ROLE OF ANTIBIOTICS IN PREVENTION OF POST

TREATMENT ENDODONTIC PAIN AND FLARE UP

J.Praveen

O.R.Ganesh

Ourvind Singh

Amith Babu

Amrita Dora

INTRODUCTION

• Antibiotics are life saving therapeutic agents of inestimable value. Many dental surgeons prescribe antibiotics to prevent the possible development of pain and swelling during endodontic therapy. This is being done more out of tradition rather than with any scientific knowledge.This sorry state of affairs has contributed to an alarming increase in the rate of microbial resistance to antibiotics.

USE OF ANTIBIOTICS IN SIP

• Symptomatic irreversible pulpitis, which is characterised by acute and intense pain, is one of the most frequent reasons that patients attend for emergency dental care.

• A review was done to provide reliable evidence regarding the effectiveness of prescribing systemic antibiotics for irreversible pulpitis by comparing clinical outcomes expressed as pain relief.

Literature Review

• Various databases were searched and a randomised controlled trial was also included.

• Evidence shows that there is no significant difference in pain relief for patients with untreated irreversible pulpitis who did or did not receive antibiotics in addition to analgesics.

Antibiotic use for irreversible pulpitis - Keenan JV, Farman AG, Fedorowicz Z, Newton JT.

Evid Based Dent. 2005;6(3):67

• There is no evidence to support the use of prophylactic antibiotics in the management of localised endodontic disease in healthy patients.

• Adverse drug reactions, while under-reported, are very common and can be life threatening.

• Proved by randomized control trials.

Antibiotic use for irreversible pulpitis. Cochrane Database of Systematic Reviews

2005, Issue 2. Art. No.: CD004969

Are antibiotics being used appropriately for emergency dental treatment? - Dailey YM, Martin MV.

Br Dent J. 2001 Dec 8;191(11):595.

• As SIP is an inflammatory lesion and can be easily treated endodontically, antibiotics play no role in such a condition.

• It is usually when the drainage becomes difficult to obtain or host resistance is reduced or virulence of organisms is more, that the antibiotics are required.

• Systemic antibiotics should be restricted to patients who have local signs of infection, malaise and elevated body temperature.

Literature Review

• Prophylactic use of antibiotics has been recommended for patients 'at risk' of infective endocarditis, rheumatic heart disease, bacterial endocarditis, prosthetic cardiac valves and congenital heart defects.

Antibiotics and endodontics - Abbott PV, Hume WR,

Pearman JW.

Aust Dent J. 1990 Dec;35(6):551

Aust Dent J. 1990 Aug;35(4):388-90

ANTIBIOTICS IN ROOT CANAL TREATMENT

Introduction

• Systemic antibiotics are used frequently in the practice of dentistry. Some times they are overused. There is no need to prescribe antibiotic in root canal treatment

• The immunologically compromised patient should also be considered an indication for antibiotic therapy, regardless of the condition of the canal…….

Text book of ENDODONTICS by JOHN I.INGLE 6th edition

Introduction

• Extension of pulpal disease into the periapical tissues can result in swelling and infection. Tissue swelling can be seen at the initial emergency visit, at an interappointment flare-up, or as a post endodontic complication.

• Swellings are either localized or diffuse. The cardinal rule for managing these infectious swellings is to attempt to establish drainage and, as indicated,to institute antibiotic therapy………

Pathway of the pulp by stephen cohen page no 43..

Literature Review

• Antibiotics are not a substitute for definitive treatment procedures designed to remove the necrotic tissue and bacteria from the radicular space. antibiotics serve a supportive role as adjuvants to treatment. Clinicians should prescribe antibiotics

• To with an increased temperature and systemic involvement…..

J Dent. 2000 Nov;28(8):539-48.

Endodontics in the adult patient: the role of antibiotics. Longman LP, Preston AJ, Martin MV, Wilson NH.

Dental Hospital, Pembroke Place, Liverpool

Literature Review

• The injudicious use of antibiotics may result in bacterial resistance.

• An infected root canal contains a complex mixed flora and it is, therefore, inappropriate to rely on them to eliminate all of the bacteria.

• Topical application of antibiotic may also increase the risk of a patient becoming sensitized to it ………

Abbott PV, Hume WR, Pearman JW.

Antibiotics and endodontics.

Australian Dental Journal 1990; 35:

Page no : 50–60.

Literature Review

• The ineffectiveness of systemic antibiotics in necrotic pulpless teeth and the periradicular tissues, the local application of antibiotics may be a more effective mode for delivery in endodontics……… this is review articles

Int Endod J. 2009 Jul;42(7):555-67.

Epub 2009 May 8.

On the local applications of antibiotics and antibiotic-based agents in endodontics and dental traumatology by Mohammadi Z, Abbott PV.

Literature Review

• There are few real indications for the systemic use of antibiotics in conjunction with endodontic treatment. They are only needed when the body's efforts at fighting bacteria are failing. Use of antibiotics to prevent infection (antibiotic prophylaxis) may prevent some case of bacterial endocarditis. Therefore, prophylaxis is recommended for individuals in high-risk and moderate-risk categories

Int Dent J. 2009 Aug;59(4):175-86.

Systemic, prophylactic and local applications of antimicrobials in endodontics: an update review by Mohammadi Z.

Literature Review

• Antibiotics can be used as an adjunct to endodontic treatment in a number of ways--locally, systemically and prophylactically Prophylactic use of antibiotics has been recommended for patients 'at risk' of infective endocarditis

• The tendency towards indiscriminate antibiotic use should be discouraged. The use of broad spectrum drugs should be restricted so that these medications remain effective in serious situations….

Aust Dent J. 1990 Feb;35(1):50-60

Abbott PV, Hume WR, Pearman JW.

University of Western Australia, Perth Dental Hospital.

Conclusions

• Antibiotics are not routinely indicated in the practice of endodontic. Therapeutic antibiotics may be required as an adjunct to operative treatment when there is pyrexia and/or gross local swelling; they are only rarely indicated in the absence of operative intervention. Prophylactic antibiotics may be required for certain patients who are susceptible to serious infective sequelae.

ANTIBIOTICS IN EXTRACTION

Literature Review

• This study was undertaken to evaluate the effectiveness of metronidazole and penicillin V in eliminating anaerobes from postextraction bacteremias.

• Although penicillin V reduced the occurrence of anaerobes, it was noted that gram-negative anaerobes were still detected in the blood of four patients in the penicillin V group.

Literature Review

• In the metronidazole group no gram-negative anaerobes were cultured. Because of the marked effectiveness of metronidazole against gram-negative anaerobes, the use of penicillin V and metronidazole in combination might be effective in the prevention of the sequelae of postextraction bacteremias.

Oral Surg Oral Med Oral Pathol.

1994 Aug;58(2):152-5.

Head TW, Bentley KC, Millar EP, deVries JA.

Literature Review

• They evaluated the efficacies of oral prophylactic treatment with amoxicillin, clindamycin and moxifloxacin in the prevention of bacteremia following dental extractions. Prophylaxis with Moxifloxacin showed high efficacy. As a consequence, MXF prophylaxis is a promising antibiotic alternative when beta-lactams are not indicate

2006 Sep;50(9):2996-3002.

Department of Special Needs, School of Medicine and Dentistry, Santiago de Compostela 15872, Spain.

Literature Review

• When blood cultures are made on patients immediately following oral surgery, a high incidence of bacteremia can be demonstrated. When such individuals are given adequate doses of antibiotics, such as Terramycin, the incidence of demonstrable bacteria in the blood stream is markedly reduced

The use of antibiotics for the prevention of

Bacteremia following extraction

Departments of Bacteriology and Oral Surgery, Baylor University College of Dentistry,

Dallas, Texas

ANTIBIOTICS IN FLARE-UP AND POST

ENDODONTIC PAIN

Flareup

• Flareup is described as the occurrence of pain, swelling or the combination of these during the course of RCT as a complication

• Hence the question arises, whether Antibiotics would prevent the occurrence of flareup? And if yes, whether they outweigh their risks for usage?

• To answer these questions, let us see some of the investigations carried out regarding this

Literature Review

• An accurate endodontic treatment of canals is sufficient to guarantee an adequate control of post-treatment pain, with no need of antibiotic prophylaxis was shown by :

Contardo L, Meneguzzi E, Cadenaro M, Di Lenarda R

Minerva Stomatol. 2005 Mar;54(3):153-60.

Clinical evaluation of antibiotic prophylaxis before endodontic treatment of necrotic teeth

Department of Dentistry and Stomatology, University of Trieste, Trieste, Italy.

Literature Review

• Endodontic treatment with prophylactic drugs to prevent exacerbations do not appear to offer any advantage over treatment without antibiotics which was shown by :

Matusow RJ

Oral Surg Oral Med Oral Pathol.1998 Jun;65(6):750-3.

The flare-up phenomenon in endodontics: a clinical perspective and review.

Department of Endodontics, Boston University, Concord, Mass.

Literature Review

• A prophylactic dose of amoxicillin before endodontic treatment of asymptomatic, necrotic teeth had no effect on the endodontic flare-up, this was shown by

Pickenpaugh L, Reader A, Beck M, Meyers WJ, Peterson LJ.

J Endod. 2001 Jan;27(1):53-6.

Effect of prophylactic amoxicillin on endodontic flare-up in necrotic teeth.

Graduate Endodontic Program, College of Dentistry, The Ohio State University, USA.

Conclusion

Hence we can safely conclude considering the various studies mentioned that the use of antibiotics is not required for prevention of flareup.

Indications For using antibiotics

Extraction

• It is stated that presurgical administration of intravenous penicillin or clindamycin lowers the rate of postoperative inflammatory complications following extraction .It was done by the Randomized Masked Controlled Trial.

Journal of Evidence-Based DentalPractice;

Vol. 8 Issue 1, p26-27

Extraction

• It is also proved that single doses of amoxicillin or erythromycin given before dental extractions successfully prevented endocarditis

Journal of the American heart association.

RCT

It is stated that antibiotic prophylaxis is given in swelling (pg no 43),antiobotic coverage must be maintained in root until pulp chamber can be disinfect and re-closed (pg no 45),apical abscess (pg no 46),in diabetes even when there is no periapical infection (pg no 61),in patient having steroidal medication because it will make patient more susceptible to infection (pg no 62), in cases of diffuse spreading cellulitis (pg no 371)

• Therapeutic antibiotics may be required as an adjunct to operative treatment when their is PYREXIA and GROSS LOCAL SWELLING.

J Dent 2000 nov ;28(8):539 -48

• Antibiotic prophylaxis is also needed in cases of malaise and elevated body temperature.

Aust Dent J.1990 Aug ;35(4):388-90.