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PRINCIPLES OF MANAGEMENT &


PREVENTION OF ODONTOGENIC
INFECTION
Contents
Introduction ........................................................................................................................................................................................................... 2
Microbiology of Odontogenic Infections ......................................................................................................................................................... 2
Stages of Odontogenic Infections; ................................................................................................................................................................ 3
Natural History of Progression of Odontogenic Infections.......................................................................................................................... 3
Principles of Management of Established Odontogenic Infections ............................................................................................................ 4
Principle 1; Determine Severity of Infection ............................................................................................................................................... 4
Complete History......................................................................................................................................................................................... 4
Physical Examination .................................................................................................................................................................................. 4
Principle 2; Evaluate State of a Patient’s Host Defense Mechanism....................................................................................................... 5
Medical Conditions that Compromise Host defense ............................................................................................................................ 5
Drugs that Compromise Host Defense ................................................................................................................................................... 5
Principle 3; Determine Whether Patient Should Be Treated by General Dentist or Oral & Maxillofacial Surgeon. ..................... 6
Criteria for referral to an OMFS ............................................................................................................................................................... 6
Criteria for Immediate Hospital Emergency Room Admission .......................................................................................................... 6
Principle 4; Treat Infection Surgically ........................................................................................................................................................... 6
Reasons for performing I&D. ................................................................................................................................................................... 6
Technique for I&D of a Vestibular Abscess or Cellulitis ..................................................................................................................... 6
Principle 5; Support Patient Medically .......................................................................................................................................................... 7
Principle 6; Choose & Prescribe Appropriate ANTIBIOTICS ............................................................................................................... 8
Principle 7; Administer Antibiotic Properly .............................................................................................................................................. 11
Principle 8; Evaluate the Patient Frequently .............................................................................................................................................. 11
Principles of Prevention of Infection .............................................................................................................................................................. 12
Principles of Prophylaxis for Post - Operative Wound Infection ......................................................................................................... 12
Principles of Prophylaxis Against Metastatic Infections .............................................................................................................................. 13
Prophylaxis against Infectious Endocarditis .............................................................................................................................................. 13
Dental Procedures in which Antibiotic Prophylaxis for IE are NOT RECOMMENDED ........................................................ 13
Prophylaxis in Patients with other Cardiovascular Conditions. ............................................................................................................. 14
THE END ........................................................................................................................................................................................................... 14
References ............................................................................................................................................................................................................ 14
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Introduction
 Odontogenic infections arise from teeth & is generally caused by bacteria that have tendency to cause abscess formation.
 These infecting bacteria enter the deep tissues of periodontium and periapical regions via roots of teeth.
o These infections range from low grade localized infections to sever life threating deep fascial space infections.
 Treatment of these infections ranges from endodontic therapy & gingival curettage to extraction, incision and drainage.

Microbiology of Odontogenic Infections


 Odontogenic infections are caused by normal oral flora;

Aerobic gram positive cocci Anaerobic gram positive cocci Anaerobic gram negative rods
 Odontogenic infection results when these bacteria gain access to deeper underlying tissues of oral cavity through necrotic
dental pulp or deep periodontal pocket.
 All odontogenic infections are poly microbial in nature (caused by multiple/mixed bacteria).

Percentage

Anaerobic Only 44%

Mixed 50%

Aerobic Only 6%

 Predominant Aerobic Bacteria in odontogenic infection are gram positive facultative;


o Streptococcus Milleri/Viridians group – found in 65% cases.
 S. anginosus, S. termedius, S. constellates
o These initiate the process of infection.
 Predominant Anaerobic Bacteria;
o Anaerobic Gram positive cocci
 Streptococcus & Pepto streptococcus
o Anaerobic Gram negative rods
 Prevotella, Fusobacterium, Porphyromonas
 Opportunistic organisms in odontogenic infections; (they are not causes of odontogenic infections)
o Anaerobic gram negative cocci
o Anaerobic gram positive rods
 Hyaluronidase synthesized by S. Milleri group allows the bacteria to spread through connective tissue.
 Metabolic by products from streptococci creates favorable environment for growth of anaerobic bacteria by;
o Releasing nutrients, lowering pH, Consuming oxygen.
 These anaerobic bacteria then cause liquefactive necrosis by Collagenases – resulting abscess formation.
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Stages of Odontogenic Infections;


Inoculation/Edema Cellulitis Abscess Resolution stage
Invading microbes are starting Infecting mixed flora stimulates Liquefaction Draining abscess, immune system
to colonized the host. the intense inflammatory necrosis destroys the bacteria and healing &
response. repair starts

Natural History of Progression of Odontogenic Infections


 Odontogenic infections have 2 major origins;
o Periapical – result from pulp necrosis (most common origin)
o Periodontal – result from periodontal pocket

Features Acute Periapical Abscess Acute Periodontal Abscess


1. Pain Sever & Throbbing Sever & Throbbing
2. Age Common in adults Common in adults
3. Pulp Necrotic & infected Vital
4. Swelling Usually, over the apex Usually over gingival 3rd
5. Sinus discharge Present Present
6. Tenderness to percussion Present Present
7. Tooth mobility Later stages Early stages
8. Origin Arises from pulp Arise from periodontal pocket
 Once the periapical area has become inoculated with bacteria and an active infection is
established, the infection spreads equally in all directions, but along the lines of least
resistance.
o Infection spread through cancellous bone until it touches the cortical plate.
 If this cortical plate is thin, the infection erodes through the bone and
enters the soft tissues
 Antibiotics alone will only arrest the infection, but will not cure it.
o So, treatment is to remove the cause by Extraction or Endodontic
treatment.
 The location of infection arising from a specific tooth is determined by;
o The thickness of the bone overlying the apex of tooth
o The relationship of the site of perforation of bone to muscle attachments of maxilla
& mandible determine the fascial space involved.

Tooth apex below the muscle attachment – vestibular abscess will occur.
Tooth apex above the muscle attachment – facial space will be infected.
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 Mostly Maxillary Teeth erode facial cortical plates
 Mostly maxillary molars cause buccal space infection (perforation above buccinators muscle)
 Maxillary canine cause infra – orbital space infection (canine space) – perforation above levator anguli oris muscle.
 Mostly mandibular anterior teeth erode facial cortical plates & cause vestibular abscess.
o Mandibular molars erode mostly lingual cortical plate.
o Mylohyoid muscle determines whether infections that are perforating lingual cortical plate;
 Go superior to muscle into sub – lingual space. OR
 Go below the mylohyoid muscle into sub – mandibular space.
 Most common odontogenic infection is vestibular space infection
 If these infections are untreated; The abscess will rupture spontaneously and drain and in result;
o The infection resolves OR
o Become chronic infection which drain into oral cavity or skin (figure; 16 – 5 in Tucker)
 As long as sinus tract continuous to drain, patient does not have pain.
 Antibiotic will stop the draining temporary and so definitive treatment will be extraction or endodontic therapy.

Principles of Management of Established Odontogenic Infections


Principle 1; Determine Severity of Infection
 Most odontogenic infections are mild and require only minor surgical therapy
 Severity can be determined by; history & physical examination

Complete History
 Chief complaint recorded in patient’s own words.
 Determine how long the infection has been present;
o Time of onset/beginning of infection by asking the patient, first appearance of symptoms;
 Pain, swelling, or drainage
o Progression of infection; symptoms of infection has been
 Constant,
 waxed and waned (undergo alternate increased or decreased)
 grown worse
o Rapidity of progress of infection; has the infection progress over a few hours or over days to a week?
 Information about patient’s symptoms; (Signs of inflammation)
o Most common complaint is pain. – ask location & spread of pain (Dolar)
o Ask the patient for swelling – sometimes hidden & sometime visible (tumor)
o Ask whether the area of infection or swelling is warm to touch. (calor)
o Ask patient, if there is any change in color (redness) over the area of infection or redness. (rubor)
o Functio laesa – trismus (maximum inter – incisal opening less than 20 mm), difficulty chewing, difficulty swallowing (dysphagia),
difficulty in breathing.
 Determine the general health of patient
o Malaise; fatigued, feverish, weak & sick patients.
 Ask about previous dental treatments (professional or self – treatment)

Physical Examination
 Examine patient’s vital signs.
o Pulse rate increases with increase in temperature of patient.
 Pulse rate of greater than 100 beats/minute indicate sever infection.
o Blood pressure is not altered by infection. But it is the pain & anxiety in a patient which increases the blood pressure. – B.P decreases in
septic shock.
o Normal respiratory rate is 14 – 16 breaths/minute
 Mild to moderate infection – respiratory rate greater than 18 breaths/minutes.
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 Orthodontic Fixed Appliances - BDS Lecture Notes PDF Download
 Amalgam Restoration - BDS Lecture Notes PDF Download
 COMPLEX NON-SKELETAL PROBLEMS IN PREADOLESCENT CHILDREN - BDS Lecture Notes
 Anatomy of Scalp - BDS Lecture Notes PDF Download
 Cerebrospinal Fluid (CSF) - BDS Lecture Notes PDF Download
 Cementum - BDS Lecture Notes PDF Download
 Recent Advances in Instrumentation Techniques - BDS Lecture Notes PDF Download
 Ameloblastoma - BDS Lecture Notes PDF Download
 Prevention of Odontogenic Infection - Principles of Management - BDS Lecture Notes
 Therapeutic Dentistry Histology of Teeth Dental Charting - BDS Lecture Notes PDF Download
 Maxillofacial Trauma and Management - BDS Lecture Notes PDF
 Technical Endodontics - BDS Lecture Notes PDF Download
And 698 more free downloads for Dental Students.
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 In odontogenic infection, there is potential for partial or complete airway upper airway obstruction as a
result of extension of the infection into the deep fascial spaces of head & neck. – that’s why respiratory rate
should be observed.
 Mild infection; vital signs normal, slight increase in temperature
 Sever infection; vital signs abnormal, high increase in temperature
 Inspect patient’s general appearance.
o Toxic Appearance; it is a patient with severe infection and elevated temperature, pulse & respiratory rate, and feeling
sick & tired. (figure 16 – 6 in contemporary OMFS, Tucker)
 Examine the head & neck for cardinal signs of infection inflammation as mentioned above.
 Palpation of swelling if present; check for;
o Tenderness
o Amount of heat
o Consistency of swelling
 Fleshy swelling – doughy swelling
 Firm or hard swelling – indurated swelling
 Fluctuant swelling – feeling like fluid filled balloon.
 This type has liquid pus in the center of indurated area.
 Perform intra oral examination to find the cause of infection.
 Perform radiographic examination
 Perform the staging of infection.
o Cellulitis is most severe presentation of infection.
o An abscess is sign of increasing host resistance to infection.
 Presence of pus indicates that the body has locally walled off the infection and that the local host resistance
mechanisms are bringing the infection under control.

Principle 2; Evaluate State of a Patient’s Host Defense Mechanism


 It is evaluated in the medical history; in which we estimate the patient’s ability to defend against infection.
o This ability can be REDUCED BY;
 Medical conditions
 Drugs
 These patients are treated vigorously, usually by OMFS because, they spread more rapidly & are sever in natures.
 If the patient with any of following conditions present to a dentist for routine therapy or minor infection – prophylactic
antibiotic must be provided to decrease the risk of P.O wound infection.

Medical Conditions that Compromise Host defense


Uncontrolled Metabolic Disease Immune System Suppressing Disease
result in decreased function of leukocytes (chemotaxis, result in decrease WBC function, antibody synthesis.
phagocytosis, and bacterial killing)
 Poorly controlled diabetes  HIV/AIDS
 Alcoholism  Lymphoma & leukemia
 Malnutrition  Malignancy
 End – stage renal disease with uremia  Congenital & acquired immunologic disease
Drugs that Compromise Host Defense
 Cancer chemotherapy drugs
 Immune suppressive drugs – organ transplantation & auto immune disease
o Cyclosporine
o Corticosteroids
o Tacrolimus (Prograf)
o Azathioprine (Imuran)
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Principle 3; Determine Whether Patient Should Be Treated by General


Dentist or Oral & Maxillofacial Surgeon.
Criteria for referral to an OMFS
01) Difficulty breathing 02) Difficulty swallowing 03) Dehydration
04) Trismus 05) Swelling extending beyond alveolar process – 06) Temperature > 101 F
EXTRA ORAL Swelling
07) Sever malaise & toxic appearance – 08) Compromised host defense 09) Need for GA
indicate systemic involvement of
infection.
10) Failed previous treatment

Criteria for Immediate Hospital Emergency Room Admission


 Threat to Airway or vital structures
 Rapidly progressing infection
 Difficulty breathing (dyspnea)
o Patient will refuse to lie down, have quiet or distorted speech
 Difficulty swallowing (dysphagia)
o Drooling is ominous sign
 Temperature > 101 F (38.3 C)

Trismus Mild Trismus Moderate Trismus Sever Trismus


Results from involvement Maximum inter – incisal opening Maximum inter – incisal opening Maximum inter – incisal opening
of muscles of mastication b/w 20 – 30 mm. b/w 10 – 20 nm. < 10 mm.
by inflammatory process.
Toxic Appearance: glazed eyes, open mouth & dehydrated, sick appearance, fatigued, high temperature.

Principle 4; Treat Infection Surgically


 The principal of management of odontogenic infections is;
o Remove the cause of infection (Primary Goal) – necrotic pulp or periodontal pocket
o Surgical drainage of accumulated pus and necrotic debris (Secondary Goal)
 Surgical Options for management of simple uncomplicated odontogenic infections.
o Endodontic treatment or Extraction with or without Incision & Drainage (I&D)
 Endodontic Tx & Extraction remove the cause of infection and drain the accumulated pus or debris.

Reasons for performing I&D.


 Remove the accumulated pus & bacteria from the tissues.
 Decreases the load of bacteria & necrotic debris.
 Reduce hydrostatic pressure by decompressing tissues.
o Improve the local blood supply
o Increase the delivery of host defenses & antibiotics.
 Prevent the spread of infection into deeper anatomic spaces.

Technique for I&D of a Vestibular Abscess or Cellulitis


Hilton’s Method of I&D is most commonly applied; The method of opening an abscess ensures that no blood vessel or nerve in the vicinity
is damaged.

01) Anesthesia
a. Regional nerve block is preferred. Alternatively, Infiltration into & around the area to be drained.
02) Stab Incision;
a. Directly over the site of maximum swelling or fluctuation and inflammation.
b. Avoid incising across Frenum or the path of mental nerve in lower premolar region.
c. It should be short, no more than 1 cm in length.
03) Insertion of Hemostat or Sinus Forceps
a. If pus is not encountered, further deepening of surgical site is achieved with sinus forceps (to avoid damage to vital structures)
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b. Closed forceps are pushed through the tough deep fascia and advanced towards the pus collection.
c. Abscess cavity is entered and forceps opened in a direction parallel to vital structures.
d. Pus flows along sides of the beaks.
e. Explore the entire cavity for additional loculi.
04) Placement of Drain
a. A soft rubber drain is inserted into the depth of the abscess cavity; and external part is secured to the wound margin with the help of
sutures.
b. Drain is left for at least 2 – 5 days.
c. Purpose of Drains;
i. Allow the discharge of tissue fluids and pus from the wound by keeping it patent.
ii. Maintain the opening
iii. Allow debridement of abscess cavity by irrigation.
d. The most commonly used drain for intra oral abscess is a quarter inch sterile Penrose drain.
i. Alternatively, thin strip of rubber dam can be used as a substitute (allergy if absent)
05) Dressing
a. Used when incisions are given extra orally.

Figures for Explanation;


Figure 16 – 9, Contemporary OMFS, (Tucker) 6th Edition
Figure 40.4, Textbook of OMFS, Jaypee, 3rd Edition

 Inoculation stage do not require I&D, just remove the necrotic pulp & do RCT or tooth & prescribe antibiotics.

Principle 5; Support Patient Medically


 For good outcome, patient’s ability to resist infection should also be good.
 There are certain diseases as mentioned above can decrease this resistance ability, that’s why they should treated effectively.
o Immune system compromising diseases
o Diabetes; infection itself does not increase the glucose level in body, but it is the host response to that infection which
raise the blood sugar.
 Control of blood sugar is directly proportional to resistance to infection.
o CVS disease should also be controlled.
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o Medications; if patient is taking anticoagulants, they should be reversed for successful surgery for infection.
o Etc.
 During infection body’s physiologic reserves are altered.
o Children are particularly susceptible to dehydration & high fever during infection
o Old patients are less susceptible to fever, but in them dehydration occurs during infection.
o Fever increases daily fluid requirements by about 800mL/F/day. & daily caloric intake by 3% - 5% per
degree Fahrenheit per day.
 However, temperature up to 103 F may be beneficial in combating infection.
o So, fever should be carefully controlled, with active hydration and nutritional support.
 Prescribe analgesic for relief of pain and to make patient rest.

Principle 6; Choose & Prescribe Appropriate ANTIBIOTICS


 There are nearly 70 antibiotics currently available.
 Before choosing specific antibiotic, first of all determine the need for antibiotic administration – means, whether the
patient needs antibiotic or not!!!
 Some misconceptions & Wrong Statements;
o All infections require antibiotics
o Extraction of offending tooth in presence of infection increase the chances of spread of infection.
o Prior to extraction, antibiotics prevent the worsening of infection.
 So, the need for antibiotics can be determined from following 3 factors;
o Seriousness of infection.
o Whether adequate surgical treatment can be achieved
 Sometimes extraction of tooth resolves the infection without antibiotics.
o State of patient’s host defenses
 Young, healthy patient may not need antibiotic while aged patient with systemic disease will need antibiotics.

Indications for Antibiotics


 Acute onset infection with diffuse swelling &  Minor, chronic, well – localized abscess
moderate to severe pain – Cellulitis. o Extraction only will heal the lesion but;
 Immune compromised patient. o Patient must be healthy, not immunocompromised &
 Deep fascial space infection Young.
 Sever pericoronitis  Well Localized dento – alveolar abscess –
o temperature >101 F periapical abscess
o trismus o With little or no swelling.
o swelling o Can be resolved by RCT, extraction along with I &
 Osteomyelitis D without antibiotics.
 Lymphadenopathy  Localized alveolar osteitis – Dry Socket
o Treatment is palliative, no antibiotics needed
 Mild pericoronitis with minor gingival edema &
mild pain.
o just irrigate with Hydrogen peroxide or chlorohexidine,
plus extraction.
 Patient Demand
 Severe Pain
 Toothache
 Multiple extraction in patient who is NOT
immunocompromised
 Drained Alveolar abscess
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Antibiotics do not speed up the wound healing and do not provide any benefit for nonbacterial
conditions.
 So, after determining the need for antibiotics, we should use empirical therapy, means give antibiotics on the assumption
that it is the appropriate drug.
 Orally administered antibiotics that are effective against odontogenic infections are;
o Penicillin – Drug of Choice.
o Amoxicillin
o Clindamycin
o Azithromycin
o Metronidazole
o Moxifloxacin
 Patient’s compliance decreases with increasing numbers of pills per day.
o Once daily – compliance 80%.
o 2x daily – compliance 69%.
o So On…
o So try to prescribe those antibiotics which can be taken few times a day.
 Routinely culture & sensitivity testing is not recommended. They are to be done in or indicated in;
o Infection spreading beyond alveolar process
o Rapidly progressing infection
o Post-operative infection
 If patient returns after 3 to 4 days with an infection, the chances of nonindigenous bacteria causing infection
are higher
o Previous, multiple antibiotic therapy
o Nonresponsive infection (after more than 48
hours)
o Recurrent infection
o Compromised host defense.
 Use the NARROW – SPECTURM
antibiotic; Advantages of Narrow – Spectrum
antibiotics;
o kills/inhabit narrow range bacteria, little or
no effect on GI tract & skin bacteria.
 While, B R O A D spectrum antibiotics, inhibit
not only oral bacteria, but can also cause death
of skin, GIT and other areas’ bacteria, and also
result in overgrowth of resistant bacteria.
o This resistance in patient can spread to
his/her families, coworkers,
community etc.
 So, in Simple infections as defined below,
narrow spectrum antibiotics are prescribed. While, in
complex; broad spectrum.

Antibiotics that have narrow spectrum are as much effective as wide spectrum bacteria but without upsetting normal host
bacteria & development of resistance.
Studynama’s BDS Community is one of India’s Largest Community of Dental Students. About
19,232 Indian Dental Course students are members of this community and share FREE study
material, cases, projects, exam papers etc. to enable each other to do well in their semester exams.

Links to Popular Study Material for BDS (Dental) students:


 Orthodontic Fixed Appliances - BDS Lecture Notes PDF Download
 Amalgam Restoration - BDS Lecture Notes PDF Download
 COMPLEX NON-SKELETAL PROBLEMS IN PREADOLESCENT CHILDREN - BDS Lecture Notes
 Anatomy of Scalp - BDS Lecture Notes PDF Download
 Cerebrospinal Fluid (CSF) - BDS Lecture Notes PDF Download
 Cementum - BDS Lecture Notes PDF Download
 Recent Advances in Instrumentation Techniques - BDS Lecture Notes PDF Download
 Ameloblastoma - BDS Lecture Notes PDF Download
 Prevention of Odontogenic Infection - Principles of Management - BDS Lecture Notes
 Therapeutic Dentistry Histology of Teeth Dental Charting - BDS Lecture Notes PDF Download
 Maxillofacial Trauma and Management - BDS Lecture Notes PDF
 Technical Endodontics - BDS Lecture Notes PDF Download
And 698 more free downloads for Dental Students.
Other Popular Links for Law Study Material:
 BDS Lecture Notes, eBooks, Guides, Projects and Case Papers FREE PDF Download
 BDS Lecture Notes, eBooks, Guides & Handouts FREE PDF Download
 BDS University Previous Year Exam Question Papers & Solutions FREE PDF Download
~ 10 ~

 Use the Antibiotic with Lowest Incidence of Toxicity & Side Effects
o Penicillin
 Allergy is major side effect (hives, itching or wheezing)
o Clindamycin
 They have low incidence of toxicity & Side effects.
 On rare occasion, this drug can cause severe watery diarrhea, called pseudomembranous colitis in severely ill &
debilitated patients.
 Other drugs which cause this pseudomembranous colitis are;
o Ampicillin (amoxicillin)
o Oral cephalosporin
 These drugs cause elimination of anaerobic gut flora which allows overgrowth of antibiotic resistant
bacteria “clostridium defficle”. This bacterium produce toxin which injure the gut wall & result in colitis
o Macrolide
 In this group erythromycin is no longer used because it causes drug reaction & involver microsomal enzyme system.
 In this group, azithromycin is best and should be used because it has low toxicity and less drug interaction.
o Moxifloxacin
 It is a new member of fluoroquinolone group and has;
 Much better effectiveness against oral pathogens as compared to older members of this class
 However, it is used by specialists because of its toxicity;
 Muscle weakness, mental clouding, drug interactions with commonly used drugs,
 Contraindicated in Children under 18 years & Pregnancy.
o Oral Cephalosporin; cephalexin & cefadroxil
 Although they have only mild toxicity they are not used for treating odontogenic infection.
 They cause allergy similar to penicillin, that’s why if the patient is allergic to penicillin, don’t give
cephalosporin also.
o Tetracycline
 They are also no longer used for treating odontogenic infection & are used
 Topically in very high local concentrations, such as when they are inserted into periodontal
pockets.
 They have minor toxicity & when taking systemically, patient may experience photosensitivity.
 Tetracycline, in pregnant women produce tooth discoloration in their infants, if given before age
of 12 years.
 Tooth discoloration results due to chelation of the tetracycline to calcium, which result in incorporation
of tetracycline into developing teeth.
o Metronidazole
 Mild toxicity = GI disturbances
 Produce Disulfiram Effects
 Patient taking metronidazole who also consumes ethanol may experience sudden, violent
abdominal cramping & vomiting.
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 Use Bactericidal Antibiotic, if possible
o Bactericidal antibiotics interfere with cell wall production in newly forming, growing bacteria.
 The defective cell wall is not able to withstand the osmotic pressure and bacterial cell die without attack from host defense cells.
o Bacteriostatic antibiotics interfere with bacterial reproduction and growth.
 They slow the bacterial reproduction and allows host defense cells to phagocytize the bacteria
o That’s why bacteriostatic antibiotics should be avoided in immunocompromised patients. & in these
immunocompromised patient bactericidal antibiotics are drug of choice.
 Use cost effective antibiotics

SUMMARY
 Antibiotics should be used in patients with complex infections, prevention of endocarditis or infections of prosthetic – implanted device.
 Antibiotics plays an adjunctive role in odontogenic infection & surgical treatment of infection is primary method.
 Use empiric antibiotic therapy with narrow spectrum antibiotic
 The antibiotic of choice for odontogenic infection is penicillin.
o Other alternatives = amoxicillin.
 Broad spectrum antibiotics such as Augmentin should not be used with simple routine odontogenic infections but should be
reserved for complex infections.
 Antibiotics for prevention are amoxicillin
o If patient is allergic to penicillin group, alternative antibiotic = clindamycin, azithromycin
 Metronidazole should be given only when anaerobic bacteria are suspected.
 Moxifloxacin should be used specialists in the treatment of severe infections.

Principle 7; Administer Antibiotic Properly


 The drug should be administered in the proper dose and at the proper dose interval.
 Plasma level of drug should be high enough to kill the bacteria but not so high to cause toxicity.
o Peak plasma levels should be at least four to five times the minimal inhibitory concentration of bacterial.
 Choose drug which could be given once a day for not more than 4 – 5 days to get more compliance.
 At follow – up additional prescription of antibiotic is necessary in case of infection that do not resolve rapidly.

Principle 8; Evaluate the Patient Frequently


 In this, patient is monitored for response to treatment and complications.
 If therapy is successful, the dentist should check the I&D site to determine whether the drain should be removed at this
time and other parameters such as temperature, trismus, swelling & patient’s subjective feelings should be evaluated.
 if therapy is UNSUCCESSFUL, the patient should be examined for clues to reason of failure of treatment.
 The patient should be examined for toxicity reactions.
 the dentist should examine the secondary infections or supra infections, if present.
o Most common secondary infection is oral or vaginal
candidiasis. the dentist should monitor the patient for
recurrent infections.
o CAUSES of Recurrent Infections;
 Incomplete therapy
 Stoppage of antibiotics early
 Early removal of drain.

This was all about principles of management of established infections.


Now we are going to learn about principles of prevention of
infections.
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Principles of Prevention of Infection


Principles of Prophylaxis for Post - Operative Wound Infection
 Advantages of prophylaxis
o Reduce the incidence of post – operative infection & post – operative illness.
 Post – operative infection delays wound healing & recovery.
o Reduce cost of health care
 Decreased expensive dentist visits
 Decrease buy of antibiotics
 Decreased missing days of work
o Decrease total amount of antibiotics
 Means infections thes po edyon ghanyoon antibiotic khaye tahikhan bhalo aa hik antibiotic khayi shade
prophlaxis lae eda kharch na karna pawandas.
 Effects of Inappropriate use of Antibiotics
o Increased risk of PO infection with resistant microbe.
o Alter host flora
o Encourage careless surgical & aseptic technique by dentist
 Dentist chawando khair aa prophylaxis antibiotic athas sterilization jo khayal na kando.
o High cost of antibiotics
 PRINCIPLES OF PROPHYLACTIC ANTIBIOTIC USE FOR POST – OPERATIVE WOUND INFECTIONS
01) Give prophylactic antibiotic in those procedure which have significant risk of infection.
a. Clean surgeries done in with strict surgical principle does not need prophylaxis.
b. Surgical Features in which Prophylaxis should be given to prevent PO wound infection
i. Increased size of inoculum
ii. Long duration of surgery
iii. Presence of foreign body, implant, dead space
iv. Immunocompromised patient.
02) Choose the correct, narrow spectrum, least toxic, bactericidal antibiotic.
a. Penicillin or amoxicillin
(antibiotic of choice) –
bactericidal
b. Clindamycin (pts. allergic to
penicillin group) –
bactericidal
c. Azithromycin (pts. allergic to
clindamycin) – bacteriostatic
03) Antibiotic plasma levels must be
high
a. Drug for prophylaxis should
be given in a dose at least
two times the usual
therapeutic dose.
b. Penicillin or amoxicillin = 2
grams
c. Clindamycin = 600 mg
d. Azithromycin = 500 mg
04) ensure that the antibiotic is in the
target tissues before surgery.
a. Must be given 2 hours or less before surgery.
b. For oral route = 1 hour before surgery.
i. For IV = much earlier than for oral route.
c. Antibiotic should be given before surgery.
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i. After surgery efficacy is
decrease & does not prevent
infection.
d. Penicillin and clindamycin should be
given every 3 hours during prolonged
surgery.
05) Use shortest antibiotic exposure that is
effective

Principles of Prophylaxis
Against Metastatic Infections
 Metastatic infection is defined as infection that
occurs at a location physically separate from the
portal of entry of the bacteria.
 The incidence of metastatic infection can be
reduced if antibiotic administration is used to
eliminate the bacteria before they can establish an
infection at the remote site.
 For metastatic infection to occur, following factors
must be present;
o Susceptible location in which an infection can be
established.
o Bacterial seeding of that susceptible area via blood
– attachment & growth of bacteria
o Impairment of local defense system
 These bacteria are protected from
WBC by thin coating of fibrin & an
extracellular matrix produced by them
resulting a biofilm.
 These bacteria are also protected from
antibiotics because in the biofilm they
are in metabolically inactive state.

Prophylaxis against Infectious


Endocarditis
 IE is caused by streptococcus viridians

All dental procedures that involve manipulation of gingival tissues or the periapical region of
teeth or perforation of the oral mucosa will require prophylaxis for IE.

Dental Procedures in which Antibiotic Prophylaxis for IE are NOT


RECOMMENDED
Routine restorative dentistry Routine LA injection RCT & rubber dam placement
Suture removal Placement of Removable appliances Making of impression
Taking of oral radiographs Fluoride treatment Orthodontic appliance adjustment
Shedding of primary teeth Placement of orthodontic bracket
 Amoxicillin is the drug of choice;
o Better GI absorption
o Higher & sustained plasma levels
o Effective killer of streptococcus viridians
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~ 14 ~
 If patient is already taking penicillin group, avoid cephalosporin because of cross resistance with the penicillin.
 If a particular patient requires a series of dental treatments that requires antibiotic prophylaxis,
o a period of 10 or more days between appointments is appropriate.
o The reason for the interval is that the continuous administration of antibiotics for several days or more may
promote colonization of the patient by bacteria that are resistant to the antibiotic being given, thus making
prophylaxis more likely to fail.
o The 10-or-more day antibiotic-free period may allow antibiotic sensitive organisms to repopulate the oral flora.

Prophylaxis in Patients with other Cardiovascular Conditions.


 No prophylaxis recommended in following conditions;
o CABG, Pacemaker, angioplasty, nonvalvular CVS disease (atherosclerotic, alloplastic vascular grafts, venacaval filters.
 Disease which require prophylaxis;
o Renal dialysis, hydrocephaly.

THE END