ANTIBIOTICS USED IN DENTISTRY

Dr. Mohamed Shokry

Oral & Maxillofacial Surgery Department
Faculty of Dentistry- Alexandria University- Egypt

DEFINTION
Antibiotics are chemical substances elaborated by various
species of micro-organisms such as fungi, actinomyces
and bacteria.
They suppress the growth of other micro-organism and
may destroy them.
Antibacterial agents
Naturally or Synthetic occurring agent which can kill or
inhibit the growth of bacterial cells.
Antibacterial agents may be:
Natural
chemicals
that
are
microorganisms:
e.g.
penicillins,
tetracyclines & chloramphenicol.

produced
by
cephalosporins,

Synthetic agents: sulfonamides and quinolones.

History
3500 BC the Sumerian doctors would give patients beer
soup mixed with snake skins and turtle shells.
Babylonian doctors would heal the eyes by using an
ointment made of frog bile and sour milk.
The Greeks used many herbs as medications .
All of these "natural " treatments contained some sort of
antibiotic.

Modern history:
In 1935, Domagk discovers synthetic antimicrobial
chemicals (sulfonamides(.
During World War II, penicillin was isolated and
injected. It was found to be extremely useful in
curing infections.
1940-1950:
streptomycin,
tetracycline were discovered

chloramphenicol,

&

Classification of antibiotics:
1. Agents that inhibits synthesis of bacterial cell wall
e.g Penicillin & cephalosporin
2. Agent that act on the
cell membrane of the
microorganism
affecting
its
permeablity
e.g:
polymyxin & polyene antifungal agent nystatin
3. Agent that affect the function of 30 s or 50 s
ribosomal subunit to cause reversible inhibition of
protein synthesis e.g chloramphenical ,Tetracycline,
Erythromycin, Clindamycin

Classification According to spectra:

Antibiotic effective against gram positive bacteria
e.g. erythromycin, lincomycin.
Antibiotic effective against gram negative bacteria
e.g. strepomycin & other aminoglycosides
Antibiotic mainly effective against gram ve & +ve
bacteria e.g. ampicillin, amoxycillin, cephalosporin

 Effective against acid fast bacilli. e.g. streptomycin,

rifampicin & viomycin
Effective against protozoa e.g. Tetracyclin
Effective against fungi e.g.nystatine

PRINCIPLES OF ANTIBIOTIC THERAPY IN DENTAL

INFECTION:
1- Bacterial
infections

flora

causing

most

odontogenic

2- The basic mechanism of host defenses

3- The principles to choose antibiotics

Bacterial flora causing most odontogenic infections

The main microbial flora of the mouth is bacteria, which
are almost always the cause of odontogenic infections.
The usual flora is both aerobes & anaerobes
The
basic
mechanism
of
host
defenses
factors affecting the host defenses mechanism:
Physiologic depression of host defence
Obesity
Disturbances of circulation
Fluid imbalance
Diseases that may inhibit host defense
Patient with cancer and leukemia
Total body radiation therapy
Poorly controlled diabetics

 Therapeutic drugs that impares host defense

mechanism
Cytotoxic drugs
Immunosuppressive drugs

Principles to choose Antibiotics:

1-

Identification of causative organism:

Causative organism can be isolated from:
Blood
Tissue fluids
pus

2- Determination of antibiotic sensitivity

When treating an infection that has not responded to
initial
antibiotic
therapy
or
when
treating
a
postoperative wound ,the causative agent must be
previously identified and the antibiotic sensitivity must
also be determined.
3- Choice of antibiotics:
Upon the culture and
sensitivity report, there may be a choice of four or
five antibiotics. Selection should be based on:
Patients previous history of allergy
Antibiotics with narrow spectrum
Drug that cause fewest adverse reactions
Drug which is least toxic
Bactericidal rather than bacteriostatic drug

The less expensive but still effective antibotic

1-Patient`s history of allergy

Allergic reaction to drugs should be considered first.

When it exists, alternative drugs must be used.
Example: erythromycin or clindamycin is usually use if the
patient is allergic to penicillin

2- Antibiotics with narrow spectrum

The only majour indication for use of broad spectrum
antibiotics coverage is in severe life threatening infection
where identification of causative agent is obscure.
Each time bacteria are exposed to antibiotics, the
opportunity for development of resistant strains is present.
If narrow spectrum antibiotics is used ,fewer organisms
have the opportunity to become resistant.
3- Drug that cause fewest adverse reactions

The goal of antibiotic therapy is to provide an

effective Drug that causes least problem to the
patient.

4- Drug which is least toxic

Toxicity reactions are those that occur as a result of
excessive dose or duration of therapy, but can occur
in individual patients with normal doses.
5- Bactericidal rather than bacteriostatic drug
Bactericidal drug:Actually kills the organism.
Bacteriostatic drug :Prevents
reproducing or growing.

the

organism

6- The less expensive still effective antibotic

from

Most effective but

considered first.

less

expensive

drug

should

be

Bacterial resistance to antibiotic:

When the drug does not reach its target
The drug is not active
Target is altered

Antibiotics are used in three general ways:

Empirical therapy (Initiative therapy)
Definitive therapy
Prophylactic or preventive therapy

Factors affecting the selection of antibiotics:

Pharamacokinetic factor
Host factors
Local factors
Genetic factors
pregnancy
Drug allergy
Pharamacokinetic factor that affect the selection of
antibiotic
Location of the infection.
Access of antibiotic to sites of infection.

e.g. if the infection in the CSF the drug must pass the
blood brain barrier.

Host factors
1. Host defense mechanisms
a. The immunocompetant host: can be cure by
slowing the
multiplication of microorganism
(bacteriostatic effect.(
b. The immunocompromised host: bacteriostatic
activity may be inadequate and a berteriocidal
agent may be required for cure.
e.g. - pt with bacterial endocarditis
pt with AIDS
Local factors
Antimicrobial activity may be significantly reduces in pus.
Penetration of antibiotic into infected areas such abscess
is imparied because vascular supply is reduce .
Presence of foreign bodies reduces the effectiveness of
antibiotic.
Genetic factors
A no. of drug (e.g. sulfanamides, chloramphenicol ) may
produces acute hemolysis in pt with glucose 6phosphate dehydrogenase deficiency.
pregnancy
Hearing loss in child with administration of streptomycin
to the mother during pregnancy.
Tetracycline can affect bones & teeth of fetus , may
develop fatal acute fatty necrosis of liver pancreatitis &
associated renal damage.

Drug allergy
A antibiotics especially- B-lactum can provoke allergic
reaction.
Sulfonamides & erythromycin also has been associated
with hypersentitivity reaction especially rash.
Other antimicrobial agent can caused drug fever.

Combined antimicrobial therapy:

Empirical therapy of severe infections in which a
cause is unknown
Treatment of polymicrobial infection
Enhancement of antibacterial
treatment of specific infection

activity

in

the

Some commonly used antibiotics

Penicillin
Derived from Penicillium fungi.
Belong to group called beta lactam antibiotics.
Types of penicillin:
Penicillin G (intravenous use) not orally because it is
destroyed by gastric acid (not acid stable).
Penicillin V (oral
use) treatment of choice for
odontogenic infection
procaine
penicillin,
penicillin (intramuscular use)

and benzathine

Mechanism of action
Act by inhibiting cell wall synthesis in bacteria.
Antibacterial spectrum of penicillin
gram ve cocci
gram +ve
some gram +ve bacilli
Adverse effect of penicillin
1. Thrombophlebitis
2. Superinfection e.g. candida
3. Allergy with manifestation like:
i.

skin rash.

ii.

Renal disturabane.

iii.

Anaphylaxis

AMINOGLYCOSIDES
They are the first bactericidal parentral antibiotics that
was effective against gram ve rods and less effective
against gram +ve rods .
Administrated only through I.V. injection.
Play a role in the treatment of sever progressive cellulites
or in the patient with depressed host resistance who has
a sever cellulites .
Examples
- Garamycin amp.{ Gentamycin} .
- Streptomycin vials

- Amikin 100 mg, 250 mg, 500 mg {Vials}

Gentamycin and streptomycin cause ototoxicity and
nephrotoxicity

Tetracycline
Bacteriostatic
gram +ve
some gram ve
Some antiviral effect
broad spectrum
Indications:
1- Management of sever periodontal disease as LJP
2- Concentrate in the periodontal tissues& destroying
anaerobic bacteria
3- Have anti-collagenase enzyme so inhibit
destruction & aid in bone regeneration

tissue

2 groups:
1-Ordinary Tetracycline
Dose is reduced with pt. of impaired renal function
because excreted in kidney
Ex: Tetracycline Hcl :
Cap. 250 mg {QID}
Tetracid:
Cap.250 mg {OID}

Hostacyclin:
Tab.500 mg {TID}
2-New Generation
No adjustment of the dose
Because there are 2 routes of
Excretion {renal . Fecal }
Ex:Vibramycin:
10 caps., 100 mg {BID}
Doxymycin:
10 caps, 100 mg {BID}

Disadvantages:
Diahrroea
Nausea & Vomiting
Candida superinfection
Fetal hepatic dysfuction
Chelating effect in teeth & bone
Renal impairment

Cephalosporins
Have broader spectrum than penicillin. E.g. Cephradine,
cefadroxil, Cephalexin
About 10 % of patient have hypersensitivity to penicillin
may be allergic to cephalosporin.
Cephalosporin have 4 generations.

The cephalosporins
are
a
class
of -lactam
antibiotics originally
derived
from
the fungus Acremonium, which was previously known as
"Cephalosporium"
Generations
First-generation cephalosporins are active predominantly
against Gram-positive bacteria,
and
successive
generations have increased activity against Gramnegative bacteria. (often with reduced activity against
Gram-positive organisms)
Adverse effect:
Diarrhea
Nausea
Rash
Pain & inflammation at injection site
Nephrotoxicity

Macrolides
They are antibiotics having
with attached sugars.

a macrocyclic lactone ring

They are bacteriostatic drug.

Macrolides
1. Azithromycin

2. Clarithromycin
3. Erythromycin
4. Telithromycin
The antimicrobial spectrum of macrolides is slightly wider
than that of penicillin, and, therefore, macrolides are a
common substitute for patients with a penicillin allergy.
Indications:
Infections caused by Gram-positive bacteria (e.g.,
Streptococcus pneumoniae.
Haemophilus influenzae
infections such as
respiratory tract and soft-tissue infections.
Urinary tract infection

Otitis media

Adverse effects:
Vomiting
Nausea
Diahrroea
Hypertention
Cardiac arrythmias
Revesible hearing loss
Quinolones
synthetic broad-spectrum antibacterial drugs for:
Oral infection
GIT infection
skin and soft tissue infections
urinary tract infection

active against:

Gram +ve

Gram ve
Anerobic bacteria
Pseudomonas

Imidazoles:
First developed to treat protozoal infections
Bactericidal to anaerobic organisms
e.g. Metronidazole
Indications
ANUG
Gingivitis
Adult periodontitis
Contraindications
First trimester of pregnancy
Blood dyscrasias
Neurogenic diseases

Adverse effects:
Anorexia
Metallic taste
Nausea
Glossitis

 Dryness of mouth

Indications for antibiotic:

Congnital or acquired heart ( Rheumatic heart
disease , Valvular diseases(

Severe kidney

diseaes as pt undergoing dialysis

Active leukemia, agranulocytosis, aplasia , anemia

Metabolic disturbances diabetes
Pt on chemotherapeutic drugs
Hard and soft tissue trauma
Odontogenig infection / pericoronitis / osteomyelitis

Contraindications:
Minor chronic localized abscess
Localized ostitis
Pt with mild pericoronitis, minor gingival oedema &
mild pain

Prophylactic antibiotic therapy:

Antimicrobial agent is chosen on basis of most likely
microorganisum to cause infection
Antibiotic loading dose should be employed
Antibiotics should be continued only as long as
microbial contamination from operative site persist

 Patient benefits
adverse effects
superinfection

from prophylaxis
included allergy

vs antibiotic
, toxicity ,

Standard recommendation
Cephalosporin ( cefadroxil)
preoperatively 500 mg orally 1hr before surgery.
postoperatively 250 mg orally 6 hr after initial dose.
Alternative recommendation
Clindamycin in penicillin allergic pt.
preoperatively 300 mg orally 1 hr before surgery.
postoperatively 150 mg orally 6 hr after initial dose

Dental procedure that require endocarditis prophylaxis:

Tooth extraction
Subgingival dental scaling
Incision & Drainage of infection
Endodontic surgery
Periodontal suergery

Dental procedures that do not require endocardiatis

prophylaxis:
Supragingival prophylaxis
Restorative tooth preparation
Placement of orthodontic appliances

 Conserative endodontic therapy

Reasons for antibiotic failure:

Inappropriate choice of antibiotics
Too low blood concentration
Poor penetration to infected site
Limited or decreased vascularity
Impaired host defence
Unfavourable local factors
Antibiotic resistant organisms
Patient failed to take antibiotics
Failure to eradicate source of infection