Systemic antibiotic prescribing patterns of dentists in Morocco: A questionnaire study

Aim

The aim of this study was to describe the use patterns of antibiotics in periodontal therapy among Moroccan dentists.

Materials and Methods

It was a cross-sectional study. An online survey among 2440 registered dentists was conducted in public, private, and semi-public sectors in Morocco. Within the interrogated dentists, 255 answer the online survey. Data analysis was done by the laboratory of biostatistics-epidemiology of the Faculty of Medicine of Casablanca.

Results

The antibiotics were prescribed for different pathologies. 26.8% of dentists prescribed antibiotics for gingivitis, 91.5% in case of ulcero-necrotizing gingivitis, 92.7% for aggressive periodontitis, 77% to chronic periodontitis patients, and 97.6% in the presence of periodontal abscess. Dentists prescribed penicillin to 37.3% of cases presenting ulcero-necrotizing gingivitis and 62.3% of patients presenting periodontal abscess. Cyclins are prescribed at a rate of 60% to aggressive periodontitis patients. The association of penicillin + metronidazole is prescribed to 37.3% of ulcero-necrotizing gingivitis patients, 47% of patients presenting aggressive periodontitis, 42.5% of chronic periodontitis patients, and 65.5% of cases presenting periodontal abscess.

Discussion

There are major discrepancies among dentists in antibiotic prescription patterns. Some dentists prescribe antibiotics to patients with gingivitis or patients undergoing noninvasive oral procedures such as air polishing and scaling which is worrisome. Dentists are prescribing antibiotics when local treatment would have sufficed. Dentists also commonly prescribed antibiotics as an adjunct to mechanical therapy for the treatment of periodontal disease.

Conclusion

Systemic antibiotics are prescribed for different conditions according to variable protocols. The appropriateness of antibiotic prescription must be reassessed critically to improve antibiotic stewardship among dentists.

Should systemic antibiotics be prescribed in periodontal abscesses and pericoronitis? A systematic review of the literature

This study assessed whether systemic antibiotics are beneficial or harmful in patients who present with an acute periodontal abscess or pericoronitis, with or without systemic involvement, and, if antibiotics are beneficial, which type, dosage, and duration are the most effective. Medline, Embase, and the Cochrane Library were screened from 1948 up to 1 April 2022 for systematic reviews, randomised clinical trials (RCTs), and other studies. Dedicated websites were consulted for systematic reviews, clinical practice guidelines, and health technology assessments on the topic. Outcomes of interest comprised tooth survival, swelling, pain, tooth mobility, periodontal probing depth, suppuration, adverse effects, quality of life measurements, and medication required for pain relief. Overall, five guidelines, seven systematic reviews, 15 RCTs, and 34 other studies were identified and selected for full-text assessment, but none of them fulfilled the inclusion criteria. At present there is no single randomised or non-randomised controlled trial assessing the harms and clinical effectiveness of systemic antibiotics in adults with a periodontal abscess or pericoronitis.

[Not Available]

A 7-year-old boy was referred to the paediatric clinic with a swollen cheek since one day. Intraoral examination revealed erythematous and swollen gingivae in the right upper quadrant. The consulted maxillofacial surgeon diagnosed him with a canine fossa abscess. The patient recovered quickly after incision and drainage, followed by antibiotic therapy.

Odontogenic orbital abscess with intracranial and pulmonary involvement

A 58-year-old woman presented to the emergency department with left ptosis and complete ophthalmoplegia. Imaging demonstrated a left orbital abscess. Her past medical history included cavitatory lung disease and "aseptic" meningitis 2 months previously. An anaerobic organism and commensal of the oral flora, Peptostreptococcus sp., was cultured from the orbital abscess. The patient was found to have a carious upper molar with chronic buccal abscess, which was extracted. This case presents an uncommon pathogen arising from an odontogenic infection as the etiology for orbital abscess, cavitatory lung disease, and meningitis in one patient.

Treatment of Acute Periodontal Abscesses Using the Biofilm Decontamination Approach: A Case Report Study

The aim of this preliminary study was to show the treatment effect of the biofilm decontamination approach on acute periodontal abscesses. Clinical cases showing acute periodontitis were treated using an oral tissue decontaminant material that contains a concentrated aqueous mixture of hydroxybenzenesulfonic and hydroxymethoxybenzene acids and sulfuric acid. The material was positioned into the pocket on the root surface and left in the site for 30 seconds. No instrumentation was performed before the treatment. No systemic or local antibiotics were used in any of the cases. A questionnaire was used for each patient to record the pain/discomfort felt when the material was administered. All of the treated cases healed well and very rapidly. The infections were quickly resolved without complications, and the pockets associated with marginal tissue recession were also reduced. The momentary pain upon introduction of the material was generally well tolerated in the nonsurgically treated cases, and it completely disappeared after a few seconds. The biofilm decontamination approach seems to be a very promising technique for the treatment of acute periodontal abscess. The local application of this material avoids the use of systemic or local antibiotics.

Prescribing for periodontal disease

With concerns about the ever-increasing development of antimicrobial resistance, it is imperative that antimicrobials are prescribed responsibly and used appropriately. This article provides an overview and simple guidelines for antimicrobial prescribing in the management of periodontal diseases.

An audit of antimicrobial prescribing in an acute dental care department

INTRODUCTION

Antimicrobial resistance is a growing problem that is likely to have a major negative impact on healthcare in the future. Dentists have a key role in ensuring that antimicrobials are prescribed correctly to reduce the emergence of resistant strains.

OBJECTIVE

To audit how appropriately antimicrobials were prescribed in the oral surgery acute dental department of Guy's Hospital in London, when compared to the standards set within the Faculty of General Dental Practice (UK) and Scottish Dental Clinical Effectiveness guidelines on antimicrobial prescribing in dentistry.

TARGET

100% compliance.

METHOD

A prospective audit consisting of two cycles (each including 60 patients) was carried out. Between each cycle, there was a two-month intervention period, which included extensive training and education of staff and students.

RESULTS

Cycle 1 showed that only 30% of prescriptions were appropriate and only 62% of practitioners were recording a diagnosis. After two months of intervention, cycle 2 was carried out; this showed a significant improvement, with 80% of prescriptions being appropriate and 100% of practitioners recording a diagnosis. The majority of inappropriate prescriptions in both cycles were for acute pulpitis without evidence of systemic involvement.

CONCLUSION

This audit has shown that clinical practice for antimicrobial prescribing did not follow the published guidelines. Following targeted interventions, a substantial improvement was made in the prescribing pattern. The target of 100% has not been reached, necessitating further intervention.

Treatment of abscessed primary molars utilizing lesion sterilization and tissue repair: literature review and report of three cases

The purpose of this report was to review an emerging alternative treatment to pulpectomies and extractions for nonvital primary teeth called lesion sterilization and tissue repair (LSTR) and provide the results of three clinical case applications. LSTR is a noninstrumentation endodontic treatment that involves a triantibiotic mixture in a propylene glycol vehicle, which is used to disinfect root canal systems. This concept was developed by the cariology research unit of the School of Dentistry, Niigata University, Niigata, Niigata Prefecture, Japan. This article reviews the development of the technique, clinical procedures required for the technique, three clinical applications and radiographic documentation and follow-up, and a short literature review of the current evidence supporting its application in clinical practice.

[Infection after dental intervention. Iatrogenic or general medical cause? Case report]

Whenever a dentist is dealing with abscess formation in the oral and maxillofacial region, it is mostly from dental origins. However, sometimes uncommon (co-)factors are present and responsible for major complications. Many general conditions or medications can significantly influence the course of an inflammation. It might spread faster and wider and also be resistant to "correct" therapy. This case report should raise awareness about general conditions supporting inflammation and demonstrate the importance of interdisciplinary treatment in these situations. A 76-year-old patient was referred to the maxillofacial surgery clinic after extraction of two teeth resulted in therapy-resistant painful swelling. Her dentist already had initiated "standard" therapy including Ponstan® (mefenamic acid) and Clamoxyl® (amoxicillin) without success. Initial blood testing came back with severe agranulocytosis. Immediately all potentially myelosuppressing drugs were stopped while myelosupporting drugs were prescribed. Under close interdisciplinary treatment conditions, healing was then uneventful without the necessity of surgical intervention. The challenge in inflammation treatment is to identify patients with uncommonly severe, fast-progressing, or therapy-resistant disease as early as possible. Further examination including blood workup for several medical parameters is indispensable in those patients.

A national survey of pediatric dentists on antibiotic use in children

PURPOSE

The purposes of this study were to: (1) examine the antibiotic prescribing practices of pediatric dentists and adherence to professional guidelines; and (2) assess their knowledge of and attitudes toward antibiotic resistance.

METHODS

A cross-sectional survey regarding antibiotic use, resistance, and knowledge of antibiotic stewardship programs was emailed to 4,636 members of the American Academy of Pediatric Dentistry (AAPD).

RESULTS

987 surveys (21 percent) were completed; 984 were analyzed. Lack of adherence to AAPD antibiotic guidelines was noted. There was a trend toward overuse of antibiotics for the following conditions: irreversible pulpitis with (32 percent) and without vital pulp (42 percent); localized dentoalveolar abscess with (68 percent) and without draining fistula (39 percent); mitral valve relapse with regurgitation (43 percent); intrusion (15 percent); extrusion (13 percent); and rheumatoid arthritis (12 percent). Determinants of antibiotic use were: facial swelling (88 percent); pain relief (15 percent); unavailable appointment for several weeks (six percent); and parental satisfaction (four percent). Although 98 percent of respondents believed that antibiotic resistance is of growing concern, only 15 percent were aware of antibiotic stewardship programs.

CONCLUSION

AAPD members overprescribe antibiotics. Educational programs to increase knowledge of antibiotic resistance and stewardship programs should be implemented to increase adherence to professional guidelines.

Microbiological analysis of a prospective, randomized, double-blind trial comparing moxifloxacin and clindamycin in the treatment of odontogenic infiltrates and abscesses

The objective of this study was to identify the oral pathogens found in odontogenic infections, to determine their susceptibilities to amoxicillin-clavulanic acid (AMC), clindamycin (CLI), doxycycline (DOX), levofloxacin (LVX), moxifloxacin (MXF), and penicillin (PEN), and to search for associations between specific pathogens and types of infection. Swabs from patients enrolled in a randomized, double-blind phase II trial comparing MXF with CLI for the treatment of odontogenic abscesses or inflammatory infiltrates were cultured on media for aerobes and anaerobes. All bacterial isolates were identified at the species level. Overall, 205 isolates were cultured from 71 patients: 77 viridans group streptococci, 56 Prevotella spp., 19 Neisseria spp., 17 Streptococcus anginosus group isolates and hemolytic streptococci, 15 other anaerobes, and 21 other bacteria. Ninety-eight percent of pathogens were susceptible to MXF, 96% to AMC, 85% to LVX, 67% to PEN, 60% to CLI, and 50% to DOX. S. anginosus group and hemolytic streptococci were found significantly more frequently (P = 0.04) in patients with abscesses (12/95) than in patients with infiltrates (5/110). In four patients with infiltrates who failed to respond to CLI therapy, three isolates of the Streptococcus mitis group and four Neisseria spp. resistant to CLI were found. In this study, S. anginosus group and hemolytic streptococci were clearly associated with odontogenic abscesses. Our analysis suggests that viridans group streptococci and Neisseria spp. play a decisive role in the etiology of odontogenic infiltrates. The high in vitro activity of MXF against odontogenic bacteria corresponds well to its clinical results in the treatment of odontogenic abscesses and infiltrates.

[Update on current care guidelines: antimicrobials in acute dentistry]

In most cases, acute oral infections originate from the dentition. The use of antimicrobials is secondary to appropriate dental care and does not allow postponing the elimination of the infection source. Medically compromised patients are more susceptible to odontogenic infection complications and antimicrobials have a more important role in their treatment. In the treatment of dental abscesses, a pre-operative 2 g single-dose of amoxicillin is recommended for all patients. An additional five to seven-day course of penicillin V or amoxicillin, in combination with metronidazole or clavulanic acid, should be considered, especially in the treatment of medically compromised patients.

Phlegmon of the face and neck: a case report

Deep face and neck infections are potentially life threatening if they are not diagnosed in time and then treated quickly. This report describes a case of face and deep neck infection, associated with a semi-impacted and decayed wisdom tooth in a cardiopathic, immunosuppressed patient suffering from, diabetes, hypothyroidism, osteoporosis, breathlessness, chronic bronchitis, with oral, cutaneous and vaginal erythematous lichen, Cushing's Syndrome, penicillin allergy, subjected to past hypophysectomy. The swelling was, first of all, treated in urgency, with an intravenous antibiotic therapy and, immediately afterwards, the phlegmonous infiltration linked to the avulsion of the lower third molar was surgically drained. The patient was then treated with intravenous multiple antibiotics, with the aim of eradicating the predominating bacteria that was encountered in the microbiological culture test. A complete remission of the pathological picture was obtained .

The knocked-out erythrocyte sedimentation rate: periodontal abscess

INTRODUCTION

The erythrocyte sedimentation rate (ESR) is a common but nonspecific test that is often used as an indicator of active disease. Infection of dental origin may be responsible for a number of cases in unresolved elevated ESR and fever etiology. Dental sepsis is the one of the potential causes of persistent fever that can escape detection.

CLINICAL PICTURE

An 18-year-old female patient was admitted to the emergency room with complaints of headache, fever, nausea, and vomiting for the past four days. Erythrocyte sedimentation rate was 110 mm/h. She was started empirically on antibiotic treatment as no etiology was found. Four days later, while searching for the etiology of the fever, the patient experienced an acute pain in association with localizing symptoms in two decayed teeth. Oral examination revealed abscess formation in both teeth.

TREATMENT

Teeth were extracted and ESR was decreased to 95 mm/h on the day of the second extraction and to 60, 35, and 10 mm/h taken weekly.

OUTCOME

During the follow-up, she was in good health with no fever seen 3 months after treatment and her ESR was 15 mm/h.

CONCLUSION

Dental infection should be considered as an unusual but very treatable cause of pyrexia of unknown origin.

Benefits of additional courses of systemic azithromycin in periodontal disease case report

The strong association of subgingival anaerobic bacteria, such as Porphyromonas gingivalis, Treponema denticola and Tannerella forsythia, with destructive periodontal disease has been well documented in the literature. Several double-blind studies have also shown the beneficial use of systemic antimicrobials that are active against these microorganisms in conjunction with conventional periodontal treatment, especially when periodontal abscesses and/or suppuration upon probing are present. Four cases with periodontal abscesses were treated with scaling/root planing in conjunction with systemic azithromycin. Partial improvement led to retreatment with two additional courses of azithromycin. Bone formation was noted on periapical radiographs after the patients took additional courses of azithromycin. In view of the benefits of using additional courses of azithromycin in the treatment of destructive periodontal disease, we conclude that the single course of systemic antimicrobials currently used in periodontal therapy may be insufficient to reach necessary therapeutic levels in infected sites.

Case report: brain and liver abscesses caused by oral infection with Streptococcus intermedius

Organ abscesses are a rare and life-threatening complication mostly of hematogenously disseminated infections. We report a case of brain and liver abscesses. Identification of the lesions was made by contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), respectively. An oral examination comprised an oral focus of infection. Streptococcus intermedius was isolated from oral smear, liver and ventricular drainage, and blood sample. After the commencement of antibiotic therapy, drainage of abscesses and oral rehabilitation, complete recovery was noted.

[Bacterial spectra and antibiotics in odontogenic infections. Renaissance of the penicillins?]

BACKGROUND

The role played by odontogenic infection in dental, oral, and maxillofacial surgery is not to be underestimated even at the present time. An extensive, standardized, prospective study was performed with the intention of verifying the bacterial spectrum of odontogenic infections to evaluate antibiotic sensitivity.

MATERIAL AND METHODS

Bacterial spectra and resistograms of 65 patients with an odontogenic infection were analyzed in a prospective study under standardized conditions for specimen collection and transport.

RESULTS

A total of 226 bacterial strains were analyzed. The ratio between anaerobes and aerobes was approximately 2:1. The most frequent aerobes were members of the genera Streptococcus (46 isolates), Staphylococcus (10 isolates), and Neisseria (9 isolates), respectively. The anaerobic gram-positive spectrum was dominated by members of the genera Eubacterium (19 isolates), Peptostreptococcus (16 isolates), and Actinomyces (12 isolates). The most frequently isolated gram-negative anaerobes were Prevotella (46 isolates), and Fusobacterium (21 isolates). The overall resistance to antibiotics was very low: only 7.3% of all bacteria were resistant to penicillin G/V, and 8.8% showed resistance to ampicillin. The resistance rates to other beta-lactam antibiotics were 4.4% to piperacillin and 0.6% to imipenem, respectively. Penicillin G presented the highest antimicrobial activity among aerobes: only 4.5% of anaerobic strains were resistant of penicillin G. The other resistance rates of anaerobic bacteria to antibiotics were as follows: ampicillin 24%, doxycycline 34%, erythromycin 18%, and clindamycin 9.3%. Penicillin G was also highly antimicrobially active to anaerobes. The resistance rates were: penicillin G 8.1%, ampicillin 2.6%, doxycycline 9.2%, erythromycin 10.2%, and clindamycin 1.4%, respectively.

Antibiotics in the Treatment of Periodontitis

The emerging worldwide problem of bacterial resistance has resulted from overuse and misuse of systemic antibiotics. It is appropriate therefore to review periodontal treatment strategies to determine whether systemic antibiotics have a role to play in the management of periodontitis. For the great majority of patients presenting with periodontal conditions, systemic antibiotics are not indicated. Instead, treatment should focus on mechanical disruption of plaque biofilms, plaque control and risk factor modification. Systemic antibiotics may be indicated in severe spreading infections, some aggressive forms of periodontitis, and necrotizing periodontal conditions. These conditions present infrequently in general practice, most will require referral to a periodontal specialist and the decision to use systemic antimicrobials as part of periodontal management is more appropriately taken within a specialist centre. Systemic antibiotics are not indicated in the vast majority of periodontal conditions encountered in general dental practice.

Craniocervical necrotizing fasciitis of odontogenic origin with mediastinal extension

We review an interesting case of craniocervical necrotizing fasciitis with thoracic extension in an immunocompetent 44-year-old man. The patient underwent aggressive medical and surgical management during a long hospitalization. Multiple surgical debridements, including transcervical mediastinal debridement, and eventually a thoracotomy for mediastinal abscess were required. The patient eventually recovered, and 3 months later he showed no sign of complications or recurrence. Craniocervical necrotizing fasciitis is a fulminant soft-tissue infection, usually of odontogenic origin, that requires prompt identification and treatment to ensure survival. Broad-spectrum intravenous antibiotics, aggressive surgical debridement and wound care, hyperbaric oxygen, and good intensive care are the mainstays of treatment.

Localized aggressive periodontitis in a six-year-old: a case report

The purpose of this report was to describe an approach to diagnose and effectively treat a pediatric patient with localized aggressive periodontitis. A 6-year-old female presented with clinical and radiographic evidence of severe attachment loss around several primary teeth. She had no history of systemic disease, periodontal disease, or caries prior to the periodontal abscess that prompted her referral. Routine immunological tests did not reveal any functional defects, but DNA testing for periodontal pathogens revealed the presence of all 8 aggressive periodontal pathogens assayed. Treatment consisted of the extraction of 2 severely affected primary teeth, increased frequency of recall appointments, and administration of systemic antibiotics. The patient's periodontal condition was stabilized 18 months post-treatment, and the 8 pathogens were no longer at detectable levels. With a treatment goal of preventing disease progression into the erupting permanent dentition, this treatment regimen provides an effective alternative to more aggressive strategies.

An objective method of assessing facial swelling in patients with dental abscesses treated with clarithromycin

AIM

The study evaluates the efficacy of a set of objective parameters for monitoring facial swelling in a group of patients treated with clarithromycin.

METHODS

Fifty consecutive patients suffering from dental abscesses (22 in the maxillary arch and 28 in the mandibular arch) were enrolled. All these patients underwent antibiotic treatment with clarithromycin in a new formulation as a single daily dose (500 mg/day for 6 days). Pain and changes in facial swelling were evaluated at baseline and each day for 6 days through subjective parameters (visual analogic scale, VAS) and objective parameters (6 different tape measurements on the skin surface above the abscess).

RESULTS

Pain and swelling recorded by patient and dentist (using VAS scores) showed statistically significant decreases (p<0.01) on days 2, 3 and 4, while no further significant variation was observed during days 4, 5 or 6. As regards the objective parameters to quantify facial swelling, the maximum dimensional change (from baseline to final values) in the mandibular arch was obtained with measurement 6 (mean value 2.27+/-0.53 cm); the maximum dimensional change in the maxillary arch was obtained with the sum of the other 5 measurements (mean value 6.34+/-4.09 cm).

CONCLUSION

The use of a single or a combination of linear measurements might provide a sensitive and reproducible method to evaluate facial swelling objectively and could be very useful in monitoring the efficacy of new antibiotics and to compare the results from different studies.

[The odontogenic abscess. Aetiology, treatment and involvement in the orofacial region]

Odontogenic infections are a common problem in daily practice. Occasionally, an odontogenic infection evolves an abscess. This article discusses the aetiology, the treatment and the involvement of odontogenic abscesses in the oro-facial region. Their occurrence, course and treatment are depending on the patient's immune response, and on microbial and environmental factors.

A lot of clot

A 37-year-old man presented with fever and a red, painful right eye. He had proptosis, conjunctival chemosis, and ophthalmoplegia OD. The patient had extremely poor dentition and had self decompressed a dental abscess prior to admission. Magnetic resonance imaging of the brain and orbital revealed extraocular muscle engorgement and a dilated superior ophthalmic vein OD. Orbital echography revealed a lack of flow in the right superior ophthalmic vein. An extensive hematologic evaluation for infection and inflammation was negative. A chest radiograph showed a lung abscess for which he received intravenous antibiotics. Over time, the periorbital erythema, ophthalmoplegia, proptosis, and pain resolved. Repeat MRI showed resolution of the orbital findings and repeat chest x-ray showed resolution of the left upper lobe abscess.

In vitro activity of moxifloxacin against bacteria isolated from odontogenic abscesses

We evaluated the antimicrobial susceptibility of 87 pathogens isolated from 37 patients with odontogenic abscesses. The most prevalent bacteria were viridans group streptococci and Prevotella species. Considering all bacterial isolates, 100% were susceptible to amoxicillin-clavulanic acid, 98% were susceptible to moxifloxacin and to levofloxacin, 76% were susceptible to doxycycline, 75% were susceptible to clindamycin, and 69% were susceptible to penicillin.

Are antibiotics being used appropriately for emergency dental treatment?

AIM

To investigate the therapeutic prescribing of antibiotics to patients presenting for emergency dental treatment.

DESIGN

A prospective clinical study.

METHOD

Information was collected via a questionnaire concerning the patient's reason for attendance and treatment undertaken at emergency dental clinics in North and South Cheshire.

RESULTS

Over an 11-week period 1,069 patients attended the five clinics, 1,011 questionnaires were analyzed. The majority of the attendees had pain (879/1011). 35% (311/879) of these patient had pulpitis and 74% (230/311) had been issued a prescription for antibiotics, without any active surgical intervention. Th principal antibiotic prescribed for both adult and child patients was amoxicillin.

CONCLUSION

The majority of patients attending the emergency dental clinics had pain, with a large proportion having localised infections either as pulpitis or localised dental abscess. Three quarters of these patients had no surgical intervention and were inappropriately prescribed antibiotics.

The periodontal abscess (II). Short-term clinical and microbiological efficacy of 2 systemic antibiotic regimes

BACKGROUND/AIMS

The aim of this short-term open parallel longitudinal clinical study was to compare the clinical and microbiological efficacy of 2 different antibiotic regimes in the treatment of acute periodontal abscesses.

METHOD

After patient selection, a clinical examination was carried out recording the following variables: pain, edema, redness, swelling, bleeding on probing, suppuration, tooth mobility, lymphadenopathy, and probing pocket depth. Microbiological samples were taken from the lesion and the patient was randomly assigned to one of two antibiotic regimes: azithromycin or amoxicillin/clavulanate. Clinical variables were recorded, and microbiological samples were taken, at 3-5 days, 10-12 days and 30 days. Additional mechanical treatment (debridement and scaling) was performed in the third visit (10-12 days). Blood and urine samples were collected at baseline and after 10-12 days. Microbiological samples were processed by anaerobic culturing, and isolated periodontal pathogens were tested for antibiotic susceptibility by means of the spiral gradient endpoint methodology.

RESULTS

15 patients took azithromycin, and 14 amoxicillin/clavulanate. Subjective clinical variables demonstrated statistically significant improvements with both antibiotic regimes, which lasted for at least 1 month (p<0.01). Objective clinical variables also showed clear improvements, being statistically significant after 30 days with probing pocket depth in the azithromycin group (p<0.01). Microbiologically, short-term reductions were detected with both antibiotics, however fast recolonization occurred after the third visit. No significant differences were found between both treatment regimes. Antibiotic susceptibilities demonstrated no resistances for amoxicillin/clavulanate, while 2-3 strains of each studied pathogen were resistant to azithromycin.

CONCLUSIONS

However, both antibiotic regimes were effective in the short-term treatment of periodontal abscesses in periodontitis patients.

[Pathogen spectrum and resistance status of exclusively anaerobic odontogenic infections]

Out of 440 dentogenic pyogenic infections, 171 exclusively caused by anaerobes were investigated to understand the importance of anaerobic bacteria in dental pyogenic processes better. Grampositive anaerobic bacteria dominated. The predominant grampositive isolates in monoinfections were Peptostreptococci and in the case of mixed infections, strains of the genus Eubacterium. Strains of Prevotella and Porphyromonas dominated the gramnegative anaerobic spectra. The resistance to penicillin was very low. Altogether, only one strain of Prevotella oris and one strain of Prevotella oralis showed resistance to penicillin.

Repeated metronidazole and amoxicillin treatment of periodontitis. A follow-up study

BACKGROUND

The prevailing concept is that little or no clear benefit is derived from antibiotic therapy in chronic periodontitis. Studies to determine the effect of metronidazole plus amoxicillin (M+A) on adult periodontitis are questionable because standard design for clinical trials was usually not used. In addition, there is no information about the effect of M+A as the sole therapy for periodontitis.

METHODS

A randomized, triple-blind, controlled clinical trial was used to determine the effect of systemic administration of M+A, as the sole therapy, in progressive adult periodontitis. Forty-six subjects with moderate to advanced adult periodontitis who showed > or =2 mm attachment loss in at least 2 sites in the previous 2 months were entered in the study. Subjects were randomly distributed to a group who received 21 tablets of metronidazole 250 mg plus amoxicillin 500 mg, or to a group receiving a placebo (1 tablet every 8 hours for 1 week). Patients were examined every 2 months for 12 months. The M+A or placebo regimen was repeated at 4 and 8 months. No effort was made to change the oral habits of patients and they received no additional therapy. Differences between groups were assessed using the Mann-Whitney U test. The differences at every 2-month interval within each group were assessed using the ANOVA test.

RESULTS

Seven subjects abandoned the study; at 12 months the M+A group had 20 subjects and the placebo group 19. There were no significant differences in the clinical parameters at baseline between the 2 groups. After 2 months and thereafter, the M+A group showed significant clinical improvement while the placebo group showed a progressive deterioration of periodontal status. At 12 months compared to baseline, subjects of the M+A group showed: 1) a significant overall mean attachment gain of 0.43 mm (P = 0.005); 2) a significant decrease of active sites (P< or =0.03); 3) a significant increase of sites gaining attachment level (P< or =0.01); 4) a significant reduction of pocket depth (P< or =0.00006); and 5) a significant decrease in percentage of bleeding on probing sites (BOP) (P< or =0.0005). Significant differences between both groups at all 2-month evaluations were found in overall mean attachment level (P < or =0.000004), in percent of active sites (P< or =0.03), and in percent of BOP sites (P< or =0.02). Sites exhibiting > or =2 mm of attachment loss in 2 successive or alternate evaluations, and periodontal abscess were noticed only in the placebo group.

CONCLUSIONS

A 1-week course of systemic M+A every 4 months, as the only therapy, arrests the progression of adult periodontitis and significantly improves the clinical parameters of the disease.

[A comparative evaluation of modern antibacterial preparations in the treatment of a severe degree of periodontitis at a stage of exacerbation]

Sensitivities of peptostreptococci, streptococci, Actinomyces, bacteroid, and fusobacterial strains pathogenic for the periodontium to wide-spectrum penicillines, cephalosporines, lincomycin, macrolides, metronidasole, and nitasole are compared. New macrolide antibiotics rulide. Macropene, gramicidin C, levomycetin, and rifampicin are highly effective. Some narrow-spectrum drugs, e.g. augmentin, cephalexin, and vancomycin (towards actinomycetes) were highly effective, too.

[The evaluation of the clinical efficacy and tolerance of azithromycin in odontostomatological infections]

BACKGROUND

Common oral bacteria are involved in the etiology of odontostomatological infections and there is a prevalence of Gram negative anaerobic microorganisms that are increasingly often found to be resistant to common beta-lactamases. In the light of this phenomenon, the use of beta-lactamases has been replaced by macrolides. The development of azithromycin, which is active against anaerobes and characterised by a wider spectrum of action against Gram negative bacteria, has opened new horizons in the therapeutic approach to odontostomatological infections.

AIMS

The aim of the study was to evaluate the clinical efficacy and the tolerability of azithromycin in odontostomatological infections. The study was performed using an open test method, without a comparative drug.

METHODS

One hundred patients, including 51 males and 49 females aged between 18 and 64 years old, were included in the study. These patients showed clinical and radiographic symptoms of acute apical periodontitis, periodontal abscess, or third molar dysodontiasis. They were divided into three groups. The drug protocol used was 500 mg/day for three days. The efficacy of the antibiotic was assessed one week after the start of treatment by evaluating the evolution of the pathology on the basis of subjective symptoms (pain) and objective signs (reddening, swelling, basal temperature). A progressive system was used to quantify the clinical findings using an arbitrary score from 0 to 3. The tolerability of treatment was evaluated by recording any signs observed in the patients' data records.

RESULTS

The initial mean score for painful symptoms passed from 2.88 to 0.34. The initial mean score for the reddening parameter also fell from 2.3 to 0.34. The same results were found for the reddening sign which presented a mean value of 2.1 at the start of treatment and 0.38 at the end. The 8 patients who presented fever also showed a remission. The overall incidence of side effects was 8%. The side effects affected the gastrointestinal tract.

CONCLUSIONS

From an analysis of these results it can be affirmed that azithromycin achieved good therapeutic results in odontostomatological infections in terms of both efficacy and tolerability.

Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy

OBJECTIVE

To evaluate shortened courses of antibiotics in the management of dentoalveolar abscesses.

DESIGN

Prospective clinical study over a 3-year period.

SETTING

Examinations department of the Liverpool University Dental Hospital.

SUBJECTS

759 patients, with acute dentoalveolar abscesses associated with swelling, and an elevation of axillary temperature to above 38.5 degrees C, were included in the investigation. The minimum age of the patients was 16 years.

INTERVENTIONS

The initial treatment was to drain the abscess by incision (124 patients), or extraction (635). The patients were prescribed amoxycillin (250 mg every 8 hours), clindamycin (150 mg every 6 hours) or erythromycin stearate (250 mg every 6 hours) and instructed to drink plenty of fluid. All the patients were seen 2 or 3 and 10 days later; only patients who were seen at these times were included in the trial.

MAIN OUTCOME MEASURES

Resolution of the swelling and a normal axillary temperature.

RESULTS

At first review 748 patients (98.6%) had normal temperatures, marked resolution of the swelling and the antibiotic was discontinued. None of these 748 patients required further antibiotic therapy.

CONCLUSIONS

The duration of antibiotic therapy in most patients with acute dentoalveolar infections can safely be 2-3 days, provided that drainage has been established. It is not, therefore, necessary for the majority of patients to complete a 5-day course of antibiotics.

An effective treatment for chronic periodontal abscesses

In the past, chronic periodontal abscess was treated by conventional gingivectomy, flap access procedures, or by extraction of the affect tooth. A modified technique for the treatment of the chronic periodontal abscess is described. A surgical approach is combined with root conditioning with doxycycline. Application of this technique has resulted in rapid, uneventful healing in which neither further tissue breakdown or recurrence of the abscess has occurred.

Antibiotics in general practice

The human race has had to endure infections for as long as it has been on earth, and has developed efficient natural defence mechanisms to combat them. Modern medicine aims to augment these natural mechanisms, to help speed up resolution of infection and decrease morbidity and mortality.

Microbial identification and antibiotic sensitivity testing, an aid for patients refractory to periodontal therapy. A report of 3 cases

The importance of microbial surveillance is illustrated in 3 clinical cases. Each case demonstrated a continued lack of response to conventional periodontal treatment. Repeated bouts of periodontal abscess formation and bone loss occurred over a 3- to 4-year period, despite numerous surgeries supplemented with antibiotics. As a result, patients were termed refractory to treatment and extensive microbiological analysis and sensitivity testing was performed. Following institution of the appropriate antibiotic and conservative therapy consisting of several sessions of scaling and root planning, each of these cases demonstrated a dramatic remission of disease progression. No further breakdown has been seen for a minimum of 2 1/2 years. While anecdotal in nature, these cases support the usefulness of microbial identification coupled with antibiotic sensitivity as an adjunct to conventional conservative periodontal therapy.

Amoxicillin concentration in pus from abscess caused by odontogenic infection

1. Amoxicillin concentration in pus from odontogenic infection was assayed and the concentrations were compared with MIC (minimum inhibitory concentration) of alpha-hemolytic streptococci isolated from odontogenic infection. 2. Measurable amoxicillin concentrations in serum and pus were found in all instances (n = 16). 3. The mean peak concentrations in serum and pus were found at identical times, 1.5 hr after administration, which were 5.92 and 0.90 micrograms/ml, respectively. 4. The mean concentration ratio of pus/serum at the peak time was 0.15. 5. All amoxicillin concentrations in pus at the peak time exceeded the MIC for 90% of alpha-hemolytic streptococci (0.25 micrograms/ml).

Persistent fever due to occult dental infection: case report and review

Dental sepsis is one potential cause of persistent fever that can escape detection. A patient with febrile episodes due to an occult tooth abscess of 2 years' duration is described. A search of the English-language literature revealed 20 other cases of fever of obscure origin arising from dental sources. This diagnosis may be suggested by repeated questioning of the patient about his or her medical history, repeated physical examination, an elevated erythrocyte sedimentation rate, or a history of failure to respond to antibiotic therapy. Dental infection is unlikely in patients who have a white blood cell count of > 11 x 10(9)/L, a temperature of > 39.5 degrees C, or positive blood cultures. The diagnosis may be made by repeated focused clinical examination, dental roentgenography, or radiolabeled leukocyte scintigraphy. Detection of dental sepsis is worthwhile since the febrile condition can be cured in all instances by tooth extraction and abscess drainage, with or without concurrent antibiotic therapy.

Gingival crevicular fluid gelatinase and its relationship to periodontal disease in human subjects

Collagenolytic enzymes released by neutrophils are associated with the destruction of periodontium in periodontal diseases. Measurement of these enzymes in gingival crevicular fluid (GCF) could be used to test for periodontal diseases and thereby simplify diagnosis. To test this hypothesis, gelatinase (MMP-9) was analyzed in GCF samples with a simple assay system. GCF was collected by a mouthrinse method from 10 patients with gingivitis (G); 10 well-treated and maintained periodontitis patients (TP) without detectable loss of attachment; and 9 patients with recurrent loss of periodontal attachment (greater than 2 mm) and/or abscess formation (RP). Clinical measurements including tooth mobility (MOB) and gingival attachment level (GAL) were made monthly for a maximum of 10 months. Active and latent forms of gelatinase were measured by a functional assay using gelatin substrate-gel enzymography and the activities were quantified by laser densitometry. Reproducibility analysis demonstrated that the assay (inter-gel, inter-assay, inter-scan) and diurnal variations were small compared to biological variation. The presence of active gelatinase was detected in 97.8% of TP samples, 86.4% of RP samples, but in only 11.4% of G samples. In addition, the mean active gelatinase activity was found to be significantly higher (p less than 0.001) in the RP (71,006 U) than the TP (43,814 U) groups, both of which were higher (p less than 0.001) than the G group (2824 U). During periods of attachment loss, samples from the RP group exhibited a 2-fold increase of mean active gelatinase activity (129,414 U).(ABSTRACT TRUNCATED AT 250 WORDS)

Serial doxycycline and metronidazole in prevention of recurrent periodontitis in high-risk patients

The efficacy of metronidazole and doxycycline in preventing recurrent periodontitis was studied in 23 patients. After treatment in the previous 7 months with either bimonthly scaling and 3 weeks of systemic doxycycline (11 subjects) or scaling and placebo (12 subjects), patients were monitored for recurrent periodontitis and were scaled every 2 months. When either a periodontal abscess or greater than 2 mm loss of gingival attachment was observed, metronidazole was administered (250 mg every 8 hours) for 10 days. In the placebo plus metronidazole group, 5 patients (42%) exhibited recurrent periodontitis after the metronidazole regimen compared with only one (9%) in the doxycycline plus metronidazole group (P less than 0.096). Subgingival plaque samples at study and healthy control sites were screened for the presence of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Eikenella corrodens, and Fusobacterium nucleatum by immunofluorescence and for spirochetes using Ryu's stain. Presence/absence analysis of the sum of scores of the 6 individual pathogens demonstrated large reductions (P less than 0.005) in the frequency of detection of pathogens in the former doxycycline compared with the placebo plus metronidazole group at both study and control sites before and one month after metronidazole. By 7 months after metronidazole, there was no detectable difference between groups. These results indicate that prevention of recurrent periodontitis with metronidazole may be enhanced by previous treatment with doxycycline.

Collagenase activity in recurrent periodontitis: relationship to disease progression and doxycycline therapy

Previous reports have suggested that active progression of periodontitis may be correlated with increased collagenolytic activity, and that improved clinical conditions after tetracycline treatment may be explained by inhibition of host collagenase. Eighty-two patients with a recent history of periodontal abscesses and/or loss of gingival attachment level (GAL) despite active periodontal therapy were enrolled in a double-blind, randomized, placebo-controlled trial. Clinical measurements, sampling of gingival crevicular fluid (GCF) and subgingival scaling were performed every 2 months. If any site exhibited greater than 2 mm loss of GAL or a periodontal abscess, patients were administered either 100 mg doxycycline per day for 3 weeks or placebo. During 12 months of monitoring, 55 patients exhibited recurrent active disease and were then randomly assigned to either the doxycycline (n = 30) or placebo (n = 25) groups. Analysis of active collagenase and latent collagenase in GCF samples were determined by functional assays and quantitated after SDS-PAGE and fluorography. Collagenase activities were assayed at sites exhibiting active destruction (study site), at sites with pocket depth comparable to the study site but without active destruction, and at healthy sites. Clinical measurements of GAL and collagenase activity were made at intervals between 1 wk and 7 months after completion of the drug regime. Within 7 months, 15 out of 19 patients on placebo exhibited recurrent disease compared to 13 out of 29 patients on doxycycline. Collagenase activity exhibited large variations among patients and was analyzed as presence or absence of active collagenase with a logistic model.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized, placebo-controlled trial of doxycycline: effect on the microflora of recurrent periodontitis lesions in high risk patients

Twenty-seven patients with a recent history of periodontal abscesses and/or loss of gingival attachment level (GAL) despite active periodontal therapy were enrolled in a double-blind, randomized, placebo-controlled trial. Clinical measurements and subgingival scaling were performed every 2 months. When a site exhibited greater than or equal to 2 mm loss of GAL or a periodontal abscess, patients were administered either doxycycline at a dosage of 200 mg to start and 100 mg per day for 3 weeks, or a placebo. Clinical measurements of GAL and microbial analysis of subgingival plaque at study and control sites were made at the time of active disease and at intervals of 1 week and 7 months after completion of the drug regime. Plaque samples were screened for the presence of Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Bacteroides intermedius (Bi), Eikenella corrodens (Ec) and Fusobacterium nucleatum (Fn) by indirect immunofluorescence antibody technique and for spirochetes (Sp) using Ryu's stain. Based on presence or absence analysis of the sum scores of the 6 pathogens, both the placebo (n = 10) and the doxycycline groups (n = 17) exhibited similar scores at the time of detection of active disease (mean placebo = 2.38 +/- 0.32; mean doxycycline = 2.95 +/- 0.27; P = 0.18). One week after treatment, the probability of detection was unchanged in the placebo group (mean placebo = 3.14 +/- 0.47), but was significantly reduced in the doxycycline group (mean doxycycline = 1.77 +/- 0.26; P = 0.0002). Study (active) sites exhibited scores 2 to 3 times higher than control (inactive) sites before doxycycline treatment.(ABSTRACT TRUNCATED AT 250 WORDS)