Quartz 4

O2. Antibiotics and Antifungals

13 min read

Aim

  • To stop inappropriate use, over-use and abuse of antibiotics for oral and dental problems !!

    • **By ALL prescribers !!

  • To educate on the appropriate indications and selection of antibiotics for oral and dental problems.

    • To highlight the significant issues of overuse, misuse, and abuse of antibiotics.

**

Why?

  • To decrease the development of resistance
  • To improve our chances of treating future infections that REALLY DO need antibiotics
  • To provide appropriate treatment for rapid relief of symptoms

Inappropriate Antibiotic Use in Dentistry1

Prevalence of Inappropriate Use

  • Inappropriate use is very common
    • Up to 50% of prescriptions for human antibiotic use are unnecessary or questionable → Samaranayake & Johnson - IDJ 1999

Info

A primary reason for this overuse, particularly in dentistry, is the prescription of antibiotics for pain relief rather than for treating a diagnosed systemic infection.

Antibiotic Use in Endodontics: A US Study

Whitten et al JADA 1996

Commentary on the US Study

  • ==Acute Irreversible Pulpitis: An inflammatory condition for which antibiotic use should be zero.==
  • ==Chronic Apical Abscess: This condition requires definitive dental treatment (root canal or extraction) to heal; antibiotics may temporarily mask symptoms (e.g., close a sinus tract) but do not resolve the underlying cause.==
  • The study noted that antibiotic use was significantly higher for acute, painful conditions compared to their chronic counterparts, indicating that prescriptions were often driven by the severity of pain rather than the presence of a systemic infection.

Some acute apical abscesses may need antibiotics – but not all !!!

Antibiotic Use in Endodontics: A Spanish Study2

Segura-Egea et al IEJ 2010; Rodriguez-Núñez et al JoE 2010

Percentage of Spanish dentists who prescribe antibiotics for:

Commentary on the Spanish Study

  • A dramatic increase in antibiotic prescriptions for acute conditions (e.g., acute apical periodontitis, acute abscess) compared to chronic ones.
  • Disappointingly high rates of inappropriate antibiotic use for inflammatory conditions like irreversible pulpitis.

Warning

==An interesting and concerning finding was that while 83% of dentists would prescribe antibiotics for a periapical abscess, less than half would for facial cellulitis. Facial cellulitis is a clear and definite indication for aggressive antibiotic therapy.==

Antibiotic Use in Endodontics: An Australian Study3

Abbott - AEJ 2000

Initial Prescriptions by Referring Practitioners

What happens in Australia ?

→ 99 patients had been prescribed antibiotics when only four needed them! !!!

Assessment by Endodontist

Same patients when assessed by the Endodontist

Cases needing Ab’s
Acute Apical Abscess (sometimes )
Facial Cellulitis (all the time)

Patient and Practitioner Perspectives4

General Medical Practitioners’ Knowledge and Management of Oral and Dental Problems

Results – Patient Expectations

Patients’ Expectations% of Patients
To be prescribed antibiotics80.7%
To be prescribed pain relief78.6%
Certificate for time off work/school22.1%
Referral to dentist7.1%

Info

This indicates a common patient misconception that antibiotics are a tool for managing pain.

Results – Managing Pain by GPs5

  • Main management of pain by GP’s
    • referral to a dentist with perscription of antibiotics

Appropriate GP Management

==While GPs in the study would also refer the patient to a dentist, the most appropriate immediate management is referral without an antibiotic prescription, as GPs typically cannot make a definitive dental diagnosis.==

Myths and Truths about Dental Pain

Myths

  • Myth: All dental pain is because of infection
    • FACTS:
      • Bacteria are present in the tooth
      • But the PRESENCE of bacteria does NOT imply infection

Info

Conditions like caries and apical periodontitis are bacterial-driven but are not infections in the traditional sense. Antibiotics are ineffective because they cannot reach the source of the bacteria (e.g., inside a necrotic, pulpless root canal).

  • Myth: Antibiotics are required
    • FACTS:
      • Antibiotics MIGHT help to relieve the symptoms (a little !!!)
      • BUT they do NOT remove the micro-organisms !!!
      • Placebo effect !!!
      • OR it is just an effect of time and/or coincidence !!!

Example

Any perceived relief may be a placebo effect or coincidence (e.g., the pain of pulpitis resolves when the pulp dies, which can take about a week, coinciding with the length of an antibiotic course).

  • “Dental treatment cannot be done until the swelling / infection has been treated”
    • Patients, doctors, nurses & some dentists !!!
  • Hence some patients will seek medical management - i.e. antibiotics !!
    • With the MISTAKEN belief that antibiotics will “treat” the infection

The Truth

==Definitive local dental treatment is the most effective way to manage the problem and should be performed promptly, even in the presence of swelling and infection. Pre-treating with antibiotics is unnecessary in the vast majority of cases.==

Truths6

FACTS: Local (i.e. dental) treatment for dental pain is:

  • Much quicker
  • Far more effective, and
  • Removes the cause of the disease

→ Hence, patients need to see a dentist for PREDICTABLE and EFFECTIVE management of oral and dental pain !!!

Understanding Dental Pathology7

A Critical Distinction

==It is critical to understand that the radiolucency seen on an x-ray in cases of apical periodontitis is inflammation, not infection due to the host defense response . It represents the body’s host defense response to the bacterial

Causes and Examples of Dental Pain8

Causes of Dental Pain

  • common and do NOT require antibiotics
    • Cracked cusps
    • Unsatisfactory or broken filling
    • Trauma - fractures, luxations
    • Food pack between teeth
    • Decay - with pulpitis / apical periodontitis
    • Temporo-mandibular joint diseases
    • Inflamed muscles of mastication
    • Periodontal disease
  • uncommon and some might need antibiotics
    • Periodontal abscess
    • Periapical abscess

Examples of Dental Pain

1. Pulpitis

  • Inflammation, not infection → AB’s not required
  • Few, if any, bacteria are in the pulp
  • AB concentration in pulp is too low to kill bacteria

Typical Symptoms

  • Reversible Pulpitis

    MILD

    • Sensitivity to cold &/or heat
    • Extreme temperature change
    • Sharp pain, short duration (few seconds)
  • Irreversible Pulpitis

    SEVERE

    • Sensitivity to cold &/or heat
    • Mild temperature change
    • Sharp pain initially
    • Then lingers - throbbing ache (> 5 mins)

2. Infected Root Canals9

  • No blood supply to the canal → no AB reaches the bacteria
  • therefore no need for antibiotics

**3. Apical Periodontitis

Info

This is an inflammatory response to bacteria within the root canal, not an infection of the periapical bone itself. The condition is resolved by treating the source: root canal treatment or extraction.

  • Inflammation, NOT infection → AB’s not required

4. Extra-Radicular Infection10

  • Bacteria protected by an extra-cellular matrix / biofilm
  • Needs surgical management to remove the matrix / biofilm
    • this biofilm makes it unlikely to respond to antibiotics

Treatment

==Effective management requires both root canal treatment (to address the intracanal source) and periapical surgery (to physically remove the external biofilm).==

5. Abscess - periapical or periodontal

  • Antibiotiecs can not penetrate the lining or the pus
  • Reduced blood flow
  • the above two factors make it that antibiotics aren’t very effective

**6. Alveolar Osteitis - “dry socket”

Info

==The proper term, alveolar osteitis, indicates that this is inflammation of the bone socket after an extraction.== thus it is not an infection but an inflammation so antibiotics are not required

Summary

Most causes of dental pain are inflammatory. It is inflamed tissue that causes pain, not always infection. An accurate diagnosis is essential to provide appropriate treatment and avoid unnecessary antibiotic prescriptions.

The Problem of Bacterial Resistance

So what is the big deal ???

What’s wrong with giving AB’s???? → Bacterial Resistance !!!

Evidence of Increasing Resistance11

Australian Data

Australia has a significantly higher rate of antibiotic consumption (defined daily dose per 1,000 people) compared to many European countries like Denmark, the Netherlands, and Sweden. There is also a tendency to use broader-spectrum antibiotics when narrow-spectrum ones would be more appropriate.

  • Prescribing a routine course of AB’s significantly increases the likelihood of an individual carrying a resistant bacterial strain
  • Resistance persists within populations
  • The burden is shared by the whole community
  • WHO recently warned of a return to the pre-antibiotic era if bacterial resistance continues to develop unabated

A Global Threat12

  • **“Antibiotic Resistance a Major Threat”

A National Threat

The UK's Chief Medical Officer has ranked antibiotic resistance alongside terrorism as a major national threat.

A Structured Approach to Managing Dental Pain

Tip

The correct approach to managing a patient with dental pain follows the three D's:

  1. Diagnosis
  2. Dental Treatment
  3. drugs

Indications for Antibiotic Use13

When are Antibiotics Needed?

  • Antibiotics do not CURE dental infections
    • They ASSIST the body’s defense mechanisms to overcome the bacterial attack
    • Only needed when the body’s efforts are failing
      • Signs of failure: → Fever, malaise, cellulitis, progressive swelling, lymph node involvement and trismus

Note

==Lymph node involvement is also known as Lymphadenopathy (swollen, tender lymph nodes).==

The Importance of Local Treatment14

  • Orofacial infections can be effectively treated by:
    • Removing as many organisms as possible
    • Drainage of pus
  • Removing as many organisms as possible
    • ➔ Reduces demand on body’s defense mechanisms
    • ➔ Reduces the number of resistant strains
  • Drainage of pus
    • ➔ Since abscesses reduce blood flow to the are Which limits AB distribution to the region

Providing Drainage151617

  • ONLY if required
  • Via the root canal
  • Or via soft tissue incision

Info

==A draining sinus (intraoral or extraoral) is a sign that the abscess is already draining, and no further incision is needed.==

Principles of Antibiotic Use for Dental and Oral Infections

  • Indications for antibiotics in Dentistry
    • There are very few REAL indications
    • Antibiotics should only be considered as an ADJUNCT to dental treatment
    • Reserve AB’s for special circumstances
    • Use locally rather than systemically → i.e. Topically, intra-dentally, etc

Example

==For example, locally applied agents (e.g., antiseptic intracanal dressings) should be used instead of systemic medication where possible.==

Limiting Systemic Antibiotic Use18

  • Systemic use of AB’s should be limited to:
    • Patients showing signs of malaise → Elevated body temperature → Lymph node involvement
    • Suppressed or compromised immune system

Factors Affecting General Resistance19

  • Patient’s general resistance affected by:
    • Drugs
    • Old age
    • Anxiety
    • Alcoholism
    • Malnourishment
    • Systemic diseases
    • Other infections, etc

ALL can cause suppression of the immune response

  • Systemic use of AB’s should be limited to:
    • Patients showing signs of malaise → Elevated body temperature → Lymph node involvement
    • Suppressed or compromised immune system
    • Cellulitis or spreading infection
    • Rapid onset (<24 hours) of severe infection → To avoid possible complications of the infection

Possible Complications from Dental Infections

  • Bacterial endocarditis
  • Cavernous sinus thrombosis
  • Orbital cellulitis
  • Ludwig’s angina
  • Brain abscess
  • Mediastinitis
  • Osteomyelitis

Ludwig's Angina

This is a particularly dangerous complication involving airway compromise due to swelling in the floor of the mouth.

Strategies for Antibiotic Prescription20

General Strategies

  • Strategies for the use of antibiotics:
    • Choose appropriate, narrow spectrum AB
    • High initial dose - double “normal” dose
    • Consider IM or IV - if severe infection
    • Commence ASAP
    • Monitor progress of the patient daily
      • **If no improvement seen after 24 - 48 hours
        • Reconsider the diagnosis
          • Consider further / different dental treatment
          • Consider using a different AB

Duration of Therapy

  • The correct time is the time that it takes for the host’s defense mechanisms to regain control
    • Evidenced by subsiding systemic manifestations
  • Oro-facial infections rarely rebound once the source of bacteria is reduced / removed
    • Continue AB’s only for 1 - 2 days after the signs of the infection diminish
      • Usually only need 4-5 days (total)

Guiding Principle

==The principle is to use higher doses for a shorter period to reduce the risk of developing resistance.==

Choosing an Antibiotic21

  • Decision should be based on the type of organisms present
    • § Microbiological analysis

Microbiological Analysis22

  • Ideally should be done for ALL cases when AB’s are being considered
    • To identify the bacteria
    • To test susceptibility to antimicrobial agents

Practical Problems23

  • Difficulties with anaerobic culturing

    • Time involved
    • Experience required for accurate identification
      • Lack of experience in commercial labs for dental samples

  • Costs

  • Treatment usually resolves the disease before the results can be obtained

  • ∴ Assumptions are made clinically

    • Based on research reports about the commonly found organisms

Susceptibility to Antibiotics24

Info

The small advantage of broad-spectrum drugs like Amoxicillin/Clavulanic Acid does not usually justify their use over a narrow-spectrum drug like Penicillin V for most dental infections.

Skucaite et al - J Endod 2010 Bacteria from Root Canals or P-ap. Abscesses

  • Penicillin - 81% (+17.4% intermed. suscept.) 98.4%
  • Amoxicillin - 84% (+16.3% intermed. suscept.) 100%
  • Amoxicillin + Clavulanic Acid - 100%
  • Clindamycin - 74%
  • Metronidazole - 44%
  • Erythromycin - 55%
  • Tetracycline - 60%

**Bacteria Exist as Communities

Info

  • Dental infections are caused by complex bacterial communities (biofilms).
  • It is not necessary to kill every single bacterium. Disrupting the community by eliminating key species can cause the entire biofilm to collapse, allowing the host's immune system to take over.

The Antibiotic Creed - “MIND ME”25

  • M Microbiology guides therapy wherever possible
  • I Indications should be evidence-based
  • N Narrowest spectrum required
  • D Dosage appropriate to site and type of infection
  • M Minimise duration of therapy
  • E Ensure monotherapy in most situations
DrugDoseUse
Penicillin VLoading: 1000 mg; Then: 500 mg q6h for 5 daysFirst choice for most odontogenic infections (gram-positive)
MetronidazoleLoading: 800 mg; Then: 400 mg q12h for 5 daysSecond choice, especially if anaerobic bacteria are suspected
ClindamycinLoading: 300 mg; Then: 150 mg q8h for 5 daysFirst choice if penicillin allergic; broad antibacterial spectrum
Amoxicillin2 gm 1 hour pre-op (prophylaxis)Primarily for prophylaxis against infective endocarditis
Tetracycline(Dose not specified for this use)Prevention of root resorption after dental trauma (inflammatory and replacement)

Summary: The Limited Role of Antibiotics26

What Antibiotics Will NOT Do27

  • Antibiotics will NOT:
    • Help resolve pulpitis
    • Prevent post-operative pain
    • Prevent “flare-ups”
    • Help “just in case”

**Correct Management of Dental Pain

  • Manage dental pain by:
    1. Removing bacteria in the tooth
    2. Removing the pathways of penetration → Decay, cracks, restorations breaking down
    3. Treating the root canals (if necessary)
    4. Restoring the tooth

Footnotes

  1. Original PDF page 2: O2 AntibioticsEndo, p.2 ↩

  2. Original PDF page 3: O2 AntibioticsEndo, p.3 ↩

  3. Original PDF page 4: O2 AntibioticsEndo, p.4 ↩

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  12. Original PDF page 17: O2 AntibioticsEndo, p.17 ↩

  13. Original PDF page 23: O2 AntibioticsEndo, p.23 ↩

  14. Original PDF page 24: O2 AntibioticsEndo, p.24 ↩

  15. Original PDF page 25: O2 AntibioticsEndo, p.25 ↩

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  17. Original PDF page 27: O2 AntibioticsEndo, p.27 ↩

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  19. Original PDF page 29: O2 AntibioticsEndo, p.29 ↩

  20. Original PDF page 30: O2 AntibioticsEndo, p.30 ↩

  21. Original PDF page 31: O2 AntibioticsEndo, p.31 ↩

  22. Original PDF page 32: O2 AntibioticsEndo, p.32 ↩

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  25. Original PDF page 35: O2 AntibioticsEndo, p.35 ↩

  26. Original PDF page 38: O2 AntibioticsEndo, p.38 ↩

  27. Original PDF page 39: O2 AntibioticsEndo, p.39 ↩

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