ORIGINAL Prescribing antibiotics in odontology and

ARTICLE
stomatology. Recommendations by the
French Health Products Safety Agency
French Health Products Safety Agency (Afssaps)
143–147, Boulevard Anatole France, 93285 Saint-Denis Cedex, France

Keywords ABSTRACT
antibiotics,
curative, In order to limit the onset of adverse effects and the increasing emergence of bacterial
odontology, resistance, the prescription of antibiotics must be reserved strictly for situations where
prophylaxis, their efficacy has been demonstrated. The French Health Products Safety Agency
recommendations, (Afssaps) has updated recommendations concerning the use of antibiotic treatment in
stomatology odontology and stomatology. The general strategy for the prescription of antibiotics
proposed by the present recommendations relies on a professional consensus. The
Received 26 March 2003;
full-length, discussed and referenced text is available at the web site of Afssaps
accepted 12 May 2003 (http://www.afssaps.sante.fr) in the ‘Documentation et publications’ rubric.

Correspondence and reprints:

emmanuel.nouyrigat@
afssaps.sante.fr

INTRODUCTION
In order to limit the onset of adverse effects and the
increasing emergence of bacterial resistance, the pre-
scription of antibiotics must be reserved strictly for
situations where their efficacy has been demonstrated.
Data on microbial epidemiology and the spectra of
antibiotics were taken into account when compiling
these recommendations on antibiotic therapy. It is
therefore possible that some antibiotics with a marketing
authorization may not be recommended in this text.
Selecting antibiotics for the treatment of orodental
infections depends on the pathogens supposedly present
in a specific disease, and on both the antibacterial
activity spectrum and the pharmacokinetics of the
antibiotics. The severity of the disease and the patient’s
history should also be considered. In current practice
there is no need to collect microbiological specimens in
most cases.
The general strategy for the prescription of antibiotics
proposed by the present recommendations relies on a
professional consensus.
METHODS
These recommendations were drafted by a multi-disci-
plinary working group taking into account published
data and the French registration dossiers. Relevant
learned societies were consulted.
The bibliographical search was achieved using Med-
line, Pascal, HealthStar, CabHealth and Bibliodent data-
bases, especially in the field of therapeutic guidelines,
consensus conferences, clinical trials, meta-analyses,
decision analyses and reviews, published in French or
English since 1996. Of the 331 references selected and
analysed, 58 were included in the referenced text and
201 indexed as additional bibliography.
The text has been read, commented upon and eval-
uated critically by a reading group including skilled
experts outside the working group. It was then submitted
for approval by the medical reference Validation Com-
mittee belonging to Afssaps.
The recommendations proposed were graded A (high-
level scientific evidence), B (intermediate-level scientific
evidence) or C (low-level scientific evidence) depending

Ó 2003 Blackwell Publishing Fundamental & Clinical Pharmacology 17 (2003) 725–729 725
726
on the level of reliability of the data on which they were
based. When the published data were inadequate or
incomplete, the recommendations were based on a
professional consensus.
PATIENTS AT RISK FOR INFECTION
Patients are considered as ‘healthy subjects’ with no
known risk for infection those who present with no risk
factor, and no particular underlying disease; some heart
diseases are considered as being at ‘no risk for infectious
endocarditis’.
Two types of patients are at risk for infection:
(1) Risk A: the risk for documented local infection
and/or for systemic superinfection (septicemia) concerns
transplanted patients (except those who receive cyclo-
sporin alone), immunocompromised patients, and those
experiencing a chronic, noncontrolled disease and
denutrition.
(2) Risk B: the risk resulting from a secondary localiza-
tion of bacteria, i.e. a new infectious focus distant from
the primary focus (infectious endocarditis, infection of
prosthetic joints) concerns patients with a documented
heart disease ‘at risk for infectious endocarditis’ and
some patients with prosthesis.
SYSTEMIC ANTIBIOTIC CURATIVE
TREATMENT
Indications for antibiotherapy
Healthy subjects
In ‘healthy subjects’, an antibiotic treatment is recom-
mended in the following affections: periapical abscess,
necrotizing ulcerative gingivitis, aggressive periodontitis,
refractory periodontitis, pericoronitis, cellulitis (except
chronic form), infectious osteitis (except dry socket),
bacterial stomatitis and bacterial infections of the saliv-
ary glands (Professional consensus).
For adult periondotitis, an antibiotic treatment, pref-
erably a monotherapy may be prescribed as second-line
treatment to support conventional mechanical therapies
(Professional consensus).
The efficacy of antibiotics is not proved in the
following affections: apical periodonditis, alveolo-dental
lesions, chronic periodontitis and in the course of
periodontal tissue regeneration (Professional consensus).
Antibiotics are not recommended in the following
affections: caries, pulp diseases, their chronic complica-
tions and pulp necrosis, chronic gingivitis, periodontal
abcess, temporary teeth eruption troubles, chronic
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Afssaps
cellulitis, dry sockets and peri-implantitis (Professional
consensus).
Patients at risk for infection
Antibiotics are recommended in:
(1) patients at risk A or B, to treat the following diseases:
periapical abcess, pulp necrosis, complicated alveolo-
dental lesions, necrotizing ulcerative gingivitis, aggres-
sive periodontitis, chronic periodontitis, refractory peri-
odontitis, pericoronitis, periodontal abcess, cellullitis,
osteitis (not recommended for dry socket in patients at
risk A), bacterial stomatitis and bacterial infections of
salivary glands;
(2) individuals at risk A with peri-implantitis and during
periodontal tissue regeneration; these procedures are
contraindicated in patients at risk B; and
(3) patients at risk B with apical periodonditis, chronic
gingivitis, gingivitis associated with systemic diseases or
drug-induced gingivitis, temporary teeth eruption troub-
les, and dry socket (Professional consensus).
The efficacy of antibiotics is not proved in patients at
risk A or B with the following diseases: irreversible
pulpitis, chronic periradicular complications, and non-
complicated alveolo-dental lesions. It is neither proved in
patients at risk A with chronic gingivitis, gingivitis
associated with systemic diseases nor drug-induced
gingivitis, and with temporary teeth eruption troubles
(Professional consensus).
Antibiotics are not recommended in (Professional
consensus):
(1) patients at risk A or B with caries and reversible
pulpitis; and
(2) in patients at risk A with dry sockets.
Selecting antibiotics
Moderate infections
In moderate infections, the antibiotics recommended
as first-line treatment include penicillin A (amoxicillin),
5-nitro-imidazole alone or associated with macrolides,
and, especially in case of allergy for b-lactams, macro-
lides, streptogramins (pristinamycin) and lincosamides.
The amoxicillin-clavulanic acid association is recom-
mended as second-line treatment. Cyclins should be kept
for the treatment of localized juvenile periodontitis,
although other antibiotics may be used. The use of
cephalosporin is not recommended.
Severe infections
In severe infections treated in specialized centers, the
same antibiotics will be used parenterally, at dosages
Prescribing antibiotics in odontology and stomatology
depending on the focus of infection and the functional
status. Glycopeptides will be prescribed in case of allergy
for b-lactams and/or resistance. Cephalosporin may be
used as second-line treatment provided the germ is
microbiologically documented and an antibiogram is
performed.
ANTIBIOTIC PROPHYLAXIS
Indications of prophylaxis depending on the risk
of the orodental procedures
Invasive procedures
Any invasive procedure (at risk for significant bleeding)
includes an infectious risk not only when carried out in
patients at risk A (except for placement of rubber dams
which presents no infectious risk for patients at risk A) or
B, but also in ‘healthy subjects’ during specific proce-
dures. Antibiotic prophylaxis is recommended in proce-
dures at risk, both in patients at risk and in ‘healthy
subjects’ (Professional consensus).
In ‘healthy subjects’, antibiotic prophylaxis is recom-
mended prior to the following invasive procedures: tooth
avulsion during disinvesting procedures, transplanta-
tions/reimplantations, periapical surgery, benign maxillar
tumour surgery, certain periodontal surgical procedures
(filling procedures and bone grafting, membranes place-
ment), bone surgery, placement of implants and bone
filling materials placement (Professional consensus).
In ‘healthy subjects’, the interest of antibiotic prophyl-
axis is not proved in the treatment of nonvital pulp teeth
(including root canal retreatment), avulsion of infected or
included tooth, and germectomy (Professional consensus).
In ‘healthy subjects’, antibiotic prophylaxis is not
recommended in the following invasive procedures:
intraligamentary local anesthetic injections, placement
of rubber dams, treatment of vital pulp tooth, prostho-
dontic cares at risk for bleeding, nonsurgical periodontal
procedures, some tooth avulsions (healthy tooth, alveo-
lectomy, radicular separation, radicular amputation),
benign tumours of soft tissue, some periodontal surgical
procedures (access flap for pocket surgery, muco-gingival
surgery), frenectomies, exposition surgery in implant
procedure, and orthodontics procedures (Professional
consensus).
In patients at risk A, undergoing invasive procedures,
antibiotic prophylaxis is recommended for endodontic
procedures, prosthetic procedures associated with bleed-
ing and every surgical procedures.
In patients at risk A, the interest of antibiotic
prophylaxis is not proved for intraligamentary local
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727
anaesthetic injections and nonsurgical periodontal pro-
cedures (Professional consensus).
In patients at risk B, undergoing invasive procedures,
antibiotic prophylaxis is recommended for intraligamen-
tary local anaesthetic injections, prosthetic procedures at
risk for bleeding, nonsurgical periodontal procedures and
placement of rubber dams (professional consensus). Endo-
dontic procedures, and surgical procedures also require
antibiotic prophylaxis. However, some of them are
contraindicated in these patients because the risk for
infection is too high: dead pulp tooth cares (including
root canal retreatment), radicular amputation, trans-
plantation/reimplantation, peri-apical surgery, periodon-
tal surgery, surgical implantation and bone filling
materials placement (Professional consensus).
Noninvasive procedures
Noninvasive procedures (at no risk for significant bleed-
ing) are not associated with no risk for infection in both
‘healthy subjects’ and patients with risk A or B; thus, no
prophylaxis is recommended in these cases (Professional
consensus).
The following procedures are considered as noninva-
sive: preventive cares, conservative procedures, non-
bleeding prosthetic cares, postoperative suture removal,
placement of removable prosthodontic appliances and
placement or adjustment of orthodontic appliances,
taking of oral X-ray radiographs, nonintraligamentory
local anaesthetic injections (Professional consensus).
Prophylaxis for iatrogenic infections
Standard prophylaxis of infectious endocarditis requires
one dose of oral antibiotic, 1 h prior to the procedure. At
present, we recommend 2 g of amoxicillin in adults and
50 mg/kg in children.
In case of allergy for b-lactams, 600 mg of clinda-
mycin is recommended in adults and 15 mg/kg in chil-
dren. One gram of pristinamycin may also be used in
adults and 25 mg/kg in children.
When parenteral administration is needed for prophyl-
axis, it is recommended to use, 1 h prior to the pro-
cedure, 2 g of amoxicillin IV in adults and 50 mg/kg in
children (30 min perfusion), followed by 1 g per os in
adults and 25 mg/kg in children, 6 h later.
In case of allergy for b-lactams and when parenteral
administration is needed for prophylaxis, a glycopeptide
may be used within 1 h before the procedure (vanco-
mycin, 1 g IV in adults and 20 mg/kg in children
infused over at least 60 min, or teicoplanin, 400 mg IV,
in adults only) (Professional consensus).
728
Prophylaxis of joint prosthetic infections is identical to
that of infectious endocarditis (Professional consensus).
Prophylaxis of local infections should be selected
according to the antibiotic spectra and the suspected
bacteria, and to the indication of metronidazole–spira-
mycin association (4.5 M UI spiramycine and 750 mg
metronidazole) (Professional consensus).
Prophylaxis of systemic infection should be selected
according to the antimicrobial spectra of the antibiotics
and to the suspected bacteria in these infections, and
injected intravenously. Amoxicillin-clavulanic acid is
recommended at the dose of 2 g amoxicillin prior to
surgical procedures; The amoxicillin–metronidazole
association may also be used. In case of allergy for
b-lactams, the association clindamycin–gentamycin is
recommended (Professional consensus).
ADDITIONAL TREATMENTS
The use of local immediate-release antibiotics is not
recommended for the treatment of orodental infections
(Professional consensus).
The interest of local slow-release antibiotics has not
been clearly demonstrated for the treatment of perio-
dontitis (Professional consensus).
The subgingival irrigation using antibiotics is
not recommended to treat periodontitis (Professional
consensus).
Nonsteroidal anti-inflammatory drugs, including aspi-
rin, should not be prescribed as first-line treatment in the
orodental infections (Professional consensus).
BIBLIOGRAPHY FOR FURTHER READING
1 Agence Nationale pour le Développement de l’Evaluation
Médicale. Prescription d’antibiotiques en odontologie et stoma-
tologie, in: Recommandations et références dentaires, ANDEM,
Paris, 1996, pp. 105–156.
2 Dajani A.S., Taubert K.A., Wilson W. et al. Prevention of
bacterial endocarditis: recommendations by the American
Heart Association. JAMA (1997) 277 1794–1801.
3 Société de Pathologie Infectieuse de Langue Française. Prophyl-
axie de l’endocardite infectieuse. Cinquième Conférence de
Consensus en thérapeutique anti-infectieuse, SPILF, 1992 March
27, Paris. Méd. Mal. Infect. (1992) 22(Suppl.) 1104–1141.
4 Ellis-Pegler R.B., Hay K.D., Lang S.D.R., Neutze J.M., Swinburn
B.A. Prevention of infective endocarditis associated with dental
treatment and other medical interventions. N. Z. Dent. J. (1999)
95 85–88.
5 Longman L.P., Martin M.V. A practical guide to antibiotic
prophylaxis in restorative dentistry. Dent. Update (1999)
26 7–14.
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Afssaps
6 American Dental Association. American Academy of Ortho-
paedic Surgeons. Antibiotic prophylaxis for dental patients with
total joint replacements. JADA (1997) 128 1004–1008.
7 Tong C.T., Rothwell B.R. Antibiotic prophylaxis in dentistry: a
review and practice recommendations. JADA (2000) 131
366–374.
8 Société Française d’Anesthésie et de Réanimation. Recomman-
dations pour la pratique de l’antibioprophylaxie en chirurgie.
Antibiotiques, (1999) 1 176–188.
9 Longman L.P., Preston A.J., Martin M.V., Wilson N.H.F.
Endodontics in the adult patient: the role of antibiotics. J. Dent.
(2000) 28 539–548.
10 Gustke C.J. Irrigation with antimicrobial agents for the
treatment of periodontitis – is it effective? Gen. Dent. (1999) 47
164–168.
11 Bado F., Fleuridas G., Lockhart R. et al. Cellulites cervicales
diffuses à propos de 15 cas. Rev. Stomatol. Chir. Maxillofac.
(1997) 98 266–268.
12 Sixou M. Interprétation des résultats bactériologiques en
parodontie, in: Chomarat M., Dubreuil L., Fosse T., Le Goff A.,
Mouton C., Roques C., Sedallian A., Sixou M. (Eds), Bactériol-
ogie pratique des anaérobies bucco-dentaires, 2M2, Paris,
1999, pp. 95–101.
13 Ragot JP. La pénicilline en stomatologie. Actual. Odontosto-
matol. (Paris) (1997) 197 35–55.
APPENDIX
Working group
P. Veyssier MD (Chairman, Infectious Diseases),
E. Nouyrigat PharmD (Project Manager, Afssaps), L. Ben
Slama MD (Stomatology), JJ. Bensahel DDS (Odont-
ology), J.C. Bertrand PhD (Stomatology, Maxillofacial
Surgery), M.L. Boy-Lefevre DDS PhD (Odontology), J.M.
Dersot DDS (Periodontology), L. Dubreuil PharmD PhD
(Microbiology), P. Lesclous DDS (Odontology), J.P. Ragot
MD (Stomatology, Maxillofacial Surgery), E. Senneville
MD (Infectious Diseases), M. Sixou DDS PhD (Odontol-
ogy), C. Denis MD (Afssaps), N. Dumarcet MD (Afssaps),
C.A. Konopka MD (Afssaps), I. Pellanne MD (Afssaps).
Reading group
C.D. Arreto DDS (Odontology), O. Barsotti DDS (Odon-
tology), P. Bouchard DDS (Odontology), A. Bouvet PhD
(Microbiology), J.P. Bru MD (Infectious Diseases),
C. Chidiac PhD (Infectious Diseases), G. de Mello DDS
PhD (Odontology), E. Deveaux DDS PhD (Odontology),
D. Duran DDS PhD (Odontology), D. Etienne DDS
(Periodontology), A. Feki DDS PhD (Odontology),
S. Fournier MD (Infectious Diseases), M. Garre PhD
(Infectious Diseases), J.L. Giovannoli DDS (Odontology),
S. Imbert MD (Stomatology), F. Joachim DDS (Odontol-
ogy), J.F. Jorry DDS (Periodontology), L. Laik DDS
Prescribing antibiotics in odontology and stomatology
(Odontology), P. Lemaitre DDS (Periodontology), C.
Leport PhD (Infectious Diseases), O. Leroy MD (Infectious
Diseases), J.M. Maes MD (Stomatology, Maxillofacial
Surgery), J.M. Mondie PhD (Stomatology, Maxillofacial
Surgery), F. Mora DDS (Periodontology), C. Mouton DDS
(Odontology), P. Ottavi MD (Stomatology), Y. Pean MD
(Biology), G. Potel PhD (Therapeutics), Y. Roche DDS
(Odontology), P. Samakh DDS (Periodontology), J. Sam-
son PhD (Stomatology, Maxillofacial Surgery), J.L. Sixou
DDS (Odontology), C.J. Soussy PhD (Microbiology).
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729
Validation committee
G. Bouvenot PhD (Chairman), J.F. Bergmann PhD,
C. Caulin PhD, B. Dupuis PhD, C. Riché MD, M. Aubier
PhD, B. Bannwarth PhD, B. Camelli MD, C. Funck-
Brentano PhD, C. Le Jeunne PhD, M. Petit PhD,
O. Reveillaud MD, C. Thery PhD, F. Tremolieres MD, O.
Wong MD, C. Denis MD, N. Dumarcet MD, E. Nouyrigat
PharmD, I. Pellanne MD, G. Rostocker MD.