Medication Summary
The goals of therapy are to treat the dental infection and prevent further complications. Amoxicillin is still the first-line drug of choice but with 34% of Prevotella species resistant to amoxicillin, the alternatives of amoxicillin/clavulanate, clindamycin, and metronidazole need to be considered.
Rastenienė et al analyzed treatment modalities and results in 1,077 patients with severe odontogenic maxillofacial infections during a 10-year period. The microbial analysis showed the highest susceptibility of predominant micro-organisms to penicillin was 76.9% and the highest resistance was to metronidazole (27.9%). [13]
A study by Roberts et al reported that an antibiotic, usually a narrow-spectrum penicillin or clindamycin, was prescribed in 65% of emergency department visits with any dental diagnosis. [14]
Topical
Silver Diamine Fluoride
This is a topical medication in which the silver acts as an antimicrobial and the fluoride promotes the remineralization of the tooth. Recommended maximum dose is one drop/25 μL per 10 kg per weekly treatment.
The main side effect has been darkening of the carious lesions.
Antibiotics
Class Summary
Therapy must cover all likely pathogens in the context of the clinical setting.
Penicillin VK (Veetids)
Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication. Inadequate concentrations may produce only bacteriostatic effects.
Amoxicillin and clavulanic acid (Augmentin)
Drug combination that extends the antibiotic spectrum of this penicillin to include bacteria normally resistant to beta-lactam antibiotics. Indicated for skin and skin structure infections caused by beta-lactamase–producing strains of Staphylococcus aureus. Administer for a minimum of 10 d.
Erythromycin (EES, E-Mycin, Ery-Tab)
DOC in patients who are allergic to penicillin. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes, inhibiting bacterial growth.
Clindamycin (Cleocin)
Lincosamide useful to treat serious skin and soft tissue infections caused by most staphylococci strains. Effective against aerobic and anaerobic streptococci, except enterococci.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.
Ampicillin and sulbactam (Unasyn)
Combination antimicrobial agent that utilizes a beta-lactamase inhibitor with ampicillin. Gives better anaerobic coverage.
Ticarcillin and clavulanate (Timentin)
Used for deep space infections. Inhibits biosynthesis of cell wall mucopeptide and is effective during stages of active growth.
Antipseudomonal penicillin plus a beta-lactamase inhibitor that provides coverage against gram-positive, gram-negative, and anaerobic organisms.
Metronidazole (Flagyl)
An imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually used in combination with other antimicrobial agents except when used for Clostridium difficile enterocolitis in which monotherapy is appropriate. An addition for treating Ludwig angina.
-
Obvious swelling of the right cheek.
-
Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection.
