Antibiotics in dentistry: good or bad?

According to Medical Advertising News (United States), dentists prescribe 2 to 10 antibiotics per day, especially often antibiotics are used in patients with pain and swelling [1]. Recommendations on the need for antibiotics for periodontal disease threaten an even greater increase in the consumption of antibiotics in dentistry. At the same time, there is virtually no data confirming the feasibility of antibiotic therapy with many manipulations in dentistry. In addition, the results of clinical studies indicate that it is undesirable to use antibiotics in certain situations.

Despite the fact that the dangers lurking in the unreasonable use of antibiotics, especially the increase in antimicrobial resistance, have been known for decades, the wide discussion that has taken place in the pages of magazines still attracts a wide attention. Many articles in magazines and newspapers are of great concern to the public. In expert publications, fairly convincing evidence has been given of the dire consequences of the misuse of antibiotics and calls have been made for their reasonable use in medicine and dentistry. However, the impression remains that antibiotics are used in dentistry to the same extent as before. Old habits and beliefs are hard to die for, as well as significant social, medical and legal pressure on dentists to prescribe antibiotics. Doctors seek to prevent the unpleasant consequences of dental procedures, and their belief that many problems in the oral cavity are caused by infections stimulates the appointment of antibiotics.

It cannot be argued that doctors randomly prescribe antibiotics. Textbooks, publications in medical journals, and faculty in dental departments likely point to the need for antibiotics (even empirically). Patients appear to feel better after being prescribed antibiotics. The reality is that the symptoms and signs of the disease are usually cyclical in nature: they pass spontaneously and start again. Temporary improvement may occur despite antibiotic therapy.

Most often in dentistry, antibiotics are prescribed for endodontic procedures, periodontal diseases and maxillofacial surgery. The most popular antibiotic is penicillin or its analogs, especially amoxicillin [1]. Dentists are well aware of the doses of penicillin, its low toxicity and its low cost. However, the observed increase in the frequency of use of other antibiotics is due to the hope of greater effectiveness of modern and expensive drugs. This confidence is based more on marketing data, as the effectiveness of many new antibiotics has not been proven in clinical trials.

With endodontic diseases, the pulp of the tooth and the apical periodontium are most often affected. The main function of the pulp is to participate in the formation of other dental tissues around it. After the completion of this process, the pulp becomes a rudimentary organ and is characterized by increased sensitivity to caries, damage when filling deep cavities and injuries. These injuries lead to inflammation, sometimes intense pain and even pulp necrosis. A mixture of necrotic tissue and bacteria, isolated inside the closed space of the dental canal, cannot be removed independently and there is a need for endodontic treatment or dental extraction. Strong stimuli (waste bacteria, debris, inflammatory mediators) penetrate from the pulp into the surrounding bone tissue in the apex region of the tooth root, causing inflammation and sometimes the formation of an abscess. This process may initially not be accompanied by clinical symptoms, but over time, pain and / or swelling appears, which in some cases can be very pronounced, but, as a rule, do not threaten the life of the patient.

It remains to be seen whether this pathology of the pulp or of the periapical region is a real infection. Most of the bacteria isolated are ordinary or compulsory facultative anaerobic microorganisms of the oral cavity and do not differ in their high pathogenicity and their rapid reproduction in the tissues of the organism (Table 1); they survive better in dead tissue [4]. Therefore, the damage they cause is secondary. In addition, there is evidence that these lesions are actually caused by immune mechanisms in response to the effects of toxins and histolytic enzymes in bacteria, as well as mediators released by inflamed or dead body cells [6,7].

Even though these conditions are linked to infectious processes, the effectiveness of antibiotic therapy in these cases is controversial. Due to the lack of blood circulation inside the necrotic pulp or abscess, it is unlikely that therapeutic concentrations of antibiotics can be created there.

Pulpitis. With pulpitis, the pulp of the tooth remains viable, but ignites. Despite severe pain, the inflammation is limited and is not a real infection. Treatment involves removing the inflamed tissue. Prescribing antibiotics is not necessary, although according to the study, dentists often use them [1].

Acute purulent apical periodontitis (acute local apical abscess). These are the most common oral abscesses. They start in the bone tissue at the top of the tooth root with a serous inflammation, which gradually suppresses. The purulent process can then spread to the soft tissue adjacent to the jaw. The resulting soft tissue swelling is localized mainly in the oral cavity, but can be thought of as slight swelling on the cheek or lip. An abscess contains a mixture of bacteria, with a predominance of anaerobes [8]. A possible relationship has been reported between gram (-) anaerobes of the root canal (Bacteroides spp.) And symptoms of tension, swelling or exudation [9,10].

Immediate help consists first of all in removing the irritant (bacteria, waste, inflammatory mediators) from the dental canal and in reducing the pressure by means of an incision and drainage. If the tooth cannot be saved, it must be removed with subsequent curettage, incision and drainage. Controlled clinical trials have shown that penicillin does not increase the effectiveness of adequate local treatment [11,12].

Acute purulent apical periodontitis complicated by phlegmon. A relatively rare phlegmon is a more serious manifestation of a localized abscess, in which the abscess and the inflammatory reaction spread to adjacent tissues and spaces. As a result, there is a distortion of the facial features due to the pronounced swelling of the soft tissue. Without treatment, the infection can spread to vital structures, leading to blindness, brain abscesses, mediastinal involvement and even death. These serious consequences are rare, mainly in debilitated patients. The role of antibiotics in preventing such phenomena remains unclear. Despite the fact that clinical trials have not proven the effectiveness of antibiotics in the treatment of acute purulent apical periodontitis, which has spread to the soft tissues of the face, their use is reasonable. The choice of an antibiotic is made empirically, because there are no reliable data on the agents responsible for the infection. However, it is known that oral infections are usually caused by a mixed microflora, with a predominance of mandatory anaerobes [5,8,9,10]. For a long time there was a theory in which the role of streptococci and the factors secreted by them contributing to the rapid development of phlegmon were established [13]. The antibiotic of choice in this case is penicillin, which is prescribed orally in large doses. Intravenous administration of antibiotics is rarely used, mainly in hospitalized patients with severe infections.

Local treatment remains the most important part of therapy and involves the removal of necrotic tissue and bacteria from the dental cavity with subsequent drainage. Removing a tooth if necessary allows you to solve both problems. Antibiotics are just an addition to local treatment, without which healing cannot be expected. In addition, serious complications have often occurred when using only antibiotics without local treatment [14].

Microbiological examination of the material can be useful in the case of phlegmon, however, it is quite difficult to obtain a good quality sample, and identification of the anaerobic flora can take from several days to several weeks. Therefore, if immediate antibiotic therapy is necessary, the choice of antibiotic should be made empirically. The results of inoculation and the determination of sensitivity are useful in the event of ineffective therapy. If the source of the infection has been identified and eliminated, good drainage is ensured and the treatment result is generally favorable.

Antibiotic prophylaxis in endodontics. Antibiotics are often prescribed to prevent complications from endodontic treatment and maxillofacial surgery. In prospective controlled clinical studies, antibiotics have been shown to provide no additional benefit in eliminating clinical symptoms that appear after endodontic treatment of the tooth [15]. In this case, undesirable drug reactions are sometimes observed [16].

The use of antibiotics to prevent infection after surgical treatment of endodontic diseases has not been reported. Clinical studies of the effectiveness of antibiotic prophylaxis in reducing infections that occur after other surgical procedures in the oral cavity have not revealed the benefits of prescribing antibiotics [17]. The same goes for the surgical treatment of endodontic diseases.

The periodontium is a tissue which is a support element of the tooth, for example the wall of the alveoli, gums and ligaments of the tooth. Periodontal inflammation occurs quite often (Table 1), especially in adults. Antibiotics are used to treat destructive periodontal diseases, for necrotic gingivitis and periodontal abscesses, as well as for the prevention of surgical complications.

Treatment of periodontal disease. The use of antibiotics for the treatment and prevention of periodontal disease has been considered in the pages of medical and popular journals. Based on data from a controlled clinical study of patients with various forms of chronic periodontitis, popular newspapers and magazines have reported that antibiotics can improve the course of the disease without costly and painful periodontal therapy and surgery [18]. The patients in this study suffered from conditions requiring surgical correction, but in some of them, recovery was achieved using systemic (metronidazole or doxycycline) and local (metronidazole and / or chlorhexidine) antibiotics and antiseptics. The authors concluded that this treatment regimen, based on the diagnosis and treatment of anaerobic periodontal infections, is very effective in patients requiring surgical treatment [18]. An editorial board review warned that surgical treatment should not be replaced with antibiotics. Weaknesses in the study design were discussed, which cast doubt on the reliability of the results.

Thus, from a modern point of view, systemic administration of antibiotics gives no benefit in addition to dental procedures in adult patients with periodontitis [20]. It is necessary to carefully collect the history before universally applying systemic or local antibiotics for the treatment of chronic periodontitis. Antibiotics are an additional useful factor in the treatment of local juvenile periodontitis [21], which is rapid and does not lend itself to standard treatment for periodontitis. Topical antibiotic supplementation can be used in the treatment of certain recurrent diseases. In any case, antibiotics should be considered as an additional factor, but not as the main condition for treatment.

Treatment of periodontal abscesses. An acute periodontal abscess manifests as a painful swelling of the gums surrounding the tooth. The reason is bacteria and bacterial products that accumulate in the gum pocket and cause tissue fusion. In addition, the immunogenic component cannot be ignored. Abscesses are usually localized and rarely spread to other tissues.

Treatment consists of local measures (elimination of irritants and drainage) and the appointment of painkillers. Antibiotics, usually tetracycline, are indicated in the presence of systemic manifestations, such as fever [22]. However, periodontal abscesses are rarely accompanied by severe symptoms of intoxication, therefore the routine use of antibiotics remains questionable.

Acute ulcerative necrotic gingivitis. This condition is called "trench mouth" because necrosis of the soft tissue surrounding the teeth was often seen in soldiers during the First World War. First of all, this pathology is observed in patients suffering from stress, lack of sleep, poor nutrition, etc. This disease is caused by spirochetes and other gram (-) anaerobes, such as Prevotella intermedia. In this case, the marginal edge of the gum is covered with a grayish film, which easily exfoliates and bleeds. This condition is often accompanied by a foul odor and pain.

Treatment is aimed at relieving acute symptoms and eliminating or reducing local irritants. Patients with regional lymphadenopathy and fever should receive oral penicillin, metronidazole or erythromycin if they are allergic to beta-lactams [22]. It must be remembered that antibiotics are complementary and not the main treatment. The first is local treatment (elimination of irritants and measures to improve oral hygiene).

Antibiotic prophylaxis for surgical procedures for periodontal disease. Antibiotics are routinely used by some clinicians to reduce postoperative complications. The results of clinical studies have not established the efficacy of antibiotic prophylaxis in surgical procedures in the oral cavity.

However, new surgical methods and technologies to improve bone regeneration use membranes that partially protrude into the oral cavity. These membranes act as a conductor for oral bacteria in the tissues. It is believed that systemic antibiotics can improve bone regeneration, possibly due to the suppression of bacteria.

Antibiotics are prescribed for pericoronitis, wounds in the facial area, for the purpose of preoperative prevention and for osteomyelitis. Maxillofacial surgeons often treat patients with several of the above conditions, including endo and periodontal infections, in an emergency.

Pericoronitis. Pericoronitis is an inflammation of the gum pocket that covers a partially erupting tooth, usually a third molar (wisdom tooth). Leftover food and bacteria fill the space between the tooth and the gum, which is injured by the upper tooth when squeezing it. This damage leads to a secondary infection, accompanied by pain and swelling, usually from the inside of the lower jaw, spreading to the side of the pharynx. A severe infection with significant facial edema and fever is sometimes observed.

The treatment of mild to moderate forms of pericoronitis involves removing the irritant under the hood, and sometimes also removing soft tissue or a tooth. More serious infections require aggressive therapy, including antibiotic therapy. Since pathogens are often inhabitants of the oral cavity, penicillin is the antibiotic of choice [23].

Face injuries. Traumatic injuries to the soft and hard tissues of the face can be treated by dentists and maxillofacial surgeons. Distinguish damage to facial soft tissue, fractures and dislocations of teeth, fractures of facial bones. With appropriate primary surgical treatment of clean wounds and their suturing, it is not necessary to prescribe antibiotics [24]. However, if the wounds are heavily contaminated or cannot be treated well, administration of antibiotics may be warranted.

Antibiotics have been widely used as an adjunct to prevent infections in the treatment of facial fractures [25]. Recent data show that antibiotics are useful during initial surgical treatment, with their cancellation after repositioning and fixation of bone fragments. Continuous antibiotic therapy after surgery does not reduce the overall incidence of the infection [26].

Antibiotic prophylaxis in maxillofacial surgery. Most surgical procedures on the tissues of the oral cavity are characterized by a low risk of developing infections. Often performed on an outpatient basis, interventions in the oral cavity are rarely extended to carry out antibiotic prophylaxis. However, certain complex manipulations, as well as interventions in patients with immune deficiencies, may require prophylactic antibiotics. These are operations such as difficult removal of the retained third molar, dental implants, reconstruction operations.

If there are indications for antibiotic prophylaxis, it should be started before surgery using the correct doses of the appropriate antibiotic and finished after surgery. Following these recommendations, the risk of infectious complications is reduced [17].

Osteomyelitis. Osteomyelitis is an inflammation of the bone marrow. Violation of microcirculation in bone tissue leads to ischemia and bone necrosis. Since the protective factors in the blood cannot reach the bone tissue, the bacteria multiply. The emerging infection spreads with the formation of sequestrants, often in the lower jaw. A provoking factor is a fractured jaw or an untreated odontogenic infection. Very often, patients with osteomyelitis have immune disorders. Osteomyelitis requires surgical treatment and appropriate antibiotic therapy [27].

The pathogens of osteomyelitis are microorganisms that cause other infections of the oral cavity [28]. Osteomyelitis of the lower jaw can be caused by Staphylococcus aureus, but with a much lower frequency than osteomyelitis of other bones in the body.

Treatment usually involves correcting the initial damage and surgical removal of the necrotic tissue. The patient should be hospitalized and high doses of antibiotics should be administered intravenously. Penicillin is the antibiotic of choice, clindamycin is an alternative. Microbiological examination can be very helpful in identifying the pathogen and choosing the right antibiotic. Antibiotic therapy should be carried out for a longer period than in the treatment of infections from another location: at least 4 weeks after the symptoms of the disease disappear.

It is generally accepted that manipulations in the oral cavity can cause hematogenous propagation of microorganisms (or their metabolic products or immune complexes) with the development of distant sites of infection [29], there is no convincing evidence to this effect. As a result, the questions - when and under what conditions antibiotic prophylaxis is needed - remain controversial [30]. For many reasons, certain heart diseases require preventive measures (Table 2) [2,31].

The validity of antibiotic prophylaxis for the prevention of metastatic infections caused by the oral microflora in patients with artificial joints [32,33], often performed by orthopedic surgeons, remains controversial. As before, there are no data on the economic feasibility of prevention, therefore, the decision on the feasibility of such antibiotic prophylaxis should be decided jointly by dentists and orthopedists [34].

Patients with immunosuppressive disorders and transplanted bone marrow can be considered a category of people who require antibiotic prophylaxis for interventions in the oral cavity. These recommendations are more empirical than practical; no clinical studies have been conducted due to their practical impossibility. Thus, patients infected with HIV and AIDS do not belong to the higher risk category than healthy patients and do not require antibiotic prophylaxis in routine dental treatment [2].