2. INTRODUCTION
This presentation will review the
evaluation and management of orofacial
infections with emphasis on:
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Antibiotic Therapy
Indications for Prophylaxis
Antifungal Agents
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3. ASSESSMENT
Requires a complete medical history and exam of the
head and neck region with awareness to systemic
factors as part of a comprehensive dental
examination
Identify local and/or systemic signs and
symptoms to support the diagnosis of infection:
< erythema, warmth, swelling, and pain >
< malaise, fever ( >38 c), chills >
Loss of function
< dysphagia, trismus, dyspnea >
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6. TREATMENT of INFECTION
Remove the cause of infection, most important
of all, drain the pus by either spontaneously or
surgically
Antibiotics are merely an adjunctive therapy.
Drainage
Host defense
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Antibiotics
7. INDICATION for ANTIBIOTICS
1. Severity of the infection
Acute onset
Diffuse swelling involves fascial spaces
2. Adequacy of removing the source of infection
When drainage can’t be established immediately
3. The state of patients’ host defense
When the patient is febrile
Compromised host defenses
For prophylaxis
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8. MICROBIOLOGY
Most oral infections are mixed in origin
consisting of aerobic and anaerobic Gram
positive and Gram negative organisms
Anaerobes predominant (75%)
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10. COMMONLY USED A/B
1. Groups of Penicillin
First choice for odontogenic infection
G(+) cocci and rod, spirochetes, anaerobes
0.7~10% hypersensitivity
Nature: penicillin G (IV), penicillin V (Oral)
Penicillinase-resistant: oxacillin, dicloxacillin
Extended spectrum: ampicillin, amoxicillin
Combine β-lactamase inhibitor: augmentin
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11. 2. Cephalosporin
More resistance to penicillinase
G(+) cocci, many G(-) rods
Third generation: Pseudomonas aeruginosa
Second choice (less effect for anaerobes)
First generation
Cefazolin
U-SAVE-A
Tydine
Second generation
Keflor
Ucefaxim
Third generation
Claforan
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Forth generation
Cefepime
12. 3. Clindamycin
G(+) cocci
Bacteriostatic -> bactericidal
Second-line drug: should be held in reserve to
treat those infections caused by anaerobes
resistant to other antibiotics
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13. 4. Aminoglycoside
G(-) aerobes, some G(+) aerobes eg S. aureus
Poorly absorbed from GI tract
Adjustment of dosage in renal dysfunction
Drugs: Gentamicin, Amikacin, Amikin
Combined with penicillin or cephalosporin
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14. 5. Metronidazole*
Only for obligate anaerobes
Can cross blood-brain barrier
To treat serious infections caused by anaerobic
bacteria, combined with β-lactam A/B
Effective against Bacteroides species, esp. in
periodontal infections
Drugs: Anegyn, Flagyne
Avoid in pregnant women
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15. 6. Vancomycin
G(+), most anaerobes, some G(-) cocci (Neisseria)
Given intravenously, BP should be monitored
Adjustment of dosage in renal dysfunction
Use as a substitute for penicillin in the
prophylaxis of the heart valve patient
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16. 7. Chloramphenicol
Wide spectrum, highly active against anaerobes
Limited to severe odontogenic infection
threatening to the eye or brain
Severe toxicity
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17. `
8. Erythromycin
G(+) cocci, oral anaerobes
Bacteriostatic
Second choice for odontogenic infections
Indication for out-patients with mild infection
Drug resistence: 50% of S. aureus, Strep. viridans,
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18. 9. Tetracycline*
Only against anaerobes
Contraindications: pregnant women, children <12
Limited usefulness in orofacial infection
Use as adjunctive therapy for refractory
periodontitis
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19. SELECTION of A/B
Use Empiric therapy routinely
Use the narrowest spectrum antibiotics
Use the antibiotics with the lowest toxicity and
side effects
Use bactericidal antibiotics if possible
Be aware of the cost of antibiotics
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20. Empiric Antibiotics in Oro-Facial Infection
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First-line
Penicillin 3MU IVA q6h -> Cefazolin 1000mg q6h
Gentamycin 60-80mg IVA q8h-q12h
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Second line (3A)
Augmentin 1200mg q8h + Amikin 375mg q12h + Anegyn
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Mild infection
Amoxicillin 250mg #2 PO q8h
Clindamycin 300mg PO q6h
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21. Side Effect of Commonly Used Antibiotics
1. Penicillin
hypersensitivity
2. Cephalosporin
hypersensitivity
3. Clindamycin
diarrhea, pseudomembrane colitis
4. Aminoglycoside
damage to kidney, 8th neurotoxicity
5. Metronidazole*
GI disturbance, seizures
6. Vancomycin
8th neurotoxicity, thrombophlebitis
7. Chloramphenicol bone marrow suppression
8. Erythromycin
mild GI disturbance
9. Tetracyclin*
tooth discoloration, photosensitivity
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25. ANTIFUNGAL AGENT
Most of fungal infection are from candida
Commonly used drugs:
(1) Nystatin (Mycostatin)= PO 4-600,000 U qid
(2) Amphotericin B= IV for severe systemic infec.
(3) Fluconazole, Ketoconazole
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26. Parmason Gargle
0.2% Chlorhexidine gluconate
Against G(+), G(-)
Reduce pain and inflammation, enhance healing
Indication: immunocompromised patient, C/T R/T
(prophylaxis mouthrinse reduce oral mucositis)
Use: 2-3 times daily,10-20cc/ time, 20-30sec.
27. Anti-Virals used in dentistry
Topical Acyclovir is useful for recurrent
herpetic infections, but must be started early in
the prodromal phase to have a worthwhile effect.
Oral Acyclovir, Valacyclovir and Famciclovir
are efficacious and safe for the treatment of the
first episode and recurrent genital herpes
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28. FOSCARNET - Class: Non-nucleoside DNA Polymerase
Inhibitors
Indications: "HSV, CMV
Treatment of acyclovir resistant HSV infections in AIDS
patients
Acyclovir resistant VZV
MOA/PCOL: Blocks the pyrophosphate binding site on
viral DNA polymerase
Adverse Effects/Other: "Not a purine or pyrimidine
analog, Phosphono formate analog
Toxic: renal impairment, CNS disturbance, leukopenia,
liver dysfunction
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