‏‏‏‏antibiotics for dental student 2024.pdf

هذه الشريحة للدكتور هشام حويتي جامعة العلوم والتكنولجيا اليمن المركز الرئيسي صنعاء

1. Antimicrobial in dentistry
Dr. Hisham Hwaiti
Dr. Hisham Hwaiti
BDS, UST
MD of Epidemiology(Public Health)
MD of OMS

2. Introduction
➢Infectious diseases: are one of the main causes of
morbidity, mortality and disability in the world.
➢In 2001 an estimated 56.2 million people died from all
causes.
➢Almost one third of these deaths (26.1%) were due to
infectious causes
➢Virtually all were in developing regions (14.7 million).
Dr. Hisham Hwaiti

3. Introduction
➢Mortality from infectious diseases was highest in sub-
Saharan Africa, with 6.8 million deaths.
➢South Asia, with 4.4 million deaths, or 76.4% from
infectious diseases.
Dr. Hisham Hwaiti

4. Introduction
➢One third of the world population has tuberculosis,
➢And Africa accounts for 90% of the 300 to 500 million
new cases of malaria annually, with 1.5 to 2.7 million
deaths per year.
➢In 2010, 65 million will have died of acquired
immunodeficiency syndrome (AIDS).
Dr. Hisham Hwaiti

5. Dr. Hisham Hwaiti

6. Dr. Hisham Hwaiti

7. Introduction
➢While these diseases present a large threat for the
well-being of humans, there are well-known
interventions that are available for controlling and
preventing them.
Dr. Hisham Hwaiti

8. Introduction
➢The wide use of antibiotics in the first half of the 20th
century and immunization in the second half lead to a
significant decrease in incidence and mortality of
many infectious diseases.
➢In 1967 the U.S. Surgeon General declared, “The time
has come to close the book on infectious diseases.”
Dr. Hisham Hwaiti

9. Introduction
➢The term “Antimicrobial” agent is an inclusive term
referring to either an antibiotic or chemotherapeutic
agent.
➢ Antibiotic: - Is a substance produced by
microorganisms which suppress the growth of or
destroy other microorganism.
➢Antibacterial: chemical substances )artificial)
➢ The antibiotics have selectivity against bacteria (selective
toxicity)
Dr. Hisham Hwaiti

10. Introduction
Antimicrobial includes:
➢Antibiotics.
➢Antiviral.
➢Antifungal.
➢Anti-parasite(protozae)
➢Anthelmintic
Dr. Hisham Hwaiti

11. Introduction
➢Narrow –spectrum antibiotics
➢Extended –spectrum antibiotics
➢Broad –spectrum antibiotics

Dr. Hisham Hwaiti

12. Introduction
➢Narrow spectrum: - Antibiotic that affects certain type
of bacteria (like gram negative bacteria only) E.g :
(Penicillin G)
➢Broad spectrum: - Drugs that can kill many types of
bacteria (like gram negative and gram positive
bacteria). E.g : Tetracyclines
Dr. Hisham Hwaiti

13. Introduction
✓Bacteriostatic &Bactericidal
✓Bacteriostatic drugs inhibit the growth of bacteria (stop
rapid reproduction of microorganism and help the body
to kill it). - Cannot be used for people that have
immunity disease (e.g → AIDs), because it depends on
patient immunity.
Dr. Hisham Hwaiti

14. Introduction
✓Bactericidal drugs kill bacteria and are less dependent on host
defense mechanisms for the success of therapy Work in the body
whether the immune system is strong or weak.
•Some primarily static drugs may become cidal (higher concentration
(as attained in the urinary tract), e.g. sulfonamides, erythromycin,
•On the other hand, some cidal drugs, e.g. cotrimoxazole,
streptomycin may only be static under certain circumstances.
Dr. Hisham Hwaiti

15. Introduction
➢Resistance of antibiotics (bacterial resistance): - Is the
ability of bacteria to resist the effect of antibiotics. -
The drugs become ineffective in inhibiting or killing the
bacteria.
Dr. Hisham Hwaiti

16. Introduction
➢Reason of bacterial resistance: Misuse (irrational use) of
antibiotics: -
➢That happens because of the patient or the doctor or the
pharmacist.
✓Patient: may not take the whole dose.
✓Doctor and pharmacist: the dose may be wrong or giving
strong antibiotic for simple infection (like localized abscess)
Dr. Hisham Hwaiti

17. Introduction
➢Mechanism of bacterial resistance:
➢Bacteria may alert some structures to provide resistance to antibiotics
such as:
✓a) Decrease permeability of the antibiotics.
✓b) Produce a new enzyme that breakdown the antibiotics(β-
lactamase)
✓c) Change the target:-
- Change the substrate.
- Change ribosome structure. Dr. Hisham Hwaiti

18. Introduction
➢ Nosocomial bacteria: are bacteria that found in the
hospital and it is very dangerous (multi-resistance) and
cause nosocomial infection and they are very resistance to
strong antibiotics because they live in sterile environment.
➢ Nosocomial infection: is an infection that is caught during
a stay in a health facility such as a hospital.

Dr. Hisham Hwaiti

19. Introduction
➢Odontogenic infections are polymicrobial.
➢Facultative organisms, particularly viridians
streptococci, accompanied by strict anaerobes, in all
types of odontogenic infection.
➢Gram-positive and Gram-negative organisms,
➢Aerobic, anaerobic, or facultative.
Dr. Hisham Hwaiti

20. Introduction
➢Viridans streptococci (Streptococcus oralis, S. sanguis, and
S.mitis), Actinomyces, Peptostreptococcus, Fusobacterium,
pigmented and nonpigmented Prevotella, Porphyromonas,
Bacteroides, and Veillonella.
➢Debridement (primary dental care) to reduce the
microbial load.
Dr. Hisham Hwaiti

21. Introduction
➢The drug of choice should be either: three main
factors:
1.Patient factors
2.Microorganism factors
3.Drug factors
Dr. Hisham Hwaiti

22. Introduction
➢The drug of choice should be either: three main factors:
1.patient factors:
✓Age : tetracyclines are contraindicated below the age of 6 years.
✓Renal and hepatic function (metabolism and output)
✓Drug allergic eg: cephalosporin,penicillin
✓Pregnancy: penicillin, cephalosporin (B) & LACTATION
✓Genetic factors
✓Local factors
Dr. Hisham Hwaiti

23. Introduction
➢The drug of choice should be either: three main factors:
1.patient factors:
✓Age : tetracyclines are contraindicated below the age of 6 years.
Dr. Hisham Hwaiti
To be avoidedTo be reduced
-Erythromycin,
-Tetracycline
-Metronidazole,
-Clindamycin,
-Chloramphenicol

24. Renal function
(metabolism and
output)
Dr. Hisham Hwaiti

25. hepatic function
(metabolism and
output)
Dr. Hisham Hwaiti

26. Introduction
➢The drug of choice should be either: three main factors:
1.patient factors:
✓Local factors:
(a)Presence of pus and secretions decrease the efficacy
especially:sulfonamides and aminoglycosides.
(b)Presence of necrotic material or foreign body, including
implants and prosthesis
(c)Hematomas foster bacterial growth; tetracyclines, penicillin
and cephalosporins.
Dr. Hisham Hwaiti

27. Introduction
➢The drug of choice should be either: three main factors:
1.patient factors:
✓Local factors:
(c) Lowering of pH at site of infection reduces activity of macrolide and
aminoglycoside antibiotics.
(d) Anaerobic environment in the center of an abscess impairs bacterial
transport processes
(e) Penetration barriers at certain sites may hamper the access of the AMA
to the site, such as in subacute bacterial endocarditis (SABE),
endophthalmitis, root canal of teeth, etc.
Dr. Hisham Hwaiti

28. Introduction
➢The drug of choice should be either: three main factors:
2. Microorganism factors:
✓Chief complains, Clinical examination, Diagnosis, culture
Dr. Hisham Hwaiti

29. Introduction
•Oro-dental infections: are often mixed bacterial infections.
•Therefore, the drugs mostly selected are from penicillin/
amoxicillin (with or without clavulanic acid)
•some cephalosporins like cefuroxime or cefaclor which are active
on anaerobes, erythromycin, azithromycin, clindamycin,
vancomycin, doxycycline, ofloxacin and metronidazole/tinidazole.
•Most dentists initiate empirical therapy with amoxicillin +
metronidazole.
Dr. Hisham Hwaiti

30. Introduction
•Oro-dental infections:
•In a few situations like ANUG and oral thrush the clinical diagnosis itself
indicates the infecting organism and directs the choice of drug (penicillin/
doxycycline + metronidazole for ANUG; nystatin/clotrimazole for thrush).
Dr. Hisham Hwaiti

31. Introduction
➢The drug of choice should be either: three main factors:
3. Drug factors:
✓Spectrum of activity selectivity
✓Site of infection passes of BBB
✓Type of activity acute infections generally resolve
faster with bactericidal than with bacteriostatic drugs
✓Sensitivity of the organism
Dr. Hisham Hwaiti

32. Introduction
➢The drug of choice should be either: three main factors:
3. Drug factors:
✓Relative toxicity
✓Route of administration
✓Evidence of clinical efficacy
✓Cost
Dr. Hisham Hwaiti

33. Introduction
➢COMBINED USE OF ANTIMICROBIALS
✓One is good,
✓Two should be better
✓Three should cure almost any infection.
Dr. Hisham Hwaiti

34. Introduction
➢OBJECTIVES OF COMBINED USE OF ANTIMICROBIALS
✓To achieve synergism
✓To prevent emergence of resistance
✓To broaden the spectrum of antimicrobial action
Dr. Hisham Hwaiti

35. Introduction
➢Disadvantages of COMBINED USE OF ANTIMICROBIALS
✓1. They foster a casual rather than rational outlook in the
diagnosis of infections and choice of AMA.
✓2. Increased incidence and variety of adverse effects. Toxicity
✓3. Increased chances of superinfections.
✓4. If inadequate doses of —resistance may be promoted.
✓5. Higher cost of therapy.
Dr. Hisham Hwaiti

36. Introduction
➢PROPHYLACTIC USE OF ANTIMICROBIALS
✓Antimicrobial prophylaxis is highly successful when it is
directed against specific organisms, e.g. use of
benzathine penicillin to prevent streptococcal infection
responsible for rheumatic fever
Dr. Hisham Hwaiti

37. Introduction
➢PROPHYLACTIC USE OF ANTIMICROBIALS
✓Antimicrobial prophylaxis in dentistry This is
warranted for two distinct purposes:
•Prevention of local wound infection, and
•Prevention of distant infection (e.g. bacterial
endocarditis) in predisposed patients following dental
procedures.
Dr. Hisham Hwaiti

38. Introduction
•Prevention of
local wound
infection, and
Prevention of
distant
infection
Dr. Hisham Hwaiti

39. Introduction
➢FAILURE OF ANTIMICROBIAL THERAPY
•1. Improper selection of drug, dose, route or duration of
treatment.
•2. Treatment begun too late.
•3. Failure to take necessary adjuvant measures, e.g. drainage
of abscesses,
•4. Poor host defense—as in leukemias, neutropenia and other
causes; especially if bacteriostatic AMA is used.
Dr. Hisham Hwaiti

40. Dr. Hisham Hwaiti

41. CLASSIFICATIONS

42. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
A.Chemical structure (β-lactam & Aminoglycosides)
B.Mechanism of action
C.Type of organisms against which primarily active
D.Spectrum of activity
E. Type of action
Dr. Hisham Hwaiti

43. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
A.Chemical structure:
1.Sulfonamides and related drugs: Sulfadiazine and others
2.Quinolones: Ciprofloxacin, Moxifloxacin, et
3.β-lactam antibiotics:Penicillins, Cephalosporins, Monobactams,Carbapenems.
4.Tetracyclines:, Doxycycline, etc.
5.Nitrobenzene derivative: Chloramphenicol
6.Aminoglycosides: Streptomycin, Gentamicin, Neomycin, etc.

44. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
A.Chemical structure:
9. Macrolide antibiotics: Erythromycin, Clarithromycin, Azithromycin, etc.
10. Lincosamide antibiotics: Lincomycin, Clindamycin.
11. Polypeptide antibiotics: Polymyxin-B, Colistin, Bacitracin, Tyrothricin.
12. Glycopeptides: Vancomycin, Teicoplanin
13. Oxazolidinone: Linezolid.
14. Nitrofuran derivatives: Nitrofurantoin, Furazolidone.

45. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
A.Chemical structure:
15. Nitroimidazoles: Metronidazole, Tinidazole.
16. Nicotinic acid derivatives: Isoniazid, Pyrazinamide, Ethionamide.
17. Polyene antibiotics: Nystatin, Amphotericin-B, Hamycin.
18. Azole derivatives: Miconazole, Clotrimazole, Ketoconazole, Fluconazole.
19. Others: Rifampin, Spectinomycin, Sod. fusidate, Cycloserine, Viomycin,
Ethambutol, Clofazimine, Griseofulvin.

46. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
B. Mechanism of action
1.Inhibit cell wall synthesis: Penicillins, Cephalosporins, Cycloserine,
Vancomycin, Bacitracin.
2.Cause leakage from cell membranes: Polypeptides—Polymyxins,
Colistin, Bacitracin. Polyenes—Amphotericin B, Nystatin, Hamycin.
3.Inhibit protein synthesis: Tetracyclines, Chloramphenicol, Erythromycin,
Clindamycin, Linezolid.

47. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
B. Mechanism of action
4. Inhibit DNA gyrase: Fluoroquinolones—Ciprofloxacin.
5. Interfere with DNA function: Rifampin.
6. Interfere with DNA synthesis: Acyclovir, Zidovudine.
7. Interfere with intermediary metabolism: Sulfonamides, Sulfones, PAS,
Trimethoprim, Pyrimethamine, Metronidazole.

48. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
C. Type of organisms against which primarily active
1.Antibacterial: Penicillins, Aminoglycosides, Erythromycin, etc.
2.Antifungal: Amphotericin B, Ketoconazole, etc.
3.Antiviral: Acyclovir, Amantadine, Zidovudine, etc.
4.Antiprotozoal: Chloroquine, Metronidazole, etc.
5.Anthelmintic: Mebendazole, Pyrantel, Niclosamide, Diethyl, etc.

49. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
D. Spectrum of activity
•Narrow spectrum: Penicillin G, Streptomycin, Erythromycin
•Broad spectrum: Tetracyclines, Chloramphenicol
The initial distinction between narrow and broad-spectrum
antibiotics is no longer clear-cut.

50. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
E. Type of action
Primarily bacteriostatic: Sulfonamides, Erythromycin, Tetracyclines,
Clindamycin, Chloramphenicol, Linezolid, Ethambutol
Primarily bactericidal: Penicillins, Cephalosporins, Aminoglycosides,
Vancomycin, Polypeptides, Ciprofloxacin, Rifampin, Metronidazole,
Cotrimoxazole

51. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
A.Chemical structure: Cell wall inhibitors:
1)β-lactam
Dr. Hisham Hwaiti

52. CLASSIFICATION
➢Antimicrobial drugs can be classified in many ways:
A.Chemical structure: Cell wall inhibitors:
1) β-lactam : Contain β-lactam ring that is responsible for allergy reaction.
2) Non β-lactam : No β-lactam ring in their structure.
Note: - When the bacteria become resistance to one type of β-lactam that
means that the bacteria have resistance to all types of β-lactam drugs
because they have the same structure.
β-lactamase enzymes
Dr. Hisham Hwaiti

53. CLASSIFICATION
β-lactam
1.PENICILLINS: Penicillin was the first antibiotic to be used clinically in 1941.
- Alexander Fleming(1928) .
* 1935 sulfonamide antibacterial
Dr. Hisham Hwaiti

54. CLASSIFICATION
Classification of penicillin:
1.Natural penicillin :
a. Short acting (4-6 hrs ) :
•Penicillin G (Benzyl Penicillin ) Strong but IV ( so used in emergency
cases)
•Penicillin V (phenoxymethyl Penicillin) Oral but weak
b. Intermediate( 12-24 hrs) :
•Procaine Penicillin G IM
c. Long acting (21 days ) :
•Benzathine Penicillin G IM
Dr. Hisham Hwaiti

55. CLASSIFICATION
Classification of penicillin:
1.Natural penicillin :
•Spectrum of Natural pencillins:
•Wide range of G+ve
•Only Neisseria from G-ve
•Only Treponemia (syphilis)from Atypical
Dr. Hisham Hwaiti

56. CLASSIFICATION
1.Natural penicillin :
•Streptococcus may cause ( Respiratory tract infection) as:
✓Sinusitis
✓Pharyngitis
✓Tonsillitis
✓Pneumonia
•Staphylococcus may cause(Skin or mucous membrane infection)
as:
✓Skin infection
✓Cellulitis
✓Soft tissue infection
Dr. Hisham Hwaiti

57. CLASSIFICATION
1.Natural penicillin :
• Bacilli :
•Bacillus anthraces . which cause ( Anthrax)
•Coryne bacterium diphtheria . which cause ( Diphtheria )
•G-ve include: ( Neisseria )
•Neisseria gonorrhea . which cause ( Gonorrhea )
•Gonorrhea is sexual transmitted diseases (STD)
•Neisseria meningitis. which cause ( meningitis )
Dr. Hisham Hwaiti

58. CLASSIFICATION
1.Natural penicillin :
Uses of Natural pencillins :
Short acting (4-6 hrs ) :
•Penicillin G (Benzyl Penicillin ) Strong but IV ( so used in
emergency cases)
Uses:
•i. Meningitis [ ceftriaxone or cefatoxime is preferred , but penicillin G is
preferred in babies ]
•ii. Endocarditis
•iii. Acute rheumatic fever
•iv. Diptheria [ Erythromycin first choice ]
•v. Anthrax [ Ciprofloxacin or Doxycycline preferred ]
Dr. Hisham Hwaiti

59. CLASSIFICATION
1.Natural penicillin :
Uses of Natural pencillins :
Short acting (4-6 hrs ) :
•Penicillin V (phenoxymethyl Penicillin) Oral but weak
Uses :
•i. First choice of Tonsillitis
•ii. Prophylaxis against rheumatic fever
Dr. Hisham Hwaiti

60. CLASSIFICATION
1.Natural penicillin :
Uses of Natural pencillins :
Intermediate( 12-24 hrs) :
•Procaine Penicillin G IM
Uses :
i.Syphilis
ii.Gonorrhea [ceftriaxone 500mg single dose(I.M) +
Azithromycin preferred
Dr. Hisham Hwaiti

61. CLASSIFICATION
1.Natural penicillin :
Uses of Natural pencillins :
Intermediate( 12-24 hrs) :
•Procaine Penicillin G IM
Uses :
i.Prophylaxis against endocarditis before some minor dental
surgeries in patient with :
✓ Valvular heart disease
✓ Artificial valves
✓ History of endocarditis
• Amoxicillin is preferred ( 4 pills before surgery)
Dr. Hisham Hwaiti

62. CLASSIFICATION
1.Natural penicillin :
Uses of Natural pencillins :
f. Long acting (21 days ) :
•Benzathine Penicillin G IM
i. Prophylaxis of rheumatic fever
ii. Syphilis
Dr. Hisham Hwaiti

63. CLASSIFICATION
1.Natural penicillin :
Disadvantage of Natural penicillin’s G :
1. Short acting
2. Narrow spectrum
3. Sensitive
4. Resistance due to pencillinase sensitive
Dr. Hisham Hwaiti

64. CLASSIFICATION
2.Semi-synthetic penicillin’s :
a.Extended spectrum pencillin :
Aminopenicillin ( second generation ) :
✓ Ampicillin
✓ Amoxicillin

Dr. Hisham Hwaiti

65. CLASSIFICATION
2.Semi-synthetic penicillin’s :
a.Extended spectrum pencillin :
Ampicillin Amoxicillin
•More active than penicillin G•More active than penicillin G
•6 hours duration ( 1*4) •8 hours duration ( 1*3)
•Food may interfere with ampicillin(
30 min before or 2 hrs after)
•It dosent interfere with food
•Side effect (moderate diarrhea ) or
( pseudo membranous colitis)
•Less side effect specially ( Diarrhea)
•More lipid soluble •More lipid soluble
Dr. Hisham Hwaiti

66. CLASSIFICATION
2.Semi-synthetic penicillin’s :
a.Extended spectrum pencillin :
Therapeutic uses :
1. Widely used in respiratory infection
2. Peptic ulcer ( because of H.pylori)
3. Typhoid ( Amoxicillin 2nd choice) , ceftriaxone or ciprofloxacin or
Co-Trimaxazole is the 1st choice
4. First choice for skin infection , cellulitis.
Dr. Hisham Hwaiti

67. CLASSIFICATION
2.Semi-synthetic penicillin’s :
a.Extended spectrum pencillin :
Therapeutic uses :
5. Urinary tract infection
6. Prophylaxis against endocarditis before dental surgery
Dr. Hisham Hwaiti

68. CLASSIFICATION
2.Semi-synthetic penicillin’s :
a.Extended spectrum pencillin :
•Side effect :
1.Hypersensitivity (10%) cross allergy
2.Secondary infection like oral candidiasis
3.Diarrhea (pseudomembranous colitis), nausea, vomiting
4.Local pain when injected
5.Nephritis : output
Dr. Hisham Hwaiti

69. CLASSIFICATION
2.Semi-synthetic penicillin’s :
a.Extended spectrum pencillin :
•Drug interaction :
•1. Penicillin’s + Gentamycin ( Synergism) but they must not mixed in
the same syringe (inactive )
•2.Hydrocortisone (inactive) if mixed in IV solution
Dr. Hisham Hwaiti

70. CLASSIFICATION
β- lactamase inhibitors :
✓Clavonic acid
✓Sulbactam
✓Tazobactam
Clavonic acid + Amoxicillin [ Augmentin]
Sulbactam + Ampicillin (Ampictam or Sulbacin).
Tazobactam + piperacillin
- In dentistry if there are signs of infection or inflammation we use strong
antibiotics such as Clavulanic acid + Amoxicillin (Augmentin) but if there is no
signs of infection or inflammation we give the patient Ampicillin or Amoxicillin as
prophylaxis.
Dr. Hisham Hwaiti

71. CLASSIFICATION
β- lactam:
2. Cephalosprin:
Classification : ( depend on the antimicrobial activity ) :
✓ Narrow ( 1st generation )
✓ Intermediate ( 2nd generation )
✓ Wide spectrum ( 3,4,5 generation )
Dr. Hisham Hwaiti

72. CLASSIFICATION
β- lactam :
2. Cephalosprin:
Dr. Hisham Hwaiti

73. CLASSIFICATION
β- lactam :
2. Cephalosprin: Narrow ( 1st generation )
✓These were developed in the 1960s .
✓Spectrum : G+ve and weak G –ve
✓Not cross BBB
✓Uses:
✓a)Pencillin substitutes ( Allergy)
✓b)First line in surgical anti-microbial prolyphlaxis ( cefazolin)
✓c) Skin infection ( skin abscess ) or boils
Dr. Hisham Hwaiti

74. CLASSIFICATION
β- lactam :
2. Cephalosprin: Intermediate ( 2nd generation )
✓These were developed subsequent to the first generation compounds
✓Their utility has declined in favour of 3rd generation cephalosporins.
✓Specrtum : G+Ve & extended to G-ve against & aerobics .
✓Not cross BBB .
✓Uses :
✓a) Respiratory tract infection ( Cefuroxime )
✓b) Mixed aerobic infection ( Peritonitis – diverticulosis )
✓c) Impetigo ( Amoxicillin preferred )
Dr. Hisham Hwaiti

75. CLASSIFICATION
β- lactam :
✓2. Cephalosprin: Wide spectrum ( Third generation )
✓These compounds introduced in the 1980s
✓They are less active on gram-positive cocci and anaerobes. As such, they are less
suitable for dental infections.
✓Spectrum : less G+ve & highly activity against G–ve
✓ Cross BBB so used in (Meningitis & hospital acquired infection)
✓Uses :
a) Meningitis, b) GIT infection, c) UTI infection, d) Lower respiratory
tract infection, e) Typhoid, f) Gonorrhea Dr. Hisham Hwaiti

76. CLASSIFICATION
β- lactam :
2. Cephalosprin:
✓Side effect :
✓1.Allergy
✓2.More toxic than penicillin ( Nephrotoxicity )
✓3.Local Pain after IM injection
✓4.Biliary stones or gall stones
✓5.Super infection due to Normal flora
✓candida albicans ( oral or vaginal candiasis )
✓6.Bleeding
Dr. Hisham Hwaiti

77. CLASSIFICATION
β- lactam :
2. Cephalosprin:
•In dental infection: There are no compelling indications for
cephalosporins in dentistry except as alternative to penicillin/
amoxicillin, especially in patients who develop rashes or other milder
allergic reactions (but not immediate type of hypersensitivity), and in
cases with penicillin/amoxicillin-resistant infection.
Dr. Hisham Hwaiti

79. Odontogenic
infection
Dr. Hisham Hwaiti

80. ✓Dentists prescribe between 7% and 11% of all common
antibiotics (betalactams, macrolides, tetracyclines, clindamycin,
metronidazole).
✓In the UK, dentists accounted for 7% of all community
prescriptions of antimicrobials.
✓The National Center for Disease Control and Prevention “CDC”
estimate that approximately one -third of all outpatient antibiotic
prescriptions are unnecessary.
Dr. Hisham Hwaiti
Odontogenic infection

81. ✓Oral bacterial infections primarily affect the teeth
(caries) and pulpal, periodontal, or pericoronal tissues.
✓pain, erythema, and edema, and difficulty chewing.
Serious, even life-threatening situations (Ludwig angina,
osteomyelitis, or cavernous sinus thrombosis).
✓When to prescribe antibiotics?
Dr. Hisham Hwaiti
Odontogenic infection

82. Dr. Hisham Hwaiti
Recommended treatment modalities for common
inflammatory oral lesions.
*Operative intervention is needed, like filling, RCT, local irrigation,
incisional drainage, and O.H.I.
**Empirical antibiotic prescribing is needed as an initial treatment.

83. ➢Must remove source of infection
➢ When to prescribe antibiotics?
✓Systemic involvement (fever, lymphadenopathy and fatique
✓Spreading of infection
✓Large swelling
✓Lymph nods involvement
✓Cellulitis
Dr. Hisham Hwaiti
Odontogenic infection

84. ✓For severe infections the dose of amoxicillin and
phenoxymethylpenicillin should be doubled.
✓ Severe infections include those cases where there is extra-oral
swelling, eye closing or trismus .
✓The patient should be instructed to notify the clinician if
symptoms do not resolve in 2 to 3 days.
✓Reevaluate the patient and Modify the therapeutic regimen
and/or a culture and susceptibility test.
Dr. Hisham Hwaiti
Odontogenic infection

85. ➢Primary line of treatment:
✓Choice for the initial treatment of an odontogenic infection:
Amoxicillin and penicillin VK.
✓Unless the patient has an allergy to penicillin,
✓Most odontogenic infections will require 5-7 days of
antibacterial chemotherapy.
Dr. Hisham Hwaiti
Strategies for the selection of adjunctive antibacterial
agents:

86. ✓For severe infections the dose of amoxicillin and
phenoxymethylpenicillin should be doubled.
✓ Severe infections include those cases where there is
extra-oral swelling, eye closing or trismus .
✓The patient should be instructed to notify the clinician
if symptoms do not resolve in 2 to 3 days.
Dr. Hisham Hwaiti
Primary line of treatment:

87. ✓Reevaluate the patient and Modify the therapeutic
regimen and/or a culture and susceptibility test.
✓Metronidazole in combination with penicillin VK
provides excellent coverage for mixed odontogenic
infections dominated by obligate anaerobes
Dr. Hisham Hwaiti
Primary line of treatment:

88. Dr. Hisham Hwaiti
Primary line of treatment:

89. Dr. Hisham Hwaiti
Primary line of treatment: or

90. Dr. Hisham Hwaiti
Primary line of treatment:

91. Dr. Hisham Hwaiti
Primary line of treatment:
•Erythromycin ―macrolide choice for the treatment of o
dontogenic infections in patients who are allergic to beta-
lactam antibiotics and pregnancy.

92. Dr. Hisham Hwaiti
Secondary line of treatment:
✓Many oral Gram-negative anaerobes have natural or intrinsic resistance.
✓ Use of clindamycin, co-amoxiclav and clarithromycin offers no advantage
over amoxicillin, phenoxymethylpenicillin, metronidazole and
erythromycin for most dental patients.
✓ Contribute to the development of antimicrobial resistance.
✓ The use of broad-spectrum antibiotics is associated with the increase in
Clostridium difficile infection observed in both primary and secondary
care.

93. Dr. Hisham Hwaiti
Secondary line of treatment:
✓Clarithromycin and azithromycin “newer macrolide antibacterial agents”
in the treatment of odontogenic infections better alternatives
erythromycin
✓ Extended spectrum against facultative and some obligate anaerobes:
✓ more favorable tissue distribution,
✓ fewer adverse effects,
✓ a once-a-day (azithromycin) or twice-a-day (clarithromycin) dosage schedule.
✓ Higher cost and the association with sudden cardiac death syndrome
after administration of macrolides (with the exception of azithromycin).

94. Dr. Hisham Hwaiti
Secondary line of treatment:
✓Co-amoxiclav 250/125 tablets are amoxicillin 250 mg as trihydrate and clavulanic
acid 125 mg as potassium salt.
✓ Cholestatic jaundice can occur either during or shortly after the use of co-
amoxiclav; in patients above the age of 65 years and in men.

95. Dr. Hisham Hwaiti
Secondary line of treatment:

96. Dr. Hisham Hwaiti
Tertiary line of treatment:
✓Clindamycin is active against Gram-positive cocci, including
streptococci and penicillin-resistant staphylococci, and can be
used if the patient has not responded to amoxicillin or
metronidazole .
✓ Cause the serious adverse effect of antibiotic-associated
colitis more frequently than other antibiotics.

97. Dr. Hisham Hwaiti
Tertiary line of treatment:
✓Appropriate 5-day regimen:
✓ Do not prescribe clindamycin to patients with diarrheal states.
✓ Clindamycin is alternative for patients allergic to beta-lactam
antibacterial agents.
✓GOOD BONE PENETRATION

98. Dr. Hisham Hwaiti
Recommendations:
✓Drainage is the recommended treatment with incisional drainage
rather than RCT.
✓ Antibiotic therapy and drainage are recommended for more severe
infections such as facial cellulitis, pericoronitis, lateral periodontal
abscess, and necrotizing ulcerative gingivitis.
✓ The type of antibiotic and dosing regimen depend on: –
✓ The severity of infection and
✓ The predominant type of causative bacteria.

99. Dr. Hisham Hwaiti
Recommendations:
✓Infections in which anaerobic bacteria are implicated
(such as pericoronitis, periodontal abscess and
necrotizing ulcerative gingivitis) are better treated with
metronidazole; the best dosage regimen is 250 mg every
8 hours.

100. Dr. Hisham Hwaiti
✓Adjunct to local measures
✓ Metronidazole is the drug of first choice in the
treatment of ANUG and treatment of pericoronitis
✓ There is systemic involvement or persistent swelling
despite local measures a suitable alternative is
amoxicillin.
Acute Necrotizing Ulcerative Gingivitis and Pericoronitis:

101. Dr. Hisham Hwaiti
Acute Necrotizing Ulcerative Gingivitis and Pericoronitis:

102. Dr. Hisham Hwaiti
Acute Necrotizing Ulcerative Gingivitis and Pericoronitis:

103. Dr. Hisham Hwaiti

104. Dr. Hisham Hwaiti
Type of
druge
Class Indications Contra- indications Side effects Interactions Adult dose
Amoxicillin Penicillin - Acute oral
infection
-Sinusitis
-Prophylaxis
-Pregnancy
-Breast
feeding
-Hypersensitivity to
penicillin,
-toxic dermatitis during
mononucleosis
-cytomegalovirus
infection,
-lymphoid leukemia,
-therapy with
allopurinol
-Diarrhea,
-Reactions due
to
hypersensitivity
-Less effect
of live
vaccines
-Less effect
with
tetracyclines
-Less effect
with PPI
drugs
250-500 mg,
8-hourly
5-7 days
Prophylaxis:
4 tabs
(4*500mg) 1
hr before
surgery
Ampicillin Penicillin - Acute oral
infection
-Sinusitis
-Prophylaxis
-Pregnancy
-Breast
feeding
-Hypersensitivity to
penicillin,
-Pain and
inflammation of
injected area.
-Nausea,
-vomiting,
-diarrhea,
-hypersensitivity
-Less effect
of live
vaccines
-Less effect
with
tetracyclines
-Less effect
with PPI
drugs
250-500 mg,
8-hourly
5-7 days
Prophylaxis:
4 tabs
(4*500mg) 1
hr before
surgery

105. Dr. Hisham Hwaiti
Type of
druge
Class Indications Contra-
indications
Side effects Interactions Adult
dose
Azithromycin
(take on
empty
stomach)
Macrolide- Acute oral infection
-Sinusitis
-Prophylaxis
-Replacement for
penicillin
-Pregnancy
-Hypersensitivit
y
-serious hepatic
failure
-Antipsychotic
drugs
(pimozide)
-Diarrhea,
-abdominal
pain,
-nausea,
-vomiting
-Less effect of live
vaccines
-Increase of bleeding
with warfarin pt
-Careful prescribe in
liver and cardiac
compromised pt.
500 mg
daily
For 5
days
1
st
day
2 tabs
MetronidazoleNitroimidaz
ole
-Acute necrotizing
gingivitis,
-periodontal
diseases.
-Effective against
anaerobic
microbes
-Pregnancy in
1
st
trimester
-Allergy
-Pt. treated
with disulfiram
in the past 2
weeks
-Nausea,
-diarrhea,
-bad taste,
-peripheral
neuropathies
(especially in
patients with
liver disease)
-Less effect of live
vaccines
-Increase of warfarin
effect
-Careful prescribe in
brestfeeding
200-
400mg,
8hourly
(take
with
meals)
Clindamycin MacrolideSerious oral bacterial
infections in case of
allergy to penicillin
HypersensitivityNausea, vomiting,
diarrhea,
pseudomembrano
us colitis
effect ofneuromuscular
drugs like pancuronium
adverse reaction with
erythromycin.
10-30
mg/kg/
daily, 4
times/
daily

106. Dr. Hisham Hwaiti
Type of
druge
Class Indications Contra-
indications
Side effects Interactions Adult dose
Minocycline
Doxycycline
Tetracycline- Mucous
membrane
pemphigoid
- Periodontal
diseases
-Pregnancy
-children< 8
years
-Allergy
-It can cause
vertigo,
-oral and skin
pigmentation.
-Less effect
of penicillin
-Less effect
of vitamins
-Don’t sun
exposure
100-200 mg/daily
For 5-7 days
20mg 2times a day
9 months after
scaling and root
planning
CefadroxilCephalosporin
Acts orally
Oral bacterial
infections
HypersensitivityRare.
Hypersensitivity
1-2 g, 2 times/daily
Cefazolin Cephalosporin
Acts orally
Oral bacterial
infections
-Hypersensitivit
y
-Reduce dosage
in case of renal
failure
Rare. Localized
pain after
injection
Hypersensitivity
Probenecid
(prolongs and
extends the
blood levels of
amoxicillin),
aminoglycoside
s and diuretics
(increase renal
toxicity).
1-2 g/daily
intramuscular or
intravenous, 4 ti mes
/daily

107. Dr. Hisham Hwaiti
Type of
druge
Class Indications Contra-
indications
Side effects Interactions Adult dose
ClarithromycinMacrolide Oral
bacterial
infections
-Hypersensitivity
-pregnancy,
-breast-feeding
-serious hepatic
failure
-Rare.
-Diarrhoea,
-Abdominal
pain,
-Nausea,
-headaches,
-skin rash
increases the
blood
haematological
levels o f
carbamazepine
and
theophylline
250 mg, 2 times
/daily
VancomycinGlycopeptidesever oral
bacterial
infections in
patients
allergic to
penicillin
Renal or auditory
impairment
-Nausea,
-fever,
-phlebitis,
-rashes,
-hearing loss,
-nephrotoxicity
500 mg, 4 times/
daily (orally or
intravenously) or 1g,
2 times/daily
intravenously

108. Dr. Hisham Hwaiti

109. Dr. Hisham Hwaiti

110. Dr. Hisham Hwaiti

111. Dr. Hisham Hwaiti
Case1:
Pulp necrosis and localized acute apical abscess, phoenix abscess :
✓Spontaneous pain
✓Swilling
✓Without systemic involvement
➢Nonsurgical RCT
➢No drainage
•Referral as ttt

112. Dr. Hisham Hwaiti
Case2:
Pulp necrosis and localized acute apical abscess :
✓Spontaneous pain
✓Swilling
✓With systemic involvement
➢Nonsurgical RCT
➢No drainage
•Referral as ttt
√

113. Dr. Hisham Hwaiti
Case3:
Pulp necrosis and localized cellulitis:
✓Spontaneous pain
✓Swilling
✓With systemic involvement
➢Nonsurgical RCT
➢No drainage
•Referral as ttt
√

114. Dr. Hisham Hwaiti
Prophylaxis :
Current guidelines March23,2023
✓Joint replacement consultation of Joint replacement surgeon
✓Prosthetic cardiac valves
✓History of infective endocarditis
✓Cardiac transplantation with valve regurgitation
✓Unrepaired cyanotic congenital heart disease including palliative
shunts and conduits

115. Dr. Hisham Hwaiti

116. Dr. Hisham Hwaiti
Thanks for your attention