Endodontic Practice US - Dental Journal and Online Dental CE - … · 2017-04-04 · 4-5 days 4-5 days Penicillin V For allergy to Penicillin V Figure 3: Examples of recommended antibiotics.

The discovery of safe, systemic antibiotics has been a major factor in the control

of infectious diseases. As such, antibiotics have increased the life expectancy and quality of life for millions of people (AAE ENDODONTICS: Colleagues for Excellence, 2012).

But this life-altering benefit comes at a price — drug-resistant bacteria. The problem is not with the antibiotics themselves, but with how they are being used and, to a larger extent, prescribed (AAE ENDODONTICS: Colleagues for Excellence, 2012).

A recent study, highlighted by the Irish media at the beginning of this year, found a 44-fold increase in the prevalence of MRSA strains and a sixfold increase in the number of strains resistant to multiple antibiotics (Kinnevey, et al., 2014).

These bacterial strains were mostly asso-ciated with skin and soft tissue infections, and were found in patients with serious life-threatening illnesses.

The dental profession also plays a part in the selection of drug-resistant bacte-rial strains, through inappropriate drug prescribing (Sweeney, et al., 2004). There is ever-increasing evidence from current endodontic literature of antibiotic resistance in endodontic infections (Jungermann, et al., 2011; Montagner, et al., 2014) — but there is a glimmer of hope.

By examining the following five myths, we can strive to achieve correct clinical use of antibacterial drugs and assist with clinical decisions regarding antibiotic therapy (AAE ENDODONTICS: Colleagues for Excellence, 2012).

The five myths

1. Antibiotics cure patientsAntibiotics do not cure patients. Once

a proper balance is re-established between the host defense (immune system and

inflammatory system) and the bacterial agents, patients cure themselves (Figures 1A and 1B).

2. Antibiotics are a substitute for clinical intervention

It’s simple: Antibiotics are not a substi-tute for surgical intervention. Endodontics removes the source of infection; patients then heal themselves (Figures 2A and 2B).

3. The most important decision is which antibiotic to use

The most important decision is not which antibiotic to use, but whether or not we need to prescribe one at all. Most endodontic infections resolve once the source of the infection has been removed (AAE ENDODONTICS: Colleagues for Excellence, 2012).

Use and abuse of antibiotics in endodontics

Dr. Eoin Mullane examines the correct clinical use of antibacterial drugs in endodontics

Eoin Mullane, BDS, MS Cert Endo (Michigan, United States), graduated from the University of Manchester in 1999, going on to practice general dentistry for 6 years. He received his masters in endodontics at the University of Michigan. He currently runs a practice limited to endodontics in Limerick and Dublin, Ireland.

Educational aims and objectivesThis clinical article aims to explore both the benefits and risks of antibiotic therapy in endodontic treatment.

Expected outcomesEndodontic Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can:• Realize some statistics regarding the prevalence of antibiotic use in endodontics.• Identify specific conditions which necessitate the use of antibiotics.• Identify specific conditions for which antibiotics should be avoided. • Realize some antibiotics’ spectrum of activity.

There is ever-increasing evidence from current endodontic

literature of antibiotic resistance in endodontic infections —

but there is a glimmer of hope.

Figures 1A and 1B: One-year recall following root canal treatment

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Never prescribe antibiotics for an irreversible pulpitis. Patients may request that you prescribe. Explain your rationale and advise analgesics only (e.g., ibuprofen), as the pulp is inflamed and not infected. In most cases, the inflammatory process eliminates bacteria that emerge from the apical foramen, and the immune system also stops bacteria spreading into the periapical tissues. Asymp-tomatic apical periodontitis does not require antibiotic therapy, and endodontic treatment alone is sufficient (AAE ENDODONTICS: Colleagues for Excellence, 2012).

An acute apical abscess can cause a localized fluctuant intraoral swelling with asso-ciated pain. Treatment involves endodontic therapy, and there is no need to prescribe antibiotics, but the patient should be advised to take non-steroidal anti-inflammatory drug (NSAID) analgesics such as ibuprofen.

If the intraradicular infection overwhelms the immune system, bacteria will gain access to the periapical tissues. This can result in an acute abscess with a concurrent facial swelling. Endodontic treatment with incision and drainage and antibiotics are indicated in Figure 4.

In order to prescribe an antibiotic, prac-titioners need to be aware of their spec-trum of activity, so that the antibiotic can target the bacteria, which are responsible

for causing endodontic infections. Bacteria that are commonly found in infected root canals are mixed gram positive and gram negative, facultative anaerobes, and strict anaerobes (e.g., Fusobacteria, Prevotella, and Porphyromonas) (Baumgartner, et al., 2008). Penicillin V is the antibiotic of choice, as its spectrum of activity is ideally suited to the bacteria that are found in infected root canals (Baumgartner, Xia, 2003).

Antibiotics should be prescribed at a high dose over a short period of time. This reduces the chance of selecting drug- resistant bacteria and lowers the risk to the patient with respect to toxicity and allergy (Pallasch, 1994). The initial dose of the anti-biotic should always be higher than the main-tenance dose.

Figures 2A and 2B: GP-tracing sinus tract. Two-year recall orthograde root canal treatment and apicectomy

CALVEPEN 666MG

CLINDAMYCIN 300MG

666mg x two stat 300mg x two stat

666mg 4 times daliy

300mg 4 times daily

4-5 days 4-5 days

Penicillin V For allergy to Penicillin V

Figure 3: Examples of recommended antibiotics. Notice loading dose

Figure 4: Gutta-percha point, tracing a sinus tract, originating from an apical lesion of endodontic origin

Conditions requiring antibiotic therapy • Fever greater than 37.8ºC • Malaise• Lymphadenopathy• Trismus• Cellulitis• Persistent infection• Increased swelling• Osteomyelitis

Conditions not requiring antibiotic therapy • Pain with no signs and symptoms

of infection – Symptomatic irreversible pulpitis – Symptomatic apical periodontitis• Necrotic pulps and radiolucency• Teeth with an associated sinus

tract• Localized fluctuant swellings

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A loading dose should always be employed, and it should be twice the maintenance dose (AAE ENDODONTICS: Colleagues for Excellence, 2012). This guarantees rapid and high blood levels of the antibiotic.

Traditionally, metronidazole was pre-scribed for endodontic infections, but its spectrum of activity is limited to anaerobes. Metronidazole should therefore not be prescribed on its own, as it is not effective against facultative anaerobes (Baumgartner, 2003). Erythromycin was also traditionally prescribed for patients who are allergic to penicillin; however, it should never be prescribed, as it is not effective against anaerobic bacteria (Baumgartner, 2006).

4. Multiple antibiotics are superior to a single antibiotic

Multiple antibiotics will guarantee a greater antibiotic spectrum, but this will result in the selection of drug-resistant bacteria (AAE ENDODONTICS: Colleagues for Excellence, 2012). The only indication for combined antibiotics is a severe infection.

5. Bacterial infections need a “complete course” of antibiotic therapy

There is no such thing as a “complete course of antibiotics” (Pallasch, 1994). The only guide is improvement in the patient’s symptoms, and this is based on the effec-tiveness and duration of antibiotic therapy (Hessen, Kaye, 1989).

Orofacial infections do not rebound, as long as the source of infection has been removed. Endodontic treatment will remove the source of infection. Therefore, once the patient’s swelling has subsided, the course of antibiotics should be stopped.

Alter existing prescribing regimeIn summary, we have discussed and

dispelled five myths relating to antibiotic therapy. Antibiotic resistance is an ever-increasing issue, and it can only be combated by effective prescribing with reduced abuse of antibiotics.

By analyzing these myths, practitioners can alter their prescribing regime. This altera-tion, most importantly, can be implemented the next time you think about prescribing an antibiotic for your patients.

REFERENCES

1. American Association of Endodontists. Use and abuse of antibiotics. Endodontics: Colleagues for Excellence news-letter. Winter 2012.

2. Baumgartner JC. Antibiotics and the treatment of endodontic infections. American Association of Endodontics Colleagues for Excellence newsletter. Summer 2006.

3. Baumgartner JC, Siqueira JF, Sedgley CM, Kishen A. Microbiology of endodontic disease. In: Ingle, JI, Bakland LK, Baumgartner JC, eds. Ingle’s Endodontics 6. People’s Medical Publishing House-USA. 2008:221-308.

4. Baumgartner JC, Xia T. Antibiotic susceptibility of bacteria associated with endodontic abscesses. J Endod. 2003;29(1): 44-47.

5. Hessen MT, Kaye D. Principles of selection and use of antibacterial agents. Infect Dis Clin North Am. 1989;3(3): 479-489.

6. Jungermann GB, Burns K, Nandakumar R, Tolba M, Venezia RA, Fouad AF. Antibiotic resistance in primary and persistent endodontic infections. J Endod. 2011;37(10):1337-1344.

7. Kinnevey PM, Shore AC, Brennan GI, Sullivan DJ, Ehricht R, Monecke S, Coleman DC. Extensive genetic diversity identified among sporadic methicillin-resistant Staphy-lococcus aureus isolates recovered in Irish hospitals between 2000 and 2012. Antimicrob Agents Chemother. 2014;58(4):1907-1917.

8. Montagner F, Jacinto RC, Correa Signoretti FG, Scheffer de Mattos V, Grecca FS, Gomes BP. Beta-lactamic resistance profiles in Porphyromonas, Prevotella, and Parvimonas species isolated from acute endodontic infections. J Endod. 2014; 40(3): 339-344.

9. Pallasch TJ. Pharmacology of Anxiety, Pain and Infection. In: Ingle JI, Bakland LK, eds. Endodontics. 4th ed. Williams and Wilkins: Malvern, PA, 1994.

10. Sweeney LC, Dave J, Chambers PA, Heritage J. Antibiotic resistance in general dental practice — a cause for concern? J Antimicrob Chemother. 2004;53(4): 567-576.

Disclaimer: The information in this article is designed to aid dentists. Practitioners must use their best professional judgment, taking into account the needs

of each individual patient when making diagnoses/treatment plans.

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