Principles of Therapy of odontogenic Infections

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in Pediatric Dentistry
Antibiotics in Pediatric Dentistry

   Treatment of Odontogenic Infection

   Infective Endocarditis Prophylaxis
 Most odontogenic infections are
 mild and require only minor

Orally administration of antibiotics are
effective against most mild and moderate
odontogenic infections
Principles of Therapy of Odontogenic Infection

      Determine the   severity of the infection

         Complete history

         Physical examination
Complete history

      Chief complaints
      Time of onset
      Duration
      Rapidly of progress
      Signs and symptoms
       (pain,swelling,warmth,redness,loss of
Physical examination

   Vital signs: temperature, pulse rate,
    respiratory rate, blood pressure

   Severe inf.         101 to 102 F
   Severe inf.         Above 100 /min
   Mild-to-moderate       up to 18 to20/min
    Pulse and respiratory rate in children

Age          3      4     5    6    9    12

Beat/min     105   100   100   95   90   85-90

Breath/min   30    28    26    23   20   20
Physical examination

   Mild infection
    Normal vital signs +mild temporary elevation

   Serious infection
     abnormal vital signs
Characteristic    Cellulitis              Abscess

 Duration         acute                 chronic
 Pain             severe,generalized    localized
 Size             large                 small
 Localization     diffused borders      well circumscribed
 Palpation        doughy to indurated    fluctuant
 Present of pus    no                    yes
 Seriousness       greater                less
 Bacteria          aerobic                anaerobic
Odontogenic Infection

    Cellulits & Abscess

    Alveolar abscess: Acute or chronic
   diffuse type of infection of the soft tissues
   primary or permanent tooth
   swelling of the face or neck
   tissue appears discolored
   high temperature
   malaise
   lethargy
   Broad-spectrom antibiotic
acute alveolar abscess
Chronic alveolar abscess
Criteria for referral to a specialist
   Rapidly progressive infection (cellulitis)
   Difficulty in breathing
   Difficulty in swallowing
   Fascial space involvement
   Elevated temperature (greater than 101F)
   Severe jaw trismus (less than 10 mm)
   Toxic appearance
   Compromised host defense
Compromised host defenses
   Uncontrolled metabolic diseases
       Severe diabetes
   Suppressing disease
      Leukemia, lymphoma, malignant tumors
   Suppressing drugs
      cancer chemotherapeutic agents
Toxic Appearance
                  Temperature, pulse rate,
                   respiratory rate

                  Sick, malaise,

                  glazed eye, open mouth

                  dehydrated
Lower face infections
Is antibiotic administration necessary?

    Seriousness of infection

    Surgical treatment

    Patient’s host defenses
Situations in which use of antibiotics is
              not necessary

      Chronic well-localized abscess

      Minor alveolar abscess
Select antibiotic
   Causative organisms based on history

   Host defense history

   Allergy history

   Previous drug history
Bacteria Responsible for Odontogenic Infection

Aerobic bacteria(25%) Anaerobic bacteria(75%)

Gram-positive Cocci    Gram-positive Cocci
                       Gram-negative Bacilli
                           Prevotella, porphyromonas
Antibiotic administration

   Proper route

   Proper dose

   Proper dosage interval
Adequate length of time

   Improvement in symptoms: within 2 days

   Reasonably asymptomatic: within 4 or 5 days

   At least 2 days after the symptoms disappear

   Usual prescription should be written for 6-7 days
    Effective orally administered antibiotics
       useful for odontogenic infections
   Penicillin
   Erithromycin
   Clarithromycin
   Clindamycin
   Cefalexin ,Cefadroxil
   Metronidazole
Penicillin V is empiric drug of choice

For most mild to moderate odontogenic infection

Allergic reaction 3%

                         Tab. 500mg
Penicillin V potassium
          (q.i.d)        Sus. 250mg/5ml
                         Sus 200000unit
Penicillin V Benzathin
           (t.i.d)        Sus 400000unit
Penicillin V Benzathin

   3-12 mon (6-10kg) 200,000 unit
   1-6 year (10-22 kg) 400,000 unit
   6-12 year (22-38 kg) 800,000 unit

   Broad spectrum. Rarely indicated for dental
   Gram-negative: H influenzae, Eschericha
    coli,Salmonella, Shigella

   Non-odontogenic maxillary sinusitis, prophylaxy
   Taste is agreeable
   Cap 250,500mg Sus 125,250mg/5ml (t.i.d)
   Amoxicillin faramox BD
   Sus 400 or 200 mg/5ml bid

Tab: 200/400 mg

Sus: 200mg/5ml q.i.d

For treatment of mild odont. Inf. In healthy
                                   penicillin-alergic patient
   Mild odontogenic infections in
    immunocompromised patients who are
    allergic to penicillin

   Sus 125mg/5ml b.i.d
   Cap 250,500 mg

Sus 100mg/5ml
Once daily for 5 days
   Chronic low-grade infections that resistant to
    Penicillin & Erithromycin

   Cap 150mg
   Sus 75mg/5ml
   Bactericidal, low toxicity ,broad spectrum
   More expensive

   Effective against oral anaerobic (Staph.,Strep.)&
   some aerobic gram-negative rodes(E coli,proteus,Klebsiella)

   Cross-sensitivity in 5-15% of patients allergic to penicillin

   Useful in the penicillin-allergic patient who has compromised
    host defense
   Sus Cefalexin 125 or 250 mg/5ml tid
Chronic infection

-lactamase – producing

In conjunction with

Sus: 125 mg/5ml, Tab: 250 mg (t.i.d)
   Average doses recommended for children
              under 60 i.b (27kg)

    Antibiotic              Usual oral dose

     Penicillin V   25-50 mg/kg/day in 4 divided doses
  Clarithromycin       15 mg/kg/day in 2 divided doses
   Erythromycin     30-40 mg/kg/day in 4 divided doses
     Cephalexin     25-50 mg/kg/day in 3 divided doses

Actual doses should be based on infection severity,
    child’s age and renal and hepatic clearances.
   Perform Surgery

   Support patient medically

   Follow up (Confirm treatment response)
Infective endocarditis (previously
referred to as bacterial endocarditis)
   an infection of the heart's inner lining
    (endocardium) or the heart valves that can
    damage or even destroy heart valves
AHA’s latest guidelines
Published in the Journal of The ADA April 2007

   Adverse reactions to antibiotics

   Drug-resistant bacteria

   Their hearts are already often exposed to bacteria
    from the mouth, which can enter their bloodstream
    during basic daily activities such as brushing or
patients who have taken prophylactic antibiotics
routinely in the past but no longer need them
   mitral valve prolapse
   rheumatic heart disease
   bicuspid valve disease
   calcified aortic stenosis
   congenital heart conditions such as ventricular
    septal defect, atrial septal defect and
    hypertrophic cardiomyopathy
Preventive antibiotics prior to a dental
procedure are advised for patients with:
   artificial heart valves
   a history of infective endocarditis
   certain specific, serious congenital (present from birth) heart
    conditions, including
       unrepaired or incompletely repaired cyanotic congenital heart
       a completely repaired congenital heart defect with prosthetic material
        or device, whether placed by surgery or by catheter intervention,
        during the first six months after the procedure
       any repaired congenital heart defect with residual defect at the site or
        adjacent to the site of a prosthetic patch or a prosthetic device
   a cardiac transplant that develops a problem in a heart valve.
Prophylaxis Recommended
   Dental extractions

   Periodontal procedures including surgery, scaling
     and root planing, probing, and recall maintenance

   Dental implant placement and reimplantation of
    avulsed teeth

    Endodontic (root canal) instrumentation or surgery
     only beyond the apex
Prophylaxis Recommended
   Subgingival placement of antibiotic fibers or strips

   Initial placement of orthodontic bands but not brackets

   Intraligamentary local anesthetic injections

   Prophylactic cleaning of teeth or implants where
     bleeding is anticipated
Prophylaxis NOT Recommended
   Restorative dentistry' (operative and prosthodontic) with
    or without retraction cords

   Local anesthetic injections(nonintraligamentary)

   Intracanal endodontic treatment; post placement and

   Placement of rubber dams

   Postoperative suture removal
Prophylaxis NOT Recommended
   Placement of removable prosthodontic or
    orthodontic appliances

   Creation of oral impressions

   Fluoride treatments

   Orthodontic appliance adjustment

   Shedding of primary teeth

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