Antibiotics: Boon or Bane in Dentistry?

: Dentistry is a vast domain devoted to managing dental infections as well as bolstering and rehabilitating the dentition lost to bacterial invasion. Antibiotics are an essential part of dentistry and its relative specialties, and prescribing antibiotics is a privilege that should not be abused. Antibiotic prescriptions in dentistry are relatively small but nonetheless significant. With the emergence of antibiotic-resistant bacterial species, there is a need to become more vigilant about their prescription, as well as an urgent need for both professional and public understanding of the appropriate use of this life-saving component of treatment. This review discusses the various principles and rationales underlying antibiotic therapy in various fields of dentistry, with an emphasis on rational antibiotic use in dentistry.


INTRODUCTION
The oral cavity is a complicated biological ecosystem repleting with organisms that live in a biofilm. For most pulpal and periodontal diseases, the change from health to disease state is associated with a change in the balance of the ecosystem, usually from resident facultative anaerobes to obligate anaerobes. Even though only a few microorganisms cause odontogenic infections, many nonpathogenic bacterial species contribute by maintaining an ecosystem favorable for pathogenic species for survival and growth. Microorganisms in a biofilm are consistently 1000-1500 times more resistant to standard antibiotic dosage. 1 Most dental pain is caused by an infection-induced inflammatory process in a closed compartment, such as the pulp and apical periodontal region, or in a sensitive and highly innervated soft tissue, such as the periosteum space, gingiva, and periodontium. The removal of infectious foci is the overarching principle of all infectious process management. Mechanical removal of infectious foci is used to control dental infections. When the soft tissue spaces are involved, it can be accomplished by removing the infected pulp, scaling and root planning and drainage of the pus. For maximum benefit, a combination of one or more of these techniques is usually used. When combined with the appropriate use of anti-inflammatory agents, this can result in immediate pain and infection relief. 2 Antibiotics do not help with pain relief because they have no effect on the inflammatory process that causes pain. In most cases, antibiotics are not required if appropriate measures to remove infectious foci are taken. The use of antibiotics in conjunction with dental procedures is frequently a source of conundrum among dental practitioners. The use of antibiotics in dental practice has been highlighted in this review article.

DEFINITION:
According to Waksman and Woodruff Antibiotics can be defined as a chemical substance produced by microorganisms, which at a high dilution can inhibit the growth and/or multiplication or kill another microorganism.

Indications:
The unintended consequences of antibiotic treatment represent a drawback to their obvious benefits. 30 On one hand, there are side effects that have consequences for the patient such as gastrointestinal, hematological, neurological, and dermatological, allergic and other conditions. On the other hand, the emergence of bacterial resistance is crucial for both patients and public health . 29 Antibiotics are generally prescribed in dental practice for the treatment of acute and chronic infections of odontogenic and non-odontogenic origins. But it is not necessary to prescribe antibiotics in all odontogenic infections. Rather than prescribing antibiotics for all infections the foci of infections can be removed which can in turn help in subsiding the infection. The detailed pharmacology of these drugs is beyond the scope of this article, but a brief discussion of an important antibiotic pharmacological profile may be beneficial. Antibiotics can kill in two ways: concentration-dependent or time-dependent. When the concentration-dependent drugs are present above a certain level, they kill the bacteria. Increasing concentration leads to faster killing. As a result, a single high dose may be sufficient to produce the desired effect. In recent years, higher antibiotic doses given for a shorter period of time have been advocated. This regimen would avoid the selection of antibiotic resistant species, and the risk of allergy or adverse events is not significantly increased for most dental specific antibiotics 6 . Antibiotic resistance is common after using lower doses of antibiotics for longer periods of time. But first, determine whether an antibiotic is indicated in that specific clinical setting and in that specific patient 7 . Table 3 contains a brief summary of the management of the most common conditions treated by a dentist, along with their management principles 2 .

In Periodontology and Implantology.
Periodontitis is a bacterial infection, which has been used to justify the routine use of antibiotics in periodontology. However, the clinical significance of bacteria being present in tissues is still unclear in periodontal infections, and it is inappropriate to base clinical treatment decisions, such as the use of adjunctive systemic antibiotics, on this premise alone. Montiero et al., conducted a survey on dentists' use of systemic antibiotics for periodontal diseases and concluded that many dentists continue to use systemic antibiotics incorrectly, without regard for evidence in published literature, for inappropriate indications, and with ineffective protocols in periodontal therapy 16 . a. GINGIVITIS AND PERIODONTITIS. Gingivitis is a local infectious process that responds well to local mechanotherapy and is contraindicated by antibiotic therapy. In normal healthy patients, the routine use of systemic antibiotics in the treatment of chronic periodontitis is not justified. Systemic antibiotics have more risks than benefits when used to treat periodontal diseases 8 . Local irrigation of antiseptic / antibiotic solutions can be used to treat periodontal pockets. Scaling and root planing with irrigation removes the calculus and infected tissue, removing the infectious foci and resolving the inflammation. The primary goal would be to mechanically disrupt the biofilm. b. AGGRESSIVE PERIODONTITIS.
In patients with aggressive periodontitis, systemic therapy in conjunction with local therapy is recommended to eliminate bacteria that invade the gingival tissues and can repopulate the pocket after scaling and root planing 2 . Antibiotics are only beneficial after the biofilm has been disrupted by appropriate mechanotherapy, and antibiotics should be used only after proper mechanotherapy has been tried and failed. Although the use of amoxicillin and metronidazole in aggressive periodontal diseases is well supported, well-designed controlled clinical trials are limited, according to a recent review 17     Oral medication Amoxicillin 2g,1hr before procedure 50mg\kg 1hr before procedure Oral route cannot be used Ampicillin 2g IM\IV, 1\2 hr before procedure 50mg IM\IV,1\2 hr before procedure Cefazolin or Ceftriaxone 1g IM\IV ,1\2 hr before procedure 50mg IM\IV, 1\2 hr before procedure Allergic to penicillin-Oral medication Clindamycin 600mg,1hr before procedure 20mg\kg ,1hr before the procedure Cephalexin or Cefadroxil 2g, 1hr before procedure 50mg\kg,1hr before the procedure Azithromycin or Clarithromycin 500mg, 1 hr before procedure 15mg\kg,1hr before the procedure Allergic to penicillin and cannot take oral medication Cefazolin or Ceftriaxone 1g IM\IV,1\2 hr before procedure 50mg\kg IM\IV, 1\2 hr before procedure Clindamycin 600mg IM\IV, 1\2 hr before procedure 20mg\kg IM\IV, 1\2 hr before procedure According to a recent review, about 12 patients must be treated with antibiotics to prevent one infection, and the risks of antibiotic use far outweigh the benefits. The use of prophylactic antibiotics before implant placement is debatable 24 . A systematic review supports the use of 2 g amoxicillin as presurgical prophylaxis, while a few other studies find no additional benefit. There is no evidence that antibiotic use prevents implant failure 25 .
C. MAXILLOFACIAL TRUAMA 2 In general, wound closure of clean and clean contaminated wounds, such as intraoral mucosal lacerations, or that can be rendered clean, do not necessitate the routine use of antibiotics. Dirty or infected wounds would require debridement prior to closure, or they could be treated with delayed primary closure or left to heal by secondary intention. Antibiotics do not replace surgical debridement. The routine use of surgical prophylaxis does not appear to provide any additional benefit in terms of infection reduction 26 . Surgeries performed with due care for surgical asepsis do not require an antibiotic prophylactic dose after the first 24 hours. Infected wounds and fractures/hardware should be treated the same as any other maxillofacial infection, with the same considerations, including surgical removal of the infectious foci with adjunctive antibiotic use 27 .

Antibiotic use in Compromised patients
Antibiotics are used in medically compromised patients with immune deficiencies because they are at a higher risk of infection and infections are more difficult to manage in this group of patients. Antibiotic-free studies in this population are neither feasible nor ethical 8 . Antibiotics may be beneficial in this group of patients when used rationally. Some recommend antibiotic prophylaxis in neutropenic patients, particularly when the absolute neutrophil count (ANC) falls below 1000-1500/microlitre, while others do not. In general, there is no clear guideline or recommendation in this regard 28 . As a result, the decision must be made on an individual basis in consultation with the treating physician/medical expert. Bactericidal drugs benefit these patients because their immune systems may not be able to clear the infection effectively with bacteriostatic drugs.

ANTIBIOTIC RESISTANCE IN DENTISTRY:
The World Health Organization has identified antimicrobial resistance as one of the most serious threats to global health, with ten million deaths predicted by 2050. It occurs when antimicrobial medications prescribed to treat infections caused by bacteria, viruses, fungi, and parasites become ineffective as a result of overuse and misuse. If coordinated global measures are not implemented quickly, the world will soon be plunged into a post-antibiotic era in which common infections will become life-threatening. Dentists are responsible for 10% of all antibiotic prescriptions for humans. Antibiotic resistance is of particular concern to dental teams because antibiotics are the most commonly prescribed class of drugs by dentists. Depending on the country, about 10% of antibiotic prescriptions are issued by dentists. Furthermore, research has shown that many of these prescriptions were unnecessary. Clear and relevant guidance is required to encourage dental teams to optimize their antibiotic prescriptions, prescribing antibiotics only when necessary.

CONCLUSION
Antibiotics in dentistry can only be used in specific situations, for specific patients, and with appropriate techniques, usually with brief preoperative plans. Postoperative plans can be used for long-term surgeries with osteotomies or for antibiotic treatments in complicated abscesses. The main factors influencing intervention success rates, rather than antibiotic administration, are correct management of oral bacterial load/contamination with elimination of infective foci, dental biofilms, and good periodontal health, as well as atraumatic surgical techniques. Antibiotics have no effect on clinical symptoms like pain and swelling. In healthy patients, routine tooth extractions can be performed without the use of antibiotics, with the same risk of complications. Implant insertion can be managed with short preoperative antibiotic prophylaxis to reduce the risk of failure, whereas postoperative regimen schemes have no beneficial effects. It is clear that, apart from invasive dental procedures in high-risk patients, not all dental procedures necessitate antibiotic prophylaxis. Antibiotic prescribing guidelines are essential for preventing antibiotic overuse. Antibiotic prescriptions should be construed as adjunct to dental treatment.