What are the indications for antibiotics in oral surgery?

From the Guidelines

Antibiotics in oral surgery are primarily indicated for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis, and for procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of oral mucosa. The use of antibiotics in oral surgery should be based on the risk of adverse outcomes from infective endocarditis, rather than the lifetime risk of acquisition of infective endocarditis 1.

Indications for Antibiotics

• Patients with prosthetic heart valves or prosthetic material used for valve repair
• Patients with a past history of infective endocarditis
• Patients with cardiac valvulopathy after cardiac transplantation
• Specific patients with congenital heart disease (CHD)
• Procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa, such as biopsies, suture removal, and placement of orthodontic bands

Antibiotic Regimens

• Amoxicillin 2g as a single dose 30-60 minutes before the procedure for prophylaxis in high-risk cardiac patients
• Amoxicillin 500mg three times daily for 5-7 days or clindamycin 300mg four times daily for penicillin-allergic patients for treatment of infections

Rationale for Antibiotic Use

The rationale for antibiotic use is to prevent bacterial spread into deeper tissues and bloodstream, particularly targeting common oral pathogens like streptococci, anaerobes, and gram-negative bacteria 1. However, the risk of antibiotic-associated adverse effects exceeds the benefit of prophylactic antibiotic therapy, and maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of infective endocarditis 1.

Important Considerations

• Antibiotics should not be used routinely for simple extractions in healthy patients or as a substitute for proper surgical technique and oral hygiene
• Overuse of antibiotics contributes to bacterial resistance, so they should be prescribed judiciously based on clinical assessment rather than as a routine practice
• The effectiveness of antibiotic prophylaxis in preventing infective endocarditis is unknown, and the current recommendations are based on a critical review of the published data and a focus on the risk of adverse outcomes after infective endocarditis 1.

From the FDA Drug Label

Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Streptococcusspecies. (α-and β-hemolytic isolates only), Streptococcus pneumoniae, Staphylococcusspp., or Haemophilus influenzae.

Infections of the Genitourinary Tract: Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Escherichia coli, Proteus mirabilis, or Enterococcus faecalis

Infections of the Skin and Skin Structure:Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Streptococcusspp. (α-and β-hemolytic isolates only), Staphylococcusspp., or E. coli.

Infections of the Lower Respiratory Tract:Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Streptococcusspp. (α-and β-hemolytic isolates only), S. pneumoniae, Staphylococcusspp., or H. influenzae.

The indications for antibiotics in oral surgery are not explicitly stated in the provided drug labels. However, based on the information provided, antibiotics such as amoxicillin may be indicated for the treatment of various infections, including:

• Upper Respiratory Tract Infections
• Infections of the Genitourinary Tract
• Infections of the Skin and Skin Structure
• Infections of the Lower Respiratory Tract

It is essential to note that the decision to use antibiotics in oral surgery should be based on the specific clinical situation and the presence of a proven or strongly suspected bacterial infection 2, 2.

From the Research

Indications for Antibiotics in Oral Surgery

The use of antibiotics in oral surgery is a common practice to prevent surgical site infections. The following are some indications for antibiotics in oral surgery:

• Surgical extractions of third molars 3
• Comminuted mandibular fractures 3
• Temporomandibular joint replacements 3
• Clean-contaminated tumour removal 3
• Complex implants 3
• Intraoral bone-grafting procedures 4, 5, 6
• Compound fractures and those communicating with paranasal sinuses in traumatology 7
• Oncological surgery, particularly in cases where oral mucosa and cervical area contact 7

Procedures that do not Require Antibiotics

The following procedures do not require routine antibiotic prophylaxis:

• Fractures of the upper or midface facial thirds 3
• Orthognathic surgery, although short-term treatment may be preferred in some cases 7
• Oral surgery and surgery of the salivary glands in healthy patients 7

Antibiotic Selection and Timing

The selection of antibiotics depends on the type of surgery and the degree of contamination 4, 7. The timing and dosage of antibiotics are also critical to their efficacy 4. A single-dose preoperative prophylactic antibiotic regimen has been shown to be effective in reducing the incidence of surgical site infections in intraoral bone-grafting procedures 5, 6.