Therapeutics In Dentistry

Antimicrobials

Iyad Abou Rabii

DDS, OMFS, MRes, PhD
 Reminder
Terms and Concepts
1. Antimicrobial or anti-infective-drugs used to prevent or
treat infections caused by pathogenic
(disease-producing) microorganisms. Include
antibacterial, antiviral, and antifungal drugs.
2. Antibacterial or antibiotic-usually refer only to drugs used
in bacterial infections.
3. Antiviral- drugs used to treat viral infections.
4. Antifungal- drugs used to treat fungal infections.
5. Antiparasitic- drugs used to treat parasite infections or
infestations.
 Reminder
6. Broad Spectrum- antibacterial drugs that are effective
against several groups of microorganisims.
7. Narrow Spectrum- antibacterial drugs which are
effective against only a few groups of
microorganisms.
8. Bacteriocidal- action of an antibacterial drug in that it
kills microorganisms.
9. Bacteriostatic- action of an antibacterial drug in that it
inhibits growth of the microorganism.
10. Superinfection- a new or secondary infection that occurs
during antimicrobial therapy of a primary infection.
 Terms
11. Antibiotic combination therapy- use 2 or more drugs
in combination to treat infections known or thought
to be caused by multiple microorganisims, to get
a synergistic effect, to prevent emergence of
drug-resistance organisims, or to treat clients
whose immune system is suppressed or client with
bone marrow or organ transplant.
Antibacterials
Mechanism of
Action:
1. Inhibition of Cell Wall
Synthesis
2. Disruption of Cell
Membrane
3. Inhibition of Protein
Synthesis
4. Interference with Metabolic
Processes
NB:
Bactericidal
Bacteriostatic
Table 1 Summary of some common antibiotics
Beta-lactams Broad-spectrum antibiotics*. Flucloxacillin and
(penicillins, co-amoxiclav are effective against some penicillin-
cephalosporins) resistant organisms.

Aminoglycosides Effective against gram negative bacteria e.g.

(streptomycin, Pseudomonas. Reserved for serious infections e.g.
gentamicin, tobramycin) septicaemia, meningitis, hospital-acquired
pneumonia.

Glycopeptides Effective against Staphylococci resistant to other

(vancomycin, drugs, including many strains of MRSA**.
teicoplanin)

Tetracyclines Broad-spectrum antibiotics

(doxycycline,
minocycline)
Macrolides Broad-spectrum antibiotics, prescribed if patient is
(erythromycin) allergic to penicillins.
Metronidazole Prescribed for surgical prophylaxis, bacterial
vaginosis, pressure sores, leg ulcers.

Quinolones Effective against gram negative bacteria,

(ciprofloxacin)
Antitubercular drugs
(rifampicin, isoniazid,
rifabutin, streptomycin)
sulphonamides (co-
trimoxazole,
trimethoprin)
gonorrhoea, gastro-intestinal infections.
Reserved for treatment/ containment of
tuberculosis(TB).
Co-trimoxazole is reserved for serious infections
associated with HIV/AIDS. Trimethoprin is
prescribed for urinary tract infections.

* Broad spectrum antibiotics are used when the infectious agent is unknown.
Narrow spectrum antibiotics are prescribed when the micro-organisms have been identified from
tissue samples.

** Many bacteria produce an enzyme which destroys beta lactam antibiotics. In addition to this,
MRSA (methicilin-resistant Staphylococcus aureus) produces an inactivating protein which
confers resistance to most other antibiotics.
Indications for the use of
antibacterials
(together with appropriate surgical drainage or
other measures)
– Cervical fascial space infections;
– Osteomyelitis and osteoradionecrosis;
– Odontogenic infections in ill, toxic or
susceptible patients (e.g.
immunocompromised);
– Acute ulcerative gingivitis;
– Some instances of:
• pericoronitis;
• dental abscess;
• dry socket;
 Prophylactic use of
Antibacterials

– infective endocarditis ;
– in cerebrospinal rhinorrhoea;
– in compound facial or skull fractures;
– in major oral and maxillofacial surgery
(e.g. osteotomies or tumour resection);
– In surgery in immunocompromised or
debilitated patients, or following
radiotherapy to the jaws.
 r t a nt
I m p o
Very fo!
In

Drainage is essential if there is

pus:
antibacterials will not remove
pus;
 Routes of administration
• Oral preparations of antimicrobials are
preferred in most instances.
• Topical antibacterials, should usually
be avoided, as they may produce
sensitization and may cause the
emergence of resistant strains.
 Routes of administration
• Parenteral administration of
antibacterials may be indicated where:
– no oral preparation is available;
– high blood levels are required rapidly (e.g.
serious infections);
– the patient cannot or will not take oral
medications (e.g. unconscious patient);
– the patient is to have a GA within the
following 4 h.
 Which Antibacterial??
• Anaerobes are implicated in many
odontogenic infections, and these often
respond to penicillins or metronidazole
• Odontogenic infections are typically
polymicrobial.
• Most bacteria causing odontogenic
infections are penicillin-sensitive. Oral
phenoxymethyl penicillin is usually
effective and is cheap.
• Amoxicillin is active orally (absorption
better than ampicillin).
• Not resistant to penicillinase.
• Contraindicated in penicillin
hypersensitivity
• 500 mg PO q6-8hr
• Augmentin is a mixture of amoxicillin
and potassium clavulanate
– inhibits some penicillinases and therefore
is active against most Staph. aureus;
– inhibits some lactamases and is therefore
active against some Gram-negative and
penicillin-resistant bacteria
• Contraindicated in penicillin
hypersensitivity.
• Metronidazole may be preferred as an
alternative to a penicillin if the patient
is allergic, or has had penicillin with
the previous month (resistant bacteria).
• Suppositories are effective.
Contraindicated in pregnancy.
• 500 mg PO, q6-8hr
• with meals.
• Use only for 7 days
• Erythromycin is an alternative for
penicillin-resistant infections where a
Beta-lactamase producing organism is
involved. However, many organisms
are now resistant to erythromycin or
rapidly develop resistance and its use
should therefore be limited to short
courses.
• 250-500 mg PO QID
• Clindamycin is no more effective than
penicillins against anaerobes
• Should not be used for routine
treatment of odontogenic infections.
• Serious side-effects, mainly antibiotic-
associated colitis. So limited use.
• Clindamycin is used for prophylaxis of
endocarditis in patients allergic to
penicillin
• 150-450 mg PO q6-8hr
• Tetracyclines have a broad
antibacterial spectrum, but of the many
preparations there is little to choose
between them.
• Use of Tetracyclines may predispose to
candidiasis.
• Useful in Acute ulcerative gingivitis.
• 100 mg PO BID
• Contraindicated in pregnancy and
children up to at least 7 years
• Cephalosporins are broad-spectrum,
expensive antibiotics with few absolute
indications for their use in dentistry,
• Gentamicin is reserved for use in
pregnancy and myasthenia gravis.
Reduce dose in renal disease, 5 mg/kg
daily.
 Which Antibacterial??
• Pus (as much as possible) should be
sent for culture and sensitivities, but
antimicrobials should be started
immediately following sampling, if
they are indicated.
 Antibacterial Teatrtment
Failure
• patient non-compliance
• local factors (e.g. foreign body);
• unusual type of infection;.
 Antibacterial Teatrtment
Failure
• inadequacy of drainage of pus;
• inappropriateness of the drug or dose;
• antimicrobial insensitivities of micro-
organism (staphylococci are now
frequently resistant to penicillin and
some show multiple.
 Antibacterial Teatrtment
Failure
• impaired host defences (unusual and
opportunistic infections are
increasingly identified, particularly in
the immunocompromised patient);
• non-infective cause for the condition!
• In serious or unusual cases of infection,
consult the clinical microbiologist.
Antifungal
• Candida Albicans
• Local Factors
• Systemic Factors
• Antifungals are used to treat oral or
oropharyngeal fungal infections but
underlying predisposing factors should
first be considered.
• In immunocompromised patients,
antifungals are used for prophylaxis,
• In immunocompromised patients
antifungals are increasingly
administrated systemically (azoles)
• Antifungal resistance is now a
significant problem to
immunocompromised persons,
especially those with a severe immune
defect, who may show Candida species
resistant to fluconazole and,
sometimes, to other azoles.
• Antifungal resistance may sometimes
be overcome by using higher drug
doses, or changing the agent
• Antifungals should be continued for at
least 1 week following resolution of
clinical manifestations.
• Nystatin is not active orally, very
active ative topically.
• Pastilles taste better than lozenge.
• Dose qid
– 500 000 unit loz-enge,
– 100 000 unit pastille or
– 100 000 unit per mL of suspension.
• Amphotericin is close to Nystatin
characteristics
• Topically applied 10 to100 mg q6h
• Miconazole is active topically and
orally.
• Also has antibacterial activity.
• Interacts with terfenadine cisapride,
astemizole and warfarin.
• Avoid in pregnancy, porphyria
• Dose
– 250 mg tablet q6h
– 25 mg/ml gel (Daktarin®) used as 5 mL
q6h for 14 days
Antiviral
• herpes viruses are associated with most
oral viral infections,
• Also (papillomaviruses, and
enteroviruses).
• HIV and other viruses may also cause
orofacial lesions.
• Management of viral infections is
predominantly supportive, as, at
present, there are few antiviral agents
of proven efficacy.
• Most antivirals will achieve maximum
benefit if given early in the disease.
• Systemic aciclovir should be used with
caution in pregnancy and renal disease.
Aciclovir may cause liver enzymes,
and urea, rashes and CNS effects.
• Famciclovir should also be used with
caution in pregnancy and renal disease.
Famciclovir may cause headache and
nausea.
• Topical Forms (cream) are preferred in
oral medicine
– 5 application by days
– 5-10 days
 Thank you

Iyad Abou Rabii

DDS, OMFS, MRes, PhD