Choice of antibiotics in the management of dentoalveolar abscess among dental practitioners

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1 Research Article Choice of antibiotics in the management of dentoalveolar abscess among dental practitioners M. Dhanvanth 1, Dhanraj Ganapathy 2, Ashish. R. Jain 2 * ABSTRACT Introduction: Dentoalveolar abscess is infections of dental origin, the majority with an endodontic or a periodontal pocket origin. An antibiotic plays a major role in limiting the spread of infection. It is found that variety of dosage, frequency, and duration for antibiotics used in the treatment of dental infection. Dentoalveolar abscess is an abscess around the root of a tooth in the alveolar cavity. It is usually the result of necrosis and infection of dental pulp following dental caries. The formation and accumulation of pus in a tooth socket or the jawbone form around the base of a tooth. Aim: The aim of the study is to assess the choice of antibiotics used among the dental practitioners for the management of dentoalveolar abscess. Materials and Methods: The aim is to investigate the knowledge of dental practitioners about therapeutic prescribing of antibiotics in the management of dentoalveolar abscess. A questionnaire study was performed on 100 dental practitioners. A self-administered validated semi-structured questionnaire to assess the antibiotic prescribing patterns among dental practitioners utilized in this study and the first three sections were used. The questionnaire composed of three sections. The demographic information regarding gender, principle work role, working experience, and being general or specialized dentist was sought first. The second section of the questionnaire was composed of a table to record: The first choice of antibiotic for the treatment of dentoalveolar abscess. The third section contained questions regarding therapeutic antibiotic prescriptions for various clinical signs. A questionnaire describes about clinical signs are elevated temperature and evidence of systemic spread; localized fluctuant swelling; gross swelling; restricted mouth opening; difficulty in swallowing; and closure of the eye due to swelling. It also explored about an antibiotic prescription. This would be a reason for prescribing antibiotics. The practitioners were asked to state the antibiotic they would prescribe, its dose, interval, and duration, for patients who were not allergic to penicillin. A practitioner was also asked what antibiotic they would choose if the patient was allergic to penicillin for the management of dentoalveolar abscess. Data entry and analysis were done. Results: The questionnaire was distributed to 100 dental surgeons and questionnaires were received back from the respondents. The respondents consisted of 49 males and 51 female dentists. Amoxicillin is the antibiotic of choice for dentoalveolar abscess without known allergy with the percentage of 45% and clindamycin is an antibiotic of choice for dentoalveolar abscess with known allergy to penicillin with the percentage of 46%. Conclusion: Results of this study demonstrate that majority of the surveyed dentists prescribe antibiotics for dentoalveolar abscess and their clinical sign, where local management would be sufficient. It is also highlighted that there is a need of developing guidelines regarding antibiotic prescription by the regulatory bodies based on available literature for development and regulating appropriate use of antibiotics. KEY WORDS: Antibiotics, Clinical features, Complications, Dentoalveolar abscess, Management of dentoalveolar abscess INTRODUCTION In dentistry, limited indications are available for the use of systemic antibiotics. Most of the oral conditions are mainly inflammatory associated with pain due to infection originating from dental pulp. This requires Access this article online Website: jprsolutions.info ISSN: operative intervention, rather than antibiotics. [1] Inappropriate use of antibiotics is said to develop bacterial resistance that is becoming a major issue. The problem of resistance development in recent years might be due to dentist practice toward the prescription of broadspectrum regimen instead into selective antibiotics. Even though the orofacial infections can be effectively managed through operative intervention and oral hygiene measures, antibiotic prescription practices for the treatment of several orofacial infections. 1 Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technicral Sciences, Saveetha University, Chennai, Tamil Nadu, India, 2 Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Poonamalle High Road, Chennai , Tamil Nadu, India. Phone: dr.ashishjain_r@yahoo.com Received on: ; Revised on: ; Accepted on:

2 Unnecessary and excessive use of antibiotics may lead to adverse effects such as gastrointestinal disorder, fatal anaphylactic shock, and other severe complications. Dentoalveolar abscess is an abscess around the root of a tooth in the alveolar cavity. It is usually the result of necrosis and infection of dental pulp following dental caries. [2] A formation and accumulation of pus in a tooth socket or the jawbone form around the base of a tooth. The pus results from a bacterial infection that is usually secondary to an infection or injury to the tooth or alveolar tissues. It is polymicrobial, with an average of 4 6 different causative organisms. It is also called periapical abscess. Abscess is a local collection of pus. It is composed of dead cells -leukocytes and bacteria. It is high in protein, often whitish-yellow, brownish, and occasionally greenish (pyocyanin). [3] Predisposing Risk Factors of Dentoalveolar Abscess Dental caries, poor dental hygiene, dental trauma are the common predisposing risk factors leading to dentoalveolar abscess. Pathogenesis of Dentoalveolar Abscess The etiology of dentoalveolar abscess is often polymicrobial with facultative anaerobes such as the viridans group streptococci and the Streptococcus anginosus group being the predominant pathogens. Strict anaerobes, especially anaerobic cocci, Prevotella and Fusobacterium species can also additionally contribute to the severity of the abscess. Clinical Features of Dentoalveolar Abscess Fever, pains, headache, malaise, weight loss, facial asymmetry if any of the facial spaces is involved along with Palpable submandibular nodes, submental lymph nodes of the affected side. Mouth opening may also be limited. Intraorally, the gingiva surrounding the involved primary tooth will be hyperemic, tender, swollen, and a discharging sinus may also be present. The swelling is around the attached gingiva of the involved primary tooth as a result of the numerous accessory canals which open up in the furcation area. The pus will erode the alveolar bone around the furcation area and then form a swelling. This is often referred to as gum boil or inappropriately called periodontal abscess because it resembles the periodontal abscess seen in the permanent tooth. For the permanent tooth, the abscess is toward the apex of the root. The infection usually involves the whole pulp tissue and then causes swelling around the apex of the tooth. This is because permanent teeth have less number of accessory canals when compared to the primary teeth. Typical findings of dental abscess history are localized, constant, deep, throbbing pain, and pain worsens with mastication or exposure to extreme temperatures, tooth may be mobile gingival or facial swelling and tenderness (or both) may be present. Management and Treatment for Dentoalveolar Abscess for Both Adult and Pediatric Patients The goals of treatment are to relieve the symptoms and prevent the spread of infection. Non-pharmacologic interventions Warm saline rinses (1 tsp in 1 cup of warm water) qid and ice pack wrapped in a towel against the cheek to reduce pain and swelling. Pharmacological interventions Analgesics for mild-to-moderate pain: Acetaminophen 325 mg, 1 2 tabs per oral 4 6 hours, or Ibuprofen 200 mg, 1 2 tabs per oral 4 6 hours can be taken to alleviate pain. Oral antibiotic therapy Penicillin VK 300 mg, 1-2 tabs poqid for 7 days - Amoxicillin 500 mg, po bid or tid for 5 days. For patients with penicillin allergy: - Clindamycin mg, poqid for 7 days can be prescribed if the primary tooth is still restorable and if the furcation area has not been perforated. A temporary crown-like stainless steel crown will also be placed on the tooth. Root canal treatment can be done for permanent teeth with closed apex. A temporary crown will be placed afterward. Apexification can also be done in a permanent tooth with open apex using calcium hydroxide or mineral trioxide aggregate. If the primary tooth is not restorable or the furcation area is perforated, the tooth will be extracted. A space maintainer is placed to keep the space for the succedaneous tooth if primary tooth is extracted. A denture is given if permanent tooth is extracted. Lesion sterilization and tissue repair are another option. This can be done when there is resorption and furcation involvement. Access cavity is made. Canal is irrigated with hypochlorite solution and dried. Triple paste (metronidazole, minocycline, and ciprofloxacin) is placed in canal and access sealed. Tooth crowned using temporary crowns. Prevention of Dentoalveolar Abscess Avoid cariogenic diets. More attention should be given to children by caregivers. They should assist/ supervise/perform tooth brushing for the child when needed. Use mouth protector during sports to avoid fractures, access regular caries preventive oral care. Complications of Dentoalveolar Abscess Hypoplasia of the permanent tooth (turner s tooth) may occur, it can also lead to cavernous sinus thrombosis, brain abscess, Ludwig angina, and occasionally death, feeding is affected because of inability to chew with that side of the mouth which may eventually lead to weight loss, caregiver absenteeism from work, there is also financial implication for the management, cellulitis, recurrent abscess formation, systemic 2391

3 infection, osteomyelitis, and sepsis. Resistance of Antibiotics in Dentoalveolar abscess The antimicrobials can never be used as a replacement for usual surgical drainage and debridement. The maintenance of an airway and abscess drainage is a condition sine qua non. The antimicrobial therapy implemented quickly after the diagnosis and before the surgery that can shorten the period of infection and minimize associated risks like bacteremia. Penicillin and Cephalosporin Historically, the penicillins have been used as the firstline agents in the treatment of odontogenic infections. Increasing rates of penicillin resistance and treatment failures have been reported. The highest rates of penicillin resistance have been observed with the members of the genus Bacteroides and Prevotella. Penicillin resistance in these pathogens has been correlated with β-lactamase production. Heimdahl reported on a series of patients with orofacial infections who failed to respond to penicillin therapy due to β-lactamase producing Bacteroides. Using an animal model, β-lactamase production by strains of Prevotella melaninogenica in a mixed infection has been shown to protect both Prevotella melaninogenica and other bacteria from penicillin. Reduced susceptibility to penicillin is more prevalent in the mitis group streptococci than in the anginosus group. In susceptibility test to antibiotics, imipenem was the most active molecule tested, confirming its general good activity against oral streptococci. Furthermore, the thirdgeneration cephalosporins such as ceftriaxone and the fourth-generation cephalosporins like cefepime showed good activity. Chinolones, glycopeptides, and rifampicin confirmed a good activity against oral streptococci. Macrolides Macrolide resistance is most commonly due to acquisition of one of a number of erm genes (erythromycin methylases resulting in reduced binding of macrolides to the 50S ribosomal subunit). Resistance to macrolides appears to have a higher prevalence in the viridans group streptococci, anaerobic streptococci, and Prevotella species. The newer macrolides, clarithromycin and azithromycin, offer improved pharmacokinetics compared to erythromycin. Metronidazole Metronidazole is a bactericidal agent that is highly active against most anaerobes, but it lacks activity against aerobic bacteria and although it makes the function in control against penicillin-resistant anaerobic Gramnegative bacilli, it only has moderate activity against microaerophilic Gram-positive cocci. In conditions of risky infections, the metronidazole is used widely in conjunction with penicillin to make sure the coverage against aerobic Gram-positive bacteria. The combination of two drugs with different dosing schedules may slow the patient compliance. This development of resistance to the agent by similar odontogenic pathogens is rare. Clindamycin Clindamycin has excellent activity against Grampositive organisms including anaerobes and β-lactamase-producing strains. Low concentrations of the drug are bacteriostatic, but bactericidal activity is achieved clinically with the usual recommended doses. Gilmore demonstrated comparable activity between clindamycin and penicillin V in the treatment of moderate-to-severe odontogenic infections. von Konow reported similar findings, but the clindamycin group had a shorter duration of fever, pain, and swelling. In one study, moxifloxacin was significantly more effective in reducing pain at days 2 3 of therapy than clindamycin. Clindamycin has recently been considered for the management of odontogenic infections because of the bacterial susceptibility to this drug, great oral absorption, low emergence of bacterial resistance, and good antibiotic levels in bone. [4] Currently, there are no specific guidelines for prophylactic or therapeutic prescribing of antibiotics in dentistry. In addition, there are no data describing the indications for which antibiotics are prescribed, whether the antibiotic agents, their dose, frequency, and duration are based on published guidelines or standards. Therefore, the purpose of this study was to describe the choice of antibiotic prescription in the management of dentoalveolar abscess among dental practitioners. We, therefore, conducted this study to evaluate the knowledge and attitude of dental practitioners in regarding their therapeutic use of antibiotics for patients with dentoalveolar infections. MATERIALS AND METHODS The aim is to investigate the knowledge of dental practitioners about therapeutic prescribing of antibiotics in the management of dentoalveolar abscess. A questionnaire study was performed on 100 dental practitioners. A self-administered validated semi-structured questionnaire to assess the antibiotic prescribing patterns among dental practitioners utilized in this study and the first three sections were used. The questionnaire composed of three sections. The demographic information regarding gender, principle work role, working experience, and being general or specialized dentist was sought first. The second section of the questionnaire was composed of a table to record: The first choice of antibiotic for the treatment of dentoalveolar abscess. The third section contained questions regarding therapeutic antibiotic prescriptions for various clinical signs. A questionnaire describes about clinical signs are elevated temperature 2392

4 and evidence of systemic spread; localized fluctuant swelling; gross swelling; restricted mouth opening; difficulty in swallowing; and closure of the eye due to swelling. It also explored about an antibiotic prescription. This would be a reason for prescribing antibiotics. The practitioners were asked to state the antibiotic they would prescribe, its dose, interval, and duration, for patients who were not allergic to penicillin. A practitioner was also asked what antibiotic they would choose if the patient was allergic to penicillin for the management of dentoalveolar abscess. Data entry and analysis were done. [5] RESULTS The questionnaire was distributed to 100 dental surgeons and questionnaires were received back from the respondents. The respondents consisted of 49 males and 51 female dentists. Amoxicillin is the antibiotic of choice for dentoalveolar abscess without known allergy with the percentage of 45% and clindamycin is an antibiotic of choice for dentoalveolar abscess with known allergy to penicillin with the percentage of 46% in Tables 1 and 2 and Figures 1 and 2. The data analysis of antibiotics in the management of dentoalveolar abscess is given below in percentage in two tables. DISCUSSION The study participants belonged to a public sector tertiary care dental institute that represents a wide range of dentists of region, with varying clinical and teaching experience. Amoxicillin is found to be the most preferred antibiotic in dentoalveolar abscess for patients without any known allergy. [5] Comparing with other parts of the world, dental practitioners in England and Australia also prescribe amoxicillin, but there was a trend toward lesser dosage over a longer duration. [6,7] In some studies, around 60% of the surveyed dental surgeons prescribe antibiotics for acute periapical infection (API) before drainage and 70% after drainage was done. Although there is no added benefit of systemic antibiotic use in the management of API, until there is systemic involvement such as fever, cellulitis, or lymphadenopathy. Most of the uncomplicated swellings are best managed by drainage of an infection. [2,8] The choices of antibiotic for the management of acute dentoalveolar abscess in patients with known allergy to penicillin in the present study are clindamycin, cephalexin, and erythromycin. A study suggested that erythromycins extensive use in different parts of the world may be linked to its recommendation in earlier literatures and its economy. However, there were 5% dentists in the present study who prescribed amoxicillin for patients with known allergy to penicillin, and this practice is not indicated to prevent anaphylaxis and hypersensitivity reactions. [9] Antibiotic therapy is required in some clinical conditions where oral Table 1: Antibiotics of choice for acute dental conditions in patients without any known allergy Drugs Percentage Amoxicillin 45 Co amoxiclav 10 Metronidazole 40 Others 5 Table 2: Antibiotic of choice for management of acute dental infection for patient with known allergy to penicillin Drugs Percentage Amoxicillin 5 Metronidazole 10 Erythromycin 15 Cephalexin 24 Clindamycin 46 Figure 1: Antibiotics of choice for acute dental conditions in patients without any known allergy Figure 2: Antibiotic of choice for management of acute dental infection for patient with known allergy to penicillin infection is associated with raised body temperature and signs of systemic spread such as lymphatic involvement and limited mouth opening. [10] A serious condition in which antibiotic therapy should be given is facial cellulitis which may or may not be associated with dysphagia. Many similar studies were done for prescribing antibiotics in the management of all dental infections and in dentistry such as periodontal abscess, acute necrotizing ulcerative gingivitis, and pericoronitis is few of the localized oral lesions requiring antibiotic use as an adjunct therapy along with the local management. [11] The management of acute pulpitis includes local interventions such as pulp capping, endodontic treatment, or extraction. The use 2393

5 of antibiotics for the management of acute pulpitis is not supported by any evidence in literature. [12,13] A considerable amount of respondents routinely prescribe antibiotics for chronic periodontitis, chronic marginal gingivitis, and dry socket although these oral conditions can efficiently be managed by local interventions as systemic antibiotics have no additional benefit on these conditions. In some studies, antibiotic use in implant dentistry, study shows 36% of respondents preferred prescribing antibiotics for dental implant placement, and 26% of amoxicillin and metronidazole are very commonly preferred by many of the surveyed dentists. For routine infections, the disadvantages of this therapy overshadow the advantages. [14,15] Whatever few studies have been conducted in Pakistan on antibiotic prescriptions, irrational and overprescribing of antibiotics are evident in these studies both in public and private sector. [16-18] This practice is found similar to studies from other developing countries due to multiple factors such as patients demand, delaying treatment, maldiagnosis, and lack of updated and appropriate knowledge of dentists. [19-21] One most important reason suggested may be the absence of antibiotic prescribing guidelines in the region by regulatory bodies. Availability of guidelines helps in regulating and monitoring standard care, minimizing irrational use of antibiotics, and hence, preventing the development of resistance. Moreover, there is no legal requirement to undergo continuing dental education for updating the knowledge of registered dentists. The present study showed evidence of prescribing of antibiotics by dentists. The indications for antibiotics in acute dentoalveolar infections have been defined as signs of spreading infection, patient malaise, temperature elevation, and lymphadenitis. [22] In general, this survey showed that dental practitioners are aware of these indications and mostly used antibiotics wisely for dentoalveolar abscess. Dentists will be monitoring and following up in h and also should counsel patients about appropriate use of medications (dosage and side effects). Recommend dietary modifications as indicated and limit consumption of sugary drinks and recommend dental hygiene or improvement to dental hygiene. [23] CONCLUSION Results of this study demonstrate that majority of the surveyed dentists prescribe antibiotics for dentoalveolar abscess and their clinical sign, where local management would be sufficient. It is also highlighted that there is a need of developing guidelines regarding antibiotic prescription by the regulatory bodies based on available literature for development and regulating appropriate use of antibiotics. REFERENCES 1. Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. 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