Antibiotics in Endodntics FINAL

Antibiotic Use in Endodontics
Prepared by: Yousra Alkhairallah R1 Saudi Board in Endodontics
Yousra alkhairallah 2010
History
Antibiotics are chemical substances produced by microorganisms which have the capacity in dilute solutions to inhibit the growth of bacteria or to destroy bacteria and other microorganisms.
The word antibiotic came from the Ancient reek ! "#$ % anti& 'against'& and ($)* % bios& 'life'+
History
,riginally known as antiobiosis& they were first described in 1-.. in bacteria when Louis Pasteur Bacillus and Robert Koch observed that an anthracis airborne bacillus could inhibit the growth of
They weren/t called antibiotics 0ntil 1122 by Selman Waksman an American microbiologis
History
Prontosil&
the
first
commercially
available ermany
antibacterial antibiotic was developed in
3leming4s accidental discovery and isolation of penicillin in 5eptember 112- marks the start of modern antibiotics
6rior to this& most wartime deaths were due to bacterial infections of wounds& rather than from the wounds themselves
History
History
1-10 7.8. 9iller& the father of oral microbiology& was the first investigator to associate the presence of bacteria with pulpal disease A classic study published in 11:; by <akehashi et al proved that bacteria caused pulpal and periradicular disease
Microbiology
As long as the pulp is vital& it is a sterile tissue as any connective tissue elsewhere in the body =nfection occurs only after pulp necrosis >o single species will be discovered to be the ma?or@ endodontic pathogen
The composition of the microbiota varies depending on the types of infection and periradicular lesions
Siqueira 2002
Microbiology
Primary root canal infection Aaused by a microorganisms coloniBing 7hereas wide rangeare ofmiEed microbial =n general& primary infections and the necrotic species is pulp associated withbacteria. chronic predominated bytissue anaerobic 6redominant species usually belong to the periradicular lesions& a more restricted genera of Bacteroides &is associated Porphyromonas & group species with The involved microbiota& usually shifts Prevotella & Fusobacterium Treponema & symptomatic periradicular diseases Peptostreptococcus& Eubacterium& and depending on the time of infection. such as acute Campylobacter . apical periodontitis and acute periradicular abscess 9oreover& it has been strongly
3acultative or microaerophilic streptococci Caumgartner are also that commonly found 11-: in can primary suggested the microbiota differ 5undDvist 11-. infections
according to the type of periradicular 5?ogren 11-Yousra alkhairallah 2010
diseases
,liveira 2000 5iDueira 2001 5iDueira 2002
Microbiology
Secondary root canal infection Aaused by microorganisms that were not present in the primary infection and have penetrated the root canal system during treatment& between appointments& or after the conclusion of the endodontic treatment =f the penetrating microorganisms are successful in surviving and coloniBing the root canal system& a secondary infection is established
5iDueira 111.
Microbiology
Persistent root canal infection
9icroorganisms that in some way resisted the intracanal procedures ofare disinfection cause ramFpositive bacteria the persistent intraradicular infections
predominant bacteria
Aausative microorganisms were members either of the primary infection or of a secondary infection The microbiota associated with persistent secondary infections is usually composed of a 5ireGn 111. of single species or at least by a lower number 9olander 111species when compared with primary infections
5undDvist 1116eciuliene 2000
Microbiology
Extraradicular infection
9ay be primary& secondary& or ctinomyces species and persistent. Propionibacterium propionicus& may be The most common form of implicated in eEtraradicular infections eEtraradicular infection is the acute periradicular abscess The source of eEtraradicular infections >air 11-2 A is usually the intraradicular infection. Happonen few oral microorganisms have the ability 11-: to overcome host defense mechanisms 5?ogren 11-=wu 1110 and thereby induce an eEtraradicular Yousra alkhairallah infection 2010
Microbiology
5iDuiera 2002
Alassification of Antibiotics
=nhibitors of Aell 7all 5ynthesis
6rotein 5ynthesis =nhibitors
=nhibitors of >ucleic Acid 5ynthesis and 3unction

Tetracycline s
,thers!
Iancomycin e Cacitracin
JFlactam antibiotics
Ahloramphenicol e
Alindamycin e 6enicillin s
9etronidaBole Kuinolone s 3lag yl AiproflaEicine
9acrolides 8oEycycline 9inocycline Tetracycline Lrythromycine ABithromycine Alarithromycin e
9onobactam s Aarbapenem s
LEtended spectrum! Antistaph! Aephalosporin AmoEicilli 9ethicillin n s Ampicillin >atural! AephaleEine6enicillin 6enicillin I
Inhibitors o !ell "all Synthesis Pinicillin #$

Adv: Adverse effects! 6enicillin I< is bactericidal against gramF positive cocci and the ma?or pathogens of >arrow spectrum Allergy miEed anaerobic infections ,ral candiasis 8efuses into most body parts including oral 9ild diarrhea tissues soon after dosing >ausea
Inhibitors o !ell "all Synthesis A%o&icillin LEtended spectrum penicillin Cacterial MesistanceN Antibacterial spectrum similar to that of penicillin & but are '!al(ulanic more effective A%o&iciliin Acid against gramFnegative bacilli
betaF=actamaseFstable antibiotics
AC prophylaEis
Inhibitors o !ell "all Synthesis

FIRST GENERATION CEPHALOSPORINS
AephaleEin O<efleEP+!
=nclude cefadroEil O8uricetsP+& cephaleEin The first generation cephalosporin often used to treat O<efleEP+& and=nfections cephradine OIeloselP+ odontogenic
indicated alternatives in early infections because 9ost activeas against gramFpositive cocci& but are they not very active against many anaerobes are effective in killing the aerobes
Active against gramFpositive staphylococci and A6 6rophylaEis Allergy to streptococci& but not enterococci. 6enicillins Active against many gramFnegative aerobic bacilli Adverse effects! diarrhea in 1Q to 10Q of patients
Inhibitors o !ell "all Synthesis SECON GENERATION CEPHALOSPORINS Cetter activity against some of the anaerobes including some Bacteroides! Peptoeoccus! and Peptostreptococcus species Aefaclor OAecloP+ and cefuroEime OAeftinP+ have been used to treat early stage infections The advantage of twiceFaFday dosing
Inhibitors o !ell "all Synthesis #anco%ycines

Lffective against multiple drug resistant organisms such as methicillinFresistant staph Mestrict its use to treat serious infections caused by gramFpositive bacteria and life threatening infections AC prophylaEis O=I+ Adverse reactions! fever& chills& red man syndrome& shock& 8oseFrelated hearing loss
Inhibitors o !ell "all Synthesis

Bacitracin
Active against a wide variety of gramFpositve organisms 6otential nephrotoEicity
Inhibitors o Protein Synthesis TETRAC!CLINE S Croad spectrum Adverse effects!

Aontraindications! Cacteriostatic astric discomfort The MenallyFimpaired patients treatment of choice in infections caused by Lffects on calcified tissues 9ycoplasma pneumonia&5pirochetes&gramFpositive 3atal hepatotoEicity 6regnant or breastFfeeding bacilli& gramFnegative bacilli&gramFnegative enteric women are also effective against Ahlamydia& rods.they 6hototoEicity Mickettsia& and Crucella species Iestibular problems Ahildren under - years of age 6seudotumor cerebri 5uperinfections
Inhibitors o Protein Synthesis "ACROLI E SLrythromycine! Lrythromycin is no longer useful because Antihacterial spectrum of the very erythromycin family is of resistant pathogens similar to penicillin I<
>arrow spectrum antibiotics Harde 111. 7as considered highly effective antibiotics for treating odontogenic infections& especially in penicillin allergy
Mesistance develops rapidly to macrolides and there may be crossFresistance between erythromycin and newer macrolides
9ontgommery111Yousra alkhairallah 2010
Inhibitors o Protein Synthesis "ACROLI E S
Alarithromycin ! Coth aBithromycin and clarithromycin are presently 5hows good activity against many gramFpositive and recommended as alternatives in the prophylactic gramFnegative aerobic and anaerobic organisms regimen for prevention of bacterial endocarditis. Active against methicillinFsensitive 5. aureus and most streptococcus species S" aureus strains resistant to erythromycin are resistant to clarithromycin ABrithromycin ! 5imilar to erythromycin in effectiveness against anaerobic gramFpositive cocci and Bacteroides sp" ABithromycine is active against staphylococci& including S" aureus and S" epidermidis! as well as streptococci& such as S" pyo#enes and S" pneumoniae" eEcellent activity against $" in%luen&ae"
Inhibitors o Protein Synthesis !linda%ycin Cacteriostatic& Adverse effectsbut elicit bactericidal effects at higher concentrations Abdominal pain& nausea& vomiting& and diarrhea Antibacterial spectrum! Hypersensitivity reactions are rare Anaerobic bacteria& such as Cacteroides fragilis 6seudomembranous >onenterococcal gramFpositive cocci colitis characteriBed by severe diarrhea& abdominal cramps& and eEcretion of blood or mucus in the stools >ot effective against mycoplasma or gramFnegative aerobes =ts small molecular weight enables it to more readily enter bacterial cytoplasm and to penetrate bone
Inhibitors o Protein Synthesis

!hlora%phenicole Active against a wide range of gramFpositive and Adverse effects: Interactions: gramFnegative bacteria&but because of its toEicity& upset itsGI use is of restricted to lifehepatic threatening infections =nhibition some of the miEed function in which there is Overgro t!no ofalternatives candida block the metabolism of such drugs as 'ar%arin! Anemias: "emolytic anemia Antimicrobial activity: phenytoin! tolbutamide and chlorpropamide LEcellent against Anaerobes Gray baby Llevation their syndrome concentrations and potentiating their effects
Inhibitors o Protein Synthesis

Metronida)ole a broad spectrum against protoBoa and anaerobic bacteria <nown for its strong antibacterial activity against anaerobic cocci as well as ramFnegative and ramF positive bacilli Meadily permeates bacterial cell membranes and it then binds to 8>A& disrupting its helical structure& which leads to rapid cell death O7indley et al. 200;+ 9etronidaBole had eEcellent activity against anaerobes but it had no activity against aerobes
Moche R Yoshimori O111.+
AB Prophyla&is
Antibiotic Prophyla&is
=nfective Lndocarditis O=L+!
=t/s a microbial infection of the A life t!reatening disease it! endothelial substantial surface of the heart or heart valves that most morbidity and mortality !ic! affects often occurs in proEimity to congenital or indivisuals it! underlying structural acDuired !o cardiac defects cardiac defects develop bacteremia Often as a result of dental #GI#genitourinary#respiratory or cardiac invasive$surgical procedures
Antibiotic Prophyla&is Cecause of the high morbidity and mortality 9anipulation of the oral tissues may be associated related to =L& it has long been advised that A6 is with a transient bacteraemia reDuired before dental procedures likely to induce
bacteraemia Cacteraemia is usually eradicated by the reticuloF
OCender R 9ontgomery 11-:+
OTomas al. 2002+ endothelial system within a fewAarmona minuteset and poses
no threat to the healthy patient. However& some medically compromised patients may be at risk from this transient bloodFborne infection& most notably infective endocarditis O=L+
O8a?ani et al. 111.+
Antibiotic Prophyla&is Bactere%ia associated *ith Endodontic treat%ent: =n >o studies bacteraemia where more elicited selective if instrumentation techniDues for A >onsurgical series of studies MATwas might found involve no statistically a detectable significant was kept within the root canal bacteraemia culturing microorganisms wereof used& the difference between the incidence bacteraemia
et al. 11.:+ incidenceinstrumentation of bacteraemia OCaumgartner has been reported as following within OTordan and R 8urso outwith 2000+ the 8etectable bacteraemia was found in only one up to S0 20Q after undergoing nonsurgical endodontic root of canal the patients nonsurgical root
canal treatment& with an incidence ofconfined S.SQ as treatment& where instrumentation was O8ebelian et al. 1112& 111;& 8ebelian et al. 111:+ opposed to -S.SQ following flap retraction& to the root canal Cacteraemia was elicited in S1%;2Q of and root 100Q canal SS.SQ following periapical curettage following dental eEtraction treatments OHeimdahl et al. 1110+ O8ebelian et al. 111-+
OCaumgartner et al. 11..+
Infecti#e endocarditis and nonsur$ical endodontics =n large case%control study three cases of =L were 0pato 11;S& no reported cases of =L traceable to found which were apparently to root canal root canal therapy had been attributed described treatment based on the premise that O<olmer the infecting 11;S+ organism was consistent with those inhabiting the root canal system and also that the patient had had
=n a review of ;S cases of =L following dental

endodontic treatment in the last S0 days
procedures& seven were attributed to previous MAT. =n all cases& there OIan was der clear evidence of 9eer et al. 1112+ eEtracanal instrumentation& mainly through the apical foramen
O9artin et al. 111.+
+oes the use o AP pre(ent EI ,

OIan der 9eer and colleagues 1112+ published a 5ame authors performed a 2Fyear caseFcontrol study. study of dental procedures in the >etherlands and the Among patients for whom prophylaEis was efficacy of antibiotic prophylaEis to prevent =L in recommended& ; of 20 cases of =L occurred despite patients with native or prosthetic cardiac valves. They receiving antibiotic prophylaEis. The authors concluded that dental or other procedures probably concluded that prophylaEis was not effective caused only a small fraction of cases of =L and that prophylaEis would prevent only a small number of OIan der 9eer and colleagues 1112+ cases even if it were 100Q effective Huge number of prophylaEis doses would be necessary to prevent a very low number of =L cases O8uval 200:+
=L is much more likely to result from freDuent eEposure to random bacteremias associated with daily activities than from bacteremia caused by a dental& = tract& or 0 tract procedure 6rophylaEis may prevent an eEceedingly small number of cases of =L& if any& in individuals who undergo a dental& = tract& or 0 tract procedure The risk of antibioticFassociated adverse events eEceeds the benefit& if any& from prophylactic antibiotic therapy 9aintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of =L
Patients
!o !ave ta%en prop!ylactic antibiotics
routinely in t!e past but no longer need t!em include people with! 9itral valve prolapse Mheumatic heart disease Cicuspid valve disease Aalcified aortic stenosis Aongenital heart conditions such as ventricular septal defect& atrial septal defect and hypertrophic cardiomyopathy
Re$imen
Adults% &'( $) c*ildren +( m$,-$. orally / * 0efore 1rocedure Adults% &'( $ I" or I2) c*ildren +( m$,-$ I" or I2 3it*in 4( min 0efore 1rocedure Adults% 6(( m$) c*ildren &( m$,-$ orally / * 0efore 1rocedure Adults% & $) c*ildren +( m$,-$ orally / * 0efore 1rocedure Adults% +(( m$) c*ildren /+ m$,-$ orally / * 0efore 1rocedure Adults% 6(( m$) c*ildren &( m$,-$ I2 3it*in 4( minutes 0efore 1rocedure Adults% /'( $) c*ildren &+ m$,-$ I" or I2 3it*in 4( min 0efore 1rocedure
A$ent
Amoxicillin Am1icillin Clindamycin Cefadroxil or ce1*alexin A7it*romycin or clarit*romycin Clindamycin Cefa7olin
Situation
Standard $eneral 1ro1*ylaxis 5na0le to ta-e oral medications Patient is aller$ic to 1enicillin
Aller$ic to 1enicillin and una0le to ta-e oral medications
!linical Scenarios
During RCT, you discovered that your patient (who needs AP) has not taken the prescribed antibiotic prophylaxis Antibiotics should be administered as soon as possible 8rug can be effective if it is given up to2 hours after bacteremia begins
Patient who is already receiving antibiotics Another possibility is the use of secondFchoice antibiotics =n patients with periodontal diseases being treated with tetracycline treatment should be stopped for a minimum of S or 2 days before giving the prophylactic regimen with amoEicillin
Antibiotic Prophyla&is Patients who re!uires "ultiple dental treat"ent sessions
7aiting for 1 to 12 days between prophylactic cover periods
AB or treat%ent o -dontogenic In ections
A+A Reco%%endations
An infection must be persistent or systemic to ?ustify the need for antibiotics! i.e. fever& swelling& lymphadenopathy& trismus& or malaise in a healthy patient. Antibiotics are also more likely to be needed in an immunocompromised patient or a patient in poor health. The decision to prescribe antibiotics should not be influenced by patient demand& eEpectation of referring dentists& ?ust in case@ situations& or because it is the day before a weekend or holiday. These reasons constitute inappropriate use of antibiotics
treat%ent o -dontogenic In ections
The decision to use an antimicrobialUantibiotic agent in managing an odontogenic infection is based on several factors The clinician must first diagnose the cause of the infection and determine the appropriate dental treatment that may include multiple modalities& including initiation of endodontic therapy and pulpectomy& odontectomy& or surgical or mechanical disruption of the infectious environment Antibiotic therapy should be used as an ad?unct to dental treatment and never used alone as the first line of care
8eterminant 3actors as to whether con?unctive antibiotic therapy is indicated ! Host defense mechanisms 5everity of the infection 9agnitude of the eEtension of the infection LEpected pathogen
The choice of an antibiotic should be based on knowledge of the usual causative microbe OLmpiric prescription+
Which AB to prescribe?
6enicillin is the gold standard in treating dental 6enicillin I< is the first choice for treatement of infections odontogenic infections O7ynn 2002+ Aerobic and anaerobic microorganisms are susceptible to penicillin O,wens and 5chuman 111S+ 6en I< is the obvious choice over 6en the greater oral absorption by 6en I< because of
=t/s bactericidal and active against replicating bacteria often encountered in odontogenic infections O5mith and Meynard1112+
Resistance?!
AcDuired resistance to penicillins >atural resistance tothe the penicillins !
&' ()lactamase activity: This family of enBymes +' Altered penicillin binding proteins: =n organisms that either lack a peptidoglycan hydrolyBes the cyclic bond of the JFlactam 9odified 6C6s have amide a lower affinity for JF=actam
ring& which results in loss of bactericidal activity antibiotics& reDuiring clinically unattainable cell wall Oe.g& 9ycoplasma+ or that have cell concentrations of the drug to effect binding and walls 2' *ecreased that impermeable permeability to to the drug: drugs may inhibition of are bacterial growth. This mechanism 8ecreased penetration of the antibiotic through the eEplain methicillin(resistant staphylococci& although cell membrane prevents the drug itouter does not eEplain its resistance to from nonF=actam reaching the target penicillinFbinding antibiotics like erythromycin to whichproteins they are also O6C6s+ refractory
=f a patient with an early stage odontogenic infection does not respond to penicillin I< within
Alindamycin or 22FS: hours& it is evidence of the presence AmoEicillinUclavulanic acid resistant bacteria OAugmentine+
Cacterial resistance to the penicillins
of
is
predominantly achieved through the production of betaFlactamase A switch to betaF=actamaseFstable antibiotics should Yousra alkhairallah 2010 be made
F=actamase inhibitor& such as amoEicillinUclavulanic acid OAuDrnentineP+& may no longer be more effective than the penicillin I< alone. =n these situat
Mesistance may also be due to alteration of penicillinFbinding proteins 8rugs which combine a betaF=actam antibiotic with a betaF=actamase inhibitor& such as amoEicillinUclavulanic acid OAugmentineP+& may no longer be more effective than the penicillin I< alone
Alindamycin
Lmpirical use of penicillin I<4 as the firstFline drug in treating early odontogenic infections is still the best way to ensure the minimal production of resistant bacteria to other classes of antibiotics& since any overuse of clindamycin or amoEicillinUclavulanic acid OAugmentinP+ is minimiBed in these situations. There is concern that overuse of clindamycin could contribute to development of clindamycinF resistant pathogens 7ynn 2002
#n late odontogenic in$ections%

Another alternative is to add second drug broad to the Alindamycin& because of aits relatively 9etronidaBole should rarely be used as a single penicillin Oeg& metronidaBole V3lagylPW+. AonseDuently& spectrum of activity and resistance to betaF=actamase agent for those infections not responding to therapy treatment degradation& is an attractive firstFline in with the penicillin& the addition of a second drug Oeg& treatment of these infections 9etronidaBole is not effective against gramFpositive metronidaBole+& not a betaF=actam or macrolide& is likely =n aerobic and anaerobic most ctinomyces! Lactobacillus! these cocci infections& bacteria usually to be more effective. Cacterial resistance to predominate and Proprionibacterium species metronidaBole is very rare
&'('R' #)*'CT#+)& =n patients hospitaliBed for severe odontogenic infections& =.I antibiotics are indicated and clindamycin is the clear empiric antibiotic of choice. Alternative antibiotics include an =.I combination of penicillin sulbactam cephalosporins and metronidaBole O0nasyn+. Oif penicillin or =.I. is ampicillinF =.I. the not Alindamycin& allergy
anaphylactoid type+& and ciprofloEacin have been used in patients allergic to penicillins

,ype of infection Larly Ofirst S days of symptoms+ >o improvement in 22FS: hours Antibiotic of c!oice 6enicillin I< OIeetids+ Alindamycin OAleocin+ AephaleEin O<efleE+ JFlactamaseFstable AC! Alindamycin AmoEicillinUclavulanic acid Alindamycin OAleocin+ AephaleEin O<efleE+ Alarithromycin OCiaEin+ Alindmycin OAleocin+ 6enicillin I<Z9etronidaBole Alindamycin OAleocin+ *ose ;00 mg Did 1;0 mg Did ;00 mg Did 1;0 mg Did ;00 mg D-h 1;0 mg Did ;00 mg Did Two ;00 tablets onceUday 1;0 mg Did ;00 mg D-h 1;0 mg Did
6enicillin allergy
Xate O Y S days+
6enicillin allergy
Pinicillin #$ . A%o&icillin
Antibiotic -se by .embers of t!e American Association of /ndodontists in t!e 0ear 2000: 1eport of a 2ational Survey 0ingling 2002
Analysis Mesults! o$ Analgesic and Antibiotic Pre$erence $or 'ndodontic ,anage"ent in -&A%
;00 mg AmoEicillin was the first choice of AC for 5ample S22 to penicillin&being used ! patients siBe! not allergic Lndodontists O11.-Q+ [ 121 n 5CAM8 O1:.1Q+ [ 10; n ;1.1 Q endodontis A 8 O1S.2+ [ -- n .2..Q 5CAM8 6 O;0..Q+ [ SS1 n .;.:Q A 8s ;1.-Q 6s The Xist of AC included! AmoEicillin&Augmentin&6enicillin& AephaleEin& Lrythromycin& 9etronidaBole and Tetracycline H.Calto &5.Al5ubait&8.Hashim200-
6enicillin I< has been found to be effective against most aerobic and anaerobic organisms present in orofacial infections and since the 1120s& continues to be the drug of choice in nonallergic& immunocompetent patients =t is a narrow spectrum antibiotic for infections caused by aerobic ramFnegative cocci and anaerobes =t is bactericidal and has a 1Q to 10Q hypersensitivity rate
AmoEicillin& a penicillin derivative with a broader spectrum& is a good choice for immunocompromised patients =t is a good drug for orofacial infections because it is readily absorbed and can be taken with food Xonger halfFlife and more sustained serum levels =ts broad spectrum is more than is reDuired for endodontic needs& and its use in a healthy individual may contribute to the global antibiotic resistance problem
=n a randomised& operatorFblind& comparative clinical trial& the efficacy of coFamoEiclav O2;0 mg amoEycillin plus 12; mg clavulanic acid& eightFhourly+ was compared to that of penicillin I O2;0 mg phenoEymethylpenicillin& siEFhourly+ in the treatment of acute dentoalveolar abscess. 5ymptoms improved in all patients& however those receiving amoEicillinUclavulanic acid recorded a significantly greater decrease in pain during the second and third days of the treatment. ,nly one patient reported a significant adverse effect associated with drug therapy& and this was in the penicillin group
Xewis 111S
Pinicillin #$ . A%o&icillin AmoEicillin does not offer any advantage over penicillin I< for treatment of odontogenic infections Xess effective than penicillin I< for aerobic gramF positive cocci& and similar to penicillin for coverage of anaerobes Although it does provide coverage against gramF negative enteric bacteria& this is not needed to treat odontogenic infections& eEcept in immunosuppressed patients where these organisms may be present =f one adheres to the principles of using the most effective narrow spectrum antibiotic& amoEicillin should not be favored over penicillin I< Yousra alkhairallah
2010
!linical Scenarios
Patient is co"plaining o$ &evere Pain with necrotic pulp and acute apical abcess
= R 8 should performed without using antibiotics& which has no benefit as a supplement to appropriate local treatement 7alton 111. 9attthews 200S
&evere pain and the diagnosis o$ irreversible pulpitis with acute periapical periodontits
8efinitive 3rom the treatment Aochrane in 5ystemic such a Meview case is by the<eenan removal etof al Administration of penicillin did not significantly reduce the 200;&evidence source of pain& thatthat there is\ was inflamed no sginificant pulpal tissue differnece and pain& percussion pain& or the number of analgesics ad?ustment in pain relief of occlusion. for patients A >5A=8 with untreated may be prescribed irreversible taken by patients with untreated irreversible pulpitis when pulpitits needed& who received but antibiotics antibiotics are versus not indicated those who in this did >agle 2000 case not 7alton R Torabini?ad <eenan2002 200; 5utherland 200S
#$ a patient presented with a locali.ed swelling a$ter co"pletion o$ RCT

Aases with acceptable MAT that develop swelling after obturation should be incised and drained\ such cases usually resolve without reFtreatment 7hen swelling occurs& a cold compress or an ice bag should be applied on the face over the affected area\ keeping it on for ten minutes and off for five& for several hours. This intraoral warming and eEtraoral chilling is usually effective in reieving postFendodontic swelling and discomfort 5tephen Aohen 200:
/ypochlorite accidents
=t is advisable to prescribe AC because of the potential for spread of infection related to tissue destruction Carrowman 200.
A$ter &urgical endodontic treat"ent

The routine use of the prophylactic& or the therapeutic use of antibiotics given to healthy patients undergoing surgical endodontic is not necessary 6allasch 11-1 Xongman R 9artin 1111 Xongman 2000 =gor 200S =Dbal 200.
Tooth avulsion
A broadFspectrum antibiotic should be administered for . days to avoid bacterial proliferation in the area of the ongoing repair process and contribute to the prevention of inflammatory resorption 5aeFXim& 7ang & Trope 111-
/ocal 0se o Antibiotics
/ocal 0se o Antibiotics The rationale $or local application o$ antibiotics

7hilst& systemic antibiotics appear to be clinically effective as an ad?unct in certain surgical and nonsurgical endodontic procedures& their administration is not without the potential risk of adverse systemic effects& such as allergic reactions& toEicity and the development of resistant strains of microbes. =n addition& the systemic administration of antibiotics relies on patient compliance with the dosing regimens followed by absorption through the gastroFintestinal tract and distribution via the circulatory system to bring the drug to the infected site. Hence& the infected area reDuires a normal blood supply which is no longer the case for teeth with necrotic pulps and for teeth without pulp tissue. Therefore& local application of antibiotics within the MA5 may be a more effective mode for delivering the drug Yousra alkhairallah O ilad et al. 1111+
2010
The first reported local use of an antibiotic in endodontic treatment was in 11;1 when used a polyantibiotic rossman paste known as 6C5A
Openicillin& bacitracin& streptomycin& and caprylate sodium+. 6C5A contained penicillin to target gramF positive organisms& bacitracin for penicillinFresistant strains& streptomycin for gramFnegative organisms& and caprylate sodium to target yeasts. These compounds were all suspended in a silicone vehicle
/ocal 0se o Antibiotics Tetracyclines%

tetracyclines have been used to remove the smear layer from instrumented root canal walls OCarkhordar et al. 111.& HaBnedaroglu R Lrsev 2001+& for irrigation of apical rootFend cavities during periapical surgical procedures OCarkhordar R Mussell 111-+& and as intracanal medicaments O9olander R8ahlen 200S+
/ocal 0se o Antibiotics &ubstantivity o$ Tetracyclines

Tetracyclines readily attach to dentine and are <hademi et al. O200:+ compared the antibacterial Abbott et al. O11--+ demonstrated that tetracyclines form subseDuently released without losing their antibacterial substantivity of 2Q AH]& 100 mg mX+1 doEycycline% a strong reversible bond with the dental hard tissues and activity. This property creates a reservoir of active HAl and 2.:Q >a,Al in bovine root dentine over five that they eEhibit slow release and diffusion through antibacterial agent& which is then released from the eEperimental periods of 0& .& 12& 21 and 2days in dentine over an eEtended period of time up to at least 12 dentine surface in a slow and sustained manner vitro. Their findings indicated that after . days& the weeks >a,Al and doEycycline groups had the lowest and the OTorabine?ad et al. 200S+ highest number of colony forming units OA30+& respectively. However& after the longer time periods& the AH] group had the lowest number of A30/s

0ioPure (,TAD) =ntroduced by Torabine?ad R Tohnson O200S+ Aontains doEycycline Oat a concentration of SQ+& citric acid O2.2;Q+ and a detergent& 6olysorbate -0 O0.;Q+
/ocal 0se o Antibiotics &everal studies have evaluated the e$$ectiveness o$ ,TAD $or the disin$ection o$ root canals 9TA8 is able to remove the smear layer OTorabine?ad R Tohnson 200S+ 9TA8 is effective against L. faecalis O5habahang R Torabine?ad 200S+ O5habahang et al. 200S+ OTorabine?ad et al. 200Sb+
5habahang
et
al.
O200S+
compared
the
antibacterial efficacy of a combination of 1.SQ >a,Al as a root canal irrigant and 9TA8 as a final rinse with that of ;.2;Q >a,Al. Their findings showed that using 9TA8 in addition to 1.SQ >a,Al was more effective at disinfecting root canals than using ;.2;Q >a,Al alone
=n another study& 5habahang R Torabine?ad O200S+ compared the antibacterial effects of 9TA8 with those of >a,Al and L8TA by standard in vitro microbiological techniDues and reported that 9TA8 was significantly more effective against L. faecalis

<ho R Caumgartner O200:+ compared the antimicrobial efficacy against L faecalis of 1.SQ >a,AlU9TA8 with that of the combined alternate use of ;.2;Q >a,Al and 1;Q L8TA for root canal irrigation. Cacterial samples taken early in the canal cleaning process revealed growth in none of the 20 samples irrigated with the ;.2;Q >a,AlU1;Q L8TA combination but - of the 20 samples irrigated with 1.SQ >a,AlU9TA8 had bacterial growth. 3urther samples taken after additional canal enlargement revealed growth in none of 20 samples when ;.2;Q >a,AlU 1;Q L8TA were used& but there was still growth in 10 of the 20 samples when 1.SQ >a,AlU9TA8 was used. This investigation showed consistent disinfection of infected root canals when a combination of ;.2;Q >a,Al and 1;Q L8TA was used. However& the combination of 1.SQ >a,AlU 9TA8 left nearly ;0Q of the canals contaminated with Yousra alkhairallah L. faecalis
2010
8avis et al. O200.+ investigated the antimicrobial action of 8ermacyn Obroad sperctrum superoEideised water+& 9TA8& 2Q AH] and ;.2;Q >a,Al against L. faecalis using a Bone of inhibition test. 9TA8 showed significantly larger Bones of inhibition than ;.2;Q >a,Al& 2Q AH] and 8ermacyn
/ocal 0se o Antibiotics Substantivity of MTAD

The substantivity of 9TA8 was significantly greater than AH] and >a,Al 9ohammadi R 5hahriari O200-+
/ocal 0se o Antibiotics Tetraclean

a miEture of an antibiotic& an acid and a detergent. However& the concentration of the antibiotic& doEycycline and the type of detergent differ from those of 9TA8 O iardino et al. 200:+ Tetraclean caused a high degree of disaggregation when compared with 9TA8 biofilm
O iardino et al. 200.+
/ocal 0se o Antibiotics Ledermi paste

XedermiE is a glucocorticosteroidFantibiotic Today& XedermiE paste remains a combination of the compound that was developed by 5chroeder R Triadan in 11:0. antibiotic& demeclocycline%HAl Oat same tetracycline a concentration of S.2Q+& and aXedermiE corticosteroid& The primary interest in developing paste was based onacetonide the use of corticosteroids1Q+& to control triamcinolone Oconcentration in a pain and inflammation associated with pulp and polyethylene glycol base periapical diseases The sole reason for adding the antibiotic component to XedermiE was to compensate for what was perceived at the time to be a possible corticoidF induced reduction in the host immune response
XedermiE paste is dentinal tubules
capable of diffusing through and cementum to reach the
periradicular and periapical tissues OAbbott 1110+
XedermiE paste prevented eEperimentally induced eEternal inflammatory root resorption in vivo 6ierce et al. O11--+

6eriodontal ligament inflammation and inflammatory root resorption were markedly inhibited by both the calcium hydroEideand corticosteroidFantibiotic pastes relative to untreated controls. Meplacement resorption was the lowest in the corticosteroidFantibiotic group& and significantly more normal periodontal ligament was present in this group than in the calcium hydroEide and control groups Thong et al. O2001+
XedermiE
pasteFtreated
roots
had
statistically
significantly more healing and less resorption than the roots treated with AaO,H+2 Cryson et al. O2002+
Lhrmann et al. O200S+ investigated the relationship of postoperative pain associated with three different treatment regimes for infected teeth with acute apical periodontitis after complete biomechanical debridement of the root canal system in patients presenting for emergency relief of pain. They reported that the patients with teeth dressed with XedermiE paste had less pain than that eEperienced by patients who had teeth dressed with calcium hydroEide or no dressing at all
/ocal 0se o Antibiotics 1eder"ix%

!ffective in preventin" infalmmatory resorption in avulsed teeth #ain mana"ement
/ocal 0se o Antibiotics Clinda"ycin

9olander R 8ahlen O200S+ investigated the effect of clindamycin on root canal infections and apical periodontitis when placed as an intracanal dressing. Alindamycin offered no advantage over conventional root canal dressings& such as calcium hydroEide Xin et al. O200S+ compared the antibacterial effect of clindamycin and tetracycline Alindamycin significantly reduced the amount of viable
/ocal 0se o Antibiotics ,etronida.ole

5iDueira R de 0Beda O111.+ 9etronidaBole was more effective than calcium hydroEideUA69A Hoelscher et al. O200:+ evaluated the antimicrobial effects against L. faecalis of five antibiotics OamoEicillin& penicillin& clindamycin& metronidaBole and doEycycline+ when added to <err 6ulp Aanal 5ealer L7T in vitro. They found that all of these antibiotics eEcept metronidaBole could enhance the antimicrobial efficacy of the sealer
/ocal 0se o Antibiotics 1ocal A0 Treat"ent $or Avulsed Teeth%

Topical doEycycline application significantly increased the chances of successful pulp revasculariBation $ve% et al &''( The beneficial effect of soaking a tooth in doEycycline has also been confirmed by Yanpiset R Trope O2000+
!onclusion
6rophylactic antibiotics are usually only indicated in medically compromised patients\ an eEception would be in the reFimplantation of an avulsed tooth
The treatment of acute and chronic infections of endodontic origin is primarily by operative intervention. The therapeutic use of antibiotics is thus as an ad?unct to mechanical treatment
!onclusion
The potential benefits of antibiotic administration should therefore outweigh the possible disadvantages associated with their use. A dentist who prescribes an antibiotic for a Duestionable indication may be seen as placing a patient at risk from potential adverse effects of drugs
The use of topical antiFmicrobial agents has declined evaluation

and
reDuires
further
research
and

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Antibiotic Use in Endodontics

Prepared by: Yousra Alkhairallah R1 Saudi Board in Endodontics

Yousra alkhairallah 2010

Yousra alkhairallah 2010

Yousra alkhairallah 2010

antibacterial antibiotic was developed in

Yousra alkhairallah 2010

Yousra alkhairallah 2010

according to the type of periradicular 5?ogren 11-Yousra alkhairallah 2010

,liveira 2000 5iDueira 2001 5iDueira 2002

Yousra alkhairallah 2010

=nhibitors of Aell 7all 5ynthesis

6rotein 5ynthesis =nhibitors

=nhibitors of >ucleic Acid 5ynthesis and 3unction

9etronidaBole Kuinolone s 3lag yl AiproflaEicine

9acrolides 8oEycycline 9inocycline Tetracycline Lrythromycine ABithromycine Alarithromycin e

Inhibitors o !ell "all Synthesis Pinicillin #$

Yousra alkhairallah 2010

Yousra alkhairallah 2010

Inhibitors o !ell "all Synthesis

Yousra alkhairallah 2010

Yousra alkhairallah 2010

Inhibitors o !ell "all Synthesis #anco%ycines

Yousra alkhairallah 2010

Inhibitors o !ell "all Synthesis

Active against a wide variety of gramFpositve organisms 6otential nephrotoEicity

Yousra alkhairallah 2010

Inhibitors o Protein Synthesis TETRAC!CLINE S Croad spectrum Adverse effects!

Yousra alkhairallah 2010

9ontgommery111Yousra alkhairallah 2010

Inhibitors o Protein Synthesis "ACROLI E S

Inhibitors o Protein Synthesis

Yousra alkhairallah 2010

Inhibitors o Protein Synthesis

Moche R Yoshimori O111.+

Yousra alkhairallah 2010

=nfective Lndocarditis O=L+!

Yousra alkhairallah 2010

bacteraemia Cacteraemia is usually eradicated by the reticuloF

OCender R 9ontgomery 11-:+

=n a review of ;S cases of =L following dental

O9artin et al. 111.+

+oes the use o AP pre(ent EI ,

Yousra alkhairallah 2010

!o !ave ta%en prop!ylactic antibiotics

Yousra alkhairallah 2010

Aller$ic to 1enicillin and una0le to ta-e oral medications

Yousra alkhairallah 2010

Yousra alkhairallah 2010

Yousra alkhairallah 2010

Antibiotic Prophyla&is Patients who re!uires "ultiple dental treat"ent sessions

7aiting for 1 to 12 days between prophylactic cover periods

Yousra alkhairallah 2010

AB or treat%ent o -dontogenic In ections

Yousra alkhairallah 2010

treat%ent o -dontogenic In ections

treat%ent o -dontogenic In ections

Yousra alkhairallah 2010

treat%ent o -dontogenic In ections

Yousra alkhairallah 2010

treat%ent o -dontogenic In ections

treat%ent o -dontogenic In ections

Yousra alkhairallah 2010

treat%ent o -dontogenic In ections