Medication Summary
When drainage cannot be achieved or the patient shows signs of systemic involvement, antibiotic therapy is indicated; in addition, an increasing number of immunocompromised patients require antibiotic therapy.
A national survey study demonstrated a significant shift from prescribing penicillin V to amoxicillin as the first choice by U.S. endodontists as well as a significant increase in the use of clindamycin for penicillin-allergic patients. Overuse of antibiotics in clinical situations where they were typically not indicated occurred most often because of patient expectations. The southeastern region of the U.S. was a significant predictor of increased antibiotic prescribing. [12]
A study by Roberts et al reported that an antibiotic (penicillin or clindamycin) was prescribed in 65% of ED visits for any dental diagnosis even though dental procedures were usually the recommended treatment. [27]
Antibiotics
Class Summary
Empiric antimicrobial therapy must be broad spectrum to cover anaerobes, Staphylococcus aureus, non-typeable Haemophilus influenzae, and others, depending on the context of the clinical setting. The most commonly prescribed antibiotic is amoxicillin/clavulanate.
Penicillin (Pfizerpen, Pen-Vee K)
Traditionally been considered the DOC for the treatment of a dental abscess. Antibiotic therapy alone, without surgical drainage, may not be effective because of poor antibiotic penetration into the abscess cavity, ineffectiveness at low pH levels, and the inoculum effect. Bactericidal against sensitive organisms when adequate concentrations are reached and is most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Binds to one or more penicillin binding proteins, which interferes with bacterial cell wall synthesis during active multiplication. Final transpeptidation step of peptidoglycan synthesis is inhibited leading to death.
Emergence of beta-lactamase producing bacteria may decreased efficacy, although it remains the antibiotic of choice for mild-to-moderate infections.
Azithromycin (Zithromax)
May be an option for the treatment of a dental abscess in patients who are allergic to penicillin or beta-lactam. Binds to the 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, inhibiting bacterial RNA-dependent protein synthesis. Concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Indicated for mild-to-moderate microbial infections.
Metronidazole (Flagyl)
Effective against obligate anaerobic organisms. It can be combined with penicillin if anaerobic organisms that produce beta-lactamase enzymes are a concern. Compliance must be considered with a 2-drug regimen. It inhibits DNA synthesis by affecting the helical DNA structure leading to DNA strand breakage causing cell death.
Clindamycin (Cleocin)
Can be used in patients who are penicillin or beta-lactam allergic. Inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit preventing peptide bond formation. Excellent activity against PO aerobes and anaerobes; penetrates bone and abscess cavities.
Amoxicillin and clavulanate (Augmentin)
Amoxicillin works by binding to one or more of the penicillin-binding proteins, which interferes with bacterial cell wall synthesis during active bacterial replication. The final transpeptidation step of peptidoglycan synthesis is inhibited leading to cell death. Clavulanic acid binds and inhibits beta-lactamase enzymes that inactivate amoxicillin resulting in an expanded spectrum of activity for Augmentin. For children, the dosing should be based on the amoxicillin component.
Cefoxitin (Mefoxin)
Binds to one or more of the penicillin binding proteins, which interferes with bacterial cell wall synthesis during active replication. The final transpeptidation step of peptidoglycan synthesis is inhibited leading to cell death. It is a second-generation cephalosporin with activity against some gram-positive cocci, gram-negative rods, and anaerobic bacteria. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin.
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Obvious swelling of the right cheek due to dental abscess.
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Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection.
