ANTIBIOTICS IN ORAL

& MAXILLOFACIAL
SURGERY
DR.ANN MARY GEORGE
• Antimicrobials are the greatest contribution of
the 20th century to therapeutics.

• Drugs in this class differ from all others in that

they are designed to inhibit \ kill the infecting
organism and to have minimal effect on the
recipient
ANTIBIOTICS

• These are substances produced by

microorganisms which suppress the
growth of or kill other microorganisms at
very low concentrations.
CLASSIFICATION
1. BASED ON CHEMICAL STRUCTURE

• Quinolones
• Beta lactam antibiotics
• Aminoglycosides
• Macrolides
• Nitro- imidazoles
• Sulfonamides
• Oxazolidinones
• Glycopeptides
• Others
2.BASED ON MECHANISM OF
ACTION
• Inhibit cell wall synthesis
• Inhibit protein synthesis
• Interfere with DNA function
• Cause misreading of m-RNA code & affect
permeability
• Inhibit DNA Gyrase enzyme
• Interfere with intermediary metabolism
3. SPECTRUM OF ACTIVITY

• NARROW SPECTRUM:
PENCILLIN G
ERYTHROMYCIN
• BROAD SPECTRUM:
TETRACYCLINE
CHLORAMPHENICOL
4.BASED ON TYPE OF ORGANISM AGAINST
WHICH THE DRUG IS PRIMARILY ACTIVE
AGAINST:

• Anti bacterial
• Anti viral
• Anti fungal
5. TYPE OF ACTION

• Bacteriostatic: sulfonamides
tetracyclines ,
erythromycin.
• Bactericidal: penicillin ,
ciprofloxacin
cephalosporin.
6. SOURCE

• Fungi: penicillin, cephalosporin.

• Bacteria: polymyxin, bacitracin.
• Actinomycetes: aminoglycosides,
macrolides, tetracyclines chloramphenicol.
PROBLEMS WITH USE OF AMA
DRUG RESISTANCE

• Natural resistance: some microbes are

naturally resistant to certain drugs their
metabolic process or target site is
unaffected by this drug.
• Acquired resistance: development of
resistance over a period of time
1. mutation
2. Gene transfer (horizontal evolution).
HYPERSENSITIVITY REACTIONS

• These are unpredictable and unrelated to

dose
• whole range of reactions from rashes to
anaphylactic reactions can be produced.
SUPERINFECTION

• The use of antibiotics cause alteration in

the normal microbial flora. The normal
microbial flora contributes to host
defence by producing substances called
BACTERIOCINS.
• Common when host defence is
compromised
NUTRITIONAL DEFICIENCIES

• Vit B complex and Vit K synthesised by

intestinal flora
• Prolonged use of antimicrobials disrupt
this flora
CHOICE OF AN ANTIBIOTIC

• Patient factors
• Organism related consideration
• Drug factors
COMBINED USE OF
ANTIMICROBIALS
• To achieve synergism
• To reduce severity or incidence of adverse
affects
• To prevent emergence of resistance
• To broaden spectrum of anti microbial
action
PHARMACOLOGY
SULFONAMIDES

• Sulfonamides were the anti-bacterial agent

active against pyogenic bacterial infections.
• Bacteriostatic act by interfering with bacterial
synthesis of folic acid
• Active against many gram+ve and gram- ve
organisms
• Nausea, vomitting, crystalluria.
QUINOLONES

• Entirely synthetic antimicrobial

• Mainly active against Gram-ve bacteria,
though newer type like flouroquinalones are
active against gram positive organisms
• Inhibit the bacterial DNA gyrase & thus
inhibit the supercoiling of DNA, hence
bactericidal
CLASSIFICATION

• First generation: nalidixic acid

• Second generation: Ciproflox Norflox
Lomeflox Oflox
• Third generation: sparflox Gatiflox Grepaflox
• Fourth generation: trovafloxacin
PENICILLINS

• Penicillins are bactericidal and have

excellent distribution throughout the body
• Newer antibiotics are measured by
keeping penicillins as standard.
• Gram positive aerobic cocci
• Mechanism of action
• Exerts action on actively dividing cells by
causing abnormal cell wall development
• Inhibits third stage of cell wall synthesis
• Adverse reactions
• Hypersensitivity (1-5%) - Irritant properties
that affect the peripheral nervous system
• Nephropathy - Allergic reaction manifested
by interstitial nephritis and hypokalemia
 PARENTERAL PREPARATIONS OF
PENICILLIN G :

• AQUEOUS PENICILLIN G : 3 to 4million units

q4hr. (children 25,000 to3, 00,000 units/kg/day)
• PROCAIN PENICILLIN G : 3,00,000 to 6,00,000
units IM 12hr
• BENZATHINE PENICILLIN G :0.6-2.4MU i.m every
2wks as aqueous suspension
SEMI SYNTHETIC PENICILLIN

• Acid resistant: phenoxy methyl penicillin

(penicillin V).
• Penicillinase resistant penicillin: methicilllin ,
cloxacillin.
• Extended spectrum:
1. AMINOPENICILLIN: amoxycillin, ampicilllin.
2. CARBOXY PENICILLINS: carbencillin
3. UREIDOPENICILLINS: piperacillin
• Beta lactamase inhibitor : clavulanic acid ,
sulbactam.
CEPHALOSPORINS

• 1st – active against mainly gram+ve: S.aureus.

Strptococci.
• 2nd – active against gram-ve organisms and anaerobes,
nisseria, haemophilus influenzae, B fragilis.
• 3rd – active against Gram –ve enterobacteriacea and
pseudomonas, and less active against gram positive
cocci.
• 4th – highly resistant to beta lactamases . due to high
potency and extended spectrum its used in hospital
acquired infections,bacteremia,septicemia.
• The major cephalosporins

First Generation Second Generation Third

Generation

Parenteral Parenteral Parenteral

Cephalothin Cefamandole Cefotaxime
Cefazolin Cefoxitin Cefoperazone
Cephapirin Cefotetan Cefuroxime Cephradine
Ceftizoxime

Ceftriaxone
Ceftazidime

Oral Oral Oral

Cephalexin Cefuroxime axetil Cefixime
Cephradine Cefprozil Cefpodoxime
Loracarbef Ceftibuten
Cefadroxil Cefaclor Cefdinir
MACROLIDE ANTIBIOTICS

• They have a macro cyclic lactone ring with attached sugars

• they are bacteriostatic. It inhibits protein synthesis.
• Used as alternate to penicillin
ERYTHROMYCIN

• Spectrum of activity.
• Erythromycin is broad spectrum antibiotic active against many
gram-positive and gram-negative bacteria, mycoplasmas,
chlamydiae, treponemas, and rickettsiae.
Aerobic bacteria.
PREPARATIONS
 CLARITHROMYCIN:

• Its spectrum of activity is similar to that of erythromycin,

but it has better pharmacokinetic properties, including a
twice-daily dose regimen.
Dosages
• A dose of 250 mg to 500 mg bid is often used depending on
the severity of infection.
• For children 6 months of age or older, 15 mg/kg/day divided
q12h for 10 days is recommended. Suspensions are available
with 125-mg/5 ml and 250-mg/5 ml.
AZITHROMYCIN:

• Azithromycin is a newer macrolide developed to

overcome some of the shortcomings of erythromycin
such as GI intolerance, low bioavailability, and somewhat
limited spectrum of activity.
PREPARATIONS
TETRACYCLINES

• Source---- soil actinomycetes

• Spectrum---Acts against wide range of organisms

• active orally
 DOSE RELATED TOXICITY

• Liver damage
• Kidney damage
• Phototoxicity
• Effect on teeth and bones
• Antianabolic effect
• Increased intracranial pressure
• Diabetes insipidus
• Vestibular toxicity
CHLORAMPHENICOL

• Source --- streptomyces venezuelae.

• Intensly bitter in taste.
• Inhibits bacterial protien synthesis,
• Active against S.typhi.
• Causes Bone marrow depression-aplastic anaemia.
• GRAY BABY SYNDROME:gray cyanosis, hpothermic
and hypotonic.
AMINOGLYCOSIDES

• They penetrate the cell wall and

membrane and bind irreversibly to the 30
S bacterial ribosomes.
• Aminoglycosides have excellent activity
against almost all aerobic gram-negative
rods.
• Aminoglycosides are particularly useful in
hospital-acquired infections, especially for
Pseudomonas spp
CLINDAMYCIN

• It is a lincosamide
antibiotic
• It penetrates to most
skeletal and soft tissues.
• Causes
Pseudomemberaneus
enterocollitis
superinfection due to
clostridium difficle.
VANCOMYCIN

• It is a glycopeptide
antibiotic
• Active against
resistant organisms
• Not well absorbed
orally .
• Inhibits bacterial cell
wall synthesis.
 METRONIDAZOLE
• Anaerobic infections
• It inhibits DNA synthesis, regardless of the growth phase of the organism, and is rapidly
bactericidal.
• Spectrum of activity
• Aerobes.
Metronidazole is not active against most aerobic bacteria.
• Anaerobes
1. Metronidazole is very active and bactericidal against anaerobes, especially gram-negative
anaerobes, including Bacteroides fragilis, other Bacteroides spp., and Fusobacterium spp.
Clostridium spp., including C.perfringens and C.difficile are susceptible to
metronidazole
2. The activity of metronidazole against anaerobic gram-positive cocci is much more
variable with resistance in up to half of tested isolates
3. Strains of Actinomyces and Propionibacterium (e.g., P.acnes) are resistant
• Parasites.
• Metronidazole is very active against Entamoeba histolytica, Giardia lamblia, and
Tricahomonas vaginalis.
NEW DEVELOPMENTS

• Antibiotic-resistant , bacterial strains have become

increasingly common and troublesome
• Nosocomial methicillin resistant S.aureus infection is now
present .
• Newer drugs and reformulations of older antibiotics have
gained importance in surgery
LINEZOLID

• Oxazolidinones group
• Very active against
gram +ve .
• Active against most of
the resistant
organisms.
• Clinical trials have
shown that drug is
well tolerated.
QUINUPRISTIN

• Belongs to new class

of streptogramins.
• Drug has 2
components that act
synergistically 2
destroy bacteria by
attacking protein
synthesis in bacterial
cells.
KETOLIDES

• Ketolides are new class of

MACROLIDES.
• Are derivatives of
erythromycin.
• Thelithromycin is used in
clinical trial against
respiratory infections.
• Pneumonia, chronic
bronchitis,sinusitis.
DAPTOMYCIN

• It is acyclic lipopeptide with a broad gram+ve spetrum .

• It has a cell membrane targeted activity
TIGILCYCLINE

• It is a glycycline derivative of tetracycline compound .

• It is active against a variety of resistant organisms.
• Nausea and vomiting are side effects
• Used in UTI and intra abdominal infections.
PROBIOTICS:

• they are living organisms that improve microbial

balance of host
• It is helpful in fighting infections of mucosal
surfaces in the gut.
• Different species of yeast and lactobacilli are
used in clinical practice.
• Enterococcus
• Lactobacillus acidophilus
PROPHYLAXIS FOR INFECTIVE
ENDOCARDITIS
ANTIBIOTICS IN ORAL
& MAXILLOFACIAL
SURGERY
• The antibiotics in oral surgery are mainly used for two
purposes.

1. Antibiotic prophylaxis to prevent infections.

2. Antibiotics in treatment of infections.
 THE PRINCIPLE OF
PROPHYLACTIC ANTIBIOTICS

1. The intended procedure must carry a significant risk of postoperative infections.

2. The correct antibiotic must be selected.
3. The antibiotic must be administered in a proper manner so that antibiotic level
should be high and use of the shortest effective antibiotic exposure is preferred
4. Not to rely solely on prophylactic antibiotics to prevent postoperative
infections.Therefore, prevention of infection can be achieved by achieving two
goals
a) Reducing the number of bacteria in the surgical wound
b) Enhancing the host defenses so as to prevent the bacteria that inevitably enter
the wound from causing clinically evident infection.
RISK OF INFECTION

• Wound contamination
• Age of patient
• Nature of underlying disease
• Presence of necrotic tissue and a decreased blood supply.
 SPECIFIC APPLICATION OF
ANTIBIOTIC USE IN
ORAL AND MAXILLOFACIAL SURGERY
 DENTOALVEOLAR SURGERY:

• Prophylactic antibiotics are indicated in following

scenario:
1. Involvement of maxillary sinus OR nasal cavity,
2. If the patient host defense mechanism is compromised,
3. Patients who have received organ transplants may be
on long-term immunosuppressive therapy and patients
who are receiving chemotherapy for cancer should have
their surgery done under preventive antibiotic
coverage.
4. Patients with uncontrolled diabetes mellitus (fluctuation
in glucose level, under insulin therapy) prophylactic
antibiotic cover indicated.
IMPACTED THIRD MOLAR SURGERY

• The infections after third molar removal are

relatively uncommon
• The postoperative infections include alveolar
osteitis and facial space infections. In these
conditions however, antibiotics are given
postoperatively/ preoperatively does not
cause significant reduction in problems.
• In these cases it should be given immediately
before surgery and for 3 to 5 days after
surgery to provide an adequate period of
coverage.
 ORTHOGNATHIC SURGERY

• Orthognathic surgery performed via an extra oral

approach is considered a clean procedure and
prophylactic antibiotic should not be necessary unless
communication with the mouth is anticipated
• Intraoral procedures and surgeries that involve
maxillary sinus and nasal passage are clean
contaminated wounds and short-term antibiotics have
been shown to reduce the postoperative infection rates
 MAXILLOFACIAL FRACTURES

• In patients with compound fractures of the facial skeleton

antibiotics are necessary to prevent infection at fracture
sites
• Patients with traumatic injuries that involve the oral
mucosa, gingiva/ tongue do not require prophylactic antibiotics
because such wounds, although contaminated, generally
heal without infections.
IMPLANT SURGERY

• Although incidence of infection seems to be

low most surgeons have used antibiotics
regimen.
• A prospective multicentric study of 2641
implants by DENT CD Et al. joms 1997.19-24.
showed that infectious complications
were reduced to almost by 50% with pre
operative & post operative and also with peri
operative use of chlorhexidine mouthwash.
ANTIBIOTIC IN HEAD AND NECK
INFECTIONS

• The infections can be

1. odontogenic
2. the sinus infections
3. osteomyelitis
Odontogenic infections are the most commonly
occurring infectious process
PRINCIPLES OF MANAGING
ODONTOGENIC INFECTIONS

1. Determine severity of infection

2. Evaluate the host defenses noting any disease states/
medications, which could adversely affect the host.
3. Drainage
4. Prescribing antibiotics of proper dosage regimen and
duration of therapy.
5. Consider culturing and susceptibility testing in case of
treatment failure
 SINUS INFECTIONS

• If the incidence of strept. pneumonia is more than 30%,

amoxicillin and clavulinic acid/ second-generation
cephalosporin is prescribed for 2 weeks.
OSTEOMYELITIS OF THE JAWS

• Odontogenic pathogens.
• Actinomyces are another prominent pathogen in
chronic osteomyelitis.
• Recommended regimen:
• 1st choice:
PENCILLIN
AQUEOUS PEN-2 mu IV every 4th hrly
OXACILLIN- 1gm IV every 4th hrly
After 48-72 hrs, PEN V 500mg 4hrly + CLOX 250mg
4hrly orally for 2- 4 wks
• 2nd choice:
CLINDAMYCIN 300- 600mg 6 hrly po
• 3rd choice: CEFAZOLIN/ CEPHALEXIN 500mg 6 – 8 hrly.
• 4th choice:
ERYTHROMYCIN 2g 6 hrly iv then 500mg every 6 hrly orally.
• The dose & duration of AMA dependent on severity of infection &
response
FACTORS AFFECTING SELECTION
OF ANTIBIOTIC
 ALLERGY/INTOLERANCE/ ADVERSE
DRUG REACTIONS

• The history of allergy obtained from the patient/ from the patient's
family
• The choice of clindamycin, metronidazole/ newer antibiotics should be
considered
• The newer B-lactam antibiotics, the monobactams and carbepenems,
have much less frequent cross sensitivity with the penicillin group.
 IMMUNE SYSTEM COMPROMISE

• Whenever possible in immune compromised patients, a

bactericidal rather than bacteriostatic antibiotic should be
selected
 PREVIOUS ANTIBIOTIC THERAPY

• Patients who are taking antibiotics consistently/ previously will have a

higher incidence and proportion of organisms resistant to that antibiotic
therapy
 ANTIBIOTICS IN PREGNANCY

• The penicillin’s, cephalosporins, erythromycin, and clindamycin

cross the placenta have therapeutic effects on the fetus as well as
the mother and are not associated with congenital defects
• Amino glycosides may produce fetal toxicity and nephrotoxicity.
• Tetracycline if given after 5 months of gestation may result in
permanent discoloration of fetal teeth, maternal liver toxicity, and
congenital defects
• Sulfonamides when administered in 3rd trimester /close to
delivery persists in blood for 2 to 3 days after birth and are
associated with jaundice, hemolytic anemia, and kernicterus in
newborn.
REFERENCES

• Essentials of medical pharmacology- TRIPATHI 5 Edition

• Basic & clinical pharmacology- KATZUNG 9 Edition
• Dental clinics of North America- dental therapeutics 2003
• Journals & internet articles.
• Antibiotics- LD by Dr. MAHABALESHWARA
• Oral & maxillofacial trauma- vol. 1 & 2
R J FONSECA, R V WALKER, N J BETTS,
H D BARBER
• Textbook of OMFS- NEELIMA A MALIK
THANK
YOU