1b34Guidelines for Antibiotics Use by Dentists

8/6/2019 1b34Guidelines for Antibiotics Use by Dentists

http://slidepdf.com/reader/full/1b34guidelines-for-antibiotics-use-by-dentists 1/41

Guidelines for Antibiotics UseGuidelines for Antibiotics Use

by Dentistsby Dentists

Dr Najla DarDr Najla Dar--OdehOdeh

Associate Professor in Oral Medicine Associate Professor in Oral MedicineUniversity of JordanUniversity of Jordan



All antibiotics are potential poisons All antibiotics are potential poisons

for some patients. Use them withfor some patients. Use them withcare and thoughtfulnesscare and thoughtfulness

(Long, 1951)(Long, 1951)



Antibiotics are societal drugs Antibiotics are societal drugs

that affect microbial resistance not only inthat affect microbial resistance not only inthe person taking the drug but alsothe person taking the drug but alsoeveryone else, because resistance geneseveryone else, because resistance genesare easily passed via personal contact,are easily passed via personal contact,fomites, and human and animal refusefomites, and human and animal refuse

(Levy SB., 2002)(Levy SB., 2002)



Does Dental Profession EncourageDoes Dental Profession EncourageDevelopment of AntibioticDevelopment of AntibioticResistance?Resistance? Y es Y es

the use of increasingly broadthe use of increasingly broad

spectrum agentsspectrum agents crowding of the most vulnerablecrowding of the most vulnerable

members of society in day caremembers of society in day carecentres and nursing homes.(incentres and nursing homes.(in

some countries)some countries)

over the counter use of antibioticsover the counter use of antibiotics



Unscientific Causes for AntibioticUnscientific Causes for Antibiotic

PrescribingPrescribing patients expectation of an antibiotic prescription,patients expectation of an antibiotic prescription,

convenience and demand necessitated by theconvenience and demand necessitated by the

social background of the patients.social background of the patients. Lack of time and pressure of workloadLack of time and pressure of workload



NonNon--indicated Cases for Antibioticindicated Cases for Antibiotic

PrescriptionPrescription acute periapical infectionacute periapical infection

dry socket dry socket

acute pulpitisacute pulpitis chronic marginal gingivitischronic marginal gingivitis

chronic periodontitis.chronic periodontitis.



guidelinesguidelines Antibiotic therapy should be used as an adjunct to Antibiotic therapy should be used as an adjunct to

dental treatment and never used alone as the first linedental treatment and never used alone as the first lineof care.of care.

Antibiotics are indicated when systemic signs of Antibiotics are indicated when systemic signs of involvement are evident. Pain alone or localizedinvolvement are evident. Pain alone or localizedswellings do not require antibiotic treatment.swellings do not require antibiotic treatment.

Fevers, malaise, lymphadenopathy or trismus areFevers, malaise, lymphadenopathy or trismus are

clinical signs that possible spread of the infection hasclinical signs that possible spread of the infection hasoccurred.occurred.

A rapidly spreading infection or persistent infections A rapidly spreading infection or persistent infections



Indications for the Use of Indications for the Use of

Antibiotics in Dentistry Antibiotics in Dentistry oral infection accompanied by elevated bodyoral infection accompanied by elevated body

temperature,temperature,

evidence of systemic spread,evidence of systemic spread,

facial cellulitis and/or dysphagia.facial cellulitis and/or dysphagia.

periodontal abscessperiodontal abscess

acute nercotizing ulcerative gingivitisacute nercotizing ulcerative gingivitis

sinusitissinusitis pericoronitispericoronitis



Prescriptions written in generic names arePrescriptions written in generic names are

as efficacious as brand names, andas efficacious as brand names, andproduce cost savings.produce cost savings.



Hit hard and hit fast. Hit hard and hit fast.

Paul Ehrlich (1913):Paul Ehrlich (1913):



Wrong ideasWrong ideas antibiotics should be used for a certain number of antibiotics should be used for a certain number of

required days to kill the resistant strains as therequired days to kill the resistant strains as thevast majority acquire their resistance viavast majority acquire their resistance via

transposable elements that are preferentiallytransposable elements that are preferentiallytransferred when antibiotics are used in subtransferred when antibiotics are used in sub--therapeutic doses or for long durationstherapeutic doses or for long durations

Finish the course : ideally the antibiotic is prescribedFinish the course : ideally the antibiotic is prescribedfor 3for 3--5 days with a sufficient loading dose5 days with a sufficient loading dose



Generally, antibiotics used in dentistry are most Generally, antibiotics used in dentistry are most effective when the organism iseffective when the organism is consistently exposedconsistently exposed totothe agent (timethe agent (time--dependent rather than concentrationdependent rather than concentration--

dependent activity)dependent activity)



Short Vs Long coursesShort Vs Long courses

Short courses are preferred to long coursesShort courses are preferred to long coursesparticularly when treating children. Childrensparticularly when treating children. Childrens

compliance with conventional courses is poorcompliance with conventional courses is poor

There is evidence that short courses of antibiotics,There is evidence that short courses of antibiotics,with appropriate treatment are adequate for resolutionwith appropriate treatment are adequate for resolution

of dental infectionsof dental infections



Adapted from Rubenstein E (2007)



Longer durationsLonger durations may result inmay result in

selection of resistant strainsselection of resistant strains

reduction in the ability of the oral flora to resist reduction in the ability of the oral flora to resist

the colonization of harmful microthe colonization of harmful micro--organismsorganismswhich are not normal resident of the oral flora,which are not normal resident of the oral flora,thereby leading to superimposed infections bythereby leading to superimposed infections bymultimulti--resistant bacteria and yeasts.resistant bacteria and yeasts.



In the majority of patientsIn the majority of patients 2 or 3 days2 or 3 days of oralof oralantibiotics, in doses recommended by the BNF,antibiotics, in doses recommended by the BNF,

will suffice for acute dentoalveolar infections.will suffice for acute dentoalveolar infections.



The 2The 2--dose 3 gm regimen of amoxicillindose 3 gm regimen of amoxicillin

has been shown to be effective inhas been shown to be effective incertain situations.certain situations.



General PrinciplesGeneral Principles



(1)make an accurate diagnosis;

(2) use appropriate antibiotics and dosingschedules;

(3) consider using narrow-spectrum antibacterial

drugs in simple infections to minimizedisturbance of the normal microflora, and

preserve the use of broad-spectrum drugs for

more complex infections



NarrowNarrow--spectrum antibioticsspectrum antibiotics

ClindamycinClindamycin

MetronidazoleMetronidazole

Penicillin VPenicillin V



BroadBroad--spectrum antibioticsspectrum antibiotics

Amoxicillin (Semisynthetic Penicillin) Amoxicillin (Semisynthetic Penicillin) Amoxicillin with Clavulanic Acid Amoxicillin with Clavulanic Acid

Ampicillin (Semisynthetic Penicillin) Ampicillin (Semisynthetic Penicillin)

Cefadroxil (FirstCefadroxil (First-- Generation Cephalosporin)Generation Cephalosporin)

Cefazolin (FirstCefazolin (First-- Generation Cephalosporin)Generation Cephalosporin)

Cephalexin (FirstCephalexin (First-- Generation Cephalosporin)Generation Cephalosporin)

Cephradine (FirstCephradine (First-- Generation Cephalosporin)Generation Cephalosporin)

Azithromycin (Macrolide) Azithromycin (Macrolide)

Clarithromycin (Macrolide)Clarithromycin (Macrolide)

Erythromycin (Macrolide)Erythromycin (Macrolide)

Tetracycline (Doxycycline, Minocycline)Tetracycline (Doxycycline, Minocycline)



(4) avoid unnecessary use of antibacterialdrugs in treating viral infections;



(5) if treating empirically, revise treatment regimen based on patient progress or test

results

(6) obtain thorough knowledge of the side

effects and drug interactions of anantibacterial drug before prescribing it



Interactions with other drugsInteractions with other drugs

additional contraceptive precautions shouldadditional contraceptive precautions shouldbe taken whilst taking a short course of abe taken whilst taking a short course of a

broad spectrum antibiotic and for 7 daysbroad spectrum antibiotic and for 7 daysafter stopping.after stopping.

A patient taking warfarin, requiring A patient taking warfarin, requiringantibiotics, should have their baseline INRantibiotics, should have their baseline INRdetermined before medication is started.determined before medication is started.



(7) educate the patient regarding properuse of the drug and stress theimportance of completing the full courseof therapy (that is, taking all doses forthe prescribed treatment time).



Special ConditionsSpecial Conditions



Periodontal DiseasePeriodontal Disease

Antimicrobial prescribing should be the Antimicrobial prescribing should be theexception rather than the rule and, in theexception rather than the rule and, in themajority of cases, only considered aftermajority of cases, only considered after

conventional therapies have beenconventional therapies have beenunsuccessful.unsuccessful.



In indicated cases of periodontal disease,In indicated cases of periodontal disease,the recommended dosage of amoxicillinthe recommended dosage of amoxicillinand metronidazole is 250 mg amoxicillinand metronidazole is 250 mg amoxicillin

and 200 mg metronidazole, three times aand 200 mg metronidazole, three times aday for 7 days.day for 7 days.

The suggested alternative to amoxicillin inThe suggested alternative to amoxicillin in

cases of known penicillin allergy iscases of known penicillin allergy isciprofloxacin (250ciprofloxacin (250 500 mg twice daily).500 mg twice daily).



The combination of metronidazoleThe combination of metronidazoleand amoxicillin is particularlyand amoxicillin is particularlyadvised for the treatment of advised for the treatment of

indicated cases of chronicindicated cases of chronicperiodontal diseases.periodontal diseases.



EndodonticsEndodontics

The treatment of acute and chronicThe treatment of acute and chronicinfections of endodontic origin isinfections of endodontic origin isprimarily by operative intervention.primarily by operative intervention.

When indicated, the antibiotic of

When indicated, the antibiotic of choice may be cephalosporins orchoice may be cephalosporins or

clindamycinclindamycin



ProphylaxisProphylaxis

Although antibiotics treat infections, limited Although antibiotics treat infections, limitedbenefit has been demonstrated in preventingbenefit has been demonstrated in preventinginfections.infections.

The absolute risk rate for bacterial endocarditisThe absolute risk rate for bacterial endocarditisafter dental treatment even in at after dental treatment even in at--risk patients isrisk patients isvery low.very low.

Reliance on antibiotics alone, and particularlyReliance on antibiotics alone, and particularlybroad spectrum rather than specific antibiotics,broad spectrum rather than specific antibiotics,may result in failure to control infections andmay result in failure to control infections and

encourage the development of resistant encourage the development of resistant



The evidence for antibiotics acting toThe evidence for antibiotics acting toprevent infection from surgicalprevent infection from surgicalwounds in the mouth is poor to nonwounds in the mouth is poor to non--existent existent



Parenteral and broadParenteral and broad--spectrumspectrumantibiotics have an important role inantibiotics have an important role in

the followingthe following1.1. patients with severe odontogenicpatients with severe odontogenic

infectionsinfections

2.2. those requiring major elective headthose requiring major elective headand neck surgeryand neck surgery

3.3. management of medicallymanagement of medically

compromised patients.compromised patients.

Prophylaxis for third molar surgeryProphylaxis for third molar surgery



Infective EndocarditisInfective Endocarditis

D t P RD t P R



Denta Proce ures Requ r ngDenta Proce ures Requ r ng Antibiotic Coverage ( Antibiotic Coverage (2007 Guidelines2007 Guidelines))

All dental procedures that involve manipulation All dental procedures that involve manipulationof gingival tissue or the periapical region of of gingival tissue or the periapical region of teeth or perforation of the oral mucosateeth or perforation of the oral mucosa

Suture removalSuture removal

ExtractionsExtractions

Periodontal procedures (scaling, root planing,Periodontal procedures (scaling, root planing,

probing, surgery, recall maintenance)probing, surgery, recall maintenance)

Implant placement and remimplantation of Implant placement and remimplantation of avulsed teethavulsed teeth



Dental Procedures RequiringDental Procedures Requiring Antibiotic Coverage ( Antibiotic Coverage (2007 Guidelines2007 Guidelines))

Endodontic instrumentation or surgery when beyondEndodontic instrumentation or surgery when beyondthe apexthe apex

Subgingival placement of antibiotic fibres or stripsSubgingival placement of antibiotic fibres or strips Intraligamentary local anaesthetic injectionsIntraligamentary local anaesthetic injections

Prophylactic cleaning of teeth or implantsProphylactic cleaning of teeth or implants

BiopsiesBiopsies

Placement of orthodontic bandsPlacement of orthodontic bands



Amoxicillin remains the first choice, however it Amoxicillin remains the first choice, however it is recommended that administration of is recommended that administration of

amoxicillin (and any other recommendedamoxicillin (and any other recommendedantimicrobial) is 30antimicrobial) is 30--60 minutes before the60 minutes before theprocedure.procedure.



Alternatives to Penicillin Alternatives to Penicillin although considered by most dentists to be thealthough considered by most dentists to be the

alternative to penicillin in penicillinalternative to penicillin in penicillin--allergic individualsallergic individualserythromycinerythromycin isis

a weakly active, bacteriostatic antibiotic to most orala weakly active, bacteriostatic antibiotic to most oralmicromicro--organismsorganisms

susceptible to acid degradation when taken orallysusceptible to acid degradation when taken orally

resistance is a problem with erythromycin and canresistance is a problem with erythromycin and can

even develop during a courseeven develop during a course

it has a high incidence of adverse effects such asit has a high incidence of adverse effects such asnausea, vomiting, abdominal pain, diarrhoea andnausea, vomiting, abdominal pain, diarrhoea andanorexia.anorexia.



ConclusionsConclusions

Appropriate dental treatment, Appropriate dental treatment,

Analgesic therapy, Analgesic therapy,

Education of the patient Education of the patient

will alleviate the patients symptoms andwill alleviate the patients symptoms and

build trust in the doctorbuild trust in the doctor patient patient relationship.relationship.

1b34Guidelines for Antibiotics Use by Dentists

Documents

Transcript of 1b34Guidelines for Antibiotics Use by Dentists