Antibiotics in Endodontics

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Antibiotics in Endodontics

• Killing the bugs
• Without the drugs

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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.

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1928Penicillin 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.

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Antibiotics use grow bacterial resistance
increases

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

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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.

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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.

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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.

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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.

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• 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

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Bacteria gain access to root canal system through

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

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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.

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Successful healing can be achieved by

• 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.

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• 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.

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• 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.

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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.

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Appropriate antibiotic use

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

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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.

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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.

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• 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.

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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.

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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.

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What are the antibiotics

• Used to manage endodontic infections

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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.

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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.

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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.

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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.

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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.

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• 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.

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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.

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Dosage

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

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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.

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Clarithromycin(Klaribac)

• Active against
• Gram-positive Gram-negative
• Aerobic Anaerobic Bacteria
• Klaribac adult dose250mg twice/daily, increased
  to 500mg if necessary in severe infections for
  (7 to 14 days).

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• 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

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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.

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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 dental visit with unplanned treatment
  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

teeth with necrotic pulp
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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

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• 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.

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• 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.

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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

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• Selected Nonnarcotic analgesics
• Acetaminophen
• Aspirin
• Diclofenac
• Ibuprofen
• Naproxen     

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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

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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

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• 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.

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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.

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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.

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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.

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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.

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Thank You