to be surgically excised.)

antibiotics. The infections that are about to breach troduced in the market, there are a very few an-
the dentoalveolar regions and threaten to extend tibiotics that are useful in dental infections. Most
into deeper hard tissues or into the soft tissue fas- infections of dental origin still respond to penicillin
cial spaces in the head and neck region will need group of antibiotics [18] and routine use of newer
use of appropriate antibiotics along with surgical antibiotics only adds to the cost and risk of anti-
therapy [14–16]. biotic resistance to these agents. Aminopenicillins
are not active against anaerobes but odontogenic
infections that show anaerobic pathogenic bacteria
Antibiotics appropriate still respond to these antibiotics and these antibiot-
for dental use ics may act by changing the ecological niche that
will result in death of the pathogenic anaerobes as
Different antibiotic prescribing trends are in practice well. [13]. Adding a drug with anaerobic cover like
among dentists [4,5,17]. Understanding the phar- metronidazole has a synergistic effect. [19]. A list of
macokinetics and pharmacodynamics is important drugs useful in dentistry are listed in Table 3. Bacte-
for appropriate use of the antibiotics. In spite of ricidal antibiotics are preferred when the host is im-
a large of number of newer antibiotics being in- mune compromised as bacteriostatic drugs require

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Table 3. Antibiotics useful in Dental Practice

Antibiotic used Cidal/Static Important characteristic

- Better oral tolerance.
Amoxicillin Cidal - Less chances of toxicity.
- Most odontogenic infections still respond to this drug.
- Similar to amoxicillin with additional Beta lactamase
Amoxicillin + clavulanate Cidal
resistance
Useful in selective cases of penicillin allergy and have good
activity against most oral pathogens but (should not used
Cephalosporins Cidal
in cases of patients showing Type I hypersensitivity to
penicillin group of drugs)
Active against obligate anaerobes but no activity against
Metronidazole Cidal facultative anaerobes like Streptococci. Useful in stage of
abscess formation.
Useful in penicillin allergic patients and has a wide
Clindamycin Static spectrum of activity including anaerobes. Useful in penicillin
allergic infections. Risk of superinfection.

High concentrations achieved in bone and gingival tissues.

Tetracyclines Static
Topical formulations available for use in periodontology

- Injectable drugs
- Active against gram negative odontogenic infections
Aminoglycosides Cidal/static - Used in combination with other drugs in severe
odontogenic infections
- Ototoxicity and hepatotixicity.

Rapid antimicrobial resistance develops with these newer

Macrolides antibiotics Static antibiotics and so they must be avoided in dental settings
when better choices are available.
Moxifloxacin has been found to be active against most
odontogenic micro-organisms. [90]. Useful in minor
Fluoroquinolones Cidal infections in penicillin allergic patients, but better
alternatives are available and hence not recommended for
routine use.

the host's immune system to completely eradicate starting any antibiotics. After collection of sample,
the infection [20]. treatment should be started immediately by use of
empiric antibiotics. For minor infections, amoxicillin
If the decision to prescribe an antibiotic is made, or amoxicillin/clavulanate is sufficient. A combina-
it may be necessary to use microbiological testing tion of beta-lactamase resistant penicillin group of
to choose the appropriate antibiotic. Microbiologi- drug and metronidazole is started in cases of seri-
cal testing by culture and sensitivity tests will help ous odontogenic infections along with appropriate
choose the best antibiotic. Samples are collected surgical therapy [16,19,21,22]. Routine culture and
in an appropriate manner after consultation with sensitivity are not recommended in minor odonto-
the lab and sent immediately, preferably before genic infections. These infections respond well to

4 Received 18 July 2014; accepted 22 August 2014 This article is available from: www.iajaa.org
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empiric antibiotic therapy with penicillin group of their efficacy as there are no clear studies on the
drugs. It and so routine culture and sensitivity is not best dosages and frequencies as applicable to den-
cost effective [21]. In case of severe infections or tistry.
infections showing rapid spread, culture and sensi-
tivity might be recommended. One must remember Higher dose of antibiotic given for a shorter dura-
that “waiting is wasting” in these scenarios. Empiric tion are advocated in recent years [4 ]. This regimen
antibiotic therapy is started and later changed, if would avoid selection of antibiotic resistant species
necessary, based on culture and sensitivity reports. and the risk of allergy or adverse events are not
significantly raised for most dental specific antibiot-
ics. Selection of antibiotic resistant species is com-
Appropriate dosage/frequency mon after using lower dose of antibiotics for longer
and duration periods of time. But before this, the first question
to ask oneself is whether an antibiotic is indicated
Discussing the detailed pharmacology of these in that particular clinical setting in that particular
drugs is beyond the scope of this article but a brief patient [3].
discussion of an important pharmacological profile
of antibiotics may be helpful. A brief tabulation of management of most common
conditions treated by a dentist with their manage-
Antibiotics can have a concentration-dependent ment principles is listed in Table 4.
killing or a time-dependent killing. The concentra-
tion-dependent drugs cause bacterial death when
present above a particular concentration. Increasing Antibiotics In Endodontic
the concentration will result in faster killing. Thus a Practice
single high dose may suffice to achieve the effect.
e.g, metronidazole. Time-dependent drugs have Most endodontic practice deals with acute and
their best effect when present at therapeutic levels chronic pulpal and periapical pathologies. Evidence
for a particular period of time. The therapeutic level has shown that antibiotics have no effect on the
of the drug must be maintained for long periods to pain in case.[10,23,24] Antibiotics are not useful
achieve best effect. Increasing the concentration of in most endodontic infections because it is doubt-
the drug may have no effect on its efficacy. These ful that systemic antibiotics are able to achieve an
drugs may be better used by increasing the fre- adequate therapeutic concentration within the ne-
quency of administration rather than increasing the crotic pulp [25]. Meticulous endodontic technique
dose. Penicillin group of drugs belong to this profile by avoiding over instrumentation will avoid periapi-
[13]. This suggests the question of whether 250 mg cal infections and flare ups during the endodontic
of amoxicillin given 4 times a day is more beneficial therapies [26]. Pain during endodontic treatment
than 500 mg of amoxicillin given 3 times a day Or is can be avoided by careful instrumentation. Non-
250 mg of amoxicillin given thrice a day sufficient? steroidal anti-inflammatory drugs (NSAIDs) can be
And in each of these settings, what is the recom- helpful to obtain pain relief [27]. Where endodontic
mended duration of therapy ? Different prescribing treatment is not feasible or in patients with non-
trends are present without adequate evidence of restorable tooth, extraction of the tooth will resolve

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Table 4. Management of common dental conditions.

Condition Treatment Approach Antibiotics

Uncomplicated endodontic lesion - Debridement of root canal No

Soft tissue swelling of endodontic origin - Debridement of root canal

No
(apical abscess / alveolar abscess) - Incision and drainage.

Endodontic lesion confined to the bone -Trephination of bone to relieve pressure

No
(apical periodontitis) and speed healing
- Scaling / removal of irritant
Periodontal abscess No
- Drainage of pus
Chronic periodontitis/ Gingivitis Scaling and root planing No

- Debridement
NUG without systemic complications in
- Irrigation No
healthy patients.
- Scaling and root planing
-Debridement
NUG with systemic complications or in Yes. Metronidazole is first choice.
-Irrigation
immune compromised patients / ANUP / HIV Penicillin group of drugs may be
-Scaling and root planing
associated NUG/NUP additional adjuvants [35]
-Systemic Antibiotics
May be considered early in
Aggressive periodontal diseases / Refractory - Debridement
generalized aggressive periodontitis
periodontal conditions - Scaling and root planing
[91]
- Incision and Drainage
Localized abscess No
- Removal of foci of infection
- Incision and drainage
Fascial space infections Yes
- Removal of foci of infection
Complicated endodontic / periodontic
- Removal of foci of infection
lesions with signs of systemic spread of Yes
- Incision and drainage
infection /involvement of fascial spaces

Systemically compromised patients with Removal of foci of infection by any Yes (use of bactericidal drugs
immune defects appropriate means recommended)

Prior to uncomplicated / complicated

- No
extractions

Prior to periodontal surgeries / endodontic

- No
surgeries

Prior to Regenerative periodontal therapy

- May be *
with membranes / grafting

Not necessary in case of single

Prior to implant surgery -
implant placement.

*n
 ot supported by strong high quality evidence, NUG Necrotizing Ulcerative Gingivitis, NUP – Necrotizing Ulcerative Periodontitis,
HIV – Human Immunodeficiency Virus

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the infectious process. As for endodontic surgeries, While some authors suggest that after appropri-
they do not require use of antibiotics in healthy pa- ate and thorough mechanotherapy, microbial test-
tients usually, but may be used if deemed necessary ing should be undertaken before starting antibiotic
by the clinician. [3]. Postoperative anti-inflammatory therapy [13] the benefit of microbial testing has also
drugs will be sufficient to control pain. Postsurgical been questioned [34].
infection is not common after endodontic surgeries
[28–30]. Gingivitis and chronic periodontitis

Acute peri-radicular abscess is a common endodon- Gingivitis is a local infectious process and responds
tic infection. A recent review concluded that there well to local mechanotherapy and antibiotic therapy
is insufficient evidence to recommend use of anti- is contraindicated [35]. Routine use of systemic an-
biotics in cases of apical periodontitis or in acute tibiotics in treatment of chronic periodontitis is not
peri-radicular abscesses [11]. In the management of justified in normal healthy patients. The risks of sys-
acute peri-radicular abscesses, the abscess should temic antibiotics outweigh the benefits for use in
first be drained by performing a pulpectomy or periodontal diseases [13]. Periodontal pockets can
incision and drainage, and relieving any traumatic be treated by local irrigation of antiseptic / antibiotic
occlusion. If adequate drainage is achieved via inci- solutions. The removal of the calculus and infected
sion and drainage, debridement, and medication of tissue by scaling and root planing procedure with
the canal system, antibiotics are not required gener- irrigation removes the infectious foci and resolves
ally [31,32]. In the event of systemic complications, the inflammation. The main objective would be to
such as fever, lymphadenopathy, or cellulitis or in disrupt the biofilm mechanically.
an immunocompromised patient, antibiotics may be
prescribed in addition to drainage of infection. [32]. The interrelationship between periodontitis and gly-
cemic control may be considered bidirectional [36].
Anyibiotics in Periodontal practice Oral hygiene education and mechanical debride-
ment of plaque and calculus combined with regular
Periodontitis is a bacterial infection and this has maintenance is important. When possible, a HbA1c
been used as a justification for the repeated routine of less than 10% should be established before sur-
use of antibiotics in periodontology. But the clinical gical treatment is performed and systemic antibiot-
relevance of bacteria being present in the tissues ics are not needed routinely. Also, periodontal treat-
is still not clearly defined in periodontal infections ment seems to improve glycemic control [37,38], It
and it is inappropriate to make clinical treatment was found that additional use of doxycycline did not
such as to use adjunctive systemic antibiotics on offer significant benefit in glycemic control [37], but
this premise alone. Montiero et al., [33] conducted when doxycycline was used, the topical local deliv-
a survey regarding the use of systemic antibiotics ery of doxycycline offered better glycemic control
by dentists for periodontal diseases and concluded (decrease by 10.5%) [39] than systemic doxycycline
that many dentists still use systemic antibiotics in- (decrease by 4.7%) [40].
correctly, without regard to evidence in published
literature, for inappropriate indications and using Aggressive periodontal diseases
inappropriate protocols that are ineffective in peri-
odontal therapy. There is considerable controversy Systemic therapy for treatment of the periodontal
on the use of microbial testing in periodontology. condition in conjunction with local therapy is indi-

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Table 5. Signs/symptoms of severe head and neck infections.

Signs/symptoms of systemic spread – pyrexia, malaise and worsening of general condition.

Rapid onset and progress

Infection in immunocompromised patients.

Large swelling involving submental/submandibular or parapharyngeal spaces – potential airway compromise

Presence of trismus indicates involvement of perimandibular spaces and is a serious sign.

cated in patients with aggressive periodontitis to have systemic complications. [35,46]. However, in
eliminate the bacteria that invade the gingival tis- patients with immunologic deficiencies or patients
sues and can repopulate the pocket after scaling with evidence of spread beyond the gingival tissues
and root planing. The use of antibiotics is beneficial as in necrotizing ulcerative periodontitis (NUP) then
only after the biofilm has been disrupted by ap- systemic antibiotics are indicated especially when
propriate mechanotherapy and antibiotics should be local root planing and curettage is not possible im-
used only after proper mechanotherapy has been mediately. [35]. Regular daily follow up and debride-
used and has been unsuccessful. The use of combi- ment with irrigation is required for management of
nation of amoxicillin and metronidazole in aggres- this lesion.
sive periodontal diseases is well supported [41–44],
however well designed controlled clinical trials are Necrotizing lesions of the gingiva and periodontium
limited as shown in a recent review [45]. can progress dramatically in Human Immunodefi-
ciency Virus (HIV) positive patients, thus it is nec-
Acute lesions of gingiva/periodontium essary to utilize thorough local therapy combined
with local use of antimicrobial mouthwashes such
The two most common acute gingival infections are as chlorhexidine and meticulous oral hygiene by the
necrotizing ulcerative gingivitis (NUG) and herpetic patient. Systemic antibiotics may be used especially
gingivostomatitis. Herpetic gingivostomatitis is a viral when systemic complications ensue or anticipated.
infection but may be complicated by superinfection Whenever possible, antibiotics should be avoided
with bacteria. These diseases occur most often in in significantly immunocompromised individuals to
healthy patients, but patients with depressed immu- minimize the risk of opportunistic infections (i.e.,
nologic responses have an increased risk for these candidiasis), superinfection, and micro-organism
gingival entities. Both may appear similar and the drug resistance [35,46,47].
treatment by debridement is effective for NUG but
may exacerbate herpetic gingivostomatitis. On the Periodontal abscess
other hand, antiviral therapy is effective for herpetic
gingival lesions but not for NUG. [35]. Periodontal abscesses can often be managed by
curetting the pocket under local anaesthesia to re-
Necrotizing lesions cause extensive tissue destruc- move plaque or any other aetiologic material. The
tion and necrosis. The treatment is mainly removal use of systemic antibiotics may be indicated when
of the necrotic tissue with pain control. Antibiotics patients have elevated temperatures or show signs
are not recommended in NUG patients who do not of cellulitis and have systemic disease/immuno-

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Table 6. Considerations for peri implant infections.

Condition Criteria for diagnosis Treatment

Inflammation
Bleeding on probing
Peri-implant Mucositis A+B
Peri-implantitis pocket depth < 4 mm
No bone loss
Peri-implantitis graded according Renvert et al. [92]
Failed implant
Peri-implantitis Grade 0 Implant fracture Explant
Implant mobility > 1 mm horizontal movability
BOP
+/- Suppuration
Peri-implantitis Grade 1 (mild) Peri implant pocket depth < 4 mm A+B
Bone loss < 2 mm
Foreign Body in implant sulcus - ? cement
BOP
+/- Suppuration
Peri-implantitis Grade 2 A+B
PPD 4-6 mm
Bone loss < 2 mm
BOP
+/- Suppuration
Peri-implantitis Grade 3 A+B+C
PPD > 6 mm
Bone loss > 2 mm

BOP = bleeding on probing; PPD = Peri implant pocket depth.

A – Mechanical debridement (plastic scalers, rubber cup, air-abrasives), oral hygiene re-education & local antisepsis with chlorhexidine
0.1–0.2%, irrigation of Peri implant pocket with anti septic agents/antibiotic slurry and application of local antiseptic agent like
chlorhexidine gel.
B – Removal of abutment.
C – Surgical access & Systemic antibiotic.

compromised condition. [35,47]. Antibiotic therapy or the foreign material (membranes). Even though
alone without subsequent drainage and subgingival studies seem to suggest no additional benefit [49–
scaling is contraindicated. [35]. 52], current practice recommends use of antibiotics
in this scenario. [35]. High dose for a short term,
Periodontal surgeries would be beneficial not exceeding 5 days, would
be sufficient in most instances [35]. Consideration
Systemic antibiotics are generally used after recon- for peri-implant infections are tabulated in Table 6.
structive periodontal therapy, although definitive
information on the advisability of this measure is Topical antibiotics in Periodontology
still lacking [48–51].
There is a need to reduce the widespread and re-
Simple routine periodontal surgeries do not need peated use of topical antibiotics as advocated by
antibiotics in the postoperative period. Regenera- some manufacturers. Topical antimicrobial therapy
tive therapies using bone grafts, allografts and peri- should be used with same caution as applied to
odontal membranes sometimes require the use of systemic therapy. Their indications are similar to sys-
antibiotics to prevent infection of the bone graft temic antibiotic therapy in periodontology [13].

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Antibiotics in Oral and ligate anaerobes and there is formation of abscess.

Cellulitis is a rapidly spreading progressive infection
Maxillofacial Surgery
caused by facultative anaerobes whereas abscess is
Antibiotics in minor oral surgery predominantly an obligate anaerobic infection with
well defined margins, fluctuant and is filled with
Most oral surgical procedures in general dental pus [13–16,21].
practice and in the clinical practice involves simple
or complicated extraction of teeth, preprosthetic Severe infections of the head and neck should pref-
hard tissue and soft tissue procedures, periapical erably be seen by a specialist early for combined
surgeries, implant placements and soft tissue biopsy antibiotic and surgical management. Severity may
procedures. These surgical procedures are deemed be indicated by signs/symptoms listed in Table 5.
clean contaminated procedures. Clean procedures
usually do not have risk of postprocedural infec- Penicillin group of drugs remain the drugs of choice
tions. Excellent aseptic precautions can reduce the for early stages of odontogenic infections. After for-
infection risk to about 3% to 5% [53]. Antibiotics mation of abscess, drugs with anaerobic spectrum
cannot reduce the risk of infection to below 1% like metronidazole or clindamycin are indicated. As
and may not be warranted. Even though antibiot- a general rule, if infection has been present for
ics are routinely used as surgical prophylaxis and more than 2-3 days, it can be expected to have pro-
in the postprocedural period, there is not enough gressed to obligate anaerobic infection and addition
evidence that such usages have a more favourable of metronidazole along with amoxicillin is beneficial
outcome in oral surgery. In general there is overuse [16,19,21]. A short course of high dose antibiotics
of antibiotic prophylaxis in minor oral surgery [54– combined with surgical drainage and daily debride-
56,56]. A recent review concludes that about 12 pa- ment/irrigation as indicated results in quicker resolu-
tients have to be treated with antibiotic to prevent tion of the infection. In general it's recommended
one infection and that the risks of antibiotic use that the antibiotic therapy should be continued at
significantly outweigh the benefits. [57]. The use of least 2-3 days beyond resolution of symptoms. [21].
prophylactic antibiotics prior to implant placement
Antibiotic use in maxillofacial trauma
is controversial. A systematic review supports the
use of 2 g amoxicillin as presurgical prophylaxis [58]
The general consideration is that wound closure
while a few other studies conclude that there is no
of clean and clean contaminated wounds like intra
added benefit [59–61]. There is no evidence that
oral mucosal lacerations or that can be rendered
implant failure is prevented by antibiotic usage [13].
clean do not require routine use of antibiotics. Dirty
Antibiotics in complex odontogenic wounds or infected wounds would need a debride-
infections ment before closure or may be treated by delayed
primary closure or left to heal by secondary inten-
Odontogenic infections begin with invasion by tion. Antibiotics are not a substitute for surgical de-
mixed bacterial flora and in the early stages facul- bridement. Routine use of surgical prophylaxis does
tative anaerobes such as streptococci predominate not seem to offer additional benefit in reduction of
and cellulitis stage is established. Due to the change infections [62–65]. Surgeries performed with due
in the environment inside the infected regions, there care for surgical asepsis do not require prophylactic
is a change in the microflora from facultative to ob- dose of antibiotics beyond the first 24 hours. In-

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fected wounds and fractures/hardware should be administration is useful in cases done under general
treated as any maxillofacial infection and the same anaesthesia conveniently administered at the time
considerations are applicable including surgical re- of induction. The concept of antibiotic re-dosing
moval of the infectious foci with adjunctive use of may be applicable to complex surgeries of longer
antibiotics. durations which is rare in usual dental practice. Use
of multiple drugs have not been found to be benefi-
Concept of surgical prophylaxis in Oral cial [66]. To In patients who are allergic to penicillin,
and Maxillofacial Surgery clindamycin may be used [54,70–72].

The decision to use prophylactic antibiotics in non- Pediatric considerations

infected cases should also be based on whether
patients have any significant medical risk factors Healthy paediatric population require the same con-
that could adversely affect their humoral and cellu- sideration as healthy adults. There is often misuse
lar immune mechanisms, and whether any systemic of antibiotics in treating children [25]. They are com-
risks are associated with the bacteremia that ac- monly over-prescribed and over/underdosed. More
companies tooth extraction. For patients in whom often, dentists give in to request from the parent
postoperative infection may be anticipated the use and fill a prescription for antibiotic even when not
of chemoprophylaxis is recommended. There is no definitely indicated.
evidence that the use of antibiotics beyond 24-48
hours has any additional benefit. [66]. The classical Antibiotic usage in compromised patients
studies on antibiotic prophylaxis recommend that
the duration of the prophylaxis drug should NOT The rationale behind using antibiotics in medically
exceed 24 hours. Antibiotics given after that do not compromised patients with immune defect is that
have a significant benefit and risk of adverse events they are at a higher risk of infection and infections
and complications increase beyond that period. are more difficult to manage in this group of pa-
tients [13,57]. Studies in this population without
The prophylactic dose of antibiotic is usually double antibiotics is not possible nor ethical. The use of
the recommended dose [67]. The dose should be antibiotics when used rationally may be beneficial
administered prior to surgery such that the peak in this group of patients. In neutropenic patients
concentration occurs at the time of taking the in- antibiotic prophylaxis is recommended by some
cision. Average peak serum levels are reached 60 especially when absolute neutrophil count (ANC)
-120 minutes after oral administration of amoxicillin drop below 1000-1500/microlitre [46,73–76], while
and immediately after intravenous administration others feel it's not recommended [77]. In general a
of amoxicillin [68,69]. Therefore, oral amoxicillin 1 definite guideline/recommendation is lacking in this
gram (double the therapeutic dose of 500 mg) is regard. [78]. So, the decision has to be made on a
recommended at least 1 hour prior to surgery (as case by case basis in consultation with the treat-
the levels peak at about 60–120 minutes after ad- ing physician/medical expert. These patients benefit
ministration) are cases done under local anaesthesia. with a bactericidal drug as their immune system
Intravenous (IV) antibiotics can be given just prior may not be able to clear the infection efficiently
to or a few minutes prior to taking the incision as with bacteriostatic drugs [20].
immediately high levels are attained in the blood. IV

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 THE INTERNATIONAL ARABIC JOURNAL 2014
OF ANTIMICROBIAL AGENTS Vol. 4 No. 2:1
doi: 10.3823/748

Consideration for chemoprophylaxis in Conclusion

certain systemic conditions
To summarise, the definitive indications for antibiot-
Bacteremia occurs whenever there is manipulation ics in dentistry are limited and specific (see Table
of gingival tissue, integrity of the mucosal barrier 4). Most odontogenic infections can be managed
is breached and during endodontic instrumenta- by removal of the focus of infection and they re-
tion. This can be potentially dangerous in patients spond well to specific limited arsenal of antibiot-
with prosthetic cardiac valves or untreated cardiac ics like amoxicillin and metronidazole. Appropriate
valve/septal defects and in patients with allograft antibiotic stewardship and rational prescription of
prosthetic joints. The indications for infective en- antibiotics by dentists is urgently needed in view of
docarditis prophylaxis are constantly being revised. the pandemic issue of antimicrobial resistance. Edu-
Regional variations exist in the recommendations cation in this regard is necessary during the training
through the world and the dentist should follow as well as in continuing dental education programs
the latest regional/national guidelines when pres- to curb antibiotic abuse.
ent. It may be prudent to consult with the treating
physician before any procedure is planned or refer
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