ORAL/DENTAL INFECTIONS

Infections of the Teeth and Supporting Structures

Infection/Condition and Likely Organism	Suggested Treatment		Comments
	Preferred Treatment	Alternative Treatment
Reversible / Irreversible Pulpitis	Systemic antibiotic use not recommended
Localised Dentoalveolar Abscess	Superficial Systemic antibiotic use not recommended (unless medically compromised)
	Deep Infection/Medically Compromised Amoxicillin 500mg PO q8h PLUS Metronidazole 400mg PO q8h OR Amoxicillin-clavulanate 625mg PO q8h	Penicillin allergy Cephalexin 500mg q12h OR Azithromycin 500mg q24h OR Clarithromycin 500mg q12h
Dry Socket	Systemic antibiotic use not recommended		Local treatment with saline irrigation and antiseptic/analgesic dressings and symptomatic relief of pain.
Localised Pericoronitis	Systemic antibiotic use not recommended in absence of regional or systemic signs and symptoms		Local treatment with antiseptic irrigation and mouthwash and symptomatic relief of pain.
Chronic Gingivitis	Systemic antibiotic use not recommended		Mechanical and chemical plaque control. *0.2% Aqueous Chlorhexidine gluconate not be used alone but as an adjunct to mechanical debridement
Chronic Periodontitis Common organisms: Aggregatibacter actinomycetemcomitans Porphyromonas gingivalis Tannerella forsythia Prevotella intermedia Spirochaetes	Systemic antibiotic use generally not recommended. Amoxicillin 500mg PO q8h PLUS Metronidazole 400mg PO q8h OR Amoxicillin-clavulanate 625mg PO q8h	Penicillin allergy Cephalexin 500mg q12h OR Azithromycin 500mg q24h OR Clarithromycin 500mg q12h OR Clindamycin 300mg PO q6h	1^st line treatment - Mechanical plaque control. Consider antibiotics if: Unresponsive to conventional mechanical therapy. Acute infection associated with systemic manifestation Medically compromised
Periodontal Abscess	Systemic antibiotic use not recommended		Incision and drainage Management of cause of abscess and symptomatic relief of pain.

Infections of the Jaws

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Osteomyelitis of the jaws (dental origin)

For acute cases, start with:

Amoxicillin 500mg PO q8h

PLUS

Metronidazole 400mg PO q8h

Amoxicillin-clavulanate

625mg PO q8h

Penicillin allergy

Clindamycin 300-450mg PO/IV q6h

For chronic cases, start with surgical treatment first. Use antibiotics only when causative organisms are identified.

Duration: 4-6 weeks

Spreading Infections and Infections of Fascial Spaces (with/without Systemic Signs)

Infection/Condition and Likely Organism	Suggested Treatment		Comments
	Preferred Treatment	Alternative Treatment
Cellulitis/Abscess of dental origin Common organisms: Viridans Streptococci Staphylococci Prevotella Peptostreptococcus Fusobacterium nucleatum Clostridium spp. Surgical site infection and Traumatic wound infection Common organisms: Viridans Streptococci Staphylococci Prevotella Peptostreptococcus Fusobacterium nucleatum	Benzylpenicillin 2-4MU IV q4-6h PLUS Metronidazole 500mg IV q8h OR Amoxicillin-clavulanate 1.2 gm IV q8h PLUS Metronidazole 500mg IV q8h	Penicillin allergy Clindamycin 300-450 IV/ PO q6h If not responding to preferred treatment: Ceftriaxone 1-2gm IV q24h PLUS Metronidazole 500mg IV q8h	Incision and drainage as required.
	Step Down/Oral Therapy Amoxicillin 250-750mg PO q8h PLUS Metronidazole 400mg PO q8-12h OR Amoxicillin-clavulanate 625mg PO q8h OR Cefuroxime 250-500mg PO q12h PLUS Metronidazole 400mg PO q8-12h	Penicillin allergy Clindamycin 300-450mg PO q6h
Infection of skin origin / Wound infection involving skin	Cloxacillin 500-1000mg IV q6h OR Clindamycin 300-450mg IV/PO q6h OR Amoxicillin 250-750mg PO q8h PLUS Metronidazole 400mg PO q8-12h

Post Implant Infection (“Periimplantitis”)

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Causative Organisms:

Actinomyces spp.

Eubacterium spp.

Propionibacterium spp.

Lactobacillus spp.

Veillonella spp.

Porphyromonas gingivalis

Prevotella intermedia

Fusobacterium nucleatum

Amoxicillin-clavulanate 625mg PO q8h

Amoxicillin 500mg PO q8h

PLUS

Metronidazole 400mg PO q8h

Penicillin allergy

Doxycycline 100mg PO q12h

Clindamycin 300mg PO q6h

Local mechanical and chemical debridement and irrigation with Chlorhexidine and optimal oral hygiene by patient is necessary.

Bacteria associated with periimplantitis are extremely resistant to antibiotics.

Antimicrobial use for Viral Infections

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Common oral viral infections:

Herpes simplex virus type 1 (HSV-1)

Primary herpetic gingivostomatitis
Herpes labialis

Herpes simplex virus type 2 (HSV-2)

Epstein-Barr virus

Infectious mononucleosis
Oral hairy leukoplakia

Varicella-zoster virus Coxsackie virus*

Herpangina
Hand, foot and mouth disease

Symptomatic treatment in most cases.

Can also consider: Topical Acyclovir 5% cream q4h for 5-10 days in prodromal phase for recurrent herpes labialis.

Systemic antiviral

Acyclovir 400-800mg PO 5 times daily for 7-14 days Acyclovir 400mg 3 times daily for 5 to 10 days in immunocompetent patient with orolabial herpes simplex virus infection.

*Management is mostly supportive. Antivirals don’t have direct effect.

Antimicrobial use for Fungal Infections

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Common oral fungal infection Oropharyngeal Candidiasis/ Oral Thrush

Topical Clotrimazole

Systemic antifungal agents

Fluconazole 200mg PO stat dose followed by 100mg PO q24h for at least 2 weeks until negative blood culture result or clinical sign of improvement.

References

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Antibiotics and The Treatment of Endodontic Infections, Endodontics colleagues for Excellence 2006; American Association of Endodontics.
Carranza’s Clinical Periodontology 12th ed.2014.
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Esposito M, Grusovin MG, Worthington HV. Treatment of peri-implantitis: what interventions are effective? A Cochrane systematic review. Eur J Oral Implantol. 2012;5 Suppl:S21-41.
Griffiths GS, Ayob R, Guerrero A, Nibali L, Suvan J, Moles DR, Tonetti MS. Amoxicillin and metronidazole as an adjunctive treatment in generalized aggressive periodontitis at initial therapy or re-treatment: a randomized controlled clinical trial. J Clin Periodontol. 2011 Jan;38.
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Incision and Drainage and Management of Cause of Abscess and Symptomatic Relief of Pain: Jan Dent Assoc2003 Nov 69 (10):660 andClin.Microbiol.Rev.2013,26(2):255.
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