[Judicious use of antibiotics in dental practice]

With the discovery of penicillin and entrance into the antibiotic era, the capability of dentists to treat dental infections have changed dramatically. Many antibacterial agents have developed since, but bacterial resistance using diverse mechanisms, have increased concomitantly. Since antimicrobial agents are frequently needed in dentistry, their judicious use is of prime importance. Dental infections can be divided to two main groups according to the origin of the infection. First, odontogenic infections (acute dento-alveolar abscess) originating from the dental pulp are most commonly caused by gram-positive anaerobic or facultative bacteria. Systemic antibiotic should be given concomitantly with drainage of the dento-alveolar abscess, debridment of the root canal of the infected tooth, and placement of inta-canal antimicrobial medication such as calcium hydroxide. Penicillin G, penicillin V (Rafapen) or amoxycillin (moxypen) are the first line systemic antimicrobial agents. In case of no improvement within 2-3 days, second line regimens such as amoxycillin-clavulanate (augmentin), cefuroxime (zinnat) or penicillin and metronidazole are recommended. In patients allergic to penicillin, clindamycinn (dalacin) is preferred over macrolides. The second group of infections originates from the periodontal apparatus, and is caused usually by gram-negative anaerobes bacilli, sometimes with Actinobacillus actinomycetemcomitance (Aa). Systemic antibiotics are only infrequently indicated in this situation, and always accompanied by scaling, root planning and curettage of the infected root and gingiva. In regenerative or post surgical periodontitis, augmentin, metronidazole or metronidazole in combination with penicillin or amoxycillin augmentin are recommended. In aggressive periodontitis the most common pathogen is Aa and therefore tetracycline, augmentin, or metronidazole and amoxicillin are recommended. In necrotizing ulcerative gingivitis, which is caused usually by fusiform bacilli and spirochetes, metronidazole or augmentin are appropriate. In patients with periodontal disease who are allergic to penicillin can be treated with a macrolides.