Antibiotics in Endodontics

Killing the bugs

Without the drugs

:Bacteria surround us
For billions of years, bacteria have
inhabited the earth, but only since the
beginning of the 20th century has
mankind been fighting these organisms.

1928
Penicillin discovered
Beginning with the discovery of penicillin in 1928,
antibiotics have been used to cure and control
infectious diseases.

But antibiotic treatment is a double-edged

sword.
As antibiotics continue to be used,
bacterial resistance continues to grow.

Antibiotics use grow; bacterial

resistance increases
All organisms evolve to survive lifethreatening circumstances. Unfortunately,
bacteria are genetic overachievers. Bacteria
have the ability to protect themselves
through two processes:
mutation
and
genetic transfer.
4

Antibiotics use causes:

1. The longer a population of bacteria
is exposed to an antibiotic, the more
resistant survivors become.
2. Beneficial microbes are also killed
by antibiotics.
3. When antibiotics are administered in
doses small enough to allow stronger
bacteria to survive, the selection
process accelerates.
5

158 antibiotics currently available:

There are currently about 158 antibiotics
available ,and strains of bacteria resistant to
each of these antibiotics have been identified.
Unfortunately, it takes a lot of money and many
years to develop new antibiotics. Because they
can be rendered useless so quickly, few new
drugs are under development.

One-third of all outpatient antibiotic

prescriptions are not necessary
Researchers at The Centers for Disease Control
estimate that one-third of all outpatient antibiotic
Prescriptions are unnecessary. As clinicians begin
to understand the gravity of the situation, they are
re-evaluating how and when to prescribe
antibiotics.
7

Misconceptions about antibiotics:

Many times, healthcare providers may prescribe
antibiotics simply because patients request it, even
when there is no clinical justification.
It can be said that the general public has been misled
to believe that antibiotics make:

Faster recovery.
Less painful recovery.
More certain recovery.

Treatment
+
Immune system = Optimum
+
healing
Antibiotics
(when appropriate)
Antibiotics are an adjunct to treatment.
It is the patients own immune system
that helps the patient achieve optimum
healing
9

Bacteria gain access to root canal system

through:
Caries.
Exposed pulp.
Cracks in dentin.
Leaking restorations.
Canals exposed by advancing periodontal
disease.

10

Endodontics without antibiotics

When inflammation or infection is present, the
circulation in the pulp is poor. And because
Antibiotics are carried by the vascular system,
their ability to reach bacteria in a strong
enough concentration is diminished. For this
reason, antibiotics are not Effective in
endodontics.
11

Successful healing: can be achieved

by
A. Optimal debridement:
Through debridement of the root canal system will
help remove bacteria and their by-products from
the canal space.
This will help eliminate infection and inflammation
and promote healing.

12

B. Optimal obturation:
If the canal system is not obturated at the
initial appointment, a medication such as
calcium hydroxide may be placed inside
the pulp chamber and root system
1. to fill the space,
2.to prevent recontamination,
3.and to kill remaining bacteria.
13

C. Well-placed final restoration:

The medication should be covered with sterile
cotton pellet and sealed with a temporary
restoration at least 3mm in thickness. Successful
healing depends on
optimal debridement followed
by a well-condensed root canal filling
and final restoration.

14

Drainage through incision:

Occasionally the infection will move beyond
the tooth and bone, into the soft tissue. This
can cause intraoral swelling.
Swelling can be treated with an incision and
drainage. This will eliminate bacteria,
relieve pressure,
improve circulation
and promote healing.
15

16

:Appropriate antibiotic use

To justify the need for antibiotics, an
infection must either be:
persistent infection or
systemic infection

17

Antibiotics are unnecessary for:

Pain
and
Localized swelling.
do not necessitate antibiotic treatment. Most dental pain
can be managed using non-narcotic analgesics
such as NSAIDs.

18

Factors to evaluate:
When determining if antibiotics should be used
to treat a patient, several factors should be
evaluated:
Patients health. Is the patient in good
health? If not, it is more likely that
antibiotics will be needed.
Development of symptoms: How rapidly
did the symptoms occur? Swelling or fever
that escalates within a 24-to 72- hour period
may indicate that an infection is spreading,
and antibiotics are likely needed.
19

Extent of inflammation: What is the

extent of soft tissue inflammation? If swelling is
localized, the infection may be managed by
surgical drainage.. A large, diffuse swelling may
require antibiotics as well as surgical drainage.

Risk vs. benefits: It is also

important to consider the benefits
versus the risks of antibiotic
treatment.
Signs of systemic involvement.

20

Risks of antibiotics treatment:

Allergic reaction: Approximately three to six
percent of patients experience an allergic
reaction to penicillin. This can range from a
minor rash to a life-threatening anaphylaxis.
Other side effects: Some patients
experience side effects, such as gastrointestinal
problems or secondary infections.
Interference with other drugs: Women of
childbearing age should be alerted of the
possibility that antibiotics may interfere with the
efficacy of birth control pills.
21

Systemic involvement warrants

antibiotics:
It is also important to determine if there are signs of
regional or systemic involvement when
prescribing antibiotics. Patients who have:

Cellulitis or extraoral swelling.

Lymphadenopathy.
Elevated body temperature.
Malaise.
Unexplained trismus.
Usually require antibiotic treatment and/or
surgical drainage.
22

What are the antibiotics

Used to manage endodontic infections

23

Penicillin VK:
Penicillin VK is the drug of choice for the majority
of oral infections.
It is effective against most aerobic and anaerobic
bacteria that are commonly present in the
mouth.

24

Dosage:
Penicillin VK:
A loading dose of 1000 mg of penicillin VK should be
given, followed by 500 mg every six hours for five to
seven days.
Consider contacting the patient after 24 hours to assess
his or her condition.
Improvement should be rapid. If there is no improvement
after 48 hours, penicillin may be supplemented with
metronidazole.

25

Metronidazole:
Metronidazole is a synthetic antibiotic that is
highly effective against strict anaerobes but is
not effective against facultative anaerobic
bacteria.
If penicillin is ineffective after 24 to 48
hours, metronidazole is a valuable antimicrobial
agent for combination antibiotic therapy.

26

Dosage:
A recommended loading dose of 500 mg of
metronidazole is recommended,
followed by an oral dosage of 250 mg every six
hours for seven to ten days.

27

Amoxicillin:
It is a derivative of penicillin VK.
It has a broader spectrum
It is better absorbed from the
gastrointestinal tract
It provides a higher and longer sustained
serum level.
but
Its use increase the antibiotic resistance .

28

Dosage for amoxicillin is similar to that

of penicillin VK.
Some practitioners may also choose to
use cephalosporin in place of a
penicillin-type drug.
Dosage for cephalosporins is similar to
that of penicillinVK.

29

:Clindamycin
is good substitute for those allergic to penicillin.
It is highly effective against strict and facultative
anaerobes
Although clindamycin has been linked with

pseudomembranous colitis,
studies show that
colitis is a possible side effect of most
antibiotics, such as amoxicillin and
cephalosporin.
30

Dosage:
A loading dose of 300 mg of clindamycin is
recommended, followed by 150 mg every
six hours for seven to ten days.

31

Erythromycin:
Erythromycin is another antibiotic that is commonly
prescribed for patients who are allergic to penicillin.
Unfortunately, it has been shown to be ineffective against
most of the anaerobes associated with endodontic
infections, so other antibiotics are preferred.

32

Clarithromycin(Klaribac)
Active against:
Gram-positive + Gram-negative
Aerobic & Anaerobic Bacteria
Klaribac adult dose=250mg twice/daily,
increased to 500mg if necessary; in severe
infections for (7 to 14 days).

33

A recent article in the JOE showed:

Augmentin which is a combination of
amoxicillin and clavulanate
Has the best efficacy against bacteria isolated from
endodontic infection and may be indicated to treat
serious endodontic infection, especially in
immunocompromised patients
34

:Treatment regimens
Short and aggressive: Treatment regimens should be
short and aggressive to minimize the development of
resistant bacteria and to achieve a therapeutic
concentration of the drug.

Patient compliance critical: The patient must

understand that adherence to the dosing schedule is
imperative to eliminate the infection.

35

Postoperative Endodontic Pain

Although some patients may experience moderate to
severe pain after endodontic treatment ,very few
experience what is now commonly referred to as
Flare-up : a postoperative problem requiring an unscheduled
teeth treatment
with necrotic pulp
dental visit with unplanned
to manage the patients
symptoms .
Numerous studies have evaluated factors related to postoperative
endodontic pain and flare-up to better predict when these
conditions are more likely to occur

36

factors related to postoperative

endodontic pain and flare-up
the presence of preoperative pain or mechanical allodynia
teeth with necrotic pulp
no correlation / the presence or absence of a periradicular
radiolucency.
that one-visit endodontic retreatment cases involving teeth
with apical periodontitis had almost a tenfold higher
incidence of flare-ups
It is recommended that retreatment of teeth with apical
periodontitis should not be completed in one visit
whereas, treatment of teeth with AP can be done in one
visit
37

Glucocorticosteroids
Glucocorticosteroids are known to reduce
the acute inflammatory response by several
mechanisms.
Therefore a number of investigations have
evaluated the efficacy of corticosteroids
(administered via either intracanal or
systemic routes) in the prevention or
control of postoperative endodontic pain or
flare-ups.

38

Dexamethasone solution
formocresol (the corticosteroid antibiotic paste
Ledermix, Intracanal steroids appear to have a
significant effect in reducing postoperative pain.
Systemic administration of dexamethasone
Reduces the severity of postoperative endodontic
pain.
However, given the relative safety/efficacy
relationship between steroids and NSAIDs, most
investigators choose an NSAID as the drug of first
choice for postoperative pain control.

39

Management of endodontic pain

endodontic pain can be managed through
combined endodontic procedures and
pharmacotherapy. A major class of drugs for
managing endodontic pain is the
nonnarcotic analgesics, which include both
NSAIDs and
acetaminophen

40

Selected Nonnarcotic analgesics

Acetaminophen
Aspirin
Diclofenac
Ibuprofen
Naproxen

41

Limitations and Drug Interactions

including those affecting the gastrointestinal
system (3% to 11% incidence) and
the CNS (1% to 9% incidence of dizziness
and headache).
NSAIDs are contraindicated in patients with
ulcers and aspirin hypersensitivity

42

The NSAIDs interact with other drugs

Summary of Drug Interactions

Anticoagulants : Prolonged prothrombin time or
increased bleeding with anticoagulants (e.g.,
coumarins)
Angiotensin-converting enzyme (ACE) inhibitors:
Reduced antihypertensive effectiveness of
captopril
Beta blockers: Reduced antihypertensive effects
of beta blockers (e.g., inderal,)
Cyclosporine: Increased risk of nephrotoxicity
Digoxin : Elevated serum digoxin levels
43

 Acetaminophen and opioid combination drugs

are an alternative for patients unable to take NSAIDs.

Further information is available from a number of sources on the

pharmacology and adverse effects of this important class of
drugs
Other resources are also available for evaluation of drug
interactions, including Internet drug search engines such as
rxlist.com,
Epocrates.com, and
Endodontics.UTHSCSA.edu.

44

Antibiotics to manage flare-ups?

Clinical trails have shown that administering
antibiotics before treatment does not reduce the
incidence of flare-ups following treatment. To
justify the use of an antibiotic in the management
of a flare-up, an infection must either be persistent
or systemic.

45

:Case study # 1
23-year-old man.
Tooth hit with baseball.
No luxation.
Localized swelling.
Because the swelling was localized,
the tooth was drained through an
access opening on the lingual
surface and the
swelling was reduced significantly.
Root canal treatment was
successful without the use of
antibiotics.
46

:Case study # 2
45-year-old woman.
Severe toothache.
Deep carious lesion.
Large, diffuse swelling.
fever,lemphadenopathy
TX: an incision for drainage. A loading
dose of 1000 mg of penicillin was
prescribed, followed by 500 mg every six hours.
The case was completed in 10 days and the
patient was symptom free.

47

Responsible use of antibiotics is up to all of us

. By stimulating the development of resistant

strains of bacteria, these medications
permanently alter the microbial environment.
Dentist, physicians and patients have a serious
responsibility to understand why antibiotics
must be administered with caution and to
adhere to the principles that govern their
appropriate use.
48

49