Antimicrobial Prophylaxis

Recommendations regarding the use of antimicrobial prophylaxis to prevent bacterial endocarditis and prosthetic joint infections in selected patients undergoing dental procedures are presented separately.

SUMMARY AND RECOMMENDATIONS

  • Odontogenic infections, consisting primarily of dental caries and periodontal disease (gingivitis and periodontitis), are common and have local (eg, tooth loss) and, in some cases, systemic implications. Suppurative odontogenic infections may extend to potential fascial spaces in the orofacial area (orofacial space infections) or deep in the head and neck (peripharyngeal space infections). The latter complication is often life threatening. Odontogenic infections can also result in osteomyelitis of the jaw or hematogenous dissemination, which may in turn cause endocarditis or prosthetic joint infections. (See ‘Introduction’ above and ‘Complications’ above.)
  • For closed space infections, it is imperative that the normal oral flora be excluded during specimen collection in order to interpret culture results. Needle aspiration of loculated pus by an extraoral approach is desirable, and specimens should be transported immediately to the laboratory under anaerobic conditions. (See ‘Specimen collection and processing’ above.)
  • The choice of imaging technique varies with the clinical setting. Computed tomography (CT) is particularly sensitive for osseous structures and remains the imaging modality of choice for assessment of most odontogenic infections. (See ‘Imaging techniques’ above.)
  • Meticulous attention to oral hygiene is the most important strategy for effective control of supragingival and subgingival plaque that, in turn, is essential for both caries prevention and the treatment of periodontitis. (See ‘Therapeutic considerations’ above.)
  • Pulpitis, inflammation of the dental pulp, occurs when progression of dental caries exposes the dental pulp, leading to infection (figure 3). The early and dominant symptom of acute pulpitis is a severe toothache that can be elicited by thermal changes, especially cold drinks. Apart from removal of the tooth, the customary approach to relieving the pain of irreversible pulpitis is by drilling into the tooth, removing the inflamed pulp (nerve), and cleaning the root canal. (See ‘Pulpitis’ above.)
  • Acute simple gingivitis rarely requires systemic antimicrobial therapy. Chlorhexidine 0.12 percent oral rinse can be used in most cases. Exceptions include patients with rapidly advancing disease, severe pain, or HIV infection in whom systemic therapy is indicated. Possible regimens include penicillin plus metronidazole, amoxicillin-clavulanate, ampicillin-sulbactam, or clindamycin (table 2). (See ‘Acute gingivitis’ above.)
  • Acute necrotizing ulcerative gingivitis, also known as Vincent’s angina or trench mouth, should be treated with systemic antimicrobials, such as metronidazole, amoxicillin-clavulanate, ampicillin-sulbactam, or clindamycin (table 2). (See ‘Acute gingivitis’ above.)
  • Certain types of severe periodontitis are amenable to systemic antimicrobials in conjunction with mechanical debridement (scaling and root planing) (table 2). This approach has often obviated the need for radical surgical resection of periodontal tissues. For chronic periodontitis, a topical antibiotic approach is used in conjunction with scaling and root planing.(See ‘Periodontitis’ above.)
  • The most important therapeutic modality for pyogenic odontogenic infections is surgical drainage and removal of necrotic tissue. Needle aspiration by the extraoral route can be particularly helpful both for microbiologic sampling and for evacuation of pus. The need for definitive restoration or extraction of the infected tooth, the primary source of infection, is usually readily apparent. Deep periodontal scaling and endodontic treatments with root filling is required in most instances. (See ‘Suppurative odontogenic infections’ above.)
  • In patients with pyogenic odontogenic infections, in addition to surgical management, antimicrobial agents are generally indicated if fever and regional lymphadenopathy are present, or when infection has perforated the bony cortex and spread into surrounding soft tissue. Ampicillin-sulbactam (3 g intravenously [IV] every six hours) provides extended coverage against oral anaerobes, including those that produce beta-lactamases, and is the treatment of choice in immunocompetent patients (table 3). An alternative is penicillin G (2 to 4 million units IV every four to six hours) in combination with metronidazole (500 mg IV or orally every eight hours). Penicillin-allergic patients should be treated with clindamycin (600 mg IV every eight hours). (See ‘Antibiotic therapy’ above.)
  • The single most cost-effective measure for reducing dental caries is fluoridation of public water supplies. Other preventive measures include regular brushing with a fluoridated toothpaste, dental flossing, and reducing the ingestion of sugar-rich foods or beverages. (See ‘Prevention’ above.)
  • Recommendations regarding the use of antimicrobial prophylaxis to prevent bacterial endocarditis and prosthetic joint infections in selected patients undergoing dental procedures are presented separately. (See “Antimicrobial prophylaxis for bacterial endocarditis” and “Epidemiology and prevention of prosthetic joint infections”, section on ‘Dental procedures’.)
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