SUBMITTED BY:

ARTI

BDS – INTERN

BATCH – 2008 – 2013

RxAntiboiticsNSAIDSGI relife eg. H2 blokers, proton pump inhibitors

Cardinal Rules: 1) Use the right drug. 2) Use the right dose. 3) Use the correct dosing schedule. 4) Correct duration.

Avoid combinations of bacteriostatic and bacteriocidal drugs.

Gram Positive?Gram Negative?Mixed Infection?Anaerobes?

Narrow Spectrum?Broad Spectrum?Anaerobes? Consider if the infection is present

> 3days or if no improvement.

Specific for the pathogen.Fewer disturbances of non-pathogenic

bacteria.Fewer side effects.Rapid response for sensitive organisms.Ex: Pen VK, Pen G, Erythromycin

Affects both Gram + and Gram – bacteria, better for mixed infections.

May give up some effectiveness for Gram + to gain effectiveness for Gram -.

Examples: Amoxicillin, Ampicillin

Necrotic pulp and apical abscesses1. Obligate anaerobic bacteria

a. Gram negative rodsPrevotella & porphyomonas spp.

Fusobacterium spp.Campylobacter rectus

b. Gram positive rodsEubacterium spp.

Actinomycetes spp.c. Gram positive cocci

Peptostreptococcus spp.2. Facultative anaerobic bacteria

Gram positive cocciStrep and Entercoccus spp.

1. ß-Lactams2. Cephalosporins3. Lincosamides4. Macrolides5. Nitroimidazoles6. Fluoroquinolones

Natural penicillins (Pen VK and Pen G)MOA: Inhibit cell wall synthesisDose: 250-500 mg qid x 7-10 daysContraindications:

AllergiesPoor renal fxn

Adverse events: GI upsetDrug interactions: oral contraceptivesPregnancy category B

Bactericidal Spectrum:

Strep, staph, enterococcus, neiseria, treponema, listeria

Resistance: Mostly staph (>80%)

Amino-penicillinsAmoxicillin, ampicillin

MOA: Inhibit cell wall synthesisDose: 250-500 mg q 8 h x 7-10 daysContraindications:

AllergiesPoor renal fxn

Adverse events: GI upsetDrug interactions: oral contraceptivesAmoxicillin and clavulanic acid (Augmentin)

. BactericidalSpectrum:

Strep, staph, enterococcus, neiseria, treponema, listeria, E. coli, proteus, H. Flu, shigella, salmonella

Resistance: Entero, citro, serratia, proteus vulagris, provedincia,

morganella, pseudomonas aeriginosa, acinetobacter

Cephalexin (Keflex)MOA: Inhibit cell wall synthesisDose: 250-1000mg q 6 h x 7-10 daysContraindications:

AllergiesPoor renal fxn

Adverse events: mild GIDrug interactions: probenecidPregnancy category B

Cephalexin (Keflex) Bactericidal Spectrum:

Gram + Resistance:

Methicillin resistant gram +

Clindamycin (Cleocin)MOA: binds to the 50S ribosomal subunit and

inhibits protein synthesisDose: 100-450mg q 6 h x 7-10 daysPrecautions:

Poor hepatic fxnAdverse events: GI upset,

pseudomembraneous colitisDrug interactions: neuromuscular blocking

agentsPregnancy category B

Bactericidal or static depending on concentration

Spectrum:Gram +, anaerobes, parasites

ResistanceEnteroccocus

*Clostridium diff. pseudomembranous colitis!!

Azithromycin (Zithromax), clarithromycin (Biaxin)MOA: bind to the 23S rRNA in the 50S subunit

ribosomeDose: 250-500 mg/day x 5-10 daysPrecautions :

Poor hepatic fxnAdverse effects: GIDrug interactions: Cytochrome P-450

(Remember Seldane?)Pregnancy category B

Bactericidal Spectrum:

Gram +, gram -, anaerobes Resistance:

B. fragilis, and strep pneumo

Doxycycline (Vibramycin)MOA: inhibit protein synthesis by preventing

aminoacyl transfer RNA from entering the acceptor sites on the ribosome

Dose: 100mg qd-bid x 7-14 daysContraindications:

pregnancyAdverse events: GI Drug interactions: anti-epilepticsPregnancy category D

DoxycyclineBacteriostaticSpectrum:

Broad, Gram +, -, anaerobes, aerobes, and spirochetes

Resistance:Widespread, cross resistance

PHOTO SENSITIVITY!!!

Metronidazole (Flagyl)MOA: reduced intermediate interacts and

breaks the bacterial or parasitic DNADose: 250-1000 mg q 6-8 h x 7-10 daysPrecautions : poor hepatic fxnAdverse events: HA, N/V/DDrug interactions: EtOH, warfarin, Li+Pregnancy category D

Bactericidal Spectrum:

Gram - anaerobes Resistance:

Rare, H. Pylori? Unpleasant metallic taste

Ciprofloxacin (Cipro)MOA: Inhibition of DNA gyrase, and Topo IIDose: 250-500 mg qd x 7-10 daysContraindications: <18 yrs old, pregnancyAdverse events: spontaneous tendon ruptureDrug interactions: probenacid, warfarinPregnancy category C

CiprofloxacinBactericidalSpectrum:

Very broad except B. fragResistance:

MRSA, MRSE

Should be given to patients with a history of:• Prosthetic cardiac valve• Previous infective endocarditis• Cardiac transplantation recipients, who develop cardiac valvulopathy• Congenital heart disease ( CHD)* including

Should not be given to patients with history of:• Heart murmur (not as listed in 1.1)• ‘Floppy valve’• Hypertrophic cardiomyopathy• Previous Rheumatic Fever• Angina, Coronary disease, Previous MI• Cardiac Failure

The following procedures and events do not need prophylaxis:• Taking dental radiographs• Dental impressions• Routine dental anaesthetic injections through non-infected tissue• Fissure sealants• Supragingival restorations• adjustment of orthodontic appliances• root canal treatment, if not penetrating the apex

COX-2(induced by inflammatory stimuli)

Ibuprofen NaproxenFenoprofenKetoprofenoxzprozin

CelecoxibValdecoxibRofecoxib

Naproxen, ibuprofen and diclofenac are frequently used as comparators in RCTs on the safety and efficacy of COX-2 inhibitors.

BUT…

Different comparator doses may influence the results of RCTs. It has been hypothesized that RCTs of COX-2 inhibitors where different doses were administered resulted in different conclusions about the cardiovascular safety of COX-2 inhibitors. High comparator doses may let COX-2 inhibitors look better in terms of safety, while low comparator doses may result in the opposite.

Dental Infection

Acute—Rapid growth< 3 days

Chronic > 3 days

Pen VK 500mg q6h orAmox 500mg q8h or

Cephalosporin

Allergic to PCN

Clindamycin 300mg q8h orCephalosporin (check allergic Rxn) or

Azith or Clarithromycin

Think AnaerobesAdd Metronidazole 250-500mg

To PCN, Amox, or Ceph

Clindamycin 300mg q8h