Endodontology, Vol.

16, 2004

Endodontic intervention verses oral antibiotic

therapy in the management of endodontically
compromised situations – Two case reports.
Dabas U* and Dabas VK*

ABSTRACT

Since many years, antibiotics in different forms have got definite application
in the fields of Medicine and Dentistry to heal various superficial and deep-
seated body and dental and oral infections. Nevertheless, lack of sound
scientific knowledge regarding judicious application of antibiotics, tradition,
mentality or common trend of prescribing antibiotics for each and every
patient with endodontic involvement, especially without emphasizing the
need for an endodontic treatment planning, too often culminate into
untoward consequences and many failures. This in turn, raises dubiety in
the psyche of a patient regarding the professional skill of a surgeon, with
often loss of faith in the profession as well. Being an Endodontist or even a
Dental Surgeon, it is imperative that one must stress the importance of
appropriate endodontic intervention in all the involved cases, with oral
antibiotic administration used only as an adjunct. Moreover, one must be
aware of all the pros and cons of antibiotic therapy and of course, the very
fact that whether they are needed or not in a particular case in the first
place.
In this article, two cases have been reported where injudicious and irrational
use of antibiotics did not yield any positive result; instead added further
woes to the patients’ agony. Eventually, with careful Endodontic intervention,
it became possible to not only provide prompt and permanent pain relief
to the patients but also salvage the natural teeth while bringing back the
smile and the lost faith of the patients towards the profession.

Introduction indeed inestimable1. Nevertheless, certain

In the field of human health care, the advent
of antibiotic constitutes one of the greatest
revolutionary advancements. Being the life
saving drugs and as therapeutic agents, the
role and value of antibiotics in the field of
Dentistry to curb dental and oral infections is
* Assistant Professors
Dept. of Conservative Dentistry and Endodontics,
K M Shah Dental College & Hospital,
Vadodara, India.
misconceptions and notions regarding their
usage in the clinical practice of Endodontics
have culminated into undesirable sequel and
end results. There prevails a common notion
and misbelief like heavy doses of any broad
spectrum antibiotic or last generation
antibiotics can heal any kind of endodontic
infection and hence, may postpone or retard
the very requirement of an endodontic
procedure. Such assumptions, too often not

2
Dabas U and Dabas VK
Fig. 1. Intra-oral periapical x-ray of # 45 showing distal
curvature of root.
only result in antibiotic abuse but terminate
into drastic consequences like persistence or
proliferation of existing problem, severe, acute
exacerbation of chronic infections, development
of resistant strain, drug toxicity, allergic and
hypersensitivity reactions, photo toxicity etc.
In all the endodontic pathologies, be pulpal
or periapical, some are infected yet few others
are only inflammatory lesions 2. Hence,
elimination of irritants, especially pathogenic
bacteria from the pulp space or root canal by
careful and appropriate endodontic procedures
is far more effective therapy over prescribing
solely oral antibiotics and recommending no
elective dental treatment in a particular case.
Following two case reports adequately
document these points.
Case report- 1
A woman, aged 32 years, reported to a
private clinic with the chief complaint of severe
pain and extra oral swelling on lower right side,
fever and diminished mouth opening. Patient
gave history of oral medication, which chiefly
composed of various groups of antibiotics
including ampicillin, cloxacillin, sparfloxacin
and ciprofloxacin for the past 20-25 days
without any relief. She had initially visited a
local dentist about 2 years back with the
complaint of moderately decayed # 45, with
hypersensitivity to cold and sweets. She was
prescribed some antibiotics and analgesics
Endodontic intervention Vs. oral antibiotic therapy...
Fig. 2. RVG scan of # 45 showing obturated canal.
and no further definitive treatment was given.
Again after few months, she started having pain
and severe sensitivity with hot and cold with
increasing size and depth of the carious lesion.
When she visited a local hospital, few antibiotics
and anti-inflammatory analgesics were
prescribed, topical application of eugenol was
done and significantly no adequate dental
treatment was advised. After that, since last
20-25 days she was suffering from excruciating,
radiating pain with massive swelling on her
lower right side. When she visited the local
hospital, an intra oral periapical x- ray of the
affected side was taken and again different types
of antibiotics were prescribed (firstly,
combination of amoxycillin and cloxacillin 500
mg t.d.s. for 4 days and then ciprofloxacin 500
mg t.d.s. for 6 days). The patient was
discharged after local application of some
sedative agent. Even after taking antibiotics for
more than 20 days, the problem went on
worsening. Moreover, due to prolonged oral
antibiotic consumption, she developed severe
indigestion, gastric problems, and loss of taste,
allergy and phototoxicity. Hence, she decided
to go for another opinion and permanent
solution to her problem.
The clinical examination revealed presence
of intraoral swelling with prominent sinus
formation in lower right buccal vestibule. Tooth
no. 45 was deeply carious distoproximally.
Intraoral periapical X-ray and RVG scan
3

Fig. 3. Intra oral periapical radiograph of # 37
showing a large carious lesion involving the pulp.
suggested deep pulpal involvement in tooth #
45 with periapical pathology and periodontal
involvement. There was a single, distally curved
root with root canal terminating approximately
1.7 mm short of apex (Fig. 1). On the same
visit, endo-perio treatment was administered.
Abscess was incised, drained and the area
was irrigated with metronidazole suspension.
Root canal was opened, irrigated with
metronidazole and subsequent NaOCl solution
and distilled water along with usual
biomechanical preparation. Occlusion was
relieved subsequently and the patient was
discharged with considerable pain relief. All
antibiotics were discontinued and the patient
was advised to take anti-inflammatory (Tab.
Rofecoxib 50 mg OD) only in case of pain. On
subsequent sittings, thorough scaling with
deep curettage was performed along with
routine endodontic procedure in # 45. The
patient was relieved of all her symptoms within
a week. Root canal was finally obturated with
gutta percha and Sealapex (Fig.2). The tooth
was restored with full cast ceramic crown.
Case report- 2
A 38-year-old woman visited a dental clinic
with chief complaint of severe pain in 37 and
difficulty in chewing on that side. There was a
history of chewing suddenly on a very hard
substance in the food 3-4 months back that
gave her instant severe pain and feeling of
something broken down. Subsequently she
4
Endodontology, Vol. 16, 2004
Fig. 4. Showing obturated root canals of # 37.
developed pain and hypersensitivity in the same
tooth with cold. When she visited a local
hospital, she was prescribed antibiotics-
Ampicillin and Cloxacillin, 500 mg thrice daily
for 5 days. No dental treatment was advised.
Hypersensitivity with cold continued and
gradually increased with hot foods also. Since
past 4-5 days, the pain started increasing and
became almost continuous without any
provocation. Again she visited the same
hospital, but instead of opting for any
appropriate dental treatment, she was
prescribed Amoxicillin + Clavunimic acid 625
mg. twice daily for 5-6 days and Tab. Diclofenac
sodium 50 mg. thrice for 5 days and was
advised to report again. Nevertheless, after
taking all the medicines, she did not get any
relief. Since previous night she was keeping
cold water in her mouth to get pain relief. She
came to the clinic for permanent management
of her problem.
Intraoral examination revealed tooth # 37
was having occlusal breakdown. Old silver
amalgam restoration in 37 had exfoliated and
there was a big, open cavity. Recurrent caries
was also found below the exfoliated restoration.
RVG scan of #37 suggested deep pulpal
involvement and less significant periapical
lesion (Fig 3.). The tooth was tender on
percussion and was giving exaggerated
response to thermal test. The condition was
diagnosed as initial hyperemia transformed into
acute pulpitis. Immediately under local
Dabas U and Dabas VK
anesthesia, root canals were opened in #37,
routine chemo mechanical preparation was
done, occlusion was relived and the patient was
discharged after sedative dressing. Oral
antibiotics were discontinued and anti-
inflammatory (Tab. Roficoxib 50 mg once or
twice as per the severity of pain) was prescribed
for 2-3 days. Within 2 days, the patient was
relieved of much of her pain. Routine endodontic
procedure was done after that and finally the
canals were obturated using Endoflas- FS
(Fig. 4). Coronal restoration was done after
completion of the endodontic treatment.
Discussion
Although antibiotics constitutes the bulk
of all the drugs and medicines employed in the
fields of medicine and dentistry in the modern
era of science3, ironically they constitute the
single most abused group of drugs in health
care today. The tragic fact attributes to
indiscriminate, irrational and insane usage of
various antibiotics to curb any infection without
appropriate knowledge of antibiotic therapy.
Nevertheless, there are certain systemic
conditions warranting prophylactic antibiotic
coverage prior to attempting any endodontic or
exodontic procedures like rheumatic heart
disease, bacterial endocarditis, prosthetic
cardiac valves, congenital heart defects, AIDS
etc. where the rationale behind advocating
prophylactic antibiotic coverage is to prevent
the inadvertent bacteraemia as a
consequences of chemo mechanical
debridement in the canal in high risk patients2.
The fact is that antibiotics control active
microbial infection if present, but cannot prevent
the possibility of infection. One cannot prevent
occurrence of any endodontic infection with oral
antibiotic therapy alone and avoid endodontic
procedure. As per the fundamental principle of
Conservative Dentistry, any carious lesion
should be treated at once with proper
restorative procedure, which could have been
done in the first reported case and all
subsequent agonies of the patient could have
Endodontic intervention Vs. oral antibiotic therapy...
very well been averted. Here, prescribing oral
antibiotics to cure sensitivity was simply not
justified! Not only that, once diagnosed with
dental caries approximating pulp and signs like
hyperemia or pulpitis got developed, instead of
prescribing antibiotics, endodontic procedures
like pulp-capping, pulpotomy or root canal
therapy etc. should have been carried out
immediately. Moreover, in this case,
purposelessly prescribing various antibiotics
was simply experimenting with the situation.
The patient suffered from untoward reactions
like severe, continued indigestion, allergy and
even phototoxicity, which are sometimes
observed with ciprofloxacin or sparfloxacin group
of antibiotics.
Even if an antibiotic is to be used to control
periapical infection, it is mandatory to have the
knowledge of microbiology of pulp infection, as
more than 85-90 % bacteria in the infected pulp-
space are anaerobes, so is the case with
lesions of periodontal pathosis. Moller4 isolated
anaerobes in 74% of his samples of endodontic
cases. Also Sundqvist in his study on
endodontically involved conditions isolated 88
strains of which about 90% were anaerobes5.
Metronidazole is a highly effective antibiotic in
the management of anaerobic infection; hence
it worked well in the first case, where it was
both, endodontic and periodontal involvement.
In cases of sinus with pulsating and pointing
intra-oral abscess, it is always advisable to
incise and drain the abscess followed by
subsequent, appropriate endodontic and
periodontal treatment.
In case of periapical pathology, majority of
lesions are inflammatory in nature and need
not necessarily be infected. As the possibility
of bacterial presence in the periapical tissues
is negligible, antibiotics are often unnecessary
in such conditions. In the second case, there
was no infection periapically during the initial
stages. Any carious lesion or tooth with
exfoliated restoration without periapical
pathology could have been restored
immediately with due precautions. From the
5

history of the patient, signs, symptoms and
clinical observation, the condition could have
been diagnosed as hyperemia at the initial
stage, which later developed into acute pulpitis.
As these are inflammatory lesions and can be
easily treated endodontically, antibiotics play
no role in such conditions. It is usually when
the drainage becomes difficult to obtain or host
resistance is reduced or virulence of organisms
is more, that the antibiotics are required 6.
Hence, after discontinuing antibiotics at once
and performing root canal therapy worked best
in the second case.
Conclusion
To render professional services in the best-
desired manner to our invaluable patients, we
the dental surgeons must possess sound
knowledge of rationale behind the usage of
antibiotics in routine endodontic practice.
Endodontic therapy now emphasizes the
importance of debridement procedures and
elimination of microorganisms and their
substrate. For any endodontically compromised
Endodontology, Vol. 16, 2004
tooth, be it pulpal or periapical pathology, an
appropriate endodontic procedural intervention
at the right time is the only eventual solution.
Judicious and rational application of relevant
antibiotics for any desired length of period in
appropriate dosage can very well be a
thoughtful adjunct. However, it certainly cannot
be the sole and ultimate mode of the treatment
modality in Endodontics.
References:
1. Holroyd SV. Clinical pharmacology of antibiotics of
dental importance, Dent. Clin. North Am. 1970; 14:697
2. Gopikrishna and Parmeshwaran. Role of antibiotics
in Endodontics J. Ind. Dent. Assoc. 2001:69-71
3. Miles M: Anesthetics, Analgesics, Antibiotics &
Endodontics, Dent Clin North Am 1984; 28: 865.
4. Moller A J.R: Microbiological examination of root
canals and periapical tissues of human teeth. Goteborg,
Akademiforlaget, 1966.
5. Sundqvist G. Bacteriological Studies of Necrotic
Dental Pulps. Umea, Sweden, University of odontology
Dissertations, 1976.
6. Weine FS. Endodontic Therapy 1996; 5th Edition,
Harcourt Brace & Company Asia Pvt. Ltd.