This is one of the most controversial topics within medicine and dentistry today. Although there are many references containing opinions regarding the benefits of antibiotic prophylaxis for patients, a 2007 review of the literature (JADA April 2007) shows that there is limited, if any definitive, scientific support for the practice in general. Over the past decade, there has been a trend towards more
conservative use of antibiotic prophylaxis for the following reasons:
- Infective endocarditis (IE) is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental procedure - Prophylaxis may prevent an exceedingly small number of cases of IE, if any.
- The risk of antibiotic-associated adverse events (hypersensitivity, pseudomembranous colitis, etc.) exceeds the benefit, if any, from prophylactic antibiotic therapy
- Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure Antibiotic prophylaxis is given in an attempt to prevent any of the following:
- Infective Endocarditis (Subacute Bacterial Endocarditis) - Late Prosthetic Joint Infection
- Local infection of a surgical site (eg 3rd molar extraction) When to Prescribe
It is your responsibility to read any new literature regarding this topic, to evaluate each patient individually, to communicate with your patient‘s PCP or cardiologist, and to use your best judgment when making the
decision of whether to administer antibiotic prophylaxis or not. The following is a summary of the guidelines found in the current literature:
All procedures when the patient has any of the following:
- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair - Previous infective endocarditis
- Unrepaired cyanotic congenital heart disease (CHD), completely repaired congenital heart defect with prosthetic material during the first six months after the procedure, and repaired CHD with residual defects at the site of a prosthetic patch or prosthetic device
- Cardiac transplantation recipients who develop cardiac valvulopathy
- Immunocompromised/ immunosuppressed (some support for only high risk procedures) High risk procedures (e.g. extraction, periodontal procedures, implants, and endodontic instrumentation) when the patient has any of the following
- Joint replacement in last 2 years - History of prosthetic joint infection
- Joint replacement plus comorbidity: type 1 diabetes, malignancy, or malnutrition What to prescribe:
Drug Dose When
Standard Amoxicillin Adults 2g, Kids 50mg/kg PO 1 hr prior
Penicillin allergy Clindamycin Adults 600mg, Kids 20mg/kg PO 1 hr prior
Azithromycin Adults 500mg, Kids 15mg/kg PO 1 hr prior
Unable to take oral medication
Ampicillin Adults 2g, Kids 50mg/kg IM / IV 30mins prior
Penicillin allergy AND unable to take oral medications
Clindamycin Adults 600mg, Kids 20mg/kg IM / IV 30mins prior
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Pharmacology
Drug Metabolism
Factors that Affect Hepatic Drug Metabolism
- Microsomal enzyme alteration (P-450) (individual genetic variation)
o Many drugs can inhibit the CYP isoforms of the P-450 drug metabolism system, therefore two simultaneous drugs normally metabolized this way may cause elevated blood levels of one, and therefore toxic effects of that drug. Example: erythromycin and clarithromycin cause elevated blood levels of theophylline, resulting in CNS toxicity of theophylline
seizures, nystagmus, depressed consciousness.
o Other drugs or foods, such as grapefruit juice, can induce the CYP isoforms resulting in a lower than usual blood level of drugs metabolized with the P-450 system
- Plasma protein binding: drugs highly bound to plasma proteins will not enter the liver as readily, resulting in a longer drug half-life, or elevated blood levels in the elderly, whose albumin levels are lower. Example: benzodiazepines can cause increased sedation and respiratory depression in the elderly.
- Pathology: liver disease generally results in elevated levels of unmetabolized drug How to write a Prescription:
Date
Patient Name, age and contact info
Rx: name of drug and dosage
Disp: amount to provide (example, number of pills)
Sig: Directions (include what route of administration, dosage, frequency, max dose if relevant)
Refills, if any
Signature
DEA# for schedule II drugs Abbreviations:
QD (quaque dies): every day
BID (bis in die): twice per day
TID (ter in die): thrice per day
QID (quater in die): four times per day
H (hora): hour
Q (quaque): every
HS (hora somni): at bedtime
NPO (nil per os): nothing by mouth
PO (per os): by mouth
PRN (pro re nata): as needed
Sig (signa): label, or let it be printed
Oral Pain (Analgesics)
- Mild: use OTC medications in suggested doses
Ibuprofen (Advil/Motrin): 400mg (2 pills) PO q4-6h PRN pain, max 3.2g/day
Acetaminophen (Tylenol): 325-650mg PO q4h PRN pain, max 4g/day
Naproxen sodium (Aleve): 220-440mg PO q8-12h PRN pain, max 1.5g/day
Aspirin (Ecotrin): 325-650mg PO q4h prn pain, max 4g/day
43 - Moderate
Ibuprofen: 800mg ibuprofen (see below)
Tylenol #3: 300mg acetaminophen and 30mg Codeine (equianalgesic to 600 mg of ibuprofen, so why use it instead of ibuprofen? Says Dr. Flynn)
Vicodin: 500mg acetaminophen and 5mg hydrocodone
Vicoprofen: 200mg ibuprofen and 7.5mg hydrocodone (for patients with liver disease)
Ibuprofen (800mg) Disp: 20 (Twenty) tablets Disp: 20 (Twenty) tablets
Sig: Take 1-2 tabs PO q4-6h PRN pain
Vicodin (500mg/5mg) Disp: 20 (Twenty) tablets
Disp: 20 (Twenty) tablets Sig: Take 1 tab PO q4-6h PRN pain, max 5 tabs/day
- Severe
Percocet: 325mg acetaminophen and 5mg oxycodone, schedule II
Combunox: 400mg ibuprofen and 5mg oxycodone, schedule II (for patients with liver disease)
Demerol: 50mg meperidine, schedule II
Percocet (325mg/5mg) Disp: 20 (Twenty) tablets Sig: Take 1 tab PO q4-6h PRN pain
Combunox (400mg/5mg) Disp: 20 (Twenty) tablets Sig: Take 1 tabs PO qid PRN pain, max 4 tabs/day, max 7 days
Demerol 50mg
Disp: 20 (Twenty) tablets Sig: Take 1 tab PO q4h PRN pain, max 6 tabs/day
Antibiotic Prophylaxis
Amoxicillin 500mg Disp: 12 (twelve) tablets Sig: Take 4 tabs PO 1 hr prior to appointment*
Clindamycin 150mg Disp: 12 (twelve) tablets Sig: Take 4 tabs PO 1 hr prior to appointment*
Azithromycin 250mg Disp: 6 (six) tablets
Sig: Take 2 tabs PO 1 hr prior to appointment*
*The extra tablets are for future visits.
Bacterial Odontogenic Infections
Penicillin VK or Amoxicillin
Clindamycin ( if penicillin allergy)
Augmentin (amoxicillin with clavulanic acid)
Penicillin VK 500mg
Disp: 28 (twenty eight) tablets
Sig: Take 2 tablets PO QID until finished
Amoxicillin 500mg Disp: 21 (twenty one) tablets Sig: Take 1 tab PO TID until finished
Augmentin 500mg Disp: 21 (twenty one) tablets Sig: Take 1 tab PO TID until finished (mostly for sinus infections, Dr.
Flynn does not approve)
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Listerine (phenol) -OTC
Peridex / Periogard (chlorhexidine gluconate): also useful when pt cannot mechanically remove plaque
Periostat (doxycycline hyclate) 0.12% Peridex
Disp: 16oz bottle
Sign: Rinse with 15mL, hold in mouth for 30 seconds and expectorate BID for 14 days
Fungal infections (candidiasis and angular cheilitis) - Topical/ Local
Mycostatin (nystatin suspension)
Mycolog (nystatin cream 1%)
Mycelex (clotrimazole troches) *Tastes better - Systemic
Diflucan (fluconazole)
Nystatin 100,000units/ml oral suspension
Disp: 300ml
Sig: Rinse with 5ml for 2 mins QID and expectorate
Mycolog (Nystatin) cream 1%
Disp: 45g tube Sig: Apply thin coat to affected area and inner surface of denture if applicable QID after meals and HS
Mycelex 10mg troches Disp: 70
Sig: Slowly dissolve in mouth 5x/day until finished
(Do not attempt at home)
Ulcerative / Erosive conditions
Recurrent aphthous stomatitis and mild lichen planus
Kenalog in Orabase (triamcinolone 0.1%)
Lidex (fluocinonide 0.05%)
Erosive lichen planus and major aphthae
Decadron elixir (dexamethasone)
Kenalog in Orabase 0.1%
Disp: 5g tube
Sig: Apply locally as directed after each meal and HS
Lidex 0.05% gel Disp: 45g tube Sig: Apply locally as directed QID
Valium (diazepam) – half life of 20-100 hrs (long acting)
Ativan (lorazepam) – half life of 9-16 hrs
Halcion (triazolam) – half life of 2 hrs (short acting) *Pregnancy category X
Valium 5mg Disp: 6 (six) tablets
Sig: Take 1 tablet PO hs and 1 tablet PO 1 hr before the appointment*
Ativan 1 mg Disp: 4 (four) tablets
Sig: Take 1 tablet PO hs and 2 tablets PO 1 hr before the appointment* then bring the last pill to the appointment with you.
Halcion 0.25 mg Disp: 4 (four) tablets
Sig: Take 1 tablet PO hs and 1 tablet PO 1 hr before the appointment*
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*When using oral sedation, the patient must have a ride to and from the appointment and sign the consent for the procedure at a date prior to the appointment. NPO status is advised, especially with Ativan, and vital signs (BP, P, O2 Saturation) must be monitored continually during the procedure.
High caries
Prevident 5000 toothpaste
Prevident 5000 dentifice Disp: 1 60g tube
Sig: brush teeth with dentifice BID and floss into contacts
Drug Interactions
In general, we should avoid polypharmacy and never prescribe anything without being aware of the patient‘s full medical history and current medications. It is our responsibility to look up any possible interactions with the drugs that we prescribe. Epocrates is Dr. Flynn‘s preference.
Contraindicated Drugs in:
Patients with liver disease
Patients with kidney disease
Pregnant patients Patients that are breast feeding
Antibiotic Mechanism Types / Targets / Examples Penicillin Bacteriocidal - inhibits
peptidoglycan cross linking by blocking transpeptidase in last step
- Narrow spectrum: gram (+) cocci and bacilli, some gram (-) cocci: penicillin G, penicillin VK
- Narrow spectrum penicillinase resistant: gram (-) beta-lactamase staphalococci: methicillin
- Moderate spectrum: gram (+) cocci and bacilli, some gram (-) cocci and rods: amoxicillin, Ampicillin
- Broad spectrum penicillinase resistant: augmentin - Extended spectrum: ticarcillin, carbenicillin, piperacillin,
azlocillin, mezlocillin Cephalosporins Bacteriocidal - inhibits
peptidoglycan cross linking by blocking transpeptidase in last step
- 1st generation: Moderate spectrum: gram (+) cocci and some gram (-) bacilli: Cephalexin, Cefazolin
- 2nd generation: Moderate spectrum with anti-Haemophilus:
fewer gram (+) cocci but more gram (-) bacilli: Cefaclor - *2nd generation – cephamycins: moderate spectrum with
anti-anaerobic activity: Cefoxitin
- 3rd generation: Broad spectrum: ceftriaxone - 4th generation: Broad spectrum with beta-lactamase
stability: Cefepime Metronidazole Bacteriocidal – inhibits Anaerobes and some protozoa
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DNA synthesis - Brand name ―Flagyl‖
Fluoro-quinolones
Bacteriocidal – inhibits DNA gyrase
(topoisomerase)
In general, early generations are more narrow spectrum and later generations more broad spectrum: gram (+) and gram (-) anerobes and facultatives
- Ciprofloxacin (2nd generation)
- Moxifloxacin (4th generation) – better for oral flora Aminoglycosides Bacteriocidal – inhibits
protein synthesis via 30S Ribosome
Gram (+) and gram (-) anerobes and some mycobateria - Streptomycin
- Gentamicin
*Side effects: Ototoxicity and nephrotoxicity Vancomycin Bacteriocidal – inhibits
D-alaryl-D-alanine cross linking
Gram (+) cocci and bacilli
Macrolides Bacteriostatic – inhibits protein synthesis via 50S
Gram (+) cocci/rods, gram (-) anaerobes, mycobacteria - Erythromycin
- Clarithromycin
- Azithromycin – best safety profile
*May cause GI irritation, erythromycin especially Clindamycin Bacteriostatic – inhibits
protein synthesis via 30S
Gram (+) and gram (-) anaerobes
*May cause pseudomembranous colitis Tetracyclines Bacteriostatic – inhibits
protein synthesis via 30S
Gram (+) and gram (-) aerobes and anaerobes, spirochetes, mycobacteria
Sulfonamides Inhibits folic acid pathway by competing for PABA
Gram (+) and gram (-)
*Not used to treat dental infections due to their low degree of effectiveness against oral pathogens
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