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KMCT DENTAL COLLEGE

Manassery, Mukkam

ANTIBIOTICS
IN
DENTISTRY

Presented By:

Niyas Ummer
1st Year PG
Department of Oral Medicine and Radiology
Overview

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Introduction
Terminology
History
Classification
General Considerations
o Routes of administration
o Choice of agent
o Combined use
o Problems with use
o Prophylactic use
o Failure

Commonly used antibiotics in dentistry


o Mechanism of action
o Uses
o Adverse Effects
o Interactions
o Contra-indications
o Dosage and availability

Recent Advances
Misuse
Conclusion
References

Introduction to Antibiotics

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The magic word Antibiotic inevitably springs to mind whenever an


infection has to be dealt with. Antimicrobial drugs are the greatest contribution to
20th century of therapeutics - Antibiotic era. Their advent changed the outlook of
the physician about the power drugs can have on diseases.
Antibiotics are essential weapon against infection; hence wise use of
antibiotics requires the clinician to take the stance that positive indication must be
present before antibiotic drugs are prescribed. As a class, antibiotics are one of the
most frequently used as well as misused drugs.

Terminologies Used
Antibiotics: Substances produced by microorganisms, which selectively suppress the
growth of or kill other microorganisms at very low concentrations. The term
"antibacterial" is derived from Greek anti - "against and baktria, "staff, cane". The
term "antibiotic" derived from anti and bios, "life".
Chemotherapy: Treatment of systemic infections with specific drugs that selectively
suppress the infecting microorganism without significantly affecting the host
Antimicrobial Agent: Synthetic as well as naturally obtained drugs that attenuate
microorganisms

History of Antibiotics
Milestones in History

Louis Pasteur observed, "if we could intervene in the antagonism observed


between some bacteria, it would offer perhaps the greatest hopes for
therapeutics
Term 'antibiosis coined by the French bacteriologist Jean Paul Vuillemin
Antibiosis first described in 1877 in bacteria when Louis Pasteur and Robert
Koch observed that an airborne bacillus could inhibit the growth of Bacillus
anthracis
Renamed antibiotics by Selman Waksman, an American microbiologist, in
1942
Synthetic antibiotic chemotherapy began in Germany with Paul Ehrlich in the
late 1880s

In 1928, Alexander Fleming observed antibiosis against bacteria by a fungus of the


genus Penicillium. He postulated the effect was mediated by an antibacterial
compound named penicillin, and that its antibacterial properties could be exploited.
He attempted to use a crude preparation to treat some infections, but unable to pursue
its further development.
Period of Empirical Use (16th - 17th Century)

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Mouldy curd by Chinese on boils


Chaulmoogra oil by Hindus in leprosy
Chenopodium by Aztecs for intestinal worms
Mercury by Paracelsus for syphilis
Cinchona bark for fevers

Chenopodium

Chaulmoogra

Phase of Dyes and Organometallic Compounds


Paul Ehrlich (1890-1935) coined the term chemotherapy. He developed two
antibiotics, atoxyl for sleeping sickness and arsphenamine for syphilis.
Paul Ehrlich

Modern Era of Antibiotics


Domagk (1935) developed Prontosil for use in pyogenic infections. It came to
be known as the first commercially available antibiotic.
Prontosil

Classification of Antibiotics

Domagk

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Based on Chemical Structure:


Sulfonamides

Sulfadiazine, Sulfones (Dapsone)

Diaminopyridines

Trimethoprim, Pyrimethamine

Quinolones

Nalidixic Acid, Norfloxacin, Ciprofloxacin

-lactam

Penicillins, Cephalosporins, Monobactams,


Carbapenems

Tetracyclines

Oxytetracycline, Doxycycline

Nitrobenzene derivative

Chloramphenicol

Aminoglycosides

Streptomycin, Gentamycin, Amikacin, Neomycin

Macrolide

Erythromycin, Clanthromycin, Azithromycin

Lincosamide

Lincomycin, Clindamycin

Glycopeptide

Vancomycin, Teicoplanin

Oxazolidinone

Linezolid

Polypeptide

Polymyxin-B, Colistin, Bacitracin, Tyrothricin

Nitrofuran derivatives

Nitrofurantoin, Furazolidone

Nitroimidazoles

Metronidazole, Tinidazole

Nicotinic acid derivatives

Isoniazid, Pyrazinamide, Ethionamide

Polyene

Nystatin, Amphotericin-B, Hamycin

Azote derivatives

Miconazole, Clotrimazole, Ketoconazole,


Fluconazole

Others

Rifampin, Spectinomycin, Sodium fusidate,


Cycloserine, Viomycin, Ethambutol, Thiacetazone,
Clofazimine, Griseofulvin

Based on type of organisms against which primarily active:


Antibacterial

Penicillins, Aminoglycosides, Erythromycin, etc.

Antifungal

Griseofulvin, Amphotericin B, Ketoconazole, etc.

Antiviral

Acyclovir, Amantadine, Zidovudine, etc.

Antiprotozoa
l

Chloroquine, Pyrimethamine, Metronidazole, Diloxanide, etc.

Anthelmintic

Mebendazole, Pyrantel, Niclosamide, Diethyl carbamazine, etc.

Based on spectrum of activity:

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Narrowspectrum

Penicillin G, Streptomycin, Erythromycin

Broad-spectrum

Tetracyclines, Chloramphenicol

Based on type of action:


Primarily
bacteriostatic

Sulfonamides, Erythromycin, Tetracyclines,


Ethambutol, Chloramphenicol, Clindamycin, Linezolid

Primarily
bactericidal

Penicillins, Cephalosporins, Aminoglycosides,


Vancomycin, Polypeptides, Nalidixic acid, Rifampin,
Ciprofloxacin, Isoniazid, Metronidazole, Pyrazinamide,
Cotrimoxazole

Based on source obtained from:


Fungi

Penicillin, Cephalosporin, Griseofulvin

Bacteria

Polymyxin B, Colistin, Bacitracin, Tyrothricin, Aztreonam

Actinomycete
s

Aminoglycosides, Tetracyclines, Chloramphenicol, Macrolides,


Polyenes

Choice of an Antibiotic Agent


Choosing the right antibiotic depends on qualities of patient, the infecting
organism and the drug, as given below.
Patient Factors
a) Age:
o The age of the patient affects kinetics of drugs, including its absorption,
metabolism and excretion.
b) Genetic Factors:
o Primaquine, nitrofurantoin, sulfonamides, chloramphenicol and
fluoroquinolones produce haemolysis in Glucose-6-Phosphate
Dehydrogenase deficient patient
c) Renal and Hepatic Function:
o Cautious use and dose modification advised when the organ for disposal
of the drug is defective/diseased

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Renal Failure
Dose reduction in
mild failure

Aminoglycosides, Amphotericin B, Cephalosporins,


Ethambutol, Vancomycin, Flucytosine

Dose reduction in
moderate-severe
failure

Metronidazole, Carbenicillin, Cotrimoxazole,


Aztreonam, Meropenem, Fluoroquinolones,
Clarithromycin, Imipenem

Drugs to be avoided

Cephalothin, Talampicillin,
Nalidixic acid, Tetracyclines, Nitrofurantoin (except
doxycycline)

Liver Disease
Dose reduction

Chloramphenicol, Isoniazid, Metronidazole, Rifampin,


Clindamycin

Drugs to be
avoided

Erythromycin estolate, Tetracyclines, Pyrazinamide, Nalidixic


acid, Talampicillin, Pefloxacin

d) Local Factors:
o Pus and secretions decrease the efficacy of sulfonamides and
aminoglycosides
o Necrotic material or foreign body makes eradication impossible
o Haematomas foster bacterial growth
o Lowering of pH at the site of infection reduces activity of macrolides
and aminoglycosides
o Anaerobic environment in the centre of an abscess impairs bacterial
transport processes which concentrate aminoglycosides in the cell
o Penetration barriers hamper the access to the site of infection
o Some drugs like trimethoprim and fluoroquinolones attain high
concentration due to ion trapping
e) Drug Allergy:
o If a drug has caused allergic reaction, it has to be avoided in that
patient.
o -lactams, sulfonamides, fluoroquinolones, nitrofurantoin frequently
cause allergy.
f) Impaired Host Defense:
o Pyogenic infections are common in neutropenic patients.
o Infections by low grade pathogens and intracellular organisms occur if
cell-mediated immunity is impaired.
o In a patient with normal host defense, a bacteriostatic AMA may
achieve cure.

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o But in an impaired host defense, intensive therapy with cidal drugs is


recommended.
g) Pregnancy:
a. All AMAs should be avoided in the pregnant because of risk to the
foetus
b. Penicillins, many cephalosporins and erythromycin - safe
c. Tetracyclines - acute yellow atrophy of liver, pancreatitis and kidney
damage in the mother - teeth and bone deformities in the offspring
d. Aminoglycosides - foetal ear damage
Risk Category of Drugs in Pregnancy
Categor
y

Description

Adequate studies in pregnant women have failed to demonstrate a


risk to the foetus

Adequate human studies are lacking, but animal studies have failed
to demonstrate a risk to the foetus amoxicillin
or,
Adequate studies in pregnant women have failed to demonstrate a
risk to the foetus, but animal studies have shown an adverse effect on
the foetus

No adequate studies in pregnant women and animal studies are


lacking or have shown an adverse effect on foetus, but potential
benefit may warrant use of the drug in pregnant women despite
potential risk

There is evidence of human foetal risk, but the potential benefits


from use of the drug may be acceptable despite the potential risk

Studies in animals or humans have demonstrated foetal


abnormalities, and potential risk clearly outweighs possible benefit

Organism-related Factors
a) Initial Empirical Therapy:
Identification of the microorganism and antimicrobial sensitivity testing are
time consuming, expensive & impractical. Sometimes, it is not possible to obtain
appropriate samples of infected material. Furthermore, well defined site and features
of the infection enable organisms causing such infections to be reliably deduced. SO
empirical therapy is usually carried out. In addition, most dental infections are acute
in nature, hence treatment cannot be delayed.
b) Identification of Causative Organism:
Type of bacteria (aerobic/anaerobic) and their specific identification is
necessary for proper management of the condition. Most odontogenic infections

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(70%) are caused by a mixture of aerobic and anaerobic bacteria. Well-circumscribed


chronic non-advancing abscesses contain mostly anaerobic bacteria. Cellulitis type of
lesions show exclusively aerobic bacteria. When the infection is contained longer &
controlled, only anaerobic flora is evident. Abscesses may contain anaerobic bacteria.
c) Antibiotic Sensitivity for Causative Organism:
Antibiotic therapy is initial / empirical or definitive, depending on whether
the organism is identified precisely.

Drug Factors
a) Spectrum of Activity:
For definitive therapy, a narrow-spectrum drug which selectively affects the
concerned organism is preferred. For empirical therapy, often a broad-spectrum drug
has to be used to cover all likely pathogens.
b) Type of Activity:
Acute infections resolve faster with a cidal drug and reduces the number of
bacteria at the site of infection. For patients with impaired host defence, lifethreatening infections, infections at less accessible sites (SABE) or when carrier state
is possible (typhoid), a bactericidal drug is preferred.
c) Sensitivity of the Organism:
On the basis of MIC values (if available) and consideration of postantibiotic
effect
d) Relative Toxicity:
Less toxic antibiotic is preferred
e) Pharmacokinetic Profile:
Antibiotic has to be present at the site of infection in sufficient concentration
for an adequate length of time. Aminoglycosides and fluoroquinolones produce
concentration-dependent inhibition, where the inhibitory effect depends on the ratio
of peak concentration to the MIC. -lactams, glycopeptides and macrolides produce
time-dependent inhibition where the antimicrobial action depends on the length of
time the concentration remains above MIC. Drug which penetrates better and attains
higher concentration at the site of infection is more effective.
f) Route of Administration:
Less severe infections warrant the use of oral antibiotic. Serious infections
require parenteral antibiotics.
g) Evidence of Clinical Efficacy:
Relative value of different AMAs in treating an infection is decided on the
basis of comparative clinical trials. Optimum dosage regimens and duration of
treatment are also determined on the basis of such trials. Reliable clinical trial data, if
available, is the final guide for choice of the antibiotic.

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h) Cost:
Less expensive drugs are to be preferred

Principles of Antibiotic Dosing for Orofacial Infections

Employ high doses for a short duration


Achieve blood levels of antibiotic at 2-8 times the MIC
Use frequent dosing intervals
Determine the duration of therapy by remission of disease
Proper time intervals (four times the T)
Proper route of administration
Penetration of drug

Routes of Administration

Antibiotic Combinations
More than one AMAs are frequently used concurrently to treat infections.
Objectives:
i.
ii.
iii.
iv.
v.

To achieve synergism and enhance antimicrobial action


To reduce severity or incidence of adverse effects
To prevent emergence of resistance
To broaden the spectrum of antimicrobial action for polymicrobial infections
For empirical therapy of an infection in which the cause is unknown

Prophylactic Use
Antibiotic prophylaxis with dental procedures is reasonable only for patients
with cardiac conditions associated with the highest risk of adverse outcomes from
endocarditis.

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High Risk Patients:


Prosthetic cardiac valve or prosthetic material used in valve repair
Previous endocarditis
Congenital heart disease only in the following categories:
Unrepaired cyanotic congenital heart disease, including those with palliative
shunts and conduits
Completely repaired congenital heart disease with prosthetic material or
device, whether placed by surgery or catheter intervention, during the first six
months after the procedure
Repaired congenital heart disease with residual defects at the site or adjacent
to the site of a prosthetic patch or prosthetic device
Cardiac transplantation recipients with cardiac valvular disease

Dental procedures for which prophylaxis is reasonable:


All dental procedures that involve manipulation of gingival tissue or the
periapical region of teeth, or perforation of the oral mucosa.
Antibiotic prophylaxis is NOT recommended for:

Routine anesthetic injections through noninfected tissue


Taking dental radiographs
Placement of removable prosthodontic or orthodontic appliances
Adjustment of orthodontic appliances
Placement of orthodontic brackets
Shedding of deciduous teeth
Bleeding from trauma to the lips or oral mucosa

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Problems associated with Antibiotic use


1. Toxicity
a) Local Irritancy:
Toxicity that is exerted at the site of administration. Gastric irritation,
pain and abscess formation are evident. Complication of IV
administration that commonly arises is thrombophlebitis of the
injected vein. E.g. erythromycin, tetracycline, chloramphenicol
b) Systemic Toxicity:
Dose related and predictable organ toxicities can also occur.
High Therapeutic Index

Penicillins, some Cephalosporins, Erythromycin

Low Therapeutic Index

Aminoglycosides, Tetracyclines, Chloramphenicol

Very Low Therapeutic


Index

Polymyxin B, Vancomycin, Amphotericin B

2. Hypersensitivity
Reactions that range from rashes to anaphylactic shock, that are unpredictable
and unrelated to dose. Practically all AMAs are capable of causing hypersensitivity.
More common culprits include penicillins, cephalosporins, sulfonamides,
fluoroquinolones.
3. Drug Resistance

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It is the unresponsiveness of a microorganism to an AMA. It can be of the following


types:
Natural Resistance:
Microorganisms inherently lack the metabolic process or the target site which
is affected by the particular drug. It is generally a group or species characteristic.
Acquired Resistance:
Development of resistance by an organism (which was sensitive before) due
to the use of an AMA over a period of time. It occurs by mutation or gene transfer.
Cross Resistance:
Acquisition of resistance to one AMA conferring resistance to another AMA,
to which the organism has not been exposed. It may be complete, or partial; two-way,
or one-way.
Prevention:
No indiscriminate and inadequate or unduly prolonged use prefer symptom
determined shorter courses
Prefer rapidly acting and selective (narrow spectrum) AMAs
Broad-spectrum drugs - only when a specific one cannot be determined or is
not suitable
Use combination of AMAs for prolonged therapy
Infection by organisms notorious for developing resistance treated intensively
4. Superinfection
Appearance of a new infection as a result of antimicrobial therapy. It is
commonly associated with the use of broad/extended-spectrum antibiotics. It is more
common when the host defense is compromised. Sites involved are those that
normally harbor commensals. They are generally more difficult to treat.
To minimize superinfections:
Use specific (narrow-spectrum) AMA
Do not use antimicrobials to treat trivial, selflimiting or untreatable (viral)
infections
Do not unnecessarily prolong antimicrobial therapy
5. Nutritional Deficiencies
Some of the B complex group of vitamins and Vitamin K are synthesized by
the intestinal flora. Prolonged use of antimicrobials which alter this flora result in
vitamin deficiencies.
6. Masking of an infection
Short course of an AMA may be sufficient to treat one infection but only
briefly suppress another one contacted concurrently. Other infection will be masked
initially, but will manifest later in a severe form.

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Failure of Antibiotic Therapy


Success of therapy measured either clinically in terms of improvement in
symptoms/signs or microbiologically as eradication of the infecting organism.
Antimicrobials may fail to cure an infection/fever, or there may be relapses. When a
real or apparent failure of the antimicrobial regimen occurs, the diagnosis and
therapy should be reviewed.
Causes of failure:
i.
Improper selection of drug, dose, route or duration
ii.
Treatment begun too late
iii.
Failure to take necessary adjuvant measures
iv. Poor host defense
v. Infecting organism present behind barriers
vi.
Trying to treat untreatable infections or other causes of fever
vii.
Presence of dormant or altered organisms which later give rise to a relapse

Common Antibiotics in Dentistry


1. PENICILLINS
Classification:
Natural penicillin

Penicillin G

Acid resistant penicillin

Penicillin V

Penicillinase resistant penicillin

Methicillin

lactamase inhibitors

Clavulanic acid

Penicillin active against


pseudomonas

Carboxy and ureidopenicillins

Extended spectrum penicillins

Aminopenicillins: Ampicillin
Carboxypenicillin: Carbenicillin
Ureidopenicillin: Piperacillin

a) Penicillin G
Antibacterial Spectrum:
Streptococci, pneumococci, N. gonorrhoea, clostridia, M. TB, spirochaetes,
actinomyces israeli, B. anthracis
Mechanism of Action:
Interfere with the synthesis of bacterial cell wall

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Adverse Effects:
Local irritancy and direct toxicity
Hypersensitivity reactions
Super infections
Jarisch-Herxhemier reactions
Uses:
i.
Dental infections: periodontal abscess, periapical abscess, pulpitis
ii.
Medicinal uses: Gonorrhoea, syphilis, tetanus
Preparations and Dose:
Sodium penicillin G inj.:
Procaine penicillin G inj.:
Fortified procaine penicillin G inj.:
Benzathine penicillin G:

Benzyl pen 0.5,1 MU inj.


0.5,1 MU dry powders in vial
3+1 lac U vial
Penidure LA 0.6, 1.2, 2.4 MU as dry
powder in vial

Contraindications:
Allergies
Poor renal function
Drug Interactions:
Oral contraceptives
Pregnancy category: B
Trade Names: PENCIP, PENTIDS, SODICILLIN
b) Ampicillin
Antibacterial Spectrum:
E. coli, proteus, salmonella, shigella and many Gram positive organisms like cocci,
bacilli etc.
Mechanism of Action:
Interfere with the synthesis of bacterial cell wall
Adverse Effects:
Diarrhoea
Rashes
Drug Interactions:
Oral contraceptives
Uses:
i.
Urinary tract infection
ii.
Respiratory tract infection
iii.
Meningitis, gonorrhoea

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iv.
v.

SABE, typhoid fever


Bacillary dysentery, septicemias

Contraindications:
Allergies
Poor renal function
Dosage:
0.5-2g oral/I.M/I.V every 6 hrs for adults
25-50 mg/kg/day for children
Trade Names: AMPISYN, AMPILIN, AMPI-500, ALFACILLIN, AMPICILLIN
c) Amoxicillin
Similar to ampicillin in all aspects except:
Oral absorption is better
Incidence of diarrhea
It is less active against Shigella and H. influenzae
Dosage:
250-500mg TDS given for 5 days
Uses:
Choice of drug for prophylaxis of local wound infection as well as distant infection
following dental surgery
Trade Names: MOX, AMOX, AMOXIL, AMOXIPEN, AUGMENTIN (Amoxicillin
and clavulanic acid)
d) Methicillin
MRSA (methicillin resistant staph. aureus) are organisms resistant to methicillin.
Drug of choice: vancomycin/linezolid. Ciprofloxacin can also be used
2. CEPHALOSPORINS
Mechanism of Action:
Interfere with the synthesis of bacterial cell wall
Classification:
a) First Generation:
Effective against gram positive cocci, including penicillinase
producing staph, most anaerobes and community acquired infections
caused by E.coli, Proteus and klebsiella
Examples are: Cefalexin, Cefadroxil

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b) Second Generation:
Show increased antibacterial activity
Cefmandole has markedly increased activity. But it has less activity
against strep.
Cefactor, increased activity against H.influenzae
c) Third Generation:
Ceftriaxone shows high efficacy in bacterial meningitis, multi
resistant typhoid fever, complicated urinary tract infections,
abdominal sepsis and septicemias
Examples are: Cefpodoxime proxetil, cefoperazone
d) Fourth Generation:
Examples are: Cefepime, cefpirome
Dosage: 250-1000 mg q 6 h x 7-10 days
Uses:
i.
Dental infections
ii.
General medical uses like meningitis, typhoid etc
Adverse Effects:
Pain after I.M injection
Diarrhoea
Hypersensitivity reactions
Nephrotoxicity
Bleeding
Neutropenia and thrombocytopenia
Contraindications:
Allergies
Poor renal function
Drug Interactions: Probenecid
Pregnancy Category: B
3. TETRACYCLINES
Antibacterial Spectrum:
Cocci: N. gonorrhoea and N. menigitidis
Bacilli: Clostridia and anaerobic bacilli, H. ducreyi
Some spirochetes, mycoplasma, actinomyces
Mechanism of Action:

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Inhibit protein synthesis by binding to 30S ribosomes - prevent aminoacyl transfer


RNA from entering the acceptor sites on the ribosome
Uses:
i.
Orodental infections
ii.
Gingivitis
iii.
Periodontal ligament related diseases
Adverse Effects:
Irritative effects
Liver damage
Kidney damage
Phototoxicity
Teeth and bones: Enamel hyperplasty, inhibition of fibula growth, dental
caries, brown discolouration, formation of calcium tetracycline crystals
Antianaboilic effects
Increased intracranial pressure
Diabetes insipidus
Vestibular toxicity
Hypersensitivity
Superinfection
Dosage: 100 mg qd-bid x 7-14 days
Contraindications:
Food
Pregnancy
Drug Interactions:
Anti-epileptics
Pregnancy category: D
4. CHLORAMPHENICOL
Antibacterial Spectrum:
H. influenzae, salmonella, klebsiella along with those sensitive to tetracycline
Mechanism of Action:
Inhibit protein synthesis binding to 50S subunit
Uses:
i.
ii.
iii.
iv.

Enteric fever
H. influenzae meningitis
Anaerobic reactions
Intraocular infections

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Adverse Effects:
Bone marrow depression
Hypersensitivity reactions
Irritative effects
Superinfections
Gray baby syndrome
Dosage: Daily dose not to exceed 23 g; duration of therapy to be < 2 weeks, total
dose in a course < 28 g
Contraindications:
Pregnancy
Drug Interactions:
Inhibits metabolism of tolbutamide, chlorpropamide, warfarin,
cyclophosphamide and phenytoin
Phenobarbitone, phenytoin, rifampin enhance metabolism
Antagonize the cidal action of -lactams/aminoglycosides on certain bacteria
Pregnancy category: D

5. AMINOGLYCOSIDES
Antibacterial Spectrum:
Gram negative bacilli, H.ducreyi, yersinia pestis, gram positive cocci, enterococci
Mechanism of Action:
Inhibit protein synthesis
Uses:
i.
ii.
iii.
iv.
v.
vi.

Tuberculosis
Plaque
Tularemia
Brucellosis
Enterococcal infections
Subacute bacterial infections

Adverse Effects:
Ototoxicity
Nephrotoxicity
Neuromuscular blockade
Allergy
Superinfection

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Dosage: 0.5-1 gm by I.M injection


Contraindications:
Pregnancy (risk of foetal ototoxicity)
Concurrent use of other ototoxic drugs, e.g. high ceiling diuretics,
minocycline.
Concurrent use of other nephrotoxic drugs, e.g. amphotericin B, vancomycin
Precautions:
Patients past middle age
Kidney damage
Drug Interactions:
Cautious use of muscle relaxants
Trade Names: GENTACIL, GENTYCIN, GENTAMICIN
6. MACROLIDES
Antibacterial Spectrum:
Streptococcus, staphylococcus, gonorrhea, clostridia

Mechanism of Action:
Act by inhibiting protein synthesis by binding to the bind to the 23S rRNA of 50S
ribosomal subunits
Uses:
i.
Dental infections: Periodontal, periapical abscess, necrotizing ulcerative
gingivitis, gingival cellulites
ii.
General medical uses: Pharyngitis, tonsillitis, rheumatic fever
Adverse Effects:
Gastrointestinal problems
Hypersensitivity
Reversible hearing impairment
Dosage:
Erythromycin: 250-500 mg 6 hourly (max.4g/day), children 30-60-mg/kg/day
Azithromycin: 500 mg once daily 1hr before or 2hrs after food for 3 days
Precautions:
Poor hepatic function
Drug Interactions:

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Cytochrome P-450
Pregnancy category: B
7. METRONIDAZOLE
Antibacterial Spectrum:
Entamoeba histolytica, giardia lamblia, anaerobic bacteria, like clostridium,
spirochetes, peptococcus
Mechanism of Action:
Reduced intermediate interacts and breaks the bacterial or parasitic DNA
Adverse Effects:
Anorexia, nausea, metallic taste, abdominal cramps
Headache, dryness of mouth, rashes, and Glossitis (rare)
Thrombophlebitis of the injected vein
Uses:
i.
ii.
iii.
iv.
v.

Orodental infections
Drug of choice in acute necrotizing ulcerative gingivitis
Periodontitis, pericoronitis, acute apical infections, brain abscess
Drug of choice for all forms of anaerobic infections, acute dysentery, liver
abscess
Drug of choice for intestinal giardiasis and trichomonas vaginitis

Dosage: 200-400 mg TDS (15-30mg/kg/day)


Trade Names: METROGYL, FLAGYL
Contraindications:
Pregnancy
Chronic alcoholism
Precautions:
Poor hepatic function
Drug Interactions:
EtOH
Warfarin
Li+
Pregnancy category: D
8. FLUOROQUINOLONES

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Antibacterial Spectrum:
All organisms are susceptible except some strep, anaerobic cocci, mycobacterium
Mechanism of Action:
Bind to A subunit of DNA gyrase with high affinity and interfere with strand cutting
and resealing functions
Adverse Effects:
GIT: Nausea, vomiting, bad taste, anorexia
CNS: Dizziness, headache, restlessness, anxiety
Skin/hypersensitivity
Uses:
i.
ii.
iii.
iv.

Urinary tract infections


Gonorrhea
Soft tissue, bone and joint infections especially gram negative organisms
Community acquired pneumonia

Dosage: Ciprofloxacin 250-500 mg QD x 7-10 days


Trade Names: BIOCIP, CIP, CIPLOX, CIPLO
Contraindications:
Children (damage of the cartilage in weight bearing joints)
Pregnancy
Drug Interactions:
Probenacid
Warfarin
Pregnancy category: C
9. CLOTRIMOXAZOLE
Combination of trimethoprim and sulfamethoxazole (1:20)
Antibacterial Spectrum:
Same as sulfonamide but include salmonella typhi, klebsiella, enterobacter
Mechanism of Action:
Inhibit bacterial dihydrofolate reductase
Uses:
i.
Pneumocystis carnii pneumonia in AIDS patients
ii.
Tonsillitis, Pharyngitis, sinusitis
iii.
Urinary tract infections, orodental infections
Adverse Effects:

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ORAL MEDICINE AND RADIOLOGY

Methamoglobinemia
Blood dyscarasis
Nausea, vomiting, stomatitis, headache and rashes
Neonatal hemolysis

Contraindications:
Pregnancy

Newer Antibiotics
i.
ii.
iii.
iv.
v.
vi.

Ceftolozane/tazobactam: Antipseudomonal cephalosporin/-lactamase


inhibitor combination (cell wall synthesis inhibitor)
Ceftazidime/avibactam: Antipseudomonal cephalosporin/-lactamase
inhibitor combination (cell wall synthesis inhibitor)
Ceftaroline/avibactam: Anti-MRSA cephalosporin/ -lactamase inhibitor
combination (cell wall synthesis inhibitor)
Plazomicin: Aminoglycoside (protein synthesis inhibitor)
Eravacycline: A synthetic tetracycline derivative / protein synthesis inhibitor
targeting the ribosome
Brilacidin: Peptide defense protein mimetic (cell membrane disruption)

Misuse in Dentistry
Treatment of Nonresponsive Infections:
Diseases caused by viruses are self-limited
Therapy of Fever of Unknown Origin:

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Fever persisting for 2 or more weeks only 1/4th are due to infections
Require treatment with agents that are not used commonly for bacterial
infections, surgical drainage or prolonged courses of pathogen-specific
therapy
May mask an underlying infection, delay the diagnosis, and prevent
identification of the infectious pathogen
Noninfectious causes
Inappropriate Reliance on Chemotherapy Alone:
Drainage, debridement, and removal of foreign body
Misuse in Dentistry
Improper Dosage:
Dosing errors (wrong frequency of administration or use of either an
excessive or a subtherapeutic dose)
Excessive amounts can result in significant toxicities
Too low a dose may result in treatment failure or resistance
Lack of Adequate Bacteriological Information:
Bacterial cultures and Gram stains of infected material
Frequent use of drug combinations or drugs with the broadest spectra
Agents are selected more likely by habit than for specific indications
Dosages employed are routine rather than individualized

Conclusion
Antibiotic therapy is an art and a science. There are so many confounding
variables (such as suspected pathogen, ability to establish drainage, pharmacokinetic
properties of the drug, mechanism of action of the antibiotic, virulence of the
infection, the current health status of the host, and host defense mechanisms), that it
is not possible to make antibiotic therapy into a mechanistic technologic science.
The most important decision for the dental practitioner to make is not only
which antibiotic to use but whether to use one at all.

References
i.
ii.
iii.

Essentials of Medical Pharmacology, 6th Edition K. D. Tripathi


Goodman & Gilmans The Pharmacological Basis of Therapeutics, 11th
Edition
Pharmacology and Pharmacotherapeutics - R. S. Satoskar

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iv.
v.

Manoj Kumar Jain, Sheetal Oswal K. Antibiotics in Dentistry An Art and


Science. Annals of Dental Specialty 2013; 1(1):20-25.
Prevention of Infective Endocarditis: Guidelines From the American Heart
Association, by the Committee on Rheumatic Fever, Endocarditis, and
Kawasaki Disease. Circulation, 2007; 116: 1736-1754.

Online sources:
http://www.medclik.com
http://en.wikipedia.org/wiki/Antibacterial

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