OPTIMIZING ANTIBIOTIC

DENTAL ABUSE :

PRACTICE WHY

TO &

PREVENT HOW ?

Dr Rishi Bali Professor , PG Department of OMFS , DAV Centenary DCH , Yamunanagar .

2

ANTIBIOTICS : DISCOVERY BY ACCIDENT

A fungal spore that the wind might have blown into his lab while Fleming was on vacation in 1928, forever changed the course of medicine... Penicillin after the mould notatum Penicillium

In 1940s, Chain & Florey ran successful trials on mice - Nobel prize in 1945

GOLDEN AGE OF ANTIBIOTICS

Biggest medical breakthrough

Miracle drug : Saved many lives

Dentists benefited greatly as most odontogenic infections were penicillin sensitive

WHY DISCUSS Antibiotics so often ?

PRECIOUS : LIFE SAVING DRUGS

UNIQUE : ANTIBIOTIC RESISTANCE

5

Alexander Fleming's Nobel Lecture , 1945

It is not difficult to make microbes resistant to penicillin. The time

may come when penicillin can be

bought by anyone in the shops exposing microbes to non-lethal quantities of the drug that make them resistant.
6

8a

ANTIBIOTICS IN DENTISTRY
10 15 % Prescriptions by dentists Approximately 1/3 prescriptions unnecessary

Do all cases benefit & are we at times abusing antibiotics ?

As ethical practitioners how should we minimize use ?
9

ANTIBIOTIC USES IN DENTISTRY

Prophylactic

Therapeutic

Empirical

10

WHAT IS PROPHYLAXIS ?
Greek word "an advance guard

11

INFECTION ?
Inoculate Incubate Multiply

Bacterial Insult Host defence

12

Dental Procedures breach the 1st line defence: Not the 2nd & 3rd !

Bacteremia

: Skin/Mucous membranes / Saliva

1st

2nd:Leucocytes
Complement system

3rd
Immunoglobuln

13

PROCEDURE BACTEREMIA (%)

Prevalence

Chewing

17-51

Toothbrushing

0-26

Dental flossing

20-58

14

NATURES PROPHYLAXIS
Surface barriers Deep tissue defending elements

15

DECISION SHOULDNT BE AUTOMATIC ?

USE ONLY WHEN CLEAR BENEFIT

Systemic / local compromise

Prosthetic heart valves or joints

Implant placement

High Blood loss , Long or Contaminated surgery

16

Every inflammation is not infection

ANTIBIOTICS NOT INDICATED
Acute pulpitis / Acute periapical infection Trismus of non infectious origin Dry socket

Chronic marginal gingivitis / periodontitis

Idiopathic facial pain

ROUTINE EXTRACTIONS
No significant drop in incidence of Dry /

Infected

socket

or

infectious
antibiotics are

complications

when

prescribed
Antibiotic use NOT RECOMMENDED with extractions in healthy patient
Oral & maxillofacial infections : 15 unanswered questions OMFclinics of North america ;Nov 2011, vol 23 , No 4

PERICORONITIS
Watchful waiting with antibiotics is abuse
Debridement, Irrigation with Betadine /H2O2 Combination of early surgical extraction & antibiotics for not more than 3 days
Oral & maxillofacial infections : 15 unanswered questions OMFS clinics of North america ;Nov 2011, vol 23 , No 4
19

IMPACTIONS & IMPLANTS

Oral Hygiene is the key . Single loading IV / Oral no more than 2 days post op

Prophylactic impactions/ Healthy Patients

Oral & maxillofacial infections : 15 unanswered questions OMFS clinics of North america ;Nov 2011, vol 23 , No 4.

ANTIBIOTICS IN ENDODONTICS

Patients with Systemic compromises/ endocarditis

Signs of infection like Lymphadenopathy, malaise or fever RCT in Non vital teeth , Apicoectomy
Antibiotic cant reach the canal once the BMP is done

GINGIVITIS & PERIODONTITIS

Systemic antibiotic therapy not appropriate for plaquemediated chronic gingivitis/periodontitis.Local

measures/drug delivery sufficient

ANUG is the only true indication for antibiotics.

Facial fractures
Depends on Type ,Treatment & Site. Maxilla , Zygoma & condylar

1 shot loading dose better than 7 days

Anderson et al .Review of prophylactic antibiotics in Facial fractures. JOMS 64 :1664,2006

23

ABUSES
Prophylactic use

Spectrum abuse
Duration

Dose
Non intervention

PROPHYLACTIC ABUSE
To cover a breach in aseptic technique

Inadequate sterilization

Fear of failure

a just in case principle is practiced

SPECTRUM ABUSE
Inj Gentamicin & 3rd generation Cephalosporins Gram ve

coverage , not effective against oral pathogens

Combination therapy popular with dentists : Cipro TZ , Oflox Oz Broad spectrum goes against narrow spectrum principle

Pulpal vs Periodontal origin infection ?

SHORT VS LONG COURSES

False conception : Use antibiotics for certain no. of days to kill resistant strains > 10 days in implants / RCT ??

Short courses adequate . Compliance with long courses is poor

ABUSE -

MISCELLANEOUS

Using lower than therapeutic dose eg 375 mg Amoxyclav. Bacteria exposed to sub-therapeutic doses acquire resistance
Antibiotics to suppress infection without local intervention

Unfortunately patients accustomed & routinely expect an antibiotic for toothache

Antibiotic resistance

The more we use the more we lose!

29

MINIMIZING ANTIBIOTIC USE

Realization to be rationale

Sound Preop work up & Prep

Good sterlization, Aseptic technique & Microbial contamination <50cfu/mm3

30

EARLY LOCAL INTERVENTION KEY TO REDUCE ANTIBIOTICS

Endo Access opening

Perio Debride/ Irrigation

OS - Remove offending tooth

Incision and drainage

31

MINIMIZING ANTIBIOTIC USE

Strict no to smoking

Good Oral Hygiene to disrupt Biofilms : Bacteria

in Biofilms are pathogenic & resistant to

antibiotics bacteria not the Free floating planktonic

Ref : Kurz A et al. N Engl J Med. 1996;334:12091215

MINIMIZING ANTIBIOTIC USE

Hair removal immediately before surgery using Clippers

Normoglycemia ,Preventing hypothermia ,Perioperative Hyperoxygenation

Shortest possible hospital stay

follow up

1. Greif et al. N Engl J Med. 2000;342:161167.

33

GUIDELINES
Use as adjunct not as 1st line cure

MIND ME

Use when systemic signs. Pain/ localized swellings dont require antibiotics always Choose narrow spectrum single drug

Prescribe adequate dose for correct duration

M microbiology guided therapy I indications evidencebased N narrowest spectrum D drug appropriate to type of infection M minimize duration E ensure ono therapy

ANTIBIOTIC PROPHYLAXIS - CAVEATS

Pre-op administration more effective : Give 1 hr prior

Late administration similar to NO administration

Single loading pre-op dose effective as 5 days course

35

ANTIBIOTICS ??
Dont be Automatic Dont consider antibiotics substitute for Local intervention Good technique Failure in infection control

All antibiotics are potential poisons for some patients. Use them with care and thoughtfulness (Long,1951)
36

Questions?