Antimicrobial Prescribing

Resources

https://www.gov.uk/guidance/dental-antimicrobial-stewardship-toolkit

Prescription Writing

Prescriptions advice:

Written or printed legibly in ink or otherwise so as to be indelible
Dated
State the name and address of the patient
Address of the prescriber and an indication of the type of prescriber
Signed by the prescriber (computer-generated facsimile signatures do not meet the legal requirement for paper prescriptions)
The age and the date of birth of the patient should preferably be stated (it is a legal requirement in the case of prescription-only medicines to state the age for children under 12 years).
The strength or quantity to be contained in capsules, lozenges, tablets etc. should be stated by the prescriber. In particular, the strength of liquid preparations should be clearly stated (e.g. 125mg/5mL).
The unnecessary use of decimal points should be avoided, e.g. 3mg, not 3.0mg. Quantities of 1 gram or more should be written as 1g etc. Quantities less than 1 gram should be written in milligrams, e.g. 500mg, not 0.5g. Quantities less than 1mg should be written in micrograms, e.g. 100 micrograms, not 0.1mg. When decimals are unavoidable, a zero should be written in front of the decimal point where there is no other figure, e.g. 0.5mL, not .5mL. Use of the decimal point is acceptable to express a range, e.g. 0.5 to 1g.
‘Micrograms’ and ‘nanograms’ should not be abbreviated. Similarly, ‘units’ should not be abbreviated.
The term ‘millilitre’ (ml or mL) is used in medicine and pharmacy, and cubic centimetre, c.c., or cm3 should not be used.
Dose and dose frequency should be stated; in the case of preparations to be taken ‘as required’, a minimum dose interval should be specified. Care should be taken to ensure children receive the correct dose of the active drug. Therefore, the dose should normally be stated in terms of the mass of the active drug, e.g. ‘125mg 3 times daily’.
The names of drugs and preparations should be written clearly and not abbreviated, using approved titles only.
The quantity to be supplied in primary care may be stated by indicating the number of days of treatment required.
Although directions should preferably be in English without abbreviation, it is recognised that some Latin abbreviations are used.

Assessment of the patient

Early recognition and management of dental infections is critical as patients (particularly children and immunocompromised patients) can become systemically ill within a very short space of time. Untreated local infections can spread, causing significant morbidity and even life-threatening sequelae, e.g. Ludwig’s angina.

An assessment of the patient and diagnosis should be recorded in the clinical records and include:

A comprehensive medical and dental history
Assessment of the presence of fever (> 38°C), malaise, fatigue or dizziness (NB: antipyretic effect of patients taking analgesics may temporarily lower the temperature)
Measurement of the patient’s pulse and temperature (normal temperature range is 36.2°C -37°C)
Definition of the nature, location and extent of the swelling, and any lymphadenopathy
Identification of the cause of the infection
Assessment of presence of sepsis using a decision support tool (e.g. NICE Sepsis: Risk stratification tools)

Hospital Referral

Referral to a hospital specialist may be necessary and urgent, particularly if there is/are:

Signs of septicaemia, such as grossly elevated temperature (above 39.5°C), lethargy, tachycardia, tachypnoea and hypotension
Signs of severe sepsis or septic shock
Spreading cellulitis
Swellings that may compromise the airway, cause difficulty in swallowing or closure of the eye
Dehydration characterised by lethargy, dizziness and headache
Significant trismus associated with a dental infection
Failure of resolution of infection following previous treatment
A patient who is unable to cooperate with necessary and appropriate care

Acute Dento-Alveolar Infections

ACUTE PERIAPICAL INFECTIONS

Acute periapical infections are infections around the apex of the tooth associated with tooth decay or trauma causing necrosis of the dental pulp. There is associated pain, swelling (localised or spreading), tenderness of the tooth to percussion and mobility, possible raised temperature, malaise, lymphadenopathy and possible dehydration.

It is widely accepted that immediate drainage of infection should be established by extraction of the causative tooth, opening of the root canal and/or incision of the swelling. Failure to do so can lead to spread of the infection and cellulitis.

SEVERE RAPIDLY SPREADING DENTO-FACIAL ABSCESSES; CELLULITIS AND LUDWIG’S ANGINA

When an abscess spreads rapidly beyond the dento-alveolar area into the surrounding tissues with systemic signs and symptoms, management usually requires hospital admission due to the possibility of severe complications.

Despite a significant reduction in frequency and mortality, odontogenic infections can still be life-threatening. They may require urgent surgical intervention and intensive care management because of the potential for spread of infection into intracranial and peri-tracheal neck spaces and the risk of airway compromise if appropriate management is not instituted.

Clinical assessment in secondary care:

Record patient’s temperature and clinical signs and symptoms
Assess extent and nature of swelling, sepsis risk and any trismus, dysphagia, dyspnoea and dysarthria
Determine source of infection and immediate risk to the airway or infraorbital spread through an OPG radiograph and/or CT scan
Assess whether cellulitis with oedema or pus is present that requires surgical drainage
Blood tests (including blood glucose) and blood/pus cultures for sensitivity testing.

ANTIMICROBIAL DRUGS OF CHOICE

Research suggests that there is no evidence to recommend one antimicrobial over another in the management of acute dental abscesses with systemic complications when drainage/and or removal of the cause is properly carried out.

Antimicrobials are prescribed either empirically based on the microbiology of dental infections and antimicrobial sensitivity established in the literature, or based on the results of microbial susceptibility testing.

Short courses of antimicrobials (up to 5 days) are effective in dental infections and also reduce the pressure to select for antibiotic resistance and reduce side effects.

1st CHOICE ANTIMICROBIAL

A penicillin, such as phenoxymethylpenicillin or amoxicillin, is effective for most dentoalveolar infections.

Amoxicillin as a short course high dose has been shown to be as efficacious as a conventional phenoxymethylpenicillin. Amoxicillin has a broader spectrum of activity than phenoxymethylpenicillin, which, though as effective, is less reliably absorbed and needs to be taken four times daily on an empty stomach.

However, amoxicillin may encourage emergence of resistant, organisms. In line with the principles of antimicrobial stewardship, when prescribing antimicrobials to treat an infection that is not life-threatening, a narrow spectrum antibiotic should generally be the first choice.

2nd CHOICE ANTIMICROBIAL

The second choice antimicrobial is either metronidazole or a macrolide, e.g. clarithromycin, which offers improved pharmacokinetics and toleration compared to erythromycin.

Metronidazole can be used:

As a first line treatment for patients allergic to a penicillin; or
As a first line treatment for patients who have had a recent course of a penicillin for another infection; or
As an adjunct to a penicillin in severe spreading infections
If a predominantly anaerobic infection is suspected or microbiologically proven

Clarithromycin can be used:

As a first line treatment for patients allergic to a penicillin
As a first line treatment for patients who have had a recent course of a penicillin

OTHER ANTIMICROBIALS

Clindamycin has effective antimicrobial activity against oral anaerobes. A higher rate of adverse gastrointestinal effects and diarrhoea has been reported in association with clindamycin treatment and it is well documented that there is an increased risk of Clostridium difficile infections with clindamycin. The significant morbidity/mortality associated with Clostridium difficile is an important risk that should be included in consent when prescribing clindamycin. Clindamycin, however, may be the only antimicrobial of choice due to allergy or drug interactions for some individual patients.

Co-amoxiclav (amoxicillin and clavulanic acid) is active against beta-lactamase producing bacteria that are resistant to amoxicillin. Co-amoxiclav should only be used in patients likely to be managed in secondary care and for a severe spreading infection with spreading cellulitis and where the infection is not responding to first line antimicrobials.

Cephalosporins have been used for oral infections but they offer no advantage over a penicillin in dental infections and are less active against anaerobes.

Chronic Dental Infections

CHRONIC DENTO-ALVEOLAR INFECTIONS

Chronic dento-alveolar infections occur as a result of decayed or restored teeth, or periodontal-endodontic lesions with a longstanding minor well-localised abscess contained by the host immune system. These infections sometimes spontaneously drain through a sinus tract which can be either intra- or extraoral.

It is generally accepted that definitive dental treatment to remove the cause leads to resolution. Longstanding chronic infections that fail to respond to treatment are indicative of a more serious problem, e.g. osteomyelitis. These patients should be referred for specialist management.

Antimicrobial therapy is rarely required unless:

There is an acute flare-up and there is evidence of severe local spread, or
There is systemic involvement shown by raised temperature and malaise

OSTEOMYELITIS (OM)

OM is an infection in the bone which usually affects the mandible.

It is the result of bacterial infection of odontogenic origin or trauma causing bone death and necrosis.

Patients generally present with:

Deep-seated throbbing pain
Swelling (initially soft because of oedema, later firm with involvement of the periosteum)
Non-healing necrotic bone
Sequestrum formation
Trismus
Fever
Halitosis
Extraoral draining sinuses
Lymphadenopathy

These patients require comprehensive clinical assessment and treatment in secondary care.

MEDICATION RELATED OSTEONECROSIS OF THE JAW (MRONJ)

MRONJ is where exposed necrotic bone in the maxillofacial region has persisted for more than 8 weeks in a patient who is, or has, undergone treatment with antiresorptive or antiangiogenic agents without current or previous radiotherapy to the area.

The exposed necrotic bone may occur spontaneously or following dento-alveolar surgery. Intraoral and extraoral fistulae may develop when the necrotic mandible or maxilla becomes secondarily infected.

OSTEORADIONECROSIS (ORN)

ORN is a sequela of radiation therapy in head and neck cancer patients. Currently, there is no gold standard treatment of ORN and no widely accepted guidelines exist due to a lack of good evidence.

A literature review showed that early-stage ORN can be treated conservatively with antimicrobials and meticulous oral hygiene, as for MRONJ. Any sign of progression may require early surgical intervention with debridement and mucosal flaps to cover exposed bone.

The role of HBO treatment and medical management (antifibrotics, antioxidants, steroids) is yet to be defined with robust clinical trials. Extensive surgical resection with microvascular free flap reconstruction may be indicated in some patients with very advanced ORN and persistent symptoms despite conservative treatments.

Pericoronitis

Pericoronitis is inflammation and infection of the soft tissues around a partially erupted tooth, usually an impacted mandibular third molar.

It is generally accepted, in line with the management of acute dental infections, that local inflammation and infection is managed with local measures, such as removal of the cause (extraction or operculectomy), incision and drainage where necessary.

Metronidazole or amoxicillin, both effective against anaerobic bacteria, are recognised as suitable choices of antimicrobial as an adjunct to local measures where indicated. Dose should be as per treating acute dento-alveolar infections

Alveolar Osteitis (Dry Socket)

Dry socket or localised osteitis is a recognised complication following tooth extraction, with incidence rates of 1-4% with routine extractions, but a reported incidence of 25- 30% with impacted lower wisdom teeth.

It occurs 3-4 days post-extraction and is self-limiting, lasting for up to 10 days. The aetiology is thought to be associated with surgical trauma, local infection, inadequate oral hygiene and poor aftercare.

In the absence of signs of a spreading infection, it is generally accepted that antimicrobials are contraindicated and management is centred around local measures.

Chlorhexidine use preventively does not reduce the incidence of dry socket, and due to possible anaphylaxis, its use is not recommended.

Antimicrobials are not recommended for the management of dry socket in the absence of signs of a spreading infection

Acute Sinusitis

Most cases of acute sinusitis (also known as rhinosinusitis) are self-limiting and usually triggered by a viral infection of the upper respiratory tract.

In the absence of a dental cause, these cases are best managed by the patient’s general medical practitioner.

Acute sinusitis can be diagnosed by:

Nasal discharge
Nasal blockage or congestion
Facial pain localised over the affected sinus that can affect the teeth, upper jaw or eye, side of the face or forehead. Pain in the absence of other symptoms is unlikely to be sinusitis and a dental cause should be ruled out
Loss or altered sense of smell

Most cases of uncomplicated acute sinusitis resolve in 2-3 weeks and respond to watchful waiting and measures to relieve symptoms.

Antimicrobials are not recommended for uncomplicated acute sinusitis

Bacterial Sialadenitis

Sialadenitis is inflammation and swelling of the parotid, submandibular, sublingual or minor salivary glands.

Acute bacterial sialadenitis is characterised by:

Rapid onset of pain
Swelling and elevated temperature
Cellulitis and induration of the adjacent soft tissues may be present, and rarely a cutaneous fistula
Exudates of pus from salivary gland opening

Chronic sialadenitis is characterised by intermittent, recurrent episodes of tender swelling, usually as a result of obstruction (stricture or calculus) of the duct which can be managed with local measures.

A clinical assessment of the patient should include palpation of the gland for the presence of calculi and examination of the ductal opening for purulence. Referral and management to a specialist is required in cases of acute infection, grossly elevated temperature and signs of airway compromise where microbiological culture of pus from the duct and blood cultures can be taken, along with an assessment of fluid and electrolyte balance.

The most common bacterial cause of acute sialadenitis is Staphylococcus aureus, which has been cultured in > 50% of cases. Streptococcal species, Gram-negative bacteria and anaerobes are also common causes.

As with acute dento-alveolar infections, accepted practice in the management of acute bacterial sialadentitis with systemic signs and symptoms is drainage of the abscess if present, removal of the cause and prescribing of antimicrobials.

There is no evidence of the efficacy of one antimicrobial or combination over another. Empirically, antimicrobial therapy in the hospital setting includes flucloxacillin and metronidazole, with addition of gentamycin where necessary, or a third generation cephalosporin for hospital in-patients. Clinicians should be aware of local policies/formularies and seek advice from a clinical microbiologist.

Periodontal Diseases

GINGIVITIS

Gingivitis is an inflammatory response of the gingival tissues resulting from bacterial plaque accumulation at and below the gingival margin. A systematic review showed that mechanical plaque control procedures are effective in reducing plaque and gingivitis, and that an antimicrobial rinse has a positive effect on gingivitis.

Systemic antimicrobials are not recommended for the management of gingivitis

NECROTISING PERIODONTAL DISEASES

These are rare and include necrotising gingivitis, necrotising periodontitis and necrotising stomatitis.

They are characterised by gingival necrosis and bleeding, pain and fetid breath. In severe cases, systemic signs and symptoms, such as lymphadenopathy, fever, and malaise may be present.

The possibility of compromised systemic health, smoking and/or stress should be investigated with the patient and managed if necessary, possibly in conjunction with the general medical practitioner.

Metronidazole or amoxicillin are both recognised as suitable choices of antimicrobial as an adjunct to local measures where indicated. Dose should be as per treating acute dento-alveolar infections.

PERIODONTITIS - Stage I, II, III; Grade A, B or periodontitis in patients aged >40-45years

It is accepted that it is possible to achieve satisfactory and stable outcomes from root surface debridement (RSD) combined with good patient oral hygiene in this group of patients.

Clinicians should weigh up any very small short-term benefits of adjunctive systemic antimicrobial treatment against development of resistance and other unwanted side effects of antimicrobials, such as diarrhoea, nausea, vomiting, thrush, gastrointestinal intolerance and antimicrobial hypersensitivity.

Systemic antimicrobials are not recommended as an adjunct to thorough and effective mechanical debridement for patients with periodontitis of slow or moderate progression, or in any patient with periodontitis aged >40-45 years

PERIODONTITIS - Stage III, IV Grade C or periodontitis in patients aged <40-45years

Patients with severe/very severe or rapidly progressing forms of periodontitis responding poorly to effective mechanical debridement and excellent patient oral hygiene should be referred for specialist management.

In this group of patients (where periodontal disease is advanced and progressing rapidly), the use of systemic antimicrobials as an adjunct to mechanical debridement and oral hygiene instruction can result in greater PD reductions and gains in CAL compared to just root surface debridement alone.

It has been suggested that locally undisrupted biofilm affects the efficacy of systemic antimicrobials, and that they should be commenced at the earliest on the day RSD is started. Current expert consensus is that antimicrobials should be prescribed at the end of a thorough course of RSD, and that such instrumentation therapy should be completed within a week or less.

Clinicians should weigh up the benefits and risks, both at an individual and general population level, when deciding to prescribe systemic antimicrobials as an adjunct to thorough and effective mechanical debridement.

The choice of antimicrobial in the management of periodontal diseases is empiric, guided by information about the nature of the involved pathogenic microorganism(s) and/or their antimicrobial susceptibility profile. The microbial flora and level of pathogenic species differ for patient and site but is usually associated with anaerobes.

First choice antimicrobial is amoxicillin + metronidazole. A shorter-duration regimen reduces potential side effects and selective resistance.

The second choice is a macrolide, e.g. azithromycin. This is normally used as an alternative to a penicillin.

Other antimicrobials include doxycycline, which has been suggested to have higher availability in the gingival crevice, significantly active against Aggregatibacter actinomycetemcomitans but doxycycline has mixed but inferior results compared to other antimicrobials.

There are a range of local/topical delivery antimicrobial systems available. Indications for their use are limited and should not be considered as a first-line periodontal treatment. Locally delivered antimicrobials are not recommended as an adjunct to effective mechanical debridement in the management of periodontitis

PERIODONTAL ABSCESS

The majority of uncomplicated swellings of periodontal origin can be successfully treated by removing the source of the infection. This can be achieved by drainage of the associated abscess (ideally by RSD via the pocket) or by extraction of the tooth.

Antimicrobials are only indicated as an adjunct to definitive treatment where there is an elevated temperature, evidence of systemic spread and local lymph node involvement; as per treating acute dento-alveolar infections.

PERI-IMPLANT DISEASE

Peri-implant disease is thought to be due to inflammation as a result of biofilm formation following bacterial colonisation of the oral implant and restoration surfaces.

It has been associated with predominantly Gram-negative anaerobic microflora.

Peri-implant mucositis is inflammation around the soft tissues of the dental implant, with no signs of bone loss. Generally, peri-implant mucositis if untreated leads to peri-implantitis.

Peri-implantitis is an inflammatory disease of the soft tissues surrounding an implant, accompanied by bone loss and multifactorial pathogenesis.

Apical peri-implantitis (retrograde peri-implantitis) is a clinically symptomatic periapical lesion that develops shortly after implant insertion, while the coronal portion of the implant achieves a normal bone to implant interface.

Antimicrobials are not recommended as an adjunct to local, or surgical, management of peri-implant disease. In the extremely rare situation where antimicrobials may be required for peri-implant diseases, see antimicrobial regimes for severe periodontitis.

Endodontic Therapy

ACUTE PULPITIS

Pulpitis is described as either ‘reversible’ or ‘irreversible’. With reversible pulpitis, the tooth may get better with time or by removal of the cause, or it may progress to irreversible pulpitis and necrosis of the pulp leading to an apical infection.

Topical antimicrobials containing preparations (e.g. ledermix) have been used in the management of pulpitis. There is no good scientific evidence to support the use of topical antimicrobials over other obtundents in the management of pulpitis.

The accepted standard of definitive care for irreversible pulpitis is extirpation of the pulp of the affected tooth or extraction.

Antimicrobials are not recommended for acute pulpitis to prevent pain associated with pulpitis

ACUTE AND CHRONIC PERIAPICAL INFECTIONS

Antimicrobials are not indicated in endodontic therapy, unless there are signs of gross local spread of infection or evidence of systemic involvement. They are rarely indicated where drainage cannot be achieved immediately or treatment has to be delayed, e.g. for referral for peri-radicular surgery.

Antimicrobials are not recommended for most endodontic treatment nor to prevent postoperative pain, swelling or endodontic flare-ups

REGENERATIVE ENDODONTIC PROCEDURES (REP)

Regenerative endodontic procedures (REPs) replace damaged tissues, including dentine, root structures and cells of the pulp-dentine complex. In immature teeth with open apices and necrotic pulps, REPs promote root development and apical closure.

The risks of using local antimicrobials for disinfection, such as discolouration from minocycline, cytotoxicity, sensitisation, difficulty of removal from the root canal, and more importantly, the development of resistance, should also be compared with using calcium hydroxide when weighing any benefit

Local antimicrobials are not recommended for REPs

TOOTH AVULSION

There are guidelines on the management of tooth avulsion which suggest that dentists should consider prescribing antimicrobials when re-implanting an avulsed tooth.

However, there are no indications for prescribing therapeutic antimicrobials in the absence of systemic infection. For prophylactic prescribing of antimicrobials to prevent infection in the management of the avulsed tooth, see section below

Systemic therapeutic antimicrobials are not recommended when re-implanting avulsed teeth in the absence of systemic infection

PERI-RADICULAR SURGERY

There are clinical situations when non-surgical root canal retreatment is inappropriate and peri-radicular surgery is the treatment of choice. A wide range of success rates for surgical endodontics has been reported (44-95%).

Therapeutic antimicrobials are not recommended for peri-radicular surgery in the absence of systemic infection

Antimicrobial Prophylaxis - healthy patients

Antimicrobials have sometimes been prescribed to healthy patients for interventive dental procedures (IDPs) to prevent surgical site infections (SSIs), promote healing

and reduce postoperative pain.

Antimicrobial prophylactic use remains a contentious issue in all surgical fields, particularly with the increasing development of antimicrobial resistance. Ideally, antimicrobials should reduce morbidity, but they can also cause adverse effects (e.g. allergy, toxicity) and increase colonisation resistance, resulting in infections with resistant micro-organisms.

MINOR ORAL SURGERY

Antimicrobials are not recommended to prevent postoperative complications after extraction of impacted teeth/retained roots, surgical extractions, peri-radicular surgery or minor surgical removal of soft tissue lesions

ORO-ANTRAL COMMUNICATIONS

Oral antral communications (OAC) may be the result of cysts, trauma, tumours, bisphosphonates or oral surgery. The extraction of maxillary posterior teeth is the most common cause of OAC.

Local management depends on the diameter of the OAC:

<2mm - close spontaneously
<5mm - sole suturing of the gingiva
>5mm - surgical closure.

Large acute OACs and cases where root or root fragments have been introduced into the sinus require immediate referral and specialist management within 48 hours.

Unless OACs are properly treated, it has been reported that approximately 50% of patients will experience sinusitis 48 hours later, and 90% of patients will develop sinusitis after two weeks of no treatment.

Antimicrobials are recommended to prevent acute sinusitis as a result of an OAC

DENTAL IMPLANTS

Dental implant procedures are graded as clean-contaminated surgery. Several systematic reviews reported that whilst the risk of implant failure (implant loss) was reduced when prophylactic antimicrobials were used, the incidence of postoperative infection (SSIs) did not significantly reduce.

Antimicrobial prophylaxis for implant placement remains controversial.

The number of patients needed to treat (NNT) with antimicrobial prophylaxis to prevent one patient having an implant failure in these studies ranged from.

Antimicrobials are not recommended for healthy patients undergoing implant surgery (without bone augmentation)

Antimicrobial prophylaxis is recommended for intraoral bone augmentation when placing dental implants. Case studies have shown that surgical site infection rates are similar after bone augmented implant placement with preoperative or pre- and postoperative prophylactic antimicrobials. It is, therefore, accepted practice to use a single dose preoperatively.

Amoxicillin is a first choice, with clindamycin as a second choice. Clinicians should be aware of the risk of significant morbidity/mortality associated with Clostridium difficile when prescribing clindamycin.

REGENERATIVE & NON-REGENERATIVE PERIODONTAL SURGERIES

Surgical site infection rates in regenerative periodontal surgeries is extremely low.

Antimicrobials are not recommended to prevent postoperative complications for non-regenerative or regenerative periodontal surgeries using EMD or GTR.

MAXFAC - OPEN REDUCTION FRACTURES

Open reduction internal fixation (ORIF) is the treatment of choice for mandible fractures.

Research has shown no postoperative infections related to maxillary, condylar or zygomatic fractures, but is linked to mandibular fractures.

Antimicrobial prophylaxis is indicated for mandibular fractures. It is generally accepted that a single full therapeutic dose is given no more than 60 minutes prior to surgical incision to prevent SSIs.

An antimicrobial for prophylaxis should cover the organisms most likely to cause infection. It should also take the local resistance patterns and the patient’s medical and drug history into account, and be based on local prescribing policies/formularies.

MAXFAC - ORTHOGNATHIC SURGERY

Orthognathic surgery is classed as major clean contaminated maxillofacial surgery.

Postoperative infection rates vary between 2% and 33%,36 therefore, antimicrobial prophylaxis is indicated.

There is some evidence to support the use of one dose of preoperative antimicrobial prophylaxis.

MAXFAC - INTRA-ORAL BONE GRAFTING

Antimicrobial prophylaxis is recommended for intraoral bone grafts

MAXFAC - SOFT TISSUE SURGERY & GRAFTING

Surgical procedures in the maxillofacial region in which the incision and exposure does not extend into the oral cavity, including submandibular and parotid gland surgery and TMJ surgery, are classed as clean surgical procedures.

Antimicrobial prophylaxis is not recommended for soft tissue surgery and grafting

MAXFAC - MAJOR HEAD & NECK ONCOLOGY SURGERY

Antimicrobial prophylaxis is recommended for head and neck oncology surgery

REIMPLANTATION OF AN AVULSED TOOTH

Some guidelines suggest that it might be prudent to consider antimicrobial prophylaxis in certain circumstances when re-implanting an avulsed tooth, e.g. medical history, however the evidence for prescribing antimicrobials for reimplantation of an avulsed tooth is very poor.

Antimicrobial prophylaxis is not routinely recommended for the avulsed tooth in a healthy patient

AUTO TRANSPLANTATION OF A TOOTH

Auto transplantation, or autografts, involve transplantation of a tooth from its alveolus to another site in the same person. A donor tooth (allograft) can be transplanted from another person. The donor teeth commonly used are third molars or premolars.

Antimicrobial prophylaxis may be indicated for auto transplantation

Antimicrobial Prophylaxis - medically compromised patient

TO BE COMPLETED

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Viral Infections

Viral infections can manifest themselves in the oral cavity, are initially diagnosed on their clinical presentation and tend to be short lived. These include herpes simplex virus, varicella zoster virus, human immunodeficiency virus, coxsackie virus and paramyxovirus. Infections with herpes simplex are the most common.

Caution is necessary in patients who are severely immunocompromised or are unable to take fluids and at risk of dehydration. These patients should be referred to hospital for specialist care. In addition, patients with prolonged infections that fail to resolve should be referred for further investigation.

Management of oral viral infections is symptomatic and usually involves:

Rest
Plenty of fluids
Soft diet
Antipyretic analgesics
Antimicrobial mouthwash to reduce secondary infection. Chlorhexidine or hydrogen peroxide are suitable agents.
The use of benzydamine mouthwash may provide some pain relief

A small number of patients may require antivirals. Nucleoside analogues, e.g. aciclovir are available for topical application. Aciclovir, valaciclovir or famciclovir can be given orally in suspension or tablet formulations where indicated.

PRIMARY HERPETIC GINGIVOSTOMATITIS

This is caused by the herpes simplex virus (HSV) and most commonly presents in young children.

The incubation period is approximately five days and infection can be subclinical.

Management is primarily with supportive measures as outlined above.

In severe cases, a full case assessment is required to assess for raised temperature, swollen lymph nodes, malaise, dehydration or if patients are immunocompromised. These patients may require systemic intravenous antiviral therapy and should be referred for urgent hospital treatment.

Antivirals are only recommended for the management of severe cases of primary herpetic stomatitis

SECONDARY (RECURRENT) HERPES SIMPLEX INFECTIONS (HSV-1)

Synonyms: herpes labialis, cold sores

Following a primary herpetic gingivostomatitis infection, herpes simplex remains latent in the trigeminal ganglion. Approximately one third of people develop herpes labialis and a secondary infection from reactivation of the virus.

Patients who are immunocompromised with frequent, persistent or troublesome recurrent HSV, have atypical lesions or an uncertain diagnosis, should be referred to a specialist for management.

Topical antiviral preparations are not routinely recommended for herpes simplex infections

OROFACIAL VARICELLA ZOSTER INFECTIONS

Synonyms: shingles

Systemic antivirals are advised in patients with herpes zoster infections as they have been found to reduce the incidence of postherpetic neuralgia and viral shedding. The reduction in viral load is beneficial as it can reduce the risk of corneal infection. Treatment with antivirals should be commenced as soon as possible and within hours of the onset of the rash.

Patients with ophthalmic involvement, who are severely immunocompromised and systemically unwell, or have a severe or widespread rash, multiple dermatomal involvement or symptoms of erythema multiforme, should be referred for specialist treatment. The same applies to immunocompromised children and pregnant or breastfeeding women.

Antivirals are recommended for orofacial varicella zoster infections

Fungal Infections

There are a number of oral fungal infections, some of which are rare, e.g. aspergillosis, histoplasmosis and cryptococcosis. Most oral fungal infections are caused by imperfect yeasts belonging to the genus Candida.

ORAL CANDIDOSIS

Oral candidosis (candidiasis) is most notably associated with Candida albicans. Other Candida species are found as commensals in the oral mucosa and may be putative pathogens (e.g. C glabrata, C tropicalis, C krusei, C auris).

Candida species carriage in the oral cavity, particularly on the dorsum of the tongue, is observed in up to 65% of patients’ mouths, with higher colonisation levels in young children and denture wearers.

Recurrent infections are problematic in patients where the risk factors or underlying disease cannot be readily eliminated or controlled.

Clinicians should always be mindful that a number of underlying factors predispose to oral candidosis:

Physiological: elderly, infants, pregnancy
Local factors: dry mouth, radiotherapy, poor oral hygiene, oral appliance wear, smoking
Medical: antimicrobial therapy, systemic and inhalation steroid therapy, immunosuppressive medication
Nutritional: iron, folate, vit B12 deficiencies, anaemia
Systemic: endocrine disorders including diabetes
Immune disorders: HIV infection, AIDS
Malignancy: acute leukaemia, agranulocytosis
Dry mouth: result of radiation, drug therapy, Sjogren’s syndrome

Several classifications of oral fungal infections have been used, but the most frequently adopted divides the infection into primary oral candidosis (localised to oral and perioral tissues) and secondary oral candidosis (generalised candida infections of mucosal membranes and cutaneous surfaces of the body).

Candida infections are superficial or invasive. Superficial infections often affect the mucous membranes and can be treated successfully with topical antifungal drugs.

When invasive, they enter the bloodstream causing systemic infections requiring oral or intravenous systemic antifungals.

Clinically, oral candidosis presents as four main variants: pseudomembranous, erythematous, hyperplastic and candida associated lesions.

PSEUDOMEMBRANOUS CANDIDOSIS

Synonyms: thrush, pseudomembranous candidosis

This condition is characterised by creamy white plaques, which diagnostically can be dislodged to leave raw bleeding mucosa. These lesions can appear on any part of the oral mucosa and pharynx.

Antifungal therapy is the mainstay of treatment, both therapeutically to treat infections and prophylactically to prevent infections, in medically compromised patients along with local measures, such as:

Good oral hygiene
Denture/appliance hygiene
Rinsing with water following using a corticosteroid inhaler, use of spacer device
Antimicrobial rinses

Prophylactic antifungals, such as fluconazole, are shown to be more effective than oral nystatin at reducing the proportion of people who develop oral candidosis. This applies to people having chemotherapy or radiotherapy for cancer, immunocompromised, infants, children and people with AIDS or low CD4+ cell counts. Prophylactic use in immunocompromised patients to prevent oral candidosis should be managed by the patient’s medical team (haematologist) as part of their treatment.

The recommended therapeutic management of fungal infections is with nystatin suspension, miconazole or fluconazole. Both miconazole and fluconazole seem more effective than nystatin. Fluconazole is effective for unresponsive infections if a topical antifungal drug cannot be used or if the patient has dry mouth.

Antifungals are recommended as an adjunct to local measures (where applicable) to manage oral candidosis

ERYTHEMATOUS CANDIDOSIS

Synonyms: antibiotic sore mouth, acute atrophic candidosis

Erythematous candidosis may involve most areas of the oral mucosa and may be painful for the patient. It can be an acute or chronic condition depending upon the duration.

Predisposing factors are similar to those seen in pseudomembranous candidosis and may result from loss of the pseudomembrane in pseudomembranous candidosis.

Mainly it is associated with broad-spectrum antimicrobials or the use of steroid inhalers.Where antimicrobial treatment is the predisposing factor, cessation of treatment leads to spontaneous resolution of the lesions once the bacterial population of the mouth recovers to pre-treatment levels. The use of spacer devices with steroid inhalers can reduce side effects of oral candidosis along with rinsing immediately after use.

Antifungals are recommended to manage erythematous candidosis as per treatment of pseudomembranous candidosis

CHRONIC HYPERPLASTIC CANDIDOSIS

Synonyms: hyperplastic candidiasis, candidal leukoplakia

This chronic form of candidosis presents as a clearly defined, fixed, raised white patch that may be speckled or nodular. It can occur anywhere in the mouth, but has classically been associated with the commissures of the mouth.

Specialist management of this condition is necessary as this is generally considered to be a potential malignant lesion and a diagnostic biopsy is required. The timing of antifungal treatment is a contentious area amongst specialists.

To avoid a second biopsy, many specialists consider use of systemic antifungal treatments prior to the initial biopsy, clearing the candida and its histological effects first, giving a more accurate assessment of the likelihood and degree of dysplasia in the first biopsy. Failure to allow adequate histological resolution time risks over-reporting the degree of dysplasia.

Some specialists prefer to take an initial biopsy, eliminate the candida if present with antifungals, and re-biopsy to assess alteration in tissue behaviour. In this protocol, there is little guidance on sampling intervals, the risk of residual histological effects or recurrence of the infection. This may have an impact on the assessment making, and continued clinical observation of the tissue is even more important in these circumstances.

CHRONIC ERYTHEMATOUS CANDIDOSIS

Synonyms: denture stomatitis, denture sore mouth

This is usually characterised by inflammation on the denture-bearing maxillary mucosa. Predisposing factors should be eliminated before administering antifungal agents, but they are sometimes required as an adjunct to local measures before constructing new dentures.

Local measures:

Strict denture hygiene using regular chemical (hypochlorite, not metal dentures, or chlorhexidine) and mechanical cleansing of dentures twice a day
Leave dentures out at night
Leave dentures out whenever it is feasible to do so during the day
Tissue conditioners/soft linings may be used to minimise mucosal trauma in poorly fitting dentures prior to construction of new dentures

Antifungals are recommended as an adjunct to local measures for chronic erythematous candidosis

Systemic antifungals are indicated only for unresponsive infections to local antifungals, which are usually associated with underlying systemic factors, e.g. immunosuppression or diabetes.

ANGULAR CHELITIS (STOMATITIS)

This condition presents as cracking and inflammation of the angles of the mouth. It is commonly a Candida-associated lesion. The condition is most frequently seen in patients who have denture-related stomatitis.

As with other oral candidal infections, it can be caused by an underlying systemic disease, such as deficiency anaemias, eating disorders, eczema, orofacial granulomatosis, Crohn’s disease and immune deficiencies. A reduced/decreased occlusal face height, can also be a possible predisposing condition.

Angular cheilitis has a multifactorial aetiology and may be caused by both yeasts (Candida spp.) and bacteria (Staphylococcus aureus and beta-haemolytic streptococci) as interacting, infective factors. In patients who do not wear dentures, bacterial infections with staphylococci and/or streptococci are more likely to be cultured from the lesions. Microbiological sampling is useful in determining the therapeutic drugs of choice.

Predisposing factors should be managed (e.g. resolution of intraoral reservoir of candida in patients with chronic erythematous candidosis, provision of new dentures with appropriate occlusal face height after new dentures) and miconazole cream should be the first choice anti-infective agent as it has antifungal activity and some activity against gram-positive cocci. When angular cheilitis is associated with chronic erythematous candidosis, the intraoral infection should be treated concomitantly to eliminate the palatal reservoir.

In cases that are proven to be staphylococci, sodium fusidate ointment is indicated.

When the lesions are unresponsive, a combination of miconazole with hydrocortisone maybe effective.

Topical antimicrobial therapy is recommended as an adjunct to management of underlying and predisposing conditions for angular cheilitis

Note that creams are used on wet surfaces and ointments on dry surfaces.

MEDIAN RHOMBOID GLOSSITIS

Synonym: glossal central papillary atrophy

This condition is uncommon and consists of a well-demarcated area of depapillation on the midline of the dorsum of the tongue (just anterior to the circumvallate papillae). Most cases are symptomless and the condition is currently thought to represent a chronic fungal (candidosis) infection.

Predisposing factors include smoking, denture-wearing, corticosteroid sprays and HIV. Management of these can be successful in reducing or resolving the lesion.

For cases with symptoms of persistent pain or a burning sensation where Candida albicans infection is shown to be present by microbiological sampling, an antifungal medication may be prescribed to manage the infection and reduce the symptoms.

Some cases of median rhomboid glossitis do not respond to antifungal therapy, so blood tests to exclude haematinic deficiencies may be indicated. Very occasionally, a biopsy may also be indicated.

In general, no treatment is necessary for median rhomboid glossitis, however antifungals (same used for pseudomembranous candidosis) may be of benefit in reducing persistent pain and burning sensations in the presence of Candida albicans infection.

CHRONIC MUCOCUTANEOUS CANDIDOSIS (CMC)

CMC is a rare disease in which individuals have frequent, usually continuous oral thrush which is difficult to treat. Most cases are recognised in childhood. When CMC is found in children it is usually considered genetic with immune defects or endocrinopathies. It is characterised by hyperplastic plaque-like lesions intraorally, with skin lesions and nail defects (candida paronychia) also likely to be present.

Management is with antifungals, such as systemic fluconazole or itraconazole, and it is best managed by specialist collaborative teams.

Do antibiotics relieve toothache?

Antibiotic use for irreversible pulpitis

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004969.pub5/full

Irreversible pulpitis, which is characterised by acute and intense pain, is one of the most frequent reasons that patients attend for emergency dental care. Apart from removal of the tooth, the customary way of relieving the pain of irreversible pulpitis is by drilling into the tooth, removing the inflamed pulp (nerve) and cleaning the root canal. However, a significant number of dentists continue to prescribe antibiotics to stop the pain of irreversible pulpitis.This review updates the previous version published in 2016.

Antibiotics do not appear to significantly reduce toothache caused by irreversible pulpitis. Furthermore, there was no difference in the total number of ibuprofen or Tylenol tablets used over the study period between both groups. The administration of penicillin does not significantly reduce the pain perception, the percussion (tapping on the tooth) perception, or the quantity of pain medication required by people with irreversible pulpitis. There was no reporting on adverse events or reactions.

Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010136.pub4/full

Dental pain can have a detrimental effect on quality of life. Symptomatic apical periodontitis and acute apical abscess are common causes of dental pain and arise from an inflamed or necrotic dental pulp, or infection of the pulpless root canal system. Clinical guidelines recommend that the first‐line treatment for these conditions should be removal of the source of inflammation or infection by local operative measures, and that systemic antibiotics are currently only recommended for situations where there is evidence of spreading infection (cellulitis, lymph node involvement, diffuse swelling) or systemic involvement (fever, malaise). Despite this, there is evidence that dentists frequently prescribe antibiotics in the absence of these signs. There is concern that this could contribute to the development of antibiotic‐resistant bacteria. This review is the second update of the original version first published in 2014.

The evidence suggests that preoperative clindamycin for adults with symptomatic apical periodontitis results in little to no difference in participant‐reported pain or swelling at any of the time points included in this review when provided with chemo‐mechanical endodontic debridement and filling under local anaesthesia. The evidence is very uncertain about the effect of postoperative phenoxymethylpenicillin for adults with localised apical abscess or a symptomatic necrotic tooth when provided with chemo‐mechanical debridement and oral analgesics. We found no studies which compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.

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