Contents

1.

Introduction

2.

Definition

3.

Mechanism of Action

4.

Types of organism against which primary active

5.

Spectrum of activity

6.

Types of Action

7.

Antibiotics obtained from

8.

Problem that arises with use of antibiotics

9.

Choice of antimicrobial therapy

10.

Failure of antimicrobial therapy

11.

Uses of antibiotics in OMFS

a)

Antibiotics in implant dentistry

b)

Antibiotics in bone grafting material

c)

In Exodontia

d)

For frontal sinus fracture

e)

In sinus lift augmentation (subantral)

f)

For perimplantitis

g)

In laser skin resurfacing

h)

In laser skin resurfacing

i)

Skeletal anchorage

j)

In mandibular surgery

k)

For recurrent cellulites

l)

For trauma patients

12.

Conclusion

13.

References

Introduction
Antimicrobial drugs are the greatest contribution of the 20 th century to therapeutics.
Their advance changed the outlook of the physician about the power drugs can have
on diseases. They are one of the few curative drugs. Then importance in magnified
in the developing countries where infective disease predominate. As aelavs they are
one of the most frequently used as well as misused drug. Drugs in this class differ
from all others in that. They are designed to indirect kill the expecting organism and
to have no minimal effect on the recipient. This type of therapy is generally called
chemotherapy.

Antibiotics
-

These are substances produced by micro organism which selectively select the
growth of or kill the other microorganism at very low concentration.

Initially the term chemotherapeutic agent was restricted to synthetic

compounds but now since many antibiotics and their analogues have been
synthesized their extension has become irrelevant, both synthesis and
microbiologically produced drugs need to be included together. It would have
more meaningful term antimicrobial agent (AMA) to designate synthesis as
well as naturally obtained drugs.

Classification
Antimicrobial drugs can be classified in many ways :
1.

Sulfonamide and related drugs : sulfonamide and others sulfones-dapsone,

para amino salicylic acid.

2.

Diamino pyrimidines : Trimethoprim, pyrimethamine

3.

Quinofone Nalidixei acid, norfloxacin, ceprofloxacin, galifloxacin

4.

B. Lacluin antibiotics Penicillin, cephalosporn, monobaclium, carbapenems.

5.

Tetracycline : Oxyletracycline, Doxycyeline

6.

Nitrobenzene Derivatives : Chloramphemiol

7.

Aminoglycosedes Streptomycin, genlamycin

8.

Macrolide antibiotics : Erythromycin, clarihanycin, Azithromycin

9.

Lincosamide Antibiotin : Lincomycin, Clindamycin

10.

Glycopeplide Antibiotics : Vancomycin, Teicoplanin

11.

Oxazoliolinone : Linezolid

12.

Polypeptide antibiotics : Polymyxin-B, Colistin, Bacitracin, Throthricin

13.

Nitrofuran Derivatives : Nitrofurantoin Furazolidone

14.

Nitroimidazoles : Metronidazoles, Tinidazoles

15.

Nicotimi Acid Derivalenie Isomazide, Pupazinamide, Ethionamide

16.

Polyene Antibiotin : Nysfalin, Amphotericin-B

17.

Azole derination : Miconazole, Cotrimazole Ketococnazole

18.

Others: Rifampicin, Streptomycin, Viomycin, Ethumbulol, Clofazimine,

Cycloserime.

Mechanism of Action
1.

Inherit cell wall synthesis

Penicillin, cephalosporin, cycloseriine, vancomycin, bacitracin

2.

Cause leakage from cell membrane

Polypeptides, polymyxins, colistin, bacitracin, polyenes, amphotericin B
nyslatin, hamycin

3.

Inherit protein synthem

Tetracycline, chloramphenicol, erythromycin, elenelamycin, linezolid

4.

Cause misreading of M-RNA code and affect permeasibility

Amynoglycosidin, streptomycin, gentamycin

5.

Inhebit DNA gyrase

Fluoroquinolones, ciprofloxacin and others

6.

Interfere with DNA function

Rifampicn, Metronidazole

7.

Interfere with DNA synthem

Acycloxin, Zidovudine

Types of Organism against Primarily Active

1.

Antibacterial : Penicillin, Aminoglycoside, Exythromycin

2.

Antifungal : Gilesofulvin, Ampholerciin-B, Keloconazole

3.

Antional : Acyclorir, Amanlaoline, Zidevidine

4.

Antiprotozeal : Chloroquine, Pyrimethamine, Metronidazole, Diloxanide

5.

Antihelthinthie : Mebendazole, Pyrantel Niclosamide, Diethyl Carbamizine

Spectrum of Activity
Narrow Spectrum

Broad Spectrum

Penicillin G

Tetracycline

Streptomycin

Chloramyhenicol

Erythromycin

Types of Action
Primarily Bacteriostatic
Sulfonamide

Erythromycin

Tetracycline

Ethambulol

Chloramphenicol

Clindamycin
Linezolid

Primarily Bactericidal
Penicillin

Cephalosporin

Aminoglycuside

Vancomycin

Polypeplides

Naledixie Acid

Rifampin

Cejrofloxacin

Isoniazid

Metronidazole

Pyrazinamide

Cotrimoxazole

Antibiotics Obtained from

Fungi Penicillin, Linseofulvein, Cephalosporin
Bacteria Polymyxin B, Tyrothricin, Colistin, Aztreonam, Bacitracin
Actinomyceles Aminoglycosidin Maerolides, Tetracycline, Polyenes, Chloramyphenicol

Problem & that arises with use of AMAs

1.

Toxicity

(a)

Local Irritancy This is exerted at the site of administration.

General

irritation pain and abscess formation at the site of an injection

thrombophlebitis of the injected view are the complication. Practically all
AMA's especially azithromycin, tetracyclin, catain, cephalosporium and
chlorampheniol are irritants.
(b)

Systemic Toxicity - Almost all AMA's produces dose related and preclitest
organ toxicities characteristic toxicities are exhibited by different AMAs.
Some have high therapeutic index-dose upto 100-fold range may be given
without apparent damage to host cell.

These include penicillin, some

cephalosporin and erythromycin. Other have lower therapeutic index-dose

have to be individualized and toxicity indicated for eg.
Aminoglycosides

8th ranid nem and kidney toxicity

Tetracycline

Liver and kidney damage antianabolei effect

Chlorampliemiet

Bone narrow depression

Some other have very low therapeutic use is highly restricted to conditions where no
suitable alternative is available eg. :

2)

Polymyxin B

Neurological and renal toxicity

Vancomycin

Hearing loss, kidney damage

Azithromycin B

Kidney, bone narrow and neurological toxicity

Hypersensitivity
Practically all AMAs are capable of causing hypersensitivity reactions. There
are unpredictable and unrelated dose. The whole range of reaction from rashes
to anaphylactic shall can be produced. The commonly involved AMA's are
penicillin, cephalosporin, sulfonamides, flurogunolones.

3)

Drug Resistance : It refers to unresponsiveness of microorganisms to an

AMA's and is alkin to the phenomena of tolerance seen in higher organisms.

Natural Remittances
Some microbes have always been reinstant to certain AMA.

These locate the

metasolie process or the forget site, which is affected by the particular drug eg. gram
negative bacilli are normally unaffected by penicillin 4 or M. tuberculosis is
insorritive to tetracyclines.

Acquired Resistance
It is developed by an organic resistance to drugs. Due to use of an AMA over a period
of time this can happen with any microbe and is a major clinical problem.
-

Development of resistance depends on the microorganism as well as the drug.

Some bacteria are notorious to rapid acquisition of remittance eg.

stophylococci, coliforu, tubeveli bacill.

Other like strep pyogem and

spinocheles have not developed significant resistance to penicillin despite its

widespread use for > 50 years.
-

Gonococci quickly develop resistance to sulfonamides, but only slowly and

low grade resistance to penicillin.

However in the past 30 years highly penicillin remittance gonococci have been
appeared.

Resistance may be developed by mutation or gene transfer.

Among the

microorganism.
4)

Superinfection (Suprainfection)

This refers to the appearance of a new infection as a result of antimicrobial

therapy.

It is commonly amended with broad/extended spectrum antiscolies such as

tetra cycline, chloramphenol ampicillin, never cephalosporin's especially when
combination of these a employed.

Suprainfections are more common when host defense is compromised.

Conditions predisposing to suprainfection are

Corticuslenoid therapy

Leukemia and other malignances when treated with anticancer and

immunosupprerants decrease WBC count.

AIDS

Agramulocytosis

Diabetis, disseminated lupin erythemalosis.

5)

Nutritional Deficiencies

Some of B complex vitamins and Vit-K synthesized by intestinal flora is

utilized eyman.

Prolonged use of antimurids which alter this flora may result in vitamin
deficiencies.

6)

Marking of an infection

A short course use of AMA may be sufficient to treat one infection but only
briefly syppren another one contacted communally.

The other infection will be marked initially only to manifest later in a severe
form eg. Sychillin is marked by use of single box of penicillin which is
sufficient to one gonorrhoea.

Choice of Antimicrobia Agent

After having established the need for using a systemic AMA in a patient by assessing
that the condition is due to a treatasle infection and that is not likely to resolve by
itself or by local measures only. The choice depends on the pentionlass of the patient,
the infecting organism and the drug.

Patient Factor
1.

Age may affect kinetics of many AMAs. Conjugation and extraction of

chloramyhenicol is inefficient in the newborn larger dose produce grey baby
syndrome.

The t of amino glycosides is prolonged in elderly and they are more prone
to develop VIII new toxicity.

Tetracyclino depends in the developing teeth and bone, direction and weaken
them, are contraindication below age of 6 year.

2.

Renal and Hepatic Function

Caution use and modification of dose of an AMA becomes necessary when the
organ of its disposed is defection.

Antimicrobial needing dose reduction/avoidance in renal failure

Reduce dose even in mild failure
Aminoglycoredes

Ampholencin B

Cephalorporni

Ethambulol

Vancomycin

Flucytorine

Reduce dose only in moderate seven failure

Metromilezole

Carbenicillin

Cotrimoxazole

Fluoroquimolunes

Aztreonam

Catrithomycin

Meropenem

Imipenem

Drug to be avoided
Cephalothin

Talampicillin

Nalidixic Acid

Tetracycline

Nitrofuranlosis

(except doxycycline)

Antimicrobials in Liver Disease

Drug to be avoided
Erythromycin Estolate

Tetracycline

Pyrazinomide

Nalidixic Acid

Talampicillin

Defloxacin

Dose reduction needed

Chloramphemcol

Isomiazid

Metromdazole

Rifampicin

Clindamycin
3)

Local Factors

Presence of pin and secretion decreases the efficacy of most AMAs especially
sulfonamides and aminoglycoxides.

Presence of necrotic material or foreign body makes eradication of infection

practically impossible.

Lowering pH at the site of infection reduces the activity of macrolide and

aminoglycoscide antirioleis.

Anaerobic environment on the centre of an abscess impain bacterial transport

processes which concentrate aminoglycosides in the bacterial cell, rendering
them less sureeptirle.

4)

Drug Allergy History of previous exposure to an AMAs should be obtained.

IF a drug has caused allergic reaction it has to be avoided in that patient eg.
drug of choices for syphilis in a patient allergic to penicillin eg. tetracycline.

5)

Impaired host defence

Integrity of host defence play a major role in overcoming an infection.
Pyogenie infection ocurs in prehopenic patients while if cell mediated
immunely empained (eg. AIDS) infections by low grade pathogens and
intracellular organisms a sound.

6)

Pregnancy

All AMA should be avoided in the pregnant because many cephalosporim and
azithromycin are safe, while safety data in most is available.

Tetracycline carry risk of acute yellow atrophy of liner, panerealitin and

kidney damage in the mother.

They also can teeth and bone deformity in the offspring.

Aminoglycosides can cause foetal can damage.

Animal studin indicate increased risk of the foctin especially with

flurogumolones

contrimoxarole,

ehlaramphemicol,

sulfonamide

and

introfenantoin.
-

Though metronide zole has not been found terafogenie its mutagenic potential
warrants caution in its use during pregnancy.

7.

Genetic Factors

Primaquine, nitrofinantion swafonamides chloropheneol and fluoroquinolones

are likely to produce haemolysh in 4.6 PD defect patient.

Failure of Antimicrobial Therapy

-

The success of antimicrobial therapy can be measured either clinically in term

of improvement in symptom/signs or microbiologically as eradication of the
infecting organism.

Antimicrobial may fail to an infection/fever or then may be replace. This is a

rare when antimicrobial therapy was begun, in the first place, on sound clinical
and/or bacteriological basis, when the real or apparent failure of regime ocean
the diagnosis and therapy should be revised one of the following cause will
usually be identified.

Improper selection of drug, route & duration of treatment.

Failure to take necessary adjunal measures.

Treatment began two lale

Poor host defence

Infecting organism present behind bamen such as vegetation on heat values

(SABE)

Inside the eye ball, blood brain barrier

Injuring to treat intreatable infusion (viral) or other cause of fever (malignancy

collages disease).

Presence of dormant or altered organism while latin given rose to a relapse.

Uses of Antibiotics in OMFS

(a)

In Implant Dentistry

When considering antiseptic prophylaxis for bone grafting procedure a

prospective placeso-controlled double blind clinical trial revealed that there
was a statistically significant increased risk of infections complication without
antibiotic prophylaxis.

Penicillin 2g was administered 1 hour postopertively.

Another prospective of a single 600 mg. dose of clindamycin versus

clidamycin 600 mg. and 300 mg. every 6 hour postoperatively.

It is concluded there is no difference between single dose and the 24 hour

regimen postoperatively.

There has been reluctancy by some practitioner to not use of clindamycin

because of adverse events, in particular the development of clostridium
difficile diarrhoea or pseudomembranous colitis.

But the true value of clindamycin as a prophylactic antibiotic should be

recognized.

Clindamycin broad spectrum actively against the aerobic, anaerobic & Blactum producing pathogen plus high oral absorption, significant soft and bone
tissue penetration and stimulatory effect on the host immune system make it
an excellent choice for antibiotic prophylaxis.

b)

In Bone Grafting Materials

Dhewelheuke et.al. investigated the effect of 20 antibiotics from different

lasser and antibacterial.

Mechanism in cell cultures of primary human adolescent (PHO)

Cycotoxicity could not be observed 24 hours after treatment of PHO with

inclusion of bacterial cell wall synthem aminoglycosides, tetracycline,
rifampin and lincomycin at any concentration.

Cefazolein decreased in proliferation of PHO at higher concentration.

Clindamycin and erythromycin demonstrated cyclotoxicity at higher

concentration.

At ultra low concentration demonstrated clindamycin and erythromycin did

not affect proliferation or metasolic activity but did an effect at moderate to
high concentration.

The fluoroquinolunes (cifrofloxacin and moxifloxacin) inhibited PHO

proliferation and intefered with metabolic activity at all concentration.

Tetracyclin and rifampin inhibited proliferation of HPO.

Aminoglycosides (gentacin) are the most frequently used antibiotics for local
treatment of bone infection and affect the mitochondrial protein synthesis but
not effect on PHO.

Lincomycin didnot inhibit proliferation or affect metarolic activity at any

concentration and display good activity against an aerobes.

Penicillin and amoxicillin did not affect PHO proliferation or metasolic

activity even at high concentration.

c)

In Exodontia

Infections can occur postoperatively 3 to 4 days to several week after surgery.

Most of there develop in third molar extraction site.

Streptococci species of bacteria appear to be the largest group of bacteria

causing postoperative infection.

The most effective treatment continues to be penicillin. However because of

increased recognition of anaerobic organism metronidazole or clindamycin
can be substituted for them.

d)

Sinus lift sub antral augmentation

To ensure antibiotic coverage before incision surgical antibiotic prophylaxis of

either penicillin (amoxicillin 2000 mg. or Augmentin 2000 mg.) or clidamycin
600 mg. in taken orally 2 hours before the procedure.

Postoperatively antibiotics of amoxicillin or augmentin 500 mg. every 6 hours

or clindamycin 300 mg. every 6 hours are taken for 5 to 7 days.

g)

For Periimplantitis

Chronic inflammation and infection of the tissue surrounding the dental

implant can lead to the loss of supportive alveolar bone. This condition is
known as periimplantitis.

PI has confirmed infection cause with high level of periodontal cathogass

including Actinobacillus actinomycelem comitass, porphysomonas gingivalis
perphynomonas intermedia, tannerella forsythia and treponema denticole.

Before antibiotic treatment mechanical debridement and antiseptic treatment

must be performed.

Systemic antibiotic therapy should be directed toward the elimination of of

gram negative anaerobic bacteria and metronidazole in the preferred
antibiotics.

The application of local antibiotics through the use of controlled delivery

devices has emerged recently a suitable treatment concept.

The antibiotic must remain at the site of action for at least 7 to 10 days in a
concentration high enough to penetrate the submucosal biofilm.

Tetracycline

periodontal

fibres

(actisite),

minocycline

hydrochloride

microsphere 1 mg (Arestin) and sustained release doxycycline (Atridox) are

the commercially available delivery system.
h)

In Laser Skin Resurfacing

Active herpes infection in the contraindication for resinfacing procedure. So

procedure should be postponed until complete resolution.

The patient should be started on prophylactic acyclovir at 400 mg. bid starting
2 days before the treatment and maintained until 5 days after the procedure, or
alternatively nalacyclovir 500 mg. bid with the same regimen.

i)

Skeletal Anchorage

Because the implants used for skeletal anchorage are transmucosal and involve
a portion of hardware that remain exposed to the oral cavity, antiinfective
coverage is employed during the post operative phase.

The most commonly used antibiotics are penicillin, amoxicillin and

clindamycin.

The patients are given a 5 day course of antinfectives orally and then surgical
placement.

j)

In Mandibular Surgery

The algorithm of antibiotic treatment are the classical ones used in

cerficofaent pathology.

Penicillin and its derivatives, third generation cephalosporins are used.

The treatment of non complicated fractures do not seen to improve versus not
using antibiotic therapy.

Though many professional used them to talk

advantage to the possibility of infection so as to reduce their incidences.

-

Antibiotic treatment in the first 72 hours is not necessary antibiotic treatment

of the infective complications (abscesses, pseudoarthosis, osteomylitis) is
where there is more consumes although in this case we talk about antibiotic
treatment and not with prophylam.

In Trauma Patient
-

It is widely accepted the use of an antibiotic prophylam in compound

fractures.

Mandible and dentoalveolar fracture antibiotics treatment is penicillin and its

derivatives, cephalosporin.

In orbital heals fracture there is no conscious on whether using antibiotics or

not some authors defends it and other do not.

Third mid and upper fracture third generation cephalosporin are used treating
those cases with liquosshea though the majority of facture in this region of the
face are considered complex or compounded, communicating the oral mucosa
with other parts such as paranasal sinuses.

In this sense under improper we would rather use propylactic antibiotic since
the very beginning of these fractures.

Recurrent Cellulites
-

Recurrent cellulites may be caused by penedu seeding with common oral

microorganisms. Infection should be treated promptly with third spectrum
antibiotics continual for weeks rather than day.

Intravenous antibiotic administration is necessary if oral treatment fails or

there is any sign of respiratory compromise.

Sdoo therapy is effective primary treatment of macrocylic disease or

secondarily for recurrent cyst following partial expiration.

04-432 absolute ethanol, doxycycline and bleonycin have all been used as
sclerosing agent.

Judicious use of antibiotic is necessary in the perioperative dental and should

be administered for 2 to 3 weeks postoperatively rather than just for days.

In Osteomyelitis
-

Osteomyelitis whether anti or chronic in nature still is a surgical disease.

Surgical disruption of the infection foci and organised abscess along with
debridement of necnolie form and foreign bodies is paramount.

Culture driven antimicrobial therapy should be ideal but often the osteomyelitis
wound is contaminated via intra-oral/extranal fisnuralim or teeth.

Empiried treatment should begin with penicillin in relatively high dose (4-6
million units) four times a day.

Alternatively clindamycin if the patients in allergic to penicillin.

Antibiotic therapy should be sustained at least 6 weeks if no longer even when

the disease process is in the acute, much less the chronic disease.

Long term antibiotic therapy needs to be of parenteral form for effectiveness

and defective treatment.

Conclusion
Antibiotic prophylasis in oral and maxillofacial surgery aims the prevention of the
infection of the surgery wound either due to characteristic of the surgery or the
general slate of the patient. This risk increases with the contamination of the surgical
operation area, making it necessary to imply in a pleophylactic treatment of the
infection in clean contaminated and contaminated surgeons and treatment of the
infection in dirty surgery. Moreoever a proper surgical technique helps to reduce the
development of post surgical infection. The elective antibiotic chemotherapy ranges
from penicillin derivative tooth betalactamase inhibities to second and third
generation cephalosporis, quinolone or clindamycin. So the antibiotic has a very
important role in pre-operative preparation and postoperative infection control in oral
and maxillofacial surgery.

References
1)

Essentials of Medical Pharmacology (6th Edition)

-

2)

K.D. Tripathi

Oral and Maxillofacial Surgery (Vol. I, II, III)

-

3)

Laskin

4)

Peterson

Fonseca