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8/3/2019 Group Report 2009
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“ Effectiveness of Systemic Antibiotic Therapy on Post-
treatment Symptoms Following Root Canal Therapy”
A Systematic Review
Group- A
Authors:
A mit Narwal
Hong Zhao
Mehdi Noroozi
Prabhjot Kaur
Preeya Chaly
Roya Khoshsar,
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ABSTRACT
Objective: The purpose of this systematic review was to find a scientific and evidence based
answer to the effectiveness of systemic antibiotic therapy on prevention or reduction of post-
operative symptoms following root canal therapy/surgical endodontics. Methods: Literature search in Pub Med based on inclusion criteria (Randomized Control Trials,
Human studies, adults age 19 or older, English Language, Permanent teeth) followed by
systematic review of selected articles.
Results: Through literature search we identified 30 articles, then relevance to our study was
established by reviewing title/abstract in group and we identified 10 articles to be studied at full
text stage. Each article was read and scored in team and finally we selected 6 double blinded
placebo controlled randomized control trials for our evidence based report.
Recommendations/Conclusion: On the basis of evidence in this literature review:
1- We found no significant difference in the effectiveness of systemic antibiotics administered
either prophylactically or therapeutically in endodontic treatment/surgery in comparison to
placebo/no intervention.
2- There is a good level of evidence implying no significant advantage in the utilization of
systemic antibiotics in prevention/reduction of symptoms following endodontic treatment.
3 M d i d t ll d t i l ith t f l f f ll d li i ti th
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Introduction
The administration of systemic antibiotics as preoperative and/or postoperative on a routine basis
in endodontic emergencies and endodontic surgeries has always drawn considerable attention1.
Seemingly there is limited empirical evidence to support the effectiveness of this approach and
questions have been raised about the safety of indiscriminate antibiotic prescription3.
Antibiotics should be prescribed on the basis of a defined need otherwise their use may presentmore of a risk to the patient than the infection being treated or prevented.
2Antibiotics can be
responsible for various adverse effects, including drug interactions, selection2 and overgrowth of
resistant microorganisms. This is validated by the fact that at least 60,000 to 100,000 deaths
occur annually in United States hospitals due to nosocomial infections caused by antibiotic
resistant microorganisms4, nausea, gastrointestinal upsets, potentially fatal allergic reactions and
antibiotic associated colitis. There is clear evidence that antimicrobials are being used
inappropriately by dentists for a variety of conditions.2
Postoperative pain and swelling following instrumentation and/or obturation is of concern for
endodontic patients, dentists, and dental staff. Investigators have reported varying frequencies of
postoperative complications commonly known as a flare-up that occurs in some patients
resulting in moderate-to-severe postoperative pain and/ swelling. The incidence of an endodontic
flare-up has been reported to be 1- 24% of the time5, 6
The main factors contributing to postoperative pain and discomfort can be classified as (a)host
factors,(b) idiopathic factors, and (c)flora of infected root canals.(5)Among the three major
elements the role of bacteria and their by products is well established Irritation of peri apical
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This report deals with the evidence available concerning the efficacy of systemic antibiotics as
preoperative and/or postoperative care in endodontic emergencies and endodontic surgeries.
Only one Cochrane systematic review was found in the literature which has reviewed the use of
antibiotics for pain relief in patients with irreversible pulpitis undergoing no endodontic
treatment. They found no evidence to support the use of antibiotics for pain relief in irreversible
pulpits 3. This review sought to provide reliable evidence concerning the effectiveness of
prescribing systemic antibiotics for endodontic treatments/surgeries. Our key questions were
whether the antibiotic therapy reduces postoperative endodontic flare-ups? If yes, how effective
it is and whether the advantages of antibiotic administration outweigh the disadvantages?
Materials and methods
A systematic review of literature was carried out to identify, appreciate and critically appraise
the most relevant research to our topic of interest.
Stage 1: Search keywords in PubMed Database
We employed the following keywords to execute our research: Permanent teeth, Endodontic
treatment, Flare-up, Pain, Percussion pain, Swelling, Infection, Systemic Antibiotics. Following
outlining the keywords, we used the PubMed database to get needed articles. We used the
combination of PubMed and MESH to extract the scientific evidence. Experts from department
of Endodontics at the Toronto Faculty of Dentistry were consulted.
2- Inclusion and exclusion criteria setup
F ll i l i i h i h fi ld f d d i h i l i d
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Exclusion Criteria: We did not consider the articles which had to do with:
Endodontic treatments on primary dentition.
Study designs other than RCT due to lower level of evidence.
Sources other than PubMed Database.
Following combination of key words and putting the limits in to place, the total numbers of 30
articles were retrieved.
Table 1: Search Strategy Table
Search Result
“endodontics "[MeSH Terms] OR "endodontics"[All Fields]OR "root canal therapy"[MeSH
Terms] OR "root canal therapy"[All Fields] OR endodontic[All Fields] OR"pulpectomy"[MeSH Terms] OR "pulpectomy"[All Fields] OR "pulpotomy"[MeSH Terms]
OR "pulpotomy"[All Fields] OR "endodontic surgery"[All Fields] OR "apicoectomy"[MeSH
Terms] OR "apicoectomy"[All Fields
24689
"anti-bacterial agents"[MeSH Terms] OR ("anti-bacterial"[All Fields] AND "agents"[All
Fields]) OR "anti-bacterial agents"[All Fields] OR ("antibacterial"[All Fields] AND
"agent"[All Fields]) OR "antibacterial agent"[All Fields] OR fluoroquinolones OR
"penicillins"[MeSH Terms] OR "penicillins"[All Fields] OR "penicillin"[All Fields] OR
"amoxicillin"[MeSH Terms] OR "amoxicillin"[All Fields] OR "metronidazole"[MeSH
Terms] OR "metronidazole"[All Fields] OR "clindamycin"[MeSH Terms] OR
519783
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Stage 3: Study Preferences
We applied the title, abstract and full text screening Stages using the PICO-C model. Based onthe model, population, intervention, control or comparator, outcome and critical appraisal of each
study is assessed and evaluated. Each article reviewed by at least three members of the group for
screening. In cases of disagreement the consensus was established. Of 30 retrieved articles, 13
rejected in the title stage by virtue of the fact that topic was absolutely irrelevant to our topic of
interest. The remaining 17 articles were undergone the abstract screening stage which resulted in
rejecting 7 articles and approving 10 ones. Evaluating the result of Pubmed search did not
provide any additional citation.
Stage 4: Study Quality Appraisal
Based on the PICO-C model, each article approved at the abstract stage was thoroughly reviewed
in full text and appraised critically using “Checklist to Assess Evidence of Efficacy of Therapy
or Prevention 7 as a guideline by at least three members of the team to minimize the probability
of double standards. Regarding the checklist if the answer to question was positive, that question
was marked 1 and if the answer was negative, that question was scored 0 and the final score of
each study with the maximum possible score of 17 was calculated thereafter by adding theses
marks. Upon consultation with the experts in the field of endodontics, we retrieved 2 articles
which had been disapproved in the abstract stage. Moreover, 3 articles were rejected given the
fact that the intervention groups in the studies were compared with control groups originating
from past studies available for authors.
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The following chart shows the number of articles approved and rejected in the 3 differentscreening stages based on our pre-defined inclusion and exclusion criteria.
Stage 1:
Pub Med Search ResultNo Further Article
17
10
Limits: Humans, Clinical Trial, Meta-Analysis,Randomized Controlled Trial, Trial, Phase IV, Controlled
Clinical Trial, English, All Adult: 19+ years
Pub Med30
Title Stage
13 rejected
17 accepted
Abstract Stage7 rejected;
10 accepted
Full Text Stage
3 rejected;7 accepted
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#
Citation REASONS FOR
EXCLUSIONS
Score Stage of
Exclusion
1 Endodontics in the adult patient: The
role of
antibiotics.L.P.Longman,A.J.Preston,M
.V.Martin,N.H.F.Wilson
Journal of Dentistry 28(2000) 539-548
August 2000
The article was a review study.
The article discusses the
indication and contraindication of
antibiotics in healthy patient and
medically compromised patients,
which also includes use of topical
antibiotics.
10/17 Full text
2 A comparison of erythromycin and
cefadroxil in the prevention of flare-
ups from asymptomatic teeth with
pulpal necrosis and associated
periapical pathosis. Morse DR, Furst
ML, Lefkowitz RD, D'Angelo D,
EspositoJV. Oral Surg Oral Med Oral
Pathol.1990, May;69(5):619-30.
No control used in the current
trial.
A comparison was done with
control taken from another study.
11/17 Full text
3 A prospective randomized trial on
efficacy of antibiotic prophylaxis in
asymptomatic teeth with pulpal
necrosis and associated periapical
pathosis. Abbott AA, Koren LZ, Morse
DR, Sinai IH, Doo RS, Furst ML.
Oral Surg Oral Med Oral Pathol. 1988Dec; 66(6):722-33. Review.
No control group in the study, Not
blinded; Prophylactic Ab group of
this study was compared with
placebo control group of the other
study,
11/17 Full Text
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Stage 5: Producing Evidence Table
We abstracted evidence from selected papers onto abstraction sheets and finally transferred thedata into the evidence table under PICOC‟s heading (Population, Intervention, Control, Outcome
and Critical appraisal)
Evidence based table was designed for 6 final randomized controlled trial, double blinded and
placebo controlled studies which had been systematically reviewed as follows:
1. Henry M, Reader A, Beck M.J Endod. 2001 Feb;27(2):117-2
2. Lindeboom JA, Frenken JW, Valkenburg P, van den Akker HP.Int Endod J. 2005
Dec;38(12):877-81
3. Walton RE, Chiappinelli J.J Endod. 1993 Sep;19(9):466-70.
4. Pickenpaugh L, Reader A, Beck M, Meyers WJ, Peterson LJ.J Endod. 2001Jan;27(1):53-6.
5. Torabinejad M, Dorn SO, Eleazer PD, Frankson M, Jouhari B, Mullin RK, Soluti
A. J Endod. 1994 Sep;20(9):427-31.
6. Torabinejad M, Cymerman JJ, Frankson M, Lemon RR, Maggio JD, Schilder H. J
Endod. 1994 Jul;20(7):345-54.
We complied with the guideline recommended by the Canadian Task Force on Preventive
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Results
Our search strategy identified 30 articles. 13 papers were excluded on title stage, and 7 papers
were excluded on abstract stage. 4 papers were rejected on full text stage of which one paper was
systematic review, and three others did not have control group and were not blinded. Therefore,
totally 6 papers were included in this review, which were all double-blinded placebo controlled
randomized clinical trials.
Preoperative prophylactic antibiotics on post-endodontic treatment symptoms
Walton and Chiappinelli (1993) carried out a study to test the effect of the prophylactic penicillin
on post-endodontic treatment symptoms. They selected 80 patients with asymptomatic periapicalperiodontitis, and divided them into three groups. Group A (26 patients) received 2 g penicillin
before the treatment and 1 g 6 hours after the treatment. Group B (24 patients) received a placebo
with same regimen, and group C (30 patients) received no medication. Post treatment symptoms
such as pain and swelling were recorded at 4,8,12,24, and 48 hours. Only one flare-up was
reported which was in placebo group. 69% of the patients in group A (penicillin) had mild-
moderate pain, as compared with 79% in placebo group B and 70% in group C (no medication).
Statistics showed no significant difference (p=0.68) among these three groups as to posttreatment symptoms.
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Another trial evaluated the value of clindamycin in the prevention of postoperative infection
(Lindeboom et al. 2005). 256 patients undergoing endodontic surgery were included. 1 hour
before surgery, 128 of them were given 600mg clindamycin orally, while another 128 patientsreceived placebo. Patients were assessed 1, 2 and 4 weeks after surgery. The infection rate in the
clindamyicn group was 1.6% (2 patients) and in the placebo group the infection rate was 3.2% (4
patients), which indicated no significant differences (p=0.448).
Post-treatment antibiotics on post-endodontic treatment pain:
Torabinejad et al. (1994) compared the effectiveness of penicillin and erythromycin on
postoperative pain for 72 hours following root canal instrumentation. Sample patients had
periapical periodontitis with varying levels of pain. Following complete root canal cleaning and
shaping, 57 patients received penicillin 500mg; 46 patients received erythromycin base 500mg,
and 53 patients were placebo group. All patients scored their levels of discomfort at each 6-hinterval for up to 72 hours after instrumentation. Patients‟ questionnaires were collected at the
obturation appointment. Data indicated that preoperative pain and apprehension had a strong
positive correlation with postoperative pain (p<0.0001, 0.012<p<0.047 respectively). In terms of
medications, penicillin and erythromycin base were significantly more effective in reducing
moderate and severe pain than placebo within the first 48 hours after instrumentation (p<0.05).
Whereas in patients with no or mild pain no statistical significant difference was showed
between the effectiveness of antibiotics and placebo.
Torabinejad et al. (1994) continued this study to further compare the effectiveness of antibiotics
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Discussion
In this evidence based report, we have tried to gather the best studies available, in order to findan answer as to whether or not antibiotics should be taking into consideration in preventing any
flare up, pain, swelling or pain on percussion after endodontic treatment of asymptomatic teeth
with necrotic pulp and periapical pathology.
After a detailed database search, we came out with six articles that might answer our concern.
All these articles were randomized clinical trials.
The reason for selecting randomized controlled trials for our study was due to the highest level of
evidence they provide as the gold standard. They are generally accepted as the most valid
method for determining the efficacy of therapeutic intervention, because the biases associated
with other experimental designs can be avoided.9
The articles subject to full-text consideration were included. Only articles approved that the
antibiotics were administered to relieve post endodontic treatment flare ups. Articles representing
antibiotic prophylaxis to only prevent heart diseases or to treat a tooth abscess were discarded.
Furthermore, the studies were critically appraised based on the checklist to assess evidence of
efficacy of therapy adapted from Fletcher and Wagner7.
Action of antibiotic in preventing flare up in endodontically treated teeth:
The use of prophylactic antibiotics to prevent an infection is based on work of Burke and Miles.
They demonstrated in animal models for the antibiotics to be effective, they must be in tissue or
wound site prior to the beginning of infections Any delay of 3-4 hours resulted in infections
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dosage were standardized for both the groups appropriately and the patients were assessed first,
second and fourth week post-operatively. Although, there was no significant difference in the
rate of infection, the randomization of surgical site was not ideal. More molars were treated inclindamycin group while more maxillary pre-molars and maxillary anterior teeth, were treated in
placebo patients.
In a randomized double-blind study Walton et al. 1993, studied the use of antibiotics in
preventing flare up between patients receiving penicillin V either 2g single dose(AHA
recommendation 1994) at the beginning of treatment and an additional of 1g six hours after the
appointment, an inert placebo control or receive no medication at all.
A single visit conventional root-canal cleaning and shaping was performed following which the
symptoms of flare-ups were self-evaluated by patients using visual pain analog at 4, 8, 12, 24
and 48 hours post-treatment. However, this study has its own drawbacks with small sample size,
treatment being rendered by undergraduates and the important factor which we thought that the
occlusion was not adjusted, which might be one of the co-factors for flare-ups.
Leigh Pickenpaugh t al. 2001, performed a study to determine the effect of prophylactic
amoxicillin on the occurrence of flare-up in asymptomatic, necrotic teeth with periapical legion
measuring 3x3 mm. They give patients either 3g dosage of amoxicillin orally 1hour before the
treatment or an inert placebo. The flare-up was defined as moderate to severe post-operative pain
or moderate to severe swelling that began 12-48 hours after the treatment and lasted for at least
48 hours. Pickenpaugh et al. 2001, claims that their results „disagree with the work of Morse and
co-authors
9
. Unfortunately their study didn‟t come without drawbacks such as a lack of samplesize, occlusion was not adjusted and its power value was 0.08.
In the double-blind study by Torabinejad et al. 1994, using a sample size of 411 patients reported
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less than 20%, instrument steps were not standardized in certain emergency appointments
because of time constraints and also there was no reporting on occlusal adjustment.
Research supporting the use of antibiotics in preventing flare-up following endodontic treatment
has come from investigators at the School of Dentistry at Temple University.
“Mata et al. 1985 used a randomized control trial to test the incidence of flare-up between the
patients receiving either penicillin V or a placebo control. The antibiotic dosage schedule was
250mg tablet of penicillin V every hour for the first 24 hours followed by one tablet every six
hours until all tablets were used. Flare-up was defined as pain and or swelling that necessitatedan unscheduled emergency visit. After treatment patients were asked to complete a pain and
swelling questionnaire for 2 days. It was found that the incidence of flare-up was less in
penicillin group as compared to the control group.
Amongst the articles in our evidence table all provided highest level of evidence I and
only one article favoured the use of antibiotics after complete instrumentation prior to obturation
(Torabinejad, M et al. 1994). The other articles did not find any statistically significant
difference between the effectiveness of various antibiotics versus placebo in controlling adverse
outcomes of flare-ups subsequent to the endodontic treatment.
Despite the conclusion drawn from the above papers, there are numerous limitations
before any clinician arrives to a decision.
A) Factor related to endodontic procedure:
i) Difference in clinicians‟ expertise: General dentist v/s Endodontists or
undergrad students v/s Postgrad students.
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adjusted it is impossible to determine if flare-up is due to infection or due
to excessive occlusal contacts.10
B) Definition of flare-up: Different studies have different definitions of flare-ups which
render it difficult to compare the results concerning efficacy of antibiotics at reducing
flare-up.9
C) Use of Analgesics: Many researchers have given their patients analgesics, which they
might have used to control their pain and swelling. As in the study of Pickenpaugh et
al (2001), Tylenol 3 and Ibuprofen was used to control flare-up. Ibuprofen is bothanalgesic and anti-inflammatory agent, while Tylenol 3 is purely analgesic. This
difference will make it difficult to standardize the definition of flare-up.10
D) Non-standardized measurement of flare-up:
i) Difference in period of flare-up evaluation.
ii) Problems associated with report of pain
Walton et al (1993), instructed patients to assess pain using a questionnaire at strict time, while
Pickenpaugh et al (2001)instructed patients to keep a diary of pain assessed before going to bed
on the day of the treatment, then on arising and before bedtime each for five days . The duration
in different studies does not monitor the pain adequately, which might affect the standardization
of the study.
iii) It is believed that individual tolerance and reaction to pain differed greatly
from person to person (Marieb, 2001). This inherited difference make it10
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Recommendations/Conclusion
At present, good level of evidence prevail to conclude that Antibiotics DO NOT play a crucialrole in subsiding post-treatment symptoms e.g. pain, percussion pain, swelling and discomfort.
Based on this systematic review, we found no significant difference in the effectiveness of
systemic antibiotics administered either prophylactically or therapeutically on post treatment
flare-ups following endodontic treatment/surgery in comparison with placebo/no intervention;
however, we need more conclusive evidence to support or refute the administration of systemic
antibiotics as a must following endodontic treatments. (Based on the CTFPHC system8, the level
of evidence is 1 and the grade of recommendation is E).
A protocol adoption for the prescription of systemic antibiotics in endodontics may be
advantageous to both patients and clinicians in the future. (Longman etal 2000)
RECOMMENDATIONS FOR FUTURE RESEARCH:
1- There is a good level of evidence implying no significant advantages in the utilization of
systemic antibiotics on prevention/reduction of symptoms after endodontic treatment
2-Studies need to be carried out more globally taking in consideration different races and
sections of population throughout the world and not merely one country.
3- The factors impacting on post treatment symptoms such as patients condition before
treatment, definition of flare-ups, quality of flare-up measurements, endodontic procedure
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References:
1- Lindeboom JAH, Frenken JWH, Valkenburg P,van den Akker HP. International Endodontic
Journel, 38, 877-881, 2005.
2- Longman L.P, A.J. Preston, M.V. Martin, N.H.F. Wilson. Endodontics in the adult patient:the
role of antibiotics. Journal of Dentistry ;28(2000)539-548
3- Keenan J .V, Farman AG, Fedorowicz Z, Newton JT. A conchrane Systematic Review No
Evidence To support the use of Antibiotics for pain relief in irreversible pulpitis Journal of
Endodontics;2006,32,no.2,1-14
4-Krishnan G,.The endodontic dilemma-rationale behind antibiotic
usage,Endodontology;2001,vol:13,19-23
5- Torabinejad M, Cymerman JJ, Frankson M, Lemon RR, Maggio JD, Schilder H.J.
Effectiveness of various medications on postoperative pain following complete
instrumentation.Journal of Endodontics;1994,20,no.7, 345-354
6- Pickenpaugh L, Reader A, Beck M, Meyers WJ, Peterson LJ. Effect of prophylactic
amoxicillin on endodontic flare-up in asymptomatic necrotic teeth. J Endod. 2001 Jan;27(1):53-6
7- Adapted from: Fletcher, Fletcher and Wagner. Clinical epidemiology – the essentials. 3rd
ed.
1996, and Sackett et al. Evidence-based medicine: how to practice and teach EBM. 1997
8- Canadian Task Force on Preventive Health Care evidence. http://www.ctfphc.org/
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Appendix1: Technology Assessment Table
Compared toplacebo,
Antibiotictherapy costs
Compared to the placebo/ no medication,Antibiotic therapy works
Better The same Worse
Less
The same
More X
Appendix2: CTFPHC Grades of Recommendations and Quality of Published Evidence
A. The CTF concludes that there is good evidence to recommend the clinical preventive action
B. The CTF concludes that there is fair evidence to recommend the clinical preventive action
C The CTF concludes that there is conflicting evidence neither recommending nor favoring the clinical
preventive action.
D The CTF concludes that there is fair evidence to recommend against the clinical preventive action.
E The CTF concludes that there is good evidence to recommend against the clinical preventive action.
I The CTF concludes that there is insufficient evidence to make a Recommendation
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Appendix 3:
Checklist to Assess Evidence of Efficacy of Therapy or Prevention
Citation: ____________________________________________________
____________________________________________________
1. Was the study ethical? ___
2. Was a strong design used to assess efficacy? __
3. Were outcomes (benefits and harms) validly and reliably measured? ___
4. Were interventions validly and reliably measured? __
5. What were the results?
Was the treatment effect large enough to be clinically important? ___
Was the estimate of the treatment effect beyond chance and relatively precise? ___
If the findings were “no difference” was the power of the study 80% or b etter ___
6. Are the results of the study valid?
Was the assignment of patients to treatments randomised? ___
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Author,
Date
Study
Design
Population InterventionEndodontic
Control Outcome Criticalappraisal
comment
s/scores
Conclusion,Strength of
evidence
andclassification
n Medication Regimen Time Procedure n Placebo
A s s e s s m e n t
F l a r e - u p
I n c i d e n c e
P v a l u e
HenryM,Reader
A, Beck M,2001
Randomizedcontrolled
Trial/ Double blind
Sample Size:41emergency adults
Age:Penicillin:37+/- 16.5
Placebo:38+/- 18.8F:20, M:21Location: The Ohio
State University
Symptomatic(spontaneous pain)/ necroticpermanent teeth with
periapical radiolucency
19 Penicillin V 500mgq.i.d
Oral7 days
Post Treatment Treatmentby
seniorEndodontic
graduatestudentsStep back
technique
22 Lactosepackaged
bypharmacy
7-dayDiary to
record pain.
Pain: Percussion
pain
Swelling,
# of analgesics
taken P >
0 . 0
5
P = 0 . 2
2
P =
0 . 8
Score:16.5/17
No significant
reduction inpain ,
sensitivity topercussion,
swelling andnumber of analgesic
medications
taken byadministrationof penicillin
postoperatively
Level of Evidence: Ι
Lindeboom
et al. 2005.
Randomized
ControlledTrialDouble-blind
placebo-controlled
trial.
Sample size: 256
Mean Age: 44.4 yrs,Range : 18-42 yrsM: 109(42.6%)
F: 147(47.4%)Location: University of
AmsterdamNon Vital Teeth withapical periodontitis,
adequate root canalfilling and free of acutesymptoms for periapical
surgery.
128 Clindamycin 600 mg
1h before
endodonticsurgery (Prophylactic)
Endodontic
Surgery,The sameduration of
surgery fortwo groups.
128 Oral
Placebo,1h beforesurgery
Pts
Assessed 1,2 and 4weeks
postoperatively
Post-op
woundinfection
intervention : 2 cases 1.6%;
95% CI: 0.48-4.72control: 4 cases 3.2%95%CI: 0.42-1.33
P = 0 . 4
4 8
Score:
14.5
Randomiz
ation insurgicalsites is not
ideal.
No statisticallysignificant
evidence of differencebetween
preoperativeclindamycin
prophylaxisand placebo inprevention of
postoperativeinfection inendodontic
surgery.
Level of
Evidence: Ι
Walton RE,Chiappinell
i J et al.
1993
RandomizedControlled
Trial
Double blind
Sample size: 80Age: 17-78 years old.
F:32, M:48,
divided in 3 groups:Group A: 26,Group B: 24,
Group C:30Location: University
of IowaPermanent teeth withnecrotic pulp & chronic
apical periodontitis
26
Penicillin V
Penicillin V
2grsSingle
dose (AHA
recomme
ndations-
1984)
6grsSingle
dose (AHA
recomme
ndations-
1984)
At thebeginning of
treatment
6 hours after
the appointment
Single Visit
Standard
endodontictreatment,No
intracanaldressing
24
30
group B:Placebo
same
regimen
Group C:No
Medication
Ptsassessed
at 4, 8, 12,
24, and 48
hours.
Flare-up:group A:0
group B:1
Mild to
moderatepain:A: 69%
B:79%C:70%
Swelling:A: 1 caseB: 1case
P = 0 . 6
8
P > 0 . 0
5 Score:
14/17
smallsamplesize;
Pts undertreatment
by Endograduatesand
undergraduates. Skills
varied
Administration
of penicillin
prophylactically
was unrelated to
post treatment
signs &
symptoms.
following canal
preparation
Using penicillin
prophylactic ally
to control Post-
op symptoms not
recommended
Level of
Evidence: Ι
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Author,
Date
Study
Design
Population InterventionEndodontic
Control Outcome Criticalappraisal
comment
s/scores
Conclusion,Strength of
evidence
andclassification
n Medication Regimen Time Procedure n Placebo
A s s e s s m e n t
F l a r e - u p
I n c i d e n c e
P v a l u e
LeighPickenpaug
h, et al.
2001
RandomizedControlled
Trial,double-blind
Placebo-controlled
Sample size : 70healthy adults
Location: The OhioState University
Asymptomaticpermanent teeth with
necrotic pulp associated
with periapical lesions3*3
34 Amoxicillin Oral3grams,
1 hourbefore
Endo Tx
Pretreatment1 h before
Two-visitstep back
technique,k type files,
2.62%sodium
hypochlorite,
sterile cottonpellet,Temp filling:
Cavit
36 3grams,one hour
beforeEndo Tx
5 1/2 – daydiary to
record Pain,percussion
pain,swelling,
number and
type of painmedicationtaken
moderate-to-
severepostoperative
pain orswelling that
began 12-48h after
endodontic
treatmentand persistedfor an
average of 48h
Intervention:4 casesControl: 3
P = 0 . 8
0
Score :14
Prophylacticdose of
amoxicillinbefore
endodontictreatment of
asymptomatic
necrotic teethhad no effecton the
endodonticflare-up.
Level of evidence: Ι
Torabinejad
et.al,1994
Randomized
control Trial
Doubleblinded
study
Sample Size:588
Range of age :18-79 yrs
F:52% M:48%
Location: Loma Lindauniversity
Permanent Symptomatic
or asymptomatic teeth
with pulpal or periapical
pathosis.
57
46
Penicillin
Erythromycin
Base
2*250mgEvery 6 hrfor 72hrs
2*250mg
Every 6 hr
for 72hrs
Drugs given
post
operativelyafter completeinstrumentatio
n beforeobturation
Multiple -
visit Endo
Treatment,StandardRCT;complete
instrumentati
-on but noobturation by
10 endo
practices and4 endo gradprogram.
Irrigation:
Sodiumhypochlorite1.5-5.25%
Intracanal
medicaments
used
53
inert-
excipients
Post
operativepainassessedby visual
analog
scaleevery 6hrs
for 72 hrs
followinginstrumentation
1-Increase
in.Pre-
operativepainassociatedwith increase
in post
operativepain.
P <
0 . 0
0 0 1
Loss to
follow upwas present
(<20%)
Score: 13.5
Penicillin and
erythromycinmore effectivein controllingmoderate to
severe post
operative painwithin first 48
hours
compared toplacebo.Penicillin and
erythromycinmight preventsevere
postoperative
complicationsin patientswith no ormild
preoperative
pain. Level of
Evidence: Ι
Apprehensio
n associated
with increasein postoperative
pain
P < 0 . 0
4 7
Greater
decrease inpost-op pain
withpenicillin
and
erythromycinthan placeboin first 48hours in pts
with
Moderate &sever pre-oppain.
P =
0 . 0
0 3
8/3/2019 Group Report 2009
http://slidepdf.com/reader/full/group-report-2009 22/22
Author,
Date
Study
Design
Population InterventionEndodontic
procedure
Control Outcome Criticalappraisal
comment s
/scores
Conclusion,Strength of
evidenceand
classification
n Medication Regimen Time n Placebo
A s s e s s m e n t
F l a r e - u p
I n c i d e n c e
P v a l u e
TorabinejadM etal,1994
Randomizedcontrol Trial
Double
blindedstudy
Range of age :18-79 yrs
Sample Size:411
F: 52%, M:48%
Location: Loma Linda
university
Permanent Symptomaticor asymptomatic teeth
with pulpal or periapicalpathosis.
46
33
Penicillin
Erythromycin
Base
2*250mg
Every 6 hrfor 72hrs
2*250mg
Every 6 hrfor 72hrs
Drugs givenpost operatively
after completeobturation
Multiplevisits of EndoTreatment,
Standardobturation
with GuttaPerchaperformed.
Irrigation:
Sodium
hypochlorite1.5-5.25%
Intracanalmedicaments
used
41 inert-excipients
Postoperative
painassessedby visual
analogue
scale of 0to 9 every
6hr for 72
hrs
Post operativepain at various
time intervalsafterobturation is
lower than
that followingcomplete
instrumentatio
n (5.83% vs.21.76%)
P < 0 . 0
0 0
1
Loss tofollow up
was present(<20%)
Score: 13.5
No significantdifference
between theeffectivenessof various
antibiotics and
placebo incontrolling
postoperative
painfollowing
obturation Level of evidence: Ι
Erythromycinwas more
effective than
placebo onlyat 6 hour s
P = 0 . 0
2 0 6