Ministry of Iraqi Higher Education and Scientific Research

Babylon university-college of dentistry

Done by students:-1-Saad J. Hamood2-Haidar M. Hassan3-Ahmed M. lefta

2015-2016Group-B-

Pharmacology for orofacial bacterial infection

Many pathologies present to dentist in clinic Many of these are inflamatory conditions associated with pain

So when need intervention we need analgesic for pain as well as antibiotic for infection The clinical situation require AB are limited .they include oral infection associated with 1- elevate body temp.2-pain 3- inflamation 4- systemic involve A- lymphadenopathy B- trismus

Step wise for AB prescribing

To prescribing AB the professional should know

associated pathogens

Spectrum of activity of most used AB in treatment of orofacial infection

Broad Extended Narrow Augmentin (amoxicillin plus clavulanate),sulfamethoxazole and trimethoprim, tetracyclines(tetracycline, doxycycline)

Cephalosporins (cephalexin, cefadroxil,

cefaclor, cefuroxime), extendedspectrumpenicillins (ampicillin,

amoxicillin), fluoroquinolones

(ciprofloxacin, levofloxacin,moxifloxacin)

Clindamycin, dicloxacillin, macrolides

(erythromycin, clarithromycin,

azithromycin), metronidazole,

penicillin G, penicillin V

Narrow spectrum

Penicillin VK : it is the first choice antibiotic for orofacial infection (ideal) . Effect : Gve+ aerobes facultative ,some anaerobes ;spirochetes It still drug of choice for Stre.infection M.O.A Penicillin G vs Penicillin V Dose : 250-500 mg every 6-8 h

Metronidazole Dose : 500mg q6-12 hEffect : obligate anaerobes such bactroid ,camp. ,prevotella , vielonella M.O.A Advese effect : metalic taste , glossitis, stomatitis , xerostomia, furry tonge CAUSION : not take with alcohol due to as disulfiram like reaction may occur

Clindamycin (AG)

• Dose : 150-450 mg q6-8h• Effect : mostly against most strain of staph.

Aurus • M.O.A• It is bacteriostatic not bactericidal•

Azithromycin + clarithromycin + erythromycin

• azithro. : dose 500mg for 1 day then 250mg *4d • Clarithro. : dose tab 250-500mg q12 h • ER of clarithro. (not for child) • 1000 * 1 • Note : both Azithromycin + clarithromycin are used

with caution in patient with history of cardiovascular disease

• Erythromycin used as alternative macrolides for patient with history of cardiovascular disease

• Dose : 250-500 mg q 6 h

Doxycycline • Dose : 100 mg q 12h• For sinusitis : cap 100mg ,2cap for 1st day then 1

daily .• Uses : for aubantimicrobial dose as adjunct to

scaling and root planing or for subgingival application .

• Causion in patient with hepatic impairment also for pregnant women and nursing mom due to it deposition in bone and teeth .also enhanced the effect of warfarin .

• Side effect : nausea,vomiting,diarrhoea,dysphagia

Extended spectrum

• Fluroquniolones (nuclic acid synthesis) • It is not used as the first line > due it may cause

colateral damage ( superinfection by resistence pathogens)

• Ciprofloxacin & Levofloxacin : dose 250-700mg q 12h

•

Penicillins ( amoxicillin&ampicillin)

• Amoxicillin : 250-500mg q 8h 500-875mg q 12h

It combid to metronidazole for treat AA. Periodontitis

• Ampicillin

Cephalexin (keflex)

• Dose : 250-1000mg q 6-12h • In patients with a history of severe reactions

(urticaria, angioedema, bronchospasm, anaphylaxis), the rate of reactions to cephalexin in patients with a history of penicillin allergy is about 10%. For patients with a history of a less-than-severe reaction to cephalexin, the rate is closer to 0.1%

Broad spectrum

• Augmentin : • Dose based on amoxicillin content 875mg q 12h ER not for patient less than 40 Kg.

• Tetracyclines ( tetracycline + doxycycline )• Dose : cap. 250-500mg q 6h

Antibiiotic for immunocompramized patient

• Numerous medical conditions are associated with suppression of the immune system either directly from an underlying disease (e.g., diabetes, cancer, organ transplantation)

• or from medications used to manage these diseases (e.g., cyclosporine,prednisone)

• immunocompromised patient is the risk of poor healing and

systemic spread of an orofacial infection

So in order to quantifying patient severity of immunosuppression • Measure ANC(absolute neutrophile count) • ANC is calculated by multiplying the percentage of

neutrophils plus bands (immature neutrophils) with the absolute number of neutrophils from the total white blood cell (WBC) count.

• For example, if a patient had 2000/μL WBCs with 45% neutrophils and 5% bands, the patient’s ANC is 1000/μL (2000/μL × 50%).

• An ANC < 500/μL represents a severe neutropenia with an increased incidence and severity of infection

Neutropenic cancer patients • Patients with cancer may be neutropenic from

their chemotherapy treatment or their underlying cancer.

• , the National Cancer Institute recommends that the American Heart Association (AHA) regimen prophylactic antibiotics be used for patients with indwelling venous access lines and an ANC between 1000 and 2000/μL before any invasive dental procedure.

• Topical antibiotics such as chlorhexidine 0.12% solution swish and expectorate with 10 mL twice daily) are appropriate for localized gingival disease during neutropenia. The use of broad-spectrum antibiotics is appropriate forthe treatment of active orofacial infections in neutropenic patients

• The antibiotic can be changed to a narrower-spectrum agent based on appropriate susceptibility of bacterial isolates as identified through culture of draining pus.

ANTIBIOTIC PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS AND PROSTHETIC JOINT INFECTIONS

• Oral bacterial pathogens may be responsible for cases of infective endocarditis (IE) or late-prosthetic joint infections.

• bacteremia from routine daily activities such as tooth brushing and chewing food

• THE NEW GUIDELINE STATES, “TREATMENTS AND PROCEDURES APPLICABLE TO THE

INDIVIDUAL PATIENT RELY ON MUTUAL COMMUNICATION BETWEEN PATIENT, PHYSICIAN, DENTIST, AND OTHER HEALTHCARE PRACTITIONERS.”

Cardiac Conditions Associated With the Highest Risk of Endocarditis for Which Antibiotic Prophylaxis Is

• •• Prosthetic cardiac valve.• •• Previous infective endocarditis.• •• Cardiac transplantation recipients who develop cardiac

valvulopathy.• •• Congenital heart disease (CHD)a:• •• Unrepaired cyanotic CHD, including palliative shunts and

conduits.• •• Completely repaired congenital heart defect with prosthetic material

or device, whether placed by surgery or by catheter intervention,• during the first 6 m after the procedure.b• •• Repaired CHD with residual defects at the site or adjacent to the site

of a prosthetic patch or prosthetic device (which inhibitendothelialization).

Bacteremic Risks of Various Dental Procedures

• Higher •• Dental extractions• •• Periodontal procedures, including surgery, subgingival placement of

antibiotic fibers/strips, scaling and root• planing, probing, and recall maintenance.• •• Dental implant placement and replantation of avulsed teeth.• •• Endodontic (root canal) instrumentation or surgery only beyond the

apex.• •• Initial placement of orthodontic bands but not brackets.• •• Intraligamentary and intraosseous local anesthetic injections.• •• Prophylactic cleaning of teeth or implants where bleeding is

anticipated

Lower • •• Restorative dentistry (operative and prosthodontic)

with/without retraction cord.c• •• Local anesthetic injections (non-intraligamentary and non-

intraosseous).• •• Intracanal endodontic treatment; post placement and buildup.• •• Placement of rubber dam.• •• Postoperative suture removal.• •• Placement of removable prosthodontic/orthodontic appliances.• •• Taking of oral impressions.• •• Fluoride treatments.• •• Taking of oral radiographs.• •• Orthodontic appliance adjustment

PROPHYLACTIC ANTIBIOTICS IN HEMODIALYSIS PATIENTS

• THE BEST STRATEGY IS TO CONSULT WITH THE PATIENT’S NEPHROLOGIST TO DETERMINE IF PROPHYLACTIC ANTIBIOTICS ARE DEEMED NECESSARY FROM THEIR MEDICAL POINT OF VIEW.

ANTI-VIRAL DRUGS

The primary viral pathogen of oral infections is:- Herpes simplex virus 1 (HSV-1)

Oral HSV-1 infections presents in two forms:-• The first is primary herpetic gingivostomatitis (HGS)

• The second is recurrent herpes labialis (RHL)

Antiviral drugs for Oral Herpes Infections

• Oral antiviral therapies (acyclovir, famciclovir, valacyclovir) are indicated in acute HGS.

First :- acyclovir

HSV- DNA polymerase

 preventing further viral DNA synthesis without affecting the normal cellular processes

Aciclovir

Aciclovir triphosphate

Mode of action

• Child dose :- 15 mg/kg daily for 7 d----five times daily(start within 72 h of symptoms)

• Adult dose :- 400 mg tid or 200 mg five times daily for 7–10 d

• Cream (5%)• Cream (5%) with hydrocortisone (1%)• Ointment (5%)

• Contraindications:- Hypersensitivity to acyclovir orValacyclovir

• Precautions:- Renal dysfunction or co- administration of nephrotoxic drugs

apply to lesion five timesdaily for 4 d

• Common side effects:-

• Important drug interactions:- Aminoglycosides , phenytoin , Mycophenolate and probenecid.

• In pregnancy:-category B• During feeding :-not use over 800mg and is preferable

topical only

Second:- Famciclovir (Famvir)

• Adults dose :-500 mg tid for 7–10 d• Cream (1%):- Apply to lesion every 2 h while awake for 4 d

• Important drug interactions Digoxin(hf), probenecid(Uric A.)

• Hypersensitivity to famciclovir• Pregnancy:-category B

• Adult dose:- 1 g bid for 7–10 d

• Interaction :-Cimetidine, phenytoin, probenecid

• Hypersensitivity to acyclovir or valacyclovir

• Prophylaxis :-500 mg qd (indefinite duration)

• In pregnancy:-category B

THIRD:-VALACYCLOVIR

Preventive strategies

• basic avoidance of triggers• use of sunscreen• use prophylactic drug therapy to reduce the

recurrence rate.• Oral acyclovir and valacyclovir• Given that valacyclovir is a once-daily

treatment• acyclovir is to be taken twice daily for

prevention

FUNGAL INFECTION

Risk factors1.Age2.Diabitic mellitus3. Poor oral hygiene4. Chronic local irritation of mucus membrane5. Oral prostheses6. immunosuppressed Patients

1. acute pseudomembranous candidiasis (commonly called thrush).

2. Acute atrophic or erythematous candidiasis

Type of poc

Oral candidiasis

Topical1. Miconazole tab 50 mg 2. nystatin 100,000 units/ml3. Clotrimazole 10ml

1.fluconazole2. Itraconazole ( first line)3.Posaconazole ( first line)4. Voriconazole (second line)5.Amphotrisene b (second line)

Mild

Moderate and sever disease

Treatment of Angular Cheilitis

1.Bacterial can be cured using mupirocin topical ointment

2. fungal topical nystatin or ketoconazole cream a mild corticosteroid, to reduce inflammation like triamcinolone

3.nither bacterial nor fungal origin, barrier creams such as petrolatum, zinc oxide, or lip balm can help protect irritated skin

Denture Stomatitis 1. chlorhexidine and chlorine-based soaks

2. oral hygiene

3. removing dentures at night

4. medications useful in reducing ulceration recurrence include colchicine, pentoxifylline, azathioprine, thalidomide, and dapsone. injectable immunosuppressant, such as interferon alfa, infliximab, and etanercept

symptom management

1.topical and oral corticosteroids.

2.Intralesional steroid injections are not advised

3.topical pimecrolimus or tacrolimus might either be considered a first-line therapy or be useful in steroid-refractory case

Lichen Planus

pemphigus vulgaris, bullous pemphigoid, and mucous membrane pemphigoid topical corticosteroids.

For refractory disease or to induce remission

combinations of oral corticosteroids and immunosuppressant medications such as azathioprine, dapsone, mycophenolate, or cyclophosphamide can be used

Other Oral Lesions