Diagnosing and managing dental infections - Review - Medical Dialogues

Dental infections are a common cause of oral pain, swelling, and discomfort. Dental caries is present in 90% of adults and 42% of children ages 6 to 19 years (1), placing dentists in a critical position to overcome the same while providing an optimized dental treatment.

Dental caries, pulpal necrosis, dental trauma, and periodontal diseases ultimately result in severe dental infections, affecting both soft and hard tissues of the oral cavity. (2) When left untreated, such oral infections can spread systemically and lead to complications like brain abscess, airway obstruction, carotid infection, sinusitis, septicemia, meningitis, cavernous sinus thrombosis, orbital abscess, and loss of vision. (3)

The polymicrobial nature of a healthy oral cavity, coupled with the invasive nature of dental treatments and the discovery of newer drug-resistant bacterial strains has made an appropriate antibiotic the need of the hour. Antibiotics have, for a long time now, occupied an irreplaceable part of managing a dental infection successfully.

Antibiotics, used as an adjunct to conventional dental therapies, are very commonly advocated for prophylaxis in local and focal infections, both of odontogenic and non-odontogenic origin. (4) Severe cases of dental infection requiring incision and drainage (I&D), debridement, and endodontic management, are usually followed by systemic antibiotic therapy (2). High-risk groups including immunosuppressed patients, medically compromised patients (diabetics), and those with prostheses are recommended to undergo dental treatments with antibiotic prophylaxis. (4)

Types of common dental infections

Dental infections can be bacterial, viral, or fungal in origin. Though oral infections can exhibit a diverse microbial flora, it has been documented that Gram-positive cocci are responsible for about 65% of orofacial infections, and Gram-negative bacilli comprise approximately 25% of diseased oral specimens. (5) This highlights the fact that a majority of dental infections are of bacterial origin, making dentists favorably positioned to initiate an empirical antibiotic drug therapy to tackle such situations.

Managing bacterial infections

Role of amoxicillin - Amoxicillin is a beta-lactam bactericidal antibiotic, deriving its origin from Penicillin. It has a wide spectrum of action against gram-positive and gram-negative bacteria and acts well against most oral aerobes and anaerobes (6). It has been documented as the first-line drug therapy against dental infections and the most frequently prescribed antibiotics among the dental fraternity (2). The therapeutic dosage of amoxicillin for Mild/Moderate infection is 500 mg every 12 hours or 250 mg every 8 hours and for severe infections 875 mg every 12 hours or 500 mg every 8 hours (14).

Studies supporting the use of amoxicillin-

1. Research has highlighted that Amoxicillin has always been the first choice for administration during endodontic root canal treatments (7).

2. Studies reveal that 2 g of amoxicillin given orally 1 hour preoperatively significantly reduces failures of dental implants (8). Single-dose oral amoxicillin (SDOAP) is specifically beneficial in dental implant surgical procedures. (9)

3. Amoxicillin has been proved to be effective against pathogens like Aggregatibacter actinomycetemcomitans and Porphyromonas Gingivalis, establishing its role in treating gingival and periodontal infections (10).

4. With studies repeatedly pointing out that bacteremia and subsequent infective endocarditis is a common complication following a tooth extraction, the practice of advocating a standard regimen of 2 g of oral amoxicillin for adults before the dental procedure commencement has been widely accepted and followed by dentists. Research has further elaborated that 2g of amoxicillin provides several hours of antibiotic coverage (4). In the case of elderly patients, The standard prophylactic regimen consists of amoxicillin 3g 1 hour before the dental procedure, then 1.5g 6 hours after the initial dose (15). Further, in case of certain high-risk cardiac patients requiring antibiotic prophylaxis before dental procedures, including those with a History of previous IE, Presence of prosthetic valves, Surgically constructed systemic or pulmonary shunt, BSAC guidelines recommend that In standard conditions, these patients should receive 3g of amoxicillin before all dental procedures involving dental-gingival manipulation (15,16).

5. Amoxicillin 2000 mg for five days at a suitable dose and interval helps to cover the treatment requirements after third molar surgery (4)

   Combination Therapy-Amoxicillin with clavulanic acid (co-amoxiclav) is a broad-spectrum antibiotic that has proven its efficacy in cases of amoxicillin resistance. (11)
   

A combination of penicillin and clavulanic acid can be preferred for infections caused by staphylococcus, streptococci, and pneumococci (11). A high dose of co-amoxiclav (875/125 mg every 8 hours or 2000/125 mg every 12 hours) is regarded to be an apt choice in the cases of severe odontogenic infections, such as abscess and pulpitis. (2)

Guidelines -

Experts suggest dentists prescribe oral amoxicillin (500 mg, 3 times per day,3-7 days) for Immuno-competent adults with pulp necrosis and localized acute apical abscess, with or without systemic involvement. (12)

Dose recommendations- Typical adult dosages of amoxicillin for mild infection of the tooth are either 500 milligrams (mg) every 12 hours or 250 mg for every 8 hours, for severe infections 875 mg every 12 hours, or 500 mg every 8 hours (14). Typical dosages of amoxicillin with clavulanic acid are around 500–2,000 mg every 8 hours or 2,000 mg every 12 hours, depending on the minimum effective dosage. (13)

In Pediatric Patients > 3 Months of Age, for mild infections, 25 mg/kg/day of amoxicillin in divided doses every 12 hours or 20 mg/kg/day divided every 8 hours is the recommended dose. For severe infections 45 mg/kg/day in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours. (14) There have been no studies demonstrating clear risk. Based on available data, amoxicillin is usually considered compatible for use during pregnancy. (6)

Amoxicillin is a pregnancy category B drug under the FDA classification system, which means Amoxicillin is acceptable in nursing mothers too. (6)

Highlighters-

1. Rational use of antibiotics along with necessary surgical intervention is the appropriate way to manage a dental infection. Antibiotics are indicated in dental practice for treating immunocompromised patients, evident signs of systemic infection, and if the signs and symptoms of infection progress rapidly (4).

2. Amoxicillin, owing to its wide spectrum of action, high safety, and tolerability profiles, and highly successful combination formula with clavulanic acid, has cemented a firm position in controlling oral infections.

3. Dentists should be well aware of the benefits of this time-tested drug, and maintain a logical approach in managing bacterial infections with combination drug therapy as and when needed.

Conclusion – Orofacial infections continue to be a global health burden. Proper antibiotic therapy, at the right time and in the right dose, can go a long way in mitigating dental pain while alleviating the chances of systemic spread. Amoxicillin, backed up by extensive research and unmatched efficacy, has been and will continue to be a major game-changer in managing dental infections successfully.

References

1. Erazo D, Whetstone DR. Dental Infections. [Updated 2021 Oct 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan

2. Ahmadi, Hanie & Ebrahimi, Alireza & Ahmadi, Fatemeh. (2021). Antibiotic Therapy in Dentistry. International Journal of Dentistry. 2021. 1-10. 10.1155/2021/6667624.

3. Li, X., Kolltveit, K. M., Tronstad, L., & Olsen, I. (2000). Systemic diseases caused by oral infection. Clinical microbiology reviews, 13(4), 547–558. https://doi.org/10.1128/CMR.13.4.547

4. Ramu, C., & Padmanabhan, T. V. (2012). Indications of antibiotic prophylaxis in dental practice- review. Asian Pacific journal of tropical biomedicine, 2(9), 749–754. https://doi.org/10.1016/S2221-1691(12)60222-6

5. Singh, M., Kambalimath, D. H., & Gupta, K. C. (2014). Management of odontogenic space infection with microbiology study. Journal of maxillofacial and oral surgery, 13(2), 133–139. https://doi.org/10.1007/s12663-012-0463-6

6. Akhavan BJ, Khanna NR, Vijhani P. Amoxicillin. [Updated 2021 Aug 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

7. Segura-Egea, J. J.; Gould, K.; Şen, B. Hakan; Jonasson, P.; Cotti, E.; Mazzoni, A.; Sunay, H.; Tjäderhane, L.; Dummer, P. M. H. (2017). Antibiotics in Endodontics: a review. International Endodontic Journal, (), –. doi:10.1111/iej.12741

8. Surapaneni, H., Yalamanchili, P. S., Basha, M. H., Potluri, S., Elisetti, N., & Kiran Kumar, M. V. (2016). Antibiotics in dental implants: A review of literature. Journal of pharmacy & bioallied sciences, 8(Suppl 1), S28–S31. https://doi.org/10.4103/0975-7406.191961

9. Rodríguez Sánchez F, Rodríguez Andrés C, Arteagoitia I. Which antibiotic regimen prevents implant failure or infection after dental implant surgery? A systematic review and meta-analysis. J Craniomaxillofac Surg. 2018 Apr;46(4):722-736. doi: 10.1016/j.jcms.2018.02.004. Epub 2018 Feb 26. PMID: 29550218.

10. Kapoor, A., Malhotra, R., Grover, V., & Grover, D. (2012). Systemic antibiotic therapy in periodontics. Dental research journal, 9(5), 505–515. https://doi.org/10.4103/1735-3327.104866

11. Evans J, Hannoodee M, Wittler M. Amoxicillin Clavulanate. [Updated 2021 Mar 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538164

12. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. Journal of the American Dental Association (1939). 2019 Nov;150(11):906-921.e12. DOI: 10.1016/j.adaj.2019.08.020. PMID: 31668170; PMCID: PMC8270006.

13. https://www.medicines.org.uk/emc/product/7211#gref

14. Simar Preet Kaur,Rekha Rao, Sanju Nanda Amoxicillin: A broad spectrum Antibiotic. International Journal of Pharmacy and Pharmaceutical Sciences. (2011).

15. Gould FK, Elliott TS, Foweraker J et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy J Antimicrob Chemother 2006 57: 1035-1042.

    16. Arthur H. Friedlander & Charles E. Marshall. Pathogenesis and Prevention of Native Valve Infective Endocarditis in Elderly Dental Patients. Drugs Aging (1994) 2012 Apr;4(4):325-30. DOI: 10.2165/00002512-199404040-00005.