Quality Resource Guide

Antibiotic Use in Dentistry 3rd Edition

www.metdental.com

4. Penicillins do not appear to be effective for

the management of symptomatic irreversible

pulpitis.

Guidelines for the selection and use

of antibiotics in adults for endodontic infections

have been published by the American

Association of Endodontists.

5. The American Academy of Pediatric Dentists

has promulgated guidelines for antibiotic use in

children.

Note that antibiotic dosages must be

adjusted for the child’s body weight.

6. Warnings with antibiotic therapy should

be issued verbally, and in writing on the

prescription. They should include the possible

development of allergic reactions, and diarrhea

and other GI disturbances.

Antibiotic Prophylaxis

While there is little scientific evidence to support

the use of prophylactic antibiotics to prevent

postoperative

complications,

guidance

from

professional resources suggests its continued

use in patients at highest risk of developing

complications from infective endocarditis.

Most regimens involve a single, preoperative

dose of a bactericidal agent with activity against

Streptococcus

viridans

. There is no documentation

showing that a second

dose will enhance

outcomes.

There is also limited evidence that

antibiotic prophylaxis reduces complications

following implant placement and no evidence

supporting use to prevent complications of third-

molar surgery.

14,15

Antibiotic prophylaxis prior

to dental treatment in patients with total joint

arthroplasty (artificial joint) is controversial, and

professional guidance now emphasizes good oral

hygiene to prevent infective complications in these

patients. At this time, there is insufficient scientific

evidence on which to base the practice.

However,

when in doubt, the dentist is obligated to consult

with the patient’s physician(s) to determine the need

for antibiotic prophylaxis and the appropriateness

of the recommended regimen.

Recent evidence from large-scale observational

studies suggests that the risk stratification for

patients with conditions that predispose to

infective endocarditis needs to be re-evaulated.

At this time, dentists should now:

•

Make specific patient groups aware of their

increased

risk

infective

endocarditis

(including patients with a history of intravenous

drug abuse);

•

Discuss

the

advantages

and

potential

drawbacks of antibiotic prophylaxis with their

patients;

•

Consult with the patient’s cardiologists as

appropriate; and

•

Allow the patient to make the ultimate decision

whether or not antibiotic prophylaxis will be

used.

Adverse Eﬀects

Antibiotics, as prescribed in dentistry, are

generally well tolerated. With the exception of

allergy, most adverse effects from antibiotics

are related to their effects on the gastrointestinal

tract. They may irritate the stomach or stimulate

contractions of gastrointestinal smooth muscle,

resulting in nausea, vomiting and cramping. They

may also disrupt the normal flora, resulting in

diarrhea or lead to antibiotic-associated colitis,

and a potentially life-threatening overgrowth of

C. difficile

Symptoms

with

most

cases

antibiotic-

associated diarrhea dissipate when the antibiotic

is discontinued. It is imperative that patients be

cautioned against the use of antidiarrheal drugs

and/or probiotics in place of medical diagnosis

and management of this rare, but serious,

complication.

The development of any sign or

symptom of an allergic reaction (rash, itching

and/or hives) requires that

the

antibiotic

agent

be discontinued immediately, and the patient be

evaluated medically.

Drug-Drug Interactions

Antibiotics are capable of adversely interacting

with other dental and medical drugs, both

through pharmacodynamic and pharmacokinetic

mechanisms. The most significant adverse

pharmacodynamic interaction for commonly

prescribed antibiotics is the mutual antagonism

that occurs when a bactericidal agent (penicillins,

cephalosporins)

co-administered

with

bacteriostatic agent (tetracycline). The recent

scientific evidence does not support an adverse

interaction between oral contraceptives and

antibiotics used in dentistry.

Conversely, if drugs with similar mechanisms of

action are administered together, a beneficial

synergism may result. Combinations of antibiotics

are not generally recommended in dentistry.

However, the addition of metronidazole to a

penicillin regimen may improve outcomes because

of the selective action of metronidazole on strictly

anaerobic organisms.

Among the antibiotics

discussed here, macrolides are the most likely

to produce pharmacokinetic drug interactions.

Serious adverse interactions of the various classes

of dental antibiotics are listed in

Table 2

Summary

Antibiotics continue to play an important, albeit

adjunctive, role in the management of routine

odontogenic infections. They are safe and effective

when prescribed at recommended doses and

based on the patient’s presenting signs, symptoms

and coexisting medical conditions. The number

of patients who are candidates for antibiotic

prophylaxis is relatively small, and prophylactic use

should be guided by the

current

recommendations

of professional organizations, as based on scientific

review.

Dentists should continue to consider

emerging

evidence for the use of low-dose

antibiotics in cases of refractory periodontitis and

other inflammatory diseases.