Antibiotic Use in Endodontics

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					         Antibiotic Use in Endodontics

                           Prepared by: Yousra Alkhairallah
                           R1 Saudi Board in Endodontics

Yousra alkhairallah 2010

            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
                Greek : ἀντί – anti, "against", and βίος – bios,

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               Originally known as antiobiosis, they were first
               described in 1877 in bacteria when Louis Pasteur
               and Robert Koch observed that an airborne bacillus
               could inhibit the growth of Bacillus anthracis

               They weren’t called    antibiotics    Until 1942 by
               Selman      Waksman   an   American    microbiologis

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            Prontosil, the first commercially available antibacterial
            antibiotic was developed in Germany

            Fleming's accidental discovery and isolation of penicillin in
            September 1928 marks the start of modern antibiotics

              Prior to this, most wartime deaths were due to bacterial
              infections of wounds, rather than from the wounds

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             1890 W.D. Miller, the father of oral microbiology, was
             the first investigator to associate the presence of
             bacteria with pulpal disease

              A classic study published in 1965 by Kakehashi et al
             proved that bacteria caused pulpal and periradicular

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             As long as the pulp is vital, it is a sterile tissue as any
             connective tissue elsewhere in the body

              Infection occurs only after pulp necrosis

             No single species will be discovered to be the
             “major” endodontic pathogen

             The composition of the microbiota varies depending
             on the types of infection and periradicular lesions

Yousra alkhairallah 2010                                   Siqueira 2002

            Primary root canal infection
             Whereas microorganisms microbial the
            Caused by a wide range of colonizing species
              In general, primary infections are mixed and
            necrotic pulp tissue chronic periradicular
             is associated with anaerobic
              predominated      by                 bacteria.
             lesions, a more restricted group oftospecies
              Predominant species usually belong        the
              generaassociated Porphyromonas, Prevotella,
             is                       with      symptomatic
            The involved microbiota usually shifts
              Fusobacterium, Treponema, Peptostreptococcus,
             periradicular diseases such as acute apical
              Eubacterium, on the time
            depending and Campylobacter. of infection.
             periodontitis and acute periradicular
             abscess it has been strongly suggested
            Moreover, or microaerophilic streptococci are
              also commonly found in primary infections
                                                 Baumgartner 1986
            that the microbiota can differ Sundqvist 1987to
                                               Sjogren 1988
            the type of periradicular    diseases
                                               Oliveira 2000
                                               Siqueira 2001
Yousra alkhairallah 2010                          Siqueira 2002

             Secondary root canal

             Caused 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

              If the penetrating microorganisms are
             successful in surviving and colonizing the
             root canal system, a secondary infection is
Yousra alkhairallah 2010                     Siqueira 1997

            Persistent root canal infection

            Microorganisms that in some way resisted the
            Gram-positive bacteria are the cause persistent
            intracanal procedures of disinfectionpredominant
            intraradicular infections
            Causative 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 single species or at
                                                   Sire´n compared
            least by a lower number of species when 1997
            with primary infections                Molander 1998
                                                   Sundqvist 1998
                                                   Peciuliene 2000

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             Extraradicular infection

             May be primary, secondary, or persistent.
             Actinomyces species and Propionibacterium
             propionicus, may be implicated in
             The most common form of extraradicular
             infection is theinfections
             extraradicular acute periradicular abscess
             The source of extraradicular infections is
             usually the intraradicular infection. A few
             oral microorganisms have the ability to
             overcome host defense mechanisms and
                                               Nair 1984
             thereby induce an extraradicular infection 1986
                                               Sjogren 1988
                                               Iwu 1990

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               Siquiera 2002
                                       Classification of Antibiotics

                                                                                             Inhibitors of Nucleic
  Inhibitors of Cell                              Protein Synthesis
                                                                                              Acid Synthesis and
   Wall Synthesis                                     Inhibitors

                              Chloramphenicole                             Tetracyclines
Others:         ß-lactam                                                                                    Metronidazole
Vancomycine                                Clindamycine       Macrolides
                antibiotics                                                                  Quinolones
                                    Penicillins                            Minocycline                         Flagyl
Monobactams                                                                Tetracycline
                                                     Extended     Erythromycine            Ciproflaxicine
                                                     spectrum:    Azithromycine
                                         Antistaph: Amoxicillin
  Carbapenems      Cephalosporins                                 Clarithromycine
                                         Methicillin Ampicillin

                   Cephalexine Penicillin G
                               Penicillin V
Inhibitors of Cell
Wall Synthesis

            Pinicillin VK
            Adverse effects:
            Penicillin VK is bactericidal against gram-positive
            cocci and the major pathogens of mixed anaerobic
              Narrow
             Allergy spectrum
             Oral candiasis
              Defuses into most body parts including oral tissues
             Mild diarrhea
             soon after dosing
             Nausea

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Inhibitors of Cell
Wall Synthesis


            Bacterial spectrum penicillin

            Antibacterial spectrum similar to that of penicillin G,
            but are more effective against Acid
            Amoxiciliin +Calvulanic gram-negative bacilli

            AB prophylaxis
            beta-Iactamase-stable antibiotics

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Inhibitors of Cell
Wall Synthesis

              Cephalexin (Keflex®):
              Include cefadroxil (Duricets®), cephalexin (Keflex®),
              The first generation cephalosporin often used to treat
              and cephradine (Velosel®)
              odontogenic Infections

               indicated as alternatives in early infectionsbut are not
              Most active against gram-positive cocci, because they
                are effective in killing the aerobes
              very active against many anaerobes
              AP Prophylaxis                Allergy to Penicillins
              Active against gram-positive staphylococci and
              streptococci, but not enterococci.
              Adverse effects: diarrhea in 1% to 10% of patients
              Active against many gram-negative aerobic bacilli

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Inhibitors of Cell
Wall Synthesis


             Better activity against some of the anaerobes
             including some Bacteroides, Peptoeoccus, and
             Peptostreptococcus species

             Cefaclor (Ceclo®) and cefuroxime (Ceftin®) have been
             used to treat early stage infections

             The advantage of twice-a-day dosing

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Inhibitors of Cell
Wall Synthesis

             Effective against multiple drug resistant
             organisms such as methicillin-resistant staph

             Restrict its use to treat serious infections caused
             by gram-positive bacteria and life threatening

             AB prophylaxis (IV)

             Adverse reactions: fever, chills, red man
             syndrome, shock, Dose-related hearing loss

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Inhibitors of Cell
Wall Synthesis


            Active against a wide variety of gram-positve organisms

            Potential nephrotoxicity

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Inhibitors of
Protein Synthesis

               Broad spectrum
              Adverse effects:

               Bacteriostatic
              Gastric discomfort
               Renally-impaired patients
               The treatment of choice in infections caused by
                 Effects on calcified tissues
              Mycoplasma pneumonia,Spirochetes,gram-positive bacilli,
              Fatal hepatotoxicity
               Pregnant or bacilli,gram-negative enteric rods.they are
              gram-negative breast-feeding women
              also effective against Chlamydia, Rickettsia, and Brucella
               Children under 8 years of age
              Vestibular problems
               Pseudotumor cerebri
               Superinfections

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Inhibitors of
Protein Synthesis


              Erythromycin is no longer very useful becauseisof
              Antihacterial spectrum of the erythromycin family similar
              resistant pathogens
              to penicillin VK

              Narrow spectrum antibiotics
                                                              Harde 1997
              Was considered highly effective antibiotics for treating
              odontogenic infections, especially in penicillin allergy
             Resistance develops rapidly to macrolides and there
             may be cross-resistance between erythromycin and
             newer macrolides


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Inhibitors of
Protein Synthesis

            Clarithromycin :
            Both azithromycin and clarithromycin are presently
            Shows good activity against many gram-positive and gram-
            recommended as alternatives in the prophylactic regimen
            negative aerobic and anaerobic organisms
            for prevention of bacterial endocarditis.
            Active against methicillin-sensitive S. aureus and most
            streptococcus species S. aureus strains resistant to
            erythromycin are resistant to clarithromycin

            Azrithromycin :
            Similar to erythromycin in effectiveness against anaerobic
            gram-positive cocci and Bacteroides sp. Azithromycine is
            active against staphylococci, including S. aureus and S.
            epidermidis, as well as streptococci, such as S. pyogenes and
            S. pneumoniae. excellent activity against H. influenzae.

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Inhibitors of
Protein Synthesis


            Adverse effects but elicit bactericidal effects at higher
             Abdominal pain, nausea, vomiting, and diarrhea

             Antibacterial spectrum:
             Hypersensitivity reactions are rare
              Anaerobic bacteria, such as Bacteroides fragilis
              Nonenterococcal gram-positive cocci
             Pseudomembranous colitis characterized by severe
            diarrhea, abdominal cramps, and excretion of blood or
            mucus in the stools
             Not effective against mycoplasma or gram-negative

             Its small molecular weight enables it to more readily
             enter bacterial cytoplasm and to penetrate bone

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Inhibitors of
Protein Synthesis


               Active against a
              Adverse effects: wide range of gram-positive and gram-
               negative bacteria,but because of its toxicity, its use is
               GI upsetto some of the hepatic mixedin which there is
              Inhibition of life threatening infections function
               no alternatives
               Overgrowth of candida
               block the metabolism of such drugs as warfarin, phenytoin,
               Anemias: and chlorpropamide
              tolbutamide Hemolytic anemia
               Antimicrobial activity:
               Excellent against Anaerobes
               Gray baby syndrome
              Elevation their concentrations and potentiating their effects

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Inhibitors of
Protein Synthesis


            a broad spectrum against protozoa and anaerobic bacteria

            Known for its strong antibacterial activity against anaerobic
            cocci as well as Gram-negative and Gram-positive bacilli

            Readily permeates bacterial cell membranes and it then
            binds to DNA, disrupting its helical structure, which leads to
            rapid cell death

                                                    (Windley et al. 2005)

            Metronidazole had excellent activity against anaerobes but it
            had no activity against aerobes

                                               Roche & Yoshimori (1997)
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                     AB Prophylaxis

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            Infective Endocarditis (IE):
                      a life threatening disease with substantial
                 It’s A microbial infection of the endothelial surface
                of the heart or heart valves that most indivisuals
                morbidity and mortality which affectsoften occurs
                   in proximity to structural or acquired cardiac
                 with underlying congenital cardiac defects who
                                    develop bacteremia

                                 Often as a result of dental
                           ,GI,genitourinary,respiratory or cardiac
                                invasive/surgical procedures

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            Because of the high morbidity and mortality related to
            Manipulation of the oral tissues may be associated with
            IE, it has long been advised that AP is required before
            a transient bacteraemia
            dental procedures likely to induce bacteraemia
                                         (Bender & Montgomery 1986)
                                      (Tomas Carmona et reticulo-
            Bacteraemia is usually eradicated by the al. 2002)
            endothelial system within a few minutes and poses no
            threat to the healthy patient. However, some medically
            compromised patients may be at risk from this transient
            blood-borne     infection,   most   notably     infective
            endocarditis (IE)
                                                   (Dajani et al. 1997)
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             Bacteremia associated with
             Endodontic treatment:

             Inseries of RCT might involve ainstrumentation for
            ANostudies where more selective techniqueswas
                 bacteraemia was elicited if detectable
             Nonsurgical studies found no statistically significant
              kept within
             bacteraemiathe root canal incidence the incidence
             culturing microorganisms were used,of bacteraemia
            difference between the
             of bacteraemia has been within and outwith al. after
            following instrumentationreported as up to 20% 2000)
                                          (Baumgartner et the root
                                           (Jordan & Durso
              Detectable bacteraemia was found in only one of
             nonsurgical    endodontic     treatment,      where
            canal 30 patients undergoing nonsurgical root canal
               treatment, with al. 1992, 1995, Debelian opposed to
                   (Debelian was incidence of 3.3% as et al.
             instrumentationet an confined to the root canal 1996)
               83.3% following flap retraction, 33.3% following
               periapical was elicited in 31–54% ofetroot dental
                                            (Heimdahl al. canal
            Bacteraemia curettage and 100% following 1990)
                                             (Debelian et al. 1998)
                                           (Baumgartner et al. 1977)

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            Infective endocarditis and nonsurgical

             Up large case–control study three IE traceable to found
             In ato 1953, no reported cases of cases of IE wereroot
             which therapy had been described root canal treatment
             canal were apparently attributed to
                                                          (Kolmer was
             based on the premise that the infecting organism1953)
             consistent with those inhabiting the root canal system and
             also that the patient had had endodontic treatment in the
             In a review of 53 cases of IE following dental
             last 30 days
             procedures, seven were attributed to previous RCT. In

                                         (Van der of et al. 1992)
             all cases, there was clear evidenceMeer extracanal
             instrumentation, mainly through the apical foramen
                                                    (Martin et al. 1997)
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            Does the use of AP prevent EI ?
              (Van der Meer and colleagues 1992) published a study of
             Same authors performed a 2-year case-control study.
              dental procedures in the Netherlands and the efficacy of
             Among patients for whom prophylaxis was
              antibiotic prophylaxis to prevent IE in patients with native
             recommended, 5 of 20 cases of IE occurred despite
              or prosthetic cardiac valves. They concluded that dental or
             receiving antibiotic prophylaxis. The authors concluded
              other procedures probably caused only a small fraction of
             that prophylaxis was not effective
              cases of IE and that prophylaxis would prevent only a
              small number of cases even if it were 100% effective
                                  (Van der Meer and colleagues 1992)
             Huge number of prophylaxis doses would be necessary to
             prevent a very low number of IE cases
                                                             (Duval 2006)
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             IE is much more likely to result from frequent exposure to
            random bacteremias associated with daily activities than
            from bacteremia caused by a dental, GI tract, or GU tract

             Prophylaxis may prevent an exceedingly small number of
            cases of IE, if any, in individuals who undergo a dental, GI
            tract, or GU tract procedure

             The risk of antibiotic-associated adverse events exceeds
            the benefit, if any, from prophylactic antibiotic therapy

             Maintenance 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 IE

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             Patients who have taken prophylactic antibiotics routinely
             in the past but no longer need them include people with:

              Mitral valve prolapse
              Rheumatic heart disease
              Bicuspid valve disease
              Calcified aortic stenosis
              Congenital heart conditions such as ventricular septal
             defect, atrial septal defect and hypertrophic cardiomyopathy

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    Situation                Agent                  Regimen
  Standard general          Amoxicillin      Adults: 2.0 g; children 50 mg/kg,
                                               orally 1 h before procedure
  Unable to take oral       Ampicillin      Adults: 2.0 g IM or IV; children 50
                                              mg/kg IM or IV within 30 min
    medications                                     before procedure

 Patient is allergic to    Clindamycin      Adults: 600 mg; children 20 mg/kg
                                               orally 1 h before procedure
                           Cefadroxil or      Adults: 2 g; children 50 mg/kg
                                               orally 1 h before procedure
                          Azithromycin or   Adults: 500 mg; children 15 mg/kg
                                               orally 1 h before procedure
 Allergic to penicillin    Clindamycin      Adults: 600 mg; children 20 mg/kg
                                               IV within 30 minutes before
and unable to take oral                                 procedure
                             Cefazolin      Adults: 1.0 g; children 25 mg/kg IM
                                                or IV within 30 min before
               Clinical Scenarios

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             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

            Drug can be effective if it is given up to2 hours after
            bacteremia begins

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              Patient who is already receiving antibiotics ?

              Another possibility is the use of second-choice
              In patients with periodontal diseases being
                treated with tetracycline treatment should be
               stopped for a minimum of 3 or 4 days before
               giving the prophylactic regimen with amoxicillin

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             Patients who requires multiple dental treatment

               Waiting for 9 to 14 days between prophylactic
               cover periods

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            AB for treatment of

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ADA Recommendations

               An infection must be persistent or systemic to justify 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, expectation of
               referring dentists, “just in case” situations, or because it is
               the day before a weekend or holiday. These reasons
               constitute inappropriate use of antibiotics

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treatment of Odontogenic

              The decision to use an antimicrobial/antibiotic
              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

              Antibiotic therapy should be used as an adjunct to
              dental treatment and never used alone as the first
              line of care

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treatment of Odontogenic

            Determinant Factors       as to whether conjunctive
            antibiotic therapy is indicated :

             Host defense mechanisms
             Severity of the infection
             Magnitude of the extension of the infection
             Expected pathogen

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treatment of Odontogenic

             The choice of an antibiotic should be based on
             knowledge of the usual causative microbe (Empiric

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treatment of Odontogenic

            Which AB to prescribe?

             Penicillin is the gold standard in treating dental infections
             Penicillin VK is the first choice for treatement of odontogenic
             Aerobic and anaerobic microorganisms are susceptible to
                                                                  (Wynn 2002)

                                               (Owens and Schuman 1993)

             Pen VK is the obvious choice over Pen G because of the
             greater oral absorption by Pen VK

             It’s bactericidal and active against replicating bacteria often
             encountered in odontogenic infections

                                                 (Smith and Reynard1992)

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treatment of Odontogenic

                 Acquiredresistanceto the penicillins :
                 Natural resistance to the penicillins

                 1. Altered penicillin binding proteins: Modified
                3. ß-lactamase activity: This family of enzymes cell
                 hydrolyzes the that amide lack a the ß-lactam ring,
                 In organisms cyclic either bond of peptidoglycan
                PBPs have a lower affinity for ß-Iactam antibiotics,
                 wall (e.g, Mycoplasma) or that activity
                 which results in loss of bactericidal have cell walls the
                requiring clinically unattainable concentrations of that
                drug to effect binding and inhibition of bacterial
                 are impermeable to the may explain methicillin-
                growth. This mechanism drugs drug: Decreased
                 2. Decreased permeability to
                 penetration of the antibiotic through the outer cell
                resistant staphylococci, although it does not explain its
                 membrane non-Iactam drug from like erythromycin to
                resistance toprevents the antibiotics reaching the target
                 penicillin-binding proteins (PBPs)
                which they are also refractory

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treatment of Odontogenic

             If a patient with an early stage odontogenic infection
             does not respond to penicillin VK within 24-36 hours,
             Clindamycin presence of resistant bacteria
             it is evidence of the or
             Amoxicillin/clavulanic acid
             (Augmentine) to the penicillins
              Bacterial resistance                               is
             predominantly achieved through the production of

             A switch to beta-Iactamase-stable antibiotics should
             be made

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Resistance may also be due to alteration of penicillin-binding proteins. Consequently, drugs which combine a beta-Iactam antibiotic with a beta-Iactamase inhib

                          treatment of Odontogenic

                                             Resistance may also be due to alteration of
                                             penicillin-binding proteins

                                             Drugs which combine a beta-Iactam antibiotic with a
                                             beta-Iactamase                           inhibitor,                   such                 as
                                             amoxicillin/clavulanic acid (Augmentine®), may no
                                             longer be more effective than the penicillin VK alone

                          Yousra alkhairallah 2010
treatment of Odontogenic

             Empirical use of penicillin VK' as the first-line 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
             amoxicillin/clavulanic    acid    (Augmentin®)       is
             minimized in these situations. There is concern that
             overuse of clindamycin could contribute to
             development of clindamycin- resistant pathogens

                                                       Wynn 2002

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treatment of Odontogenic

            In late odontogenic infections:

             Clindamycin, because of itsarelativelydrug to spectrum of
             Another alternative is to add second broad the penicillin
              Metronidazole should rarely be used as a single agent
             (eg, metronidazole to beta-Iactamase degradation, is an
            activity and resistance [Flagyl®]). Consequently, for those
             infections not responding to treatment with penicillin, the
            attractive first-line therapy in the treatment of these
              Metronidazole is not effective against gram-positive
            infections of a second drug (eg, metronidazole), not a beta-
             aerobic cocci and most Actinomyces, Lactobacillus, and
             Iactam or macrolide, is likely to be more effective. Bacterial
             Proprionibacterium species
             In these infections, anaerobic bacteria usually
             resistance to
            predominate metronidazole is very rare

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treatment of Odontogenic

             In patients hospitalized for severe odontogenic infections,
             I.V antibiotics are indicated and clindamycin is the clear
             empiric antibiotic of choice. Alternative antibiotics include
             an I.V combination of penicillin and metronidazole or I.V.
             ampicillin-sulbactam      (Unasyn®).      Clindamycin,     I.V.
             cephalosporins     (if   penicillin   allergy   is   not   the
             anaphylactoid type), and ciprofloxacin have been used in
             patients allergic to penicillins

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             treatment of Odontogenic
 Type of infection          Antibiotic of choice                Dose

Early (first 3 days of     Penicillin VK (Veetids®)          500 mg qid
    symptoms)              Clindamycin (Cleocin®)            150 mg qid
                            Cephalexin (Keflex®)             500 mg qid
No improvement in         ß-lactamase-stable AB:
    24-36 hours                 Clindamycin                  150 mg qid
                         Amoxicillin/clavulanic acid         500 mg q8h

 Penicillin allergy       Clindamycin (Cleocin®)             150 mg qid
                            Cephalexin (Keflex®)             500 mg qid
                          Clarithromycin (Biaxin®)     Two 500 tablets once/day
  Late ( > 3 days)         Clindmycin (Cleocin®)             150 mg qid
                         Penicillin VK+Metronidazole         500 mg q8h

 Penicillin allergy        Clindamycin (Cleocin®)            150 mg qid
treatment of Odontogenic
Pinicillin VK X Amoxicillin

                       Antibiotic Use by Members of the American
                       Association of Endodontists in the Year 2000:
                                Report of a National Survey
                                       Yingling 2002

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Pinicillin VK X Amoxicillin

              Analysis of Analgesic and Antibiotic Preference for
              Endodontic Management in KSA:
              500 mg Amoxicillin was the first choice of AB for
              patients not 342
              Sample size: allergic to penicillin,being used :
              Endodontists (19.8%) = 129 n
              SBARD endodontis n
              51.1 % (16.1%) = 105
              AGD (13.4) = 88 n
              72.7% SBARD
              GP (50.7%) = 331 n
              75.6% AGDs
              59.8% GPs
              The List of AB included:
              Amoxicillin,Augmentin,Penicillin, Cephalexin,
              Erythromycin, Metronidazole and Tetracycline

                                        H.Balto ,S.AlSubait,D.Hashim2008

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Pinicillin VK X Amoxicillin

              Penicillin VK has been found to be effective against most
              aerobic and anaerobic organisms present in orofacial
              infections and since the 1940s, continues to be the drug
              of choice in nonallergic, immunocompetent patients

              It is a narrow spectrum antibiotic for infections caused by
              aerobic Gram-negative cocci and anaerobes

              It is bactericidal and has a 1% to 10% hypersensitivity rate

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Pinicillin VK X Amoxicillin

             Amoxicillin, a penicillin derivative with a broader
             spectrum, is a good choice for immunocompromised

             It is a good drug for orofacial infections because it is
             readily absorbed and can be taken with food

             Longer half-life and more sustained serum levels

             Its broad spectrum is more than is required for endodontic
             needs, and its use in a healthy individual may contribute
             to the global antibiotic resistance problem

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Pinicillin VK X Amoxicillin

              In a randomised, operator-blind, comparative clinical
              trial, the efficacy of co-amoxiclav (250 mg amoxycillin plus
              125 mg clavulanic acid, eight-hourly) was compared to
              that of penicillin V (250 mg phenoxymethylpenicillin, six-
              hourly) in the treatment of acute dentoalveolar abscess.
              Symptoms improved in all patients, however those
              receiving    amoxicillin/clavulanic   acid      recorded   a
              significantly greater decrease in pain during the second
              and third days of the treatment. Only one patient
              reported a significant adverse effect associated with drug
              therapy, and this was in the penicillin group

Yousra alkhairallah 2010                                         Lewis 1993
Pinicillin VK X Amoxicillin

            Amoxicillin does not offer any advantage over
            penicillin VK for treatment of odontogenic infections

            Less effective than penicillin VK for aerobic gram-
            positive cocci, and similar to penicillin for coverage of

            Although it does provide coverage against gram-
            negative enteric bacteria, this is not needed to treat
            odontogenic infections, except in immunosuppressed
            patients where these organisms may be present

            If one adheres to the principles of using the most
            effective narrow spectrum antibiotic, amoxicillin
            should not be favored over penicillin VK

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               Clinical Scenarios

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treatment of Odontogenic

              Patient is complaining of Severe Pain with necrotic
              pulp and acute apical abcess

              I & D should performed without using antibiotics, which
              has no benefit as a supplement to appropriate local

                                                        Walton 1997
                                                      Mattthews 2003

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treatment of Odontogenic

             Severe pain and the diagnosis of irreversible pulpitis with
             acute periapical periodontits

              From the Cochrane such a Review by Keenan the
             Definitive treatment inSystemiccase is the removal ofet al
             Administration of penicillin did not significantly reduce pain,
              2005,evidence that there inflamed pulpal tissue and
             source of pain, that is; was no sginificant differnece in
             percussion pain, or the number of analgesics taken by
              pain relief of occlusion. untreated irreversible pulpitits
             adjustment for patients with A NSAID may be prescribed
             patients with untreated irreversible pulpitis
              who needed, but antibiotics are not indicated not
             when received antibiotics versus those who did in this case
                                                                 Nagle 2000
                                                              Keenan 2005
                                              Walton & Torabinijad 2002
                                                         Sutherland 2003

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treatment of Odontogenic

             If a patient presented with a localized swelling after
             completion of RCT

             Cases with acceptable RCT that develop swelling after
             obturation should be incised and drained; such cases
             usually resolve without re-treatment

             When 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 extraoral chilling is usually effective
             in reieving post-endodontic swelling and discomfort

                                                    Stephen Cohen 2006

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treatment of Odontogenic

             Hypochlorite accidents

             It is advisable to prescribe AB because of the potential for
             spread of infection related to tissue destruction

                                                        Barrowman 2007

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treatment of Odontogenic

             After Surgical endodontic treatment

            The routine use of the prophylactic, or the therapeutic use
            of antibiotics given to healthy patients undergoing surgical
            endodontic is not necessary

                                                        Pallasch 1989
                                               Longman & Martin 1991
                                                       Longman 2000
                                                            Igor 2003
                                                           Iqbal 2007

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treatment of Odontogenic

            Tooth avulsion

               A broad-spectrum antibiotic should be administered for 7
               days to avoid bacterial proliferation in the area of the
               ongoing repair process and contribute to the prevention
               of inflammatory resorption

                                            Sae-Lim, Wang , Trope 1998

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          Local Use of Antibiotics

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Local Use of

              The rationale for local application of antibiotics

              Whilst, systemic antibiotics appear to be clinically effective
              as an adjunct in certain surgical and nonsurgical endodontic
              procedures, their administration is not without the
              potential risk of adverse systemic effects, such as allergic
              reactions, toxicity and the development of resistant strains
              of microbes. In addition, the systemic administration of
              antibiotics relies on patient compliance with the dosing
              regimens followed by absorption through the gastro-
              intestinal tract and distribution via the circulatory system to
              bring the drug to the infected site. Hence, the infected area
              requires 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 RCS may be a more effective mode for delivering the

 Yousra alkhairallah 2010                                   (Gilad et al. 1999)
Local Use of

               The first reported local use of an antibiotic in endodontic
               treatment was in 1951 when Grossman used a
               polyantibiotic paste known as PBSC (penicillin, bacitracin,
               streptomycin, and caprylate sodium). PBSC contained
               penicillin to target gram-positive organisms, bacitracin for
               penicillin-resistant   strains,   streptomycin   for   gram-
               negative organisms, and caprylate sodium to target
               yeasts. These compounds were all suspended in a silicone

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Local Use of


             tetracyclines have been used to remove the smear layer from
             instrumented root canal walls (Barkhordar et al. 1997,
             Haznedaroglu & Ersev 2001), for irrigation of apical root-end
             cavities during periapical surgical procedures (Barkhordar &
             Russell 1998), and as intracanal medicaments (Molander
             &Dahlen 2003)

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Local Use of

             Substantivity of Tetracyclines

              Khademi al. (1988) attach compared tetracyclines form a
                         et al. demonstrated that the subsequently
             Tetracyclines readily (2006) to dentine and are antibacterial
             Abbott et
              substantivity of 2% CHX, their dental doxycycline–HCl that
                                                mL)1 hard tissues and This
             released without losing 100 mg antibacterial activity. and
             strong reversible bond with the
             property creates a reservoir of active antibacterial agent,
              2.6% NaOCl in bovine root dentine over five experimental
             they exhibit slow release and diffusion through dentine over
              periods of 0, 7, 14,of time up to at leastsurface in slow and
                                   21 and 28 dentine 12 weeks
             which is then released from the days in vitro. Theirafindings
             an extended period
             sustained manner
              indicated that after 7 days, the NaOCl and doxycycline
              groups had the lowest and the highest number of colony
                                                   (Torabinejad et longer
              forming units (CFU), respectively. However, after theal. 2003)
              time periods, the CHX group had the lowest number of

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Local Use of

             BioPure (MTAD)

             Introduced by Torabinejad & Johnson (2003)

             Contains doxycycline (at a concentration of 3%), citric acid
             (4.25%) and a detergent, Polysorbate 80 (0.5%)

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Local Use of

             Several studies have evaluated the effectiveness of
             MTAD for the disinfection of root canals

             MTAD is able to remove the smear layer
                                     (Torabinejad & Johnson 2003)

             MTAD is effective against E. faecalis

                                    (Shabahang & Torabinejad 2003)
                                            (Shabahang et al. 2003)
                                          (Torabinejad et al. 2003b)

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Local Use of

                Shabahang et al. (2003) compared the antibacterial
                efficacy of a combination of 1.3% NaOCl as a root
                canal irrigant and MTAD as a final rinse with that of
                5.25% NaOCl. Their findings showed that using
                MTAD in addition to 1.3% NaOCl was more
                effective at disinfecting root canals than using
                5.25% NaOCl alone

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Local Use of

              In another study, Shabahang & Torabinejad (2003)
              compared the antibacterial effects of MTAD with
              those of NaOCl and EDTA by standard in vitro
              microbiological techniques and reported that MTAD
              was significantly more effective against E. faecalis

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Local Use of

             Kho & Baumgartner (2006) compared the antimicrobial
             efficacy against E faecalis of 1.3% NaOCl/MTAD with that
             of the combined alternate use of 5.25% NaOCl and 15%
             EDTA for root canal irrigation. Bacterial samples taken
             early in the canal cleaning process revealed growth in
             none of the 20 samples irrigated with the 5.25%
             NaOCl/15% EDTA combination but 8 of the 20 samples
             irrigated with 1.3% NaOCl/MTAD had bacterial growth.
             Further samples taken after additional canal enlargement
             revealed growth in none of 20 samples when 5.25%
             NaOCl/ 15% EDTA were used, but there was still growth in
             10 of the 20 samples when 1.3% NaOCl/MTAD was used.
             This investigation showed consistent disinfection of
             infected root canals when a combination of 5.25% NaOCl
             and 15% EDTA was used. However, the combination of
             1.3% NaOCl/ MTAD left nearly 50% of the canals
             contaminated with E. faecalis

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Local Use of

               Davis et al. (2007) investigated the antimicrobial action of
               Dermacyn (broad sperctrum superoxideised water),
               MTAD, 2% CHX and 5.25% NaOCl against E. faecalis using a
               zone of inhibition test. MTAD showed significantly larger
               zones of inhibition than 5.25% NaOCl, 2% CHX and

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Local Use of

              Substantivity of MTAD

              The substantivity of MTAD was significantly greater than
              CHX and NaOCl

                                       Mohammadi & Shahriari (2008)

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Local Use of


               a mixture of an antibiotic, an acid and a detergent.
               However, the concentration of the antibiotic, doxycycline
               and the type of detergent differ from those of MTAD

                                                   (Giardino et al. 2006)

               Tetraclean caused a high degree of biofilm disaggregation
               when compared with MTAD

                                                   (Giardino et al. 2007)

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Local Use of

                Ledermix paste

                Ledermix is a glucocorticosteroid-antibiotic compound
               Today, Ledermix paste remains a combination of the
                that was developed by Schroeder & Triadan in 1960.
               same tetracycline antibiotic, demeclocycline–HCl (at a
                The primary interest in developing Ledermix paste was
               concentration of 3.2%), and a corticosteroid,
                based on the use of corticosteroids to control pain and
               triamcinolone acetonide (concentration 1%), in a
                inflammation associated with pulp and periapical
               polyethylene glycol base
                The sole reason for adding the antibiotic component to
                Ledermix was to compensate for what was perceived at
                the time to be a possible corticoid-induced reduction in
                the host immune response

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Local Use of

               Ledermix paste is capable of diffusing through dentinal
               tubules and cementum to reach the periradicular and
               periapical tissues

                                                           (Abbott 1990)

               Ledermix paste prevented experimentally induced external
               inflammatory root resorption in vivo

                                                      Pierce et al. (1988)

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Local Use of

              Periodontal ligament inflammation and inflammatory root
              resorption were markedly inhibited by both the calcium
              hydroxideand corticosteroid-antibiotic pastes relative to
              untreated controls. Replacement resorption was the
              lowest        in   the   corticosteroid-antibiotic   group,   and
              significantly more normal periodontal ligament was
              present in this group than in the calcium hydroxide and
              control groups

                                                            Thong et al. (2001)

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Local Use of

               Ledermix paste-treated roots had statistically significantly
               more healing and less resorption than the roots treated
               with Ca(OH)2

                                                      Bryson et al. (2002)

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Local Use of

               Ehrmann et al. (2003) 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 Ledermix paste had less pain
               than that experienced by patients who had teeth dressed
               with calcium hydroxide or no dressing at all

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Local Use of


               Effective in preventing infalmmatory resorption in
              avulsed teeth

               Pain management

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Local Use of


             Molander & Dahlen (2003)

             investigated the effect of clindamycin on root canal
             infections and apical periodontitis when placed as an
             intracanal dressing. Clindamycin offered no advantage over
             conventional root canal dressings, such as calcium

             Lin et al. (2003)

             compared the antibacterial effect of clindamycin and
             tetracycline Clindamycin significantly reduced the amount
             of viable

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Local Use of


             Siqueira & de Uzeda (1997)

             Metronidazole        was    more     effective   than    calcium

             Hoelscher et al. (2006) evaluated the antimicrobial effects
             against E. faecalis of five antibiotics (amoxicillin, penicillin,
             clindamycin, metronidazole and doxycycline) when added to
             Kerr Pulp Canal Sealer EWT in vitro. They found that all of
             these antibiotics except metronidazole could enhance the
             antimicrobial efficacy of the sealer

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Local Use of

                Local AB Treatment for Avulsed Teeth:

               Topical doxycycline application significantly increased the
               chances of successful pulp revascularization

                                                           Cvek et al 1990

               The beneficial effect of soaking a tooth in doxycycline has
               also been confirmed by

                                                  Yanpiset & Trope (2000)

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               Prophylactic antibiotics are usually only indicated in
               medically compromised patients; an exception would
               be in the re-implantation 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 adjunct
               to mechanical treatment

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              The potential benefits of antibiotic administration should
              therefore    outweigh    the    possible    disadvantages
              associated with their use. A dentist who prescribes an
              antibiotic for a questionable indication may be seen as
              placing a patient at risk from potential adverse effects of

                The use of topical anti-microbial agents has declined
                and requires further research and evaluation

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