Dental antibiotics – When to use what

Dental antibiotics – When to use what

Cephalosporins don’t offer any advantage over penicillin V unless the patient is in the hospital. Cephalosporins are effective against S aureus, an organism responsible for many secondary infections that patients acquire in hospitals. For penicillin-allergic patients, the antibiotic of choice is clindamycin. If allergic to both then see below.  Macrolides, such as erythromycin and azithromycin, have no place in the treatment of odontogenic infections and have the potential to cause significant harm. Tetracyclines, although effective for the treatment of some periodontal infections, are not indicated in the treatment of patients with infections of odontogenic origin.

If the source of the infection has been removed and the patient fails to respond favorably after two to three days of penicillin V or clindamycin therapy, it is necessary to add metronidazole. Metronidazole is highly effective against anaerobic bacteria but inactive against obligate aerobes. Therefore, it is not appropriate as a first line of defense or replacement antibiotic for infections of odontogenic origin, but is very effective in combination with the primary antibiotic of choice.

The recommended dental antibiotic dosages are as follows:

  • Penicillin V: 500mg QID
  • Amoxicillin: 500mg TID
  • Clindamycin: 300mg TID or QID
  • Metronidazole: 500mg TID or QID

What to do when a patient is allergic to both penicillin and clindamycin?

When patient is allergic to both penicillin and clindamycin then probably best to have them ask MD.  Dentaltown thread on this.  Great study on allergy to antibiotics.

  • Azithromycin Z-Pack 3 or 5 day pack
  • Clarithromycin 500mg (2 tabs for premed) 250-500mg q 12hr 7-14 day
  • Erythromycin 500 mg (2 tabs for premed) 250-500mg q6-12hr 7 day

Penicillin allergy chart = very useful!

Should patients take the full does of antibiotics?

The dosage and time lines are arbitrary and best guesses more than anything that comes from solid research. Add in the fact that every infection and individual is different and that the bacteria is mutating means IMHO the guidelines are not terribly useful. The AAE put out a very nice dental antibiotics myths. I especially like the following two myths,

  • Myth #7: Antibiotic dosages, dosing intervals and duration of therapy are established for most infections.
  • Myth #8: Bacterial infections require a “complete course” of antibiotic therapy.

Another article from Discover Oct 2014 issue that lists plenty of research showing that it is likely NOT the best advice to take all antibiotics.

What if a patient is already taking an antibiotic and requires a prophylactic antibiotic?

“Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the recommendations for infective endocarditis recommend that the dentist select an antibiotic from a different class than the one the patient is already taking. For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin or clarithromycin for prophylaxis.”   From this post on antibiotic prophylaxis recommendations.

 

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12 Responses to “Dental antibiotics – When to use what”

  1. dianeOctober 1, 2017 at 1:16 am #

    What is a patient is allergic to both Amoxicillin and Clindamycin?

    • bryanabauerOctober 2, 2017 at 4:29 am #

      Amoxicillin and penicillin are equal in terms of allergy so you can refer to the paragraph that starts>

      What to do when a patient is allergic to both penicillin and clindamycin

  2. EniJanuary 17, 2018 at 11:03 pm #

    What to do if the pt is fnishing a 5 day course of Metronidazol 400mg/there times a day on the day of the xla? Is he still need Amoxicillin 1 h prior to the xla? TIA

    • Bauer BryanJanuary 18, 2018 at 8:28 am #

      Yes. Patients are supposed to mix up their antibiotics for treatment. “Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the recommendations for infective endocarditis recommend that the dentist select an antibiotic from a different class than the one the patient is already taking. For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin or clarithromycin for prophylaxis.” https://www.bauersmiles.com/2013/07/antibiotic-prophylaxis-dentistry.html/

  3. Jennifer MercerJanuary 25, 2018 at 12:29 am #

    I am a healthy 44 yr old female. I had #3 extracted after failed retreated root canal. It had a visible abscess with no pain on Jan 3rd. Before the extraction I was in 7 days of Amoxicillian. Tooth extracted, bone graft and membrane placed. He put me on ibuprofen 800mg. had awful taste and bleeding, it abscessesed within a few days. On Jan 10th, they removed bone graft, cleaned and scraped the area extensively. He replaced bone graft and membrane and put me on Clindamycin for 10 days. Within 2 days the membrane fell out and bad taste and bleeding continued. On Jan 15th they put me on Levafloxcian for 7 days. By Jan 19th I sought help from an Oral Surgeon that took CT and found a hole in the sinus area. He did surgery to repair the next day. He mentioned the hole was very obvious and that my home was very white(more than he had ever seeen), the smell and taste are gone. No more bleeding. Within 3 days on Levafloxcin I started having tingling, burning skin, very sore muscles and joints. I can hardly move around. The oral surgeon told me to stop the Leva and called in Amoxocillian for 5 days. Told me to go to my PCP for the reaction. She has me seeing an Orthopedic doctor to check for damage from the Leva. I went for post-op 5 days later said the surgical site was looking good but was concerned about area in roof of my mouth. Wants to look at in one week and possibly send me to infectious specialist! I’m very scared now!

    • Bauer BryanJanuary 27, 2018 at 4:47 am #

      Sounds like you had a bad infection but are over the worst of it now. Follow up with PCP like they said.

  4. Kim GenereuxFebruary 1, 2018 at 4:45 pm #

    I had 2 root canals done and had a tremendous flare up that caused a canine space soft tissue infection. The lacrimal duct between my eye and nose also swelled up/ the exudate was just clear and gooey. I could barely see out of my eye! After a week on clindamycin, I went off and it swelled up again within 24 hours. I was given another course of same clindamycin and worry that when I take last pill tonight the infection will return. What is the best protocol for a stubborn canine space infection related to flare-ups?

    • Bauer BryanFebruary 1, 2018 at 9:19 pm #

      Are you on any medications that inhibit your immune system? Things for autoimmune diseases all do so RA and Sjogrens are two examples. Those make it nearly impossible to get rid of infection. If so you want a drug holiday if MD says ok. For meds you need to follow up with your dentist or MD as what to use next. Too many variables.

  5. VenusFebruary 21, 2018 at 11:12 am #

    Hi, I was prescribed Clindamycin cause i’m allergic to Penicllin to treat a wisdom tooth infection before extraction. the antibiotic made me very sick since i have ibs and possibly celiac disease. it took away the tooth infection but i think i may have another one again on the lower left wisdom tooth and have appointment today for surgery to have the two pulled out. not sure if i do have an infection again, could be soreness from brushing and flossing. but since i had to stop the clindamycin when i had massive chronic diarreha to the point of sending me to the ER cause of dehydration, is why i suspect i got it back. i will NEVER trust an antibiotic ever again!!! if in case they see the infection came back, they may prescribe another antibiotic, the truth is i cant stand to be on any of them!!! it will trigger dehydration that will send me to the hospital again. please help me in advising what can i take as an alternative to heal a bacterial infection? even if i am fine, and they can proceed with surgery, i would like to know for the near future what can be taken in place of antibiotics in case i get a bacterial infection in the near future. i can NOT ever be like this again. My life is too precious to let these doctors destroy my life with these antibiotics. i was tested for C. difficile and came out negative, but it felt like it was a serious and still is somewhat a type of colitis i have never dealt with before. I am also looking for other alternatives for a colonoscopy since the bowel prep is very much like the dehydration cycle i just went through, which was HELL! i’ve looked online for days to try and find an alternative, but all i see is to take another antibiotic! what the f***!

    • Bauer BryanFebruary 22, 2018 at 6:23 am #

      Most infected teeth don’t need an antibiotic they just need to be removed. Antibiotics probably help in most cases and are needed some times but getting the tooth out is the number one goal. Get the tooth out.

  6. Cindy KappsMarch 2, 2018 at 11:49 am #

    I became ill after amoxicillin for a “possible abcess”….developed c diff….recovered well with metronazidole…..now my tooth is flaring again…..what are dentists best options….so I don’t go thru this again.

    • Bauer BryanMarch 2, 2018 at 8:47 pm #

      Treat the source of the infection. Root canal or extraction. I try not to give people antibiotics unless really necessary for the exact reason that you stated, c diff is no joke.

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