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Antibiotics in EndodonticsAntibiotics in Endodontics

Killing the bugsKilling the bugs

Without the drugsWithout the drugs

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Bacteria surround usBacteria surround us::

For billions of years, bacteria haveFor billions of years, bacteria have

inhabited the earth, but only since the inhabited the earth, but only since the

beginning of the 20beginning of the 20thth century has century has

mankind been fighting these organisms.mankind been fighting these organisms.

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19281928Penicillin discoveredPenicillin discovered

Beginning with the discovery of penicillin in 1928, Beginning with the discovery of penicillin in 1928, antibiotics have been used to cure and control antibiotics have been used to cure and control

infectious diseasesinfectious diseases. .

But antibiotic treatment is a double-edged But antibiotic treatment is a double-edged sword. sword.

As antibiotics continue to be used, As antibiotics continue to be used,

bacterial resistance continues to grow.bacterial resistance continues to grow.

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Antibiotics use grow; bacterial Antibiotics use grow; bacterial resistance increasesresistance increases

All organisms evolve to survive life-All organisms evolve to survive life-threatening circumstances. Unfortunately, threatening circumstances. Unfortunately, bacteria are genetic overachievers. bacteria are genetic overachievers. Bacteria Bacteria have the ability to protect themselves have the ability to protect themselves through two processes:through two processes:

mutation mutation

and and

genetic transfer. genetic transfer.

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Antibiotics use causes:Antibiotics use causes:

1. 1. The longer a population of bacteria The longer a population of bacteria is exposed to an antibiotic, the more is exposed to an antibiotic, the more resistant survivors become. resistant survivors become.

2. 2. Beneficial microbesBeneficial microbes are also are also killed killed by antibiotics. by antibiotics.

3. 3. When antibiotics are administered inWhen antibiotics are administered in doses small enough to allow stronger doses small enough to allow stronger bacteria to survive, the selection bacteria to survive, the selection process accelerates. process accelerates.

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158 antibiotics currently available:158 antibiotics currently available:

There are currently about 158 antibiotics There are currently about 158 antibiotics

available ,and strains of bacteria resistant to available ,and strains of bacteria resistant to

each of these antibiotics have been identified. each of these antibiotics have been identified.

Unfortunately, it takes a lot of money and many Unfortunately, it takes a lot of money and many

years to develop new antibiotics. Because they years to develop new antibiotics. Because they

can be rendered useless so quickly, few new can be rendered useless so quickly, few new

drugs are under development. drugs are under development.

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One-third of all outpatient antibiotic One-third of all outpatient antibiotic prescriptions areprescriptions are not necessarynot necessary

Researchers at Researchers at The Centers for Disease ControlThe Centers for Disease Control

estimate that estimate that one-thirdone-third of all outpatient antibiotic of all outpatient antibiotic

Prescriptions are unnecessary. Prescriptions are unnecessary. As clinicians begin As clinicians begin

to understand the gravity of the situation, they are to understand the gravity of the situation, they are

re-evaluating how and when to prescribe re-evaluating how and when to prescribe

antibiotics.antibiotics.

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Misconceptions about antibiotics:Misconceptions about antibiotics:Many times, healthcare providers may prescribeMany times, healthcare providers may prescribe

antibiotics simply because patients request it, even antibiotics simply because patients request it, even

when there is no clinical justification. when there is no clinical justification.

It can be said that the general public has been misled It can be said that the general public has been misled

to believe that antibiotics make:to believe that antibiotics make:

Faster recovery.Faster recovery.

Less painful recovery.Less painful recovery.

More certain recovery.More certain recovery.

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TreatmentTreatment ++Immune system = Optimum Immune system = Optimum + healing+ healingAntibioticsAntibiotics(when appropriate)(when appropriate)

Antibiotics are an Antibiotics are an adjunctadjunct to treatment. to treatment. It is the patient’s own It is the patient’s own immune systemimmune systemthat helps the patient achieve optimum that helps the patient achieve optimum healinghealing

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Bacteria gain access to root canal system Bacteria gain access to root canal system through:through:

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

disease.disease.

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Endodontics without antibioticsEndodontics without antibiotics

When inflammation or infection is present, the When inflammation or infection is present, the

circulation in the pulp is poorcirculation in the pulp is poor.. And because And because

Antibiotics are carried by the vascular system, Antibiotics are carried by the vascular system,

their ability to reach bacteria in a strong their ability to reach bacteria in a strong enough concentration is diminished. For this enough concentration is diminished. For this reason, reason, antibiotics are not Effective in antibiotics are not Effective in endodontics.endodontics.

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Successful healing: Successful healing: can becan be achieved achieved byby

A.A. Optimal debridement:Optimal debridement:

Through debridement of the root canal system will Through debridement of the root canal system will

help remove bacteria and their by-products from help remove bacteria and their by-products from

the canal space. the canal space.

This will help eliminate infection and inflammation This will help eliminate infection and inflammation

and promote healing.and promote healing.

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B.B. Optimal obturation:Optimal obturation:

If the canal system is not obturated at the If the canal system is not obturated at the

initial appointment, a medication such as initial appointment, a medication such as

calcium hydroxide may be placed inside calcium hydroxide may be placed inside

the pulp chamber and root system the pulp chamber and root system

1. 1. to fill the spaceto fill the space, ,

2.2.to prevent recontamination,to prevent recontamination,

3.3.and to kill remaining bacteria.and to kill remaining bacteria.

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C.C. Well-placed final restoration:Well-placed final restoration:

The medication should be covered with sterile The medication should be covered with sterile

cotton pellet and sealed with a temporary cotton pellet and sealed with a temporary

restoration at least 3mm in thickness. Successful restoration at least 3mm in thickness. Successful

healing depends onhealing depends on

optimal debridement followedoptimal debridement followed

by by a well-condensed root canal fillinga well-condensed root canal filling

and and final restoration.final restoration.

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Drainage through incision:Drainage through incision:

Occasionally the infection will move beyond Occasionally the infection will move beyond

the tooth and bone, into the soft tissue. This the tooth and bone, into the soft tissue. This

can cause intraoral swelling.can cause intraoral swelling.

Swelling can be treated with an incision and Swelling can be treated with an incision and

drainage. This will drainage. This will eliminate bacteria, eliminate bacteria,

relieve pressure, relieve pressure,

improve circulationimprove circulation

and promote healing.and promote healing.

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Appropriate antibiotic useAppropriate antibiotic use::

To justify the need for antibiotics, an To justify the need for antibiotics, an

infection must either be: infection must either be:

persistent infection or persistent infection or

systemic infectionsystemic infection

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Antibiotics are unnecessary for:Antibiotics are unnecessary for:

PainPain

andand

Localized swelling.Localized swelling.

do not necessitate antibiotic treatment. Most dental pain do not necessitate antibiotic treatment. Most dental pain

can be managed using non-narcotic analgesics can be managed using non-narcotic analgesics

such as NSAIDs. such as NSAIDs.

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Factors to evaluate:Factors to evaluate:

When determining if antibiotics should be used When determining if antibiotics should be used to treat a patient, several factors should be to treat a patient, several factors should be evaluated: evaluated:

Patient’s health. Patient’s health. Is the patient in good Is the patient in good health? If not, it is more likely that health? If not, it is more likely that antibiotics will be needed.antibiotics will be needed.

Development of symptoms: Development of symptoms: How rapidly How rapidly did the symptoms occur? Swelling or fever did the symptoms occur? Swelling or fever that escalates within a 24-to 72- hour period that escalates within a 24-to 72- hour period may indicate that an infection is spreading, may indicate that an infection is spreading, and antibiotics are likely needed. and antibiotics are likely needed.

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

Risk vs. benefits: Risk vs. benefits: It is also It is also important to consider the benefits important to consider the benefits versus the risks of antibiotic versus the risks of antibiotic treatment.treatment.

Signs of systemic involvement.Signs of systemic involvement.

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Allergic reaction:Allergic reaction: Approximately three to six Approximately three to six percent of patients experience an allergic percent of patients experience an allergic reaction to penicillin. This can range from a reaction to penicillin. This can range from a minor rash to a life-threatening anaphylaxis.minor rash to a life-threatening anaphylaxis.

Other side effects:Other side effects: Some patients Some patients experience side effects, such as gastrointestinal experience side effects, such as gastrointestinal problems or secondary infections. problems or secondary infections.

Interference with other drugs:Interference with other drugs: Women of Women of childbearing age should be alerted of the childbearing age should be alerted of the possibility that antibiotics may interfere with the possibility that antibiotics may interfere with the efficacy of birth control pills.efficacy of birth control pills.

Risks of antibiotics treatment:Risks of antibiotics treatment:

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Systemic involvement warrants Systemic involvement warrants antibiotics:antibiotics:

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

Cellulitis or extraoral swelling.Cellulitis or extraoral swelling. Lymphadenopathy.Lymphadenopathy. Elevated body temperature.Elevated body temperature. Malaise.Malaise. Unexplained trismus.Unexplained trismus.

Usually require antibiotic treatment and/or Usually require antibiotic treatment and/or surgical drainage. surgical drainage.

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What are the antibioticsWhat are the antibiotics

Used to manage endodontic infectionsUsed to manage endodontic infections

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Penicillin VK:Penicillin VK:

Penicillin VK is Penicillin VK is the drug of choicethe drug of choice for the majority for the majority

of of oral infections.oral infections.

It is effective against most It is effective against most aerobicaerobic and and anaerobicanaerobic

bacteriabacteria that are commonly present in the that are commonly present in the

mouth.mouth.

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Dosage:Dosage:

Penicillin VK:Penicillin VK:

A loading dose of A loading dose of 1000 mg1000 mg of penicillin VK should be of penicillin VK should be given, followed by given, followed by 500 mg500 mg every six hours for every six hours for five to five to seven days.seven days.

Consider contacting the patient after 24 hours to assess Consider contacting the patient after 24 hours to assess his or her condition. his or her condition.

Improvement should be rapid. If there is no improvement Improvement should be rapid. If there is no improvement after 48 hours, penicillin may be supplemented with after 48 hours, penicillin may be supplemented with metronidazole.metronidazole.

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Metronidazole:Metronidazole:

Metronidazole is a synthetic antibiotic that is Metronidazole is a synthetic antibiotic that is

highly effective against highly effective against strict anaerobesstrict anaerobes but is but is

not effective against facultative anaerobic not effective against facultative anaerobic

bacteria. bacteria.

►►If penicillin is ineffective after 24 to 48 If penicillin is ineffective after 24 to 48

hours, metronidazole is a valuable antimicrobial hours, metronidazole is a valuable antimicrobial

agent for combination antibiotic therapy. agent for combination antibiotic therapy.

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Dosage:Dosage:

A recommended loading dose of A recommended loading dose of 500 mg500 mg of of metronidazole is recommended, metronidazole is recommended,

followed by an oral dosage of followed by an oral dosage of 250 mg250 mg every six every six hours for hours for seven to tenseven to ten days. days.

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Amoxicillin:Amoxicillin:

It is a derivative of penicillin VK. It is a derivative of penicillin VK.

It has a broader spectrumIt has a broader spectrumIt is better absorbed from the It is better absorbed from the

gastrointestinal tractgastrointestinal tractIt provides a higher and longer It provides a higher and longer

sustained serum level.sustained serum level.

butbut

Its use increase the antibiotic resistanceIts use increase the antibiotic resistance..

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Dosage for amoxicillin is similar to that Dosage for amoxicillin is similar to that of penicillin VK.of penicillin VK.

Some practitioners may also choose to Some practitioners may also choose to use use cephalosporin cephalosporin in place of a in place of a penicillin-type drug.penicillin-type drug.

Dosage for cephalosporins is similar to Dosage for cephalosporins is similar to that of penicillinVK. that of penicillinVK.

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ClindamycinClindamycin::

is good substitute for those allergic to penicillin.is good substitute for those allergic to penicillin.

It is highly effective against strict and facultative It is highly effective against strict and facultative anaerobesanaerobes

Although clindamycin has been linked withAlthough clindamycin has been linked with

pseudomembranous colitispseudomembranous colitis,, studies show that studies show that

colitis is a possible side effect of most colitis is a possible side effect of most antibiotics, such as amoxicillin and antibiotics, such as amoxicillin and cephalosporin. cephalosporin.

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Dosage:Dosage:

A loading dose of A loading dose of 300 mg300 mg of clindamycin is of clindamycin is

recommended, followed by recommended, followed by 150 mg150 mg every every

six hours for six hours for seven to tenseven to ten days. days.

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Erythromycin:Erythromycin:

Erythromycin is another antibiotic that is commonly Erythromycin is another antibiotic that is commonly

prescribed for patients who are allergic to penicillin.prescribed for patients who are allergic to penicillin.

Unfortunately, it has been shown to be Unfortunately, it has been shown to be ineffective ineffective

against most of the anaerobes associated with against most of the anaerobes associated with

endodontic infectionsendodontic infections, so other antibiotics are , so other antibiotics are

preferred. preferred.

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Clarithromycin(Klaribac)Clarithromycin(Klaribac)

Active against:Active against:

Gram-positive + Gram-negativeGram-positive + Gram-negative

Aerobic & AnaerobicAerobic & Anaerobic BacteriaBacteria

Klaribac adult dose=250mg twice/daily, Klaribac adult dose=250mg twice/daily, increased to 500mg if necessary; in severe increased to 500mg if necessary; in severe infections for (7 to 14 days).infections for (7 to 14 days).

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A recent articleA recent article in the in the JOEJOE showed:showed:

AugmentinAugmentin which is a combination of which is a combination of amoxicillinamoxicillin and and clavulanateclavulanate

Has the best efficacy against bacteria isolated from Has the best efficacy against bacteria isolated from endodontic infection and may be indicated to treat endodontic infection and may be indicated to treat serious endodontic infection, especially in serious endodontic infection, especially in immunocompromisedimmunocompromised patients patients

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Treatment regimensTreatment regimens::

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

Patient compliance critical:Patient compliance critical: The patient must The patient must understand that adherence to the dosing schedule is understand that adherence to the dosing schedule is imperative to eliminate the infection.imperative to eliminate the infection.

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Postoperative Endodontic PainPostoperative Endodontic Pain

Although some patients may experience moderate to Although some patients may experience moderate to severe pain after endodontic treatment ,very few severe pain after endodontic treatment ,very few experience what is now commonly referred to asexperience what is now commonly referred to as

Flare-upFlare-up : : a postoperative problem requiring an unscheduled a postoperative problem requiring an unscheduled dental visit with unplanned treatment to manage the patient’s dental visit with unplanned treatment to manage the patient’s symptoms .symptoms .

Numerous studies have evaluated factors related to postoperative Numerous studies have evaluated factors related to postoperative endodontic pain and flare-up to better predict when these endodontic pain and flare-up to better predict when these conditions are more likely to occurconditions are more likely to occur

teeth with necrotic pulp

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factors related to postoperativefactors related to postoperative endodontic pain and flare-upendodontic pain and flare-up

►►the presence of the presence of preoperativepreoperative pain or mechanical allodynia pain or mechanical allodynia

►►teeth with necrotic pulp teeth with necrotic pulp ►►no correlation / the presence or absence of a periradicular no correlation / the presence or absence of a periradicular

radiolucency. radiolucency. ►►that one-visit endodontic retreatment cases involving teeth that one-visit endodontic retreatment cases involving teeth

with apical periodontitis had almost a tenfold higher with apical periodontitis had almost a tenfold higher incidence of flare-ups incidence of flare-ups

►►It is recommended that retreatment of teeth with apical It is recommended that retreatment of teeth with apical periodontitis should not be completed in one visit periodontitis should not be completed in one visit

►►whereas, treatment of teeth with AP can be done in one whereas, treatment of teeth with AP can be done in one visitvisit

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GlucocorticosteroidsGlucocorticosteroids Glucocorticosteroids are known to reduce Glucocorticosteroids are known to reduce

the acute inflammatory response by several the acute inflammatory response by several mechanisms.mechanisms.

Therefore a number of investigations have Therefore a number of investigations have evaluated the efficacy of corticosteroids evaluated the efficacy of corticosteroids (administered via either (administered via either intracanalintracanal or or systemic systemic routes) in the prevention or routes) in the prevention or control of postoperative endodontic pain or control of postoperative endodontic pain or flare-ups. flare-ups.

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DexamethasoneDexamethasone solution solution formocresolformocresol (the corticosteroid antibiotic paste (the corticosteroid antibiotic paste LedermixLedermix,, Intracanal steroids appear to have a Intracanal steroids appear to have a

significant effect in reducing postoperative pain.significant effect in reducing postoperative pain. Systemic administration of Systemic administration of dexamethasonedexamethasone

Reduces the severity of postoperative endodontic Reduces the severity of postoperative endodontic pain. pain.

However, given the relative safety/efficacy However, given the relative safety/efficacy relationship between steroids and NSAIDs, most relationship between steroids and NSAIDs, most investigators choose an NSAID as the drug of first investigators choose an NSAID as the drug of first choice for postoperative pain control. choice for postoperative pain control.

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Management of endodontic painManagement of endodontic pain

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

NSAIDsNSAIDs and and acetaminophenacetaminophen

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Selected Nonnarcotic analgesicsSelected Nonnarcotic analgesics

AcetaminophenAcetaminophen AspirinAspirin DiclofenacDiclofenac IbuprofenIbuprofen NaproxenNaproxen          

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Limitations and Drug InteractionsLimitations and Drug Interactions

including those affecting the gastrointestinal including those affecting the gastrointestinal system (3% to 11% incidence) and system (3% to 11% incidence) and

the CNS (1% to 9% incidence of dizziness the CNS (1% to 9% incidence of dizziness and headache). and headache).

NSAIDs are contraindicated in patients with NSAIDs are contraindicated in patients with ulcers and ulcers and aspirin aspirin hypersensitivity hypersensitivity

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The NSAIDs interact with other drugsThe NSAIDs interact with other drugs

Summary of Drug InteractionsSummary of Drug Interactions AnticoagulantsAnticoagulants : Prolonged prothrombin time or : Prolonged prothrombin time or

increased bleeding with anticoagulants (e.g., increased bleeding with anticoagulants (e.g., coumarins)coumarins)

Angiotensin-converting enzymeAngiotensin-converting enzyme (ACE) inhibitors: (ACE) inhibitors: Reduced antihypertensive effectiveness of Reduced antihypertensive effectiveness of captoprilcaptopril

Beta blockers:Beta blockers: Reduced antihypertensive effects Reduced antihypertensive effects of beta blockers (e.g., inderal,)of beta blockers (e.g., inderal,)

CyclosporineCyclosporine: Increased risk of nephrotoxicity: Increased risk of nephrotoxicity DigoxinDigoxin : Elevated serum digoxin levels : Elevated serum digoxin levels

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AcetaminophenAcetaminophen and and opioid combinationopioid combination drugs drugs

are an alternative for patients unable to take NSAIDs.are an alternative for patients unable to take NSAIDs. Further information is available from a number of sources on the Further information is available from a number of sources on the

pharmacology and adverse effects of this important class of pharmacology and adverse effects of this important class of drugsdrugs

Other resources are also available for evaluation of drug Other resources are also available for evaluation of drug

interactions, including Internet drug search engines such as interactions, including Internet drug search engines such as rxlist.comrxlist.com, ,

Epocrates.comEpocrates.com, and , and Endodontics.UTHSCSA.eduEndodontics.UTHSCSA.edu. .

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Antibiotics to manage flare-ups?Antibiotics to manage flare-ups?

Clinical trails have shown that administering Clinical trails have shown that administering

antibiotics before treatment does not reduce the antibiotics before treatment does not reduce the

incidence of flare-ups following treatment. To incidence of flare-ups following treatment. To

justify the use of an antibiotic in the management justify the use of an antibiotic in the management

of a flare-up, an infection must either be persistent of a flare-up, an infection must either be persistent

or systemic.or systemic.

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Case study # 1Case study # 1::

23-year-old man.23-year-old man.Tooth hit with baseball.Tooth hit with baseball.No luxation.No luxation.Localized swelling.Localized swelling.

Because the swelling was localized, Because the swelling was localized, the tooth was drained through an the tooth was drained through an access opening on the lingual access opening on the lingual surface and the surface and the

swelling was reduced significantly. swelling was reduced significantly. Root canal treatment was Root canal treatment was successful successful without without the use of the use of antibiotics. antibiotics.

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Case study # 2Case study # 2::

45-year-old woman.45-year-old woman.Severe toothache.Severe toothache.Deep carious lesion.Deep carious lesion.Large, diffuse swelling.Large, diffuse swelling.

fever,lemphadenopathyfever,lemphadenopathyTXTX: an incision for drainage. A loading : an incision for drainage. A loading

dose of dose of 1000 mg of penicillin1000 mg of penicillin was was

prescribed, followed by prescribed, followed by 500 mg500 mg every six hours. every six hours. The case was completed in The case was completed in 10 days10 days and the and the patient was symptom free.patient was symptom free.

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Responsible use of antibiotics is up to all of usResponsible use of antibiotics is up to all of us

. By stimulating the development of resistant . By stimulating the development of resistant strains of bacteria, these medications strains of bacteria, these medications permanently alter the microbial environment.permanently alter the microbial environment.

Dentist, physicians and patients have a serious Dentist, physicians and patients have a serious responsibility to understand why antibiotics responsibility to understand why antibiotics must be administered with caution and to must be administered with caution and to adhere to the principles that govern their adhere to the principles that govern their appropriate use. appropriate use.

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