To sum up, the risk/benefit ratio should be always weighed before prescribing antibiotics.
Appropriately selected patients will benefit from systemically administered antibiotics.
A restrictive and conservative use of antibiotics is highly recommended in endodontic practice, but indiscriminate use is contrary to sound clinical practice
Future generations will thank us for today’s conscientious and judicious use of antibiotics
3. CONTENTS
• INTODUCTION
• HISTORY
• CLASSIFICATION OF
ANTIBIOTICS
• SELECTION OF
ANTIMICROBIALAGENTS
• BACETRIOLOGY
• ODONTOGENIC INFECTION
• COMMONLY USE ANTIIBIOTIC
IN ORAL INFECTION
• COMPLICATION OF ANTIBIOTIC
THERAPY
• FASCIAL SPACE INFECTION
• MANAGEMENT OF ABSSCESS
AND CELLULITIS
• ANTIBIOTIC PROPHYLAXIS
• RESISTANCE
• ANTIBIOTIC DOSAGE
• USE OF ANTIBIOTIC AS AN INTRA
CANAL MEDICAMENT
• MYTHS
• CONCLUSION
• REFRENCES
3
4. • Antibiotics-These are substances produced by
microorganisms, which selectively suppress the growth of or
kill other microorganisms at very low concentrations
• Antimicrobial agent (AMA)-synthetic as well as naturally
obtained drugs that attenuate microorganisms
• Chemotherapy-Treatment of systemic infections with specific
drugs that selectively suppress the infecting microorganism
without significantly affecting the host
4
6. Empirical phase
• Mouldy curd by Chinese on boils
• Chaulmoogra oil for leprosy,
• Chenopodium by Aztecs for intestinal worms,
• Mercury by Paracelsus (16th century) for syphilis,
• Cinchona bark (17th century) for fevers.
6
7. Ehrlich's phase (1890-1935)
• Ehrlich given the idea that if certain dyes could selectively stain microbes,
they could also be selectively toxic to these organisms. He tried
methyleneblue, trypan red, etc
• He developed arsphenamine in 1906 and neoarsphenamine in 1909 for
syphilis.
• He coined the term 'chemotherapy'
7
8. Modern era
• Domagk (1935) - The therapeutic effect of Prontosil.
• Pasteur (1877) - Demonstrated the phenomenon of antibiosis :
growth of anthrax bacilli in urine was inhibited by air-borne
bacteria.
8
9. • Fleming (1929) - Discovered penicillin .
• Chain and Florey (1941)- Clinical use of penicillin .
• Waksman and his colleagues (1944)- Discovered
streptomycin
9
11. CLASSIFICATION OF ANTIBIOTIC
11
• Based on
A. Chemical structure
B. Mechanism of action
C. Type of organism against which primarily active
D. Spectrum of activity
E. Type of action
TRIPATHI 6TH EDITION
16. SELECTION OF ANTIMICROBIALAGENTS
The organism’s identity
Patient factors
The site of the infection
The organism’s susceptibility to a particular agent
The safety of the agent
The cost of therapy
16
Lippincotts pharmacology 5th edition
18. • The pulpodentin complex is sterile.
• Bacterial invasion of dentinal tubules occurs more
rapidly in nonvital teeth than in vital ones.
18
COHEN 10TH EDITION
22. When do you need the drugs to kill the bugs?
• Fever > 100° F
• Malaise
• Lymphadenopathy
• Trismus
• Increased Swelling
• Cellulitis
• Osteomyelitis
• Persistent Infection
22
American Association of Endodontists, 2006
23. Just say NO! Kill the bugs without the drugs
Irreversible pulpitis,
Acute apical periodontitis,
Draining sinus tracts,
After endodontic surgery,
To prevent flare-ups,
After incision for drainage of a localized swelling
(without cellulitis, fever, or lymphadenopathy)
23
COHEN 10th edition
26. DOSAGE
26
Antibiotic Dosage Duration
Penicllin V 250mg/500mg Every4-6hours/5-7days
Amoxicillin /
Amoxicillin with clavulanate
250mg/500 mg Every 8 hours/5-7 days
Clindamycin 300 mg/600mg Every 6 hours/5-7 days.
Metronidazole 200mg/400 mg Every 8 hours/5-7 days.
Azithromycin 250mg/500mg Once a day /5-7 days.
American Association of Endodontists 2006
28. COMPLICATIONS OF ANTIBIOTIC THERAPY
• Hypersensitivity
• Direct toxicity
• Superinfections
28
lippincotts pharmacology 5th edition
29. THE FASCIAL SPACES
The mandible and
below
The buccal
vestibule
Body of the
mandible
The mental space
The submental
space
The sublingual
space
Submandibular
space
The cheek and
lateral face
The buccal
vestibule of the
maxilla
The buccal space
The submasseteric
space
The temporal space
The pharyngeal and
cervical areas
The pterygo-
mandibular space
The para-
pharyngeal
spaces
The cervical
spaces
The
midface
The palate
The base of
the upper
lip
The canine
spaces
The
periorbital
spaces
29
30. Management of Abscesses and Cellulitis
• Correct diagnosis
• Removal of the cause
• Incision for drainage is indicated for any infection marked
by cellulitis. It is important to provide a pathway of
drainage to prevent further spread of the abscess and/or
cellulitis.
30
COHEN 10th edition
31. Systemic Antibiotics for Endodontic Infections
• Selection of antibiotics-
– Empirical
– based on the results of microbial susceptibility tests.
• For diseases with known microbial causes, empirical
therapy may be used.
• Most of the bacterial species involved with endodontic
infections, including abscesses, are susceptible to
penicillins .
31
COHEN 10TH EDITION
33. 33
• Managment
Amoxicillin (500 mg, orally) at
intervals of 8 h for 7 days and
dexamethasone (4 mg, intramuscularly)
at intervals of 24 h for 3 days
2% chlorhexidine gel applied with a 5-
ml syringe
34. TOOTH AVULSION
• Systemic administration of antibiotics is generally
recommended in order to prevent the harmful effects of
bacterial contamination.
• Antibiotics decrease the incidence of inflammatory root
resorption but have a limited, or no, effect on the pulp
34
Australian Dental Journal Endodontic Supplement 2007
35. • Gram-negative obligate anaerobic rods
– Porphyromonas spp.
– Prevotella spp.
• Prophylactic use of antibiotic to decrease incidence of
flare up Controversy.
Flare-Up’s
Cohen pathways of pulp : 10 th edition 35
37. Infective Endocarditis (IE)
• A life threatening disease with substantial morbidity and
mortality which affects individuals with underlying
structural cardiac defects who develop bacteremia.
37
41. • The French agency for Health Product Health Safety
advices against or contraindicates
– Dental facial surgery,
– Bone surgery,
– Periodontal surgery,
– Root canal treatment in these patients except under emergency
situations,
As these patients are prone to high risk of infection.
41
Asian Pac J Trop Biomed 2012; 2(9): 749-754
43. PREGNANCY
• Any drug used during pregnancy should be taken
only under the supervision of the patient’s
physician.
43
lippincotts pharmacology 5th edition
44. 44
CATEGORY DESCRIPTION DRUS
A No human fetal risk or
remote possibility of fetal
harm
B No controlled studies show
human risk;
animal studies Suggest
potential Toxicity
β-Lactams,β-Lactams with inhibitors,
Cephalosporins, Aztreonam , Clindamycin,
Erythromycin, Azithromycin, Metronidazole
Nitrofurantoin. Sulfonamides
C Animal fetal toxicity
demonstrated; human risk
Undefined
Chloramphenicol, Fluoroquinolones,
Clarithromycin, Trimethoprim, Vancomycin
Gentamicin, Trimethoprim-sulfamethoxazole
D Human fetal risk present,
but benefits
Mayoutweigh Risks
Tetracyclines, Aminoglycosides
(except gentamicin)
X Human fetal risk present
but does not
Outweigh benets;
contraindicated in
pregnancy
United States FDA categories of antimicrobials and fetal risk.
lippincotts pharmacology 5th edition
45. Partial List of Drugs Usually Compatible With Both
Pregnancy and Breast-Feeding
• Local anesthetics including lidocaine , etidocaine , and
prilocaine
• Penicillins- 250mg/500mg(Every 8 hours)
• Clindamycin- 300/600mg(6 hrs)
• Azithromycin- 250/500mg(OD)
• Acyclovir
• Prednisone
45
COHEN 10TH EDITION
55. LOCAL DRUG DELIVERY
• Bacteria located inside dentinal tubules are protected from
host defence cells, systemic antibiotics and
chemomechanical preparation.
• Therefore, endodontic medicaments must be able to
penetrate into dentinal tubules and kill bacteria within
them.
55
Australian Dental Journal Endodontic Supplement 2007;52:1.
57. Grossmann Poly Antibiotic Paste
• 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).
Australian Dental Journal Endodontic supplement :2007
57
58. • All compounds were all suspended in a silicone vehicle.
• The composition was ineffective against anaerobic species
58
Australian Dental Journal Endodontic Supplement 2007;52:1.
Penicillin Gram-positive organisms
Bacitracin For penicillin-resistant strains
Streptomycin Gram-negative organisms
Caprylate sodium Yeasts
59. Septomixine Forte
• Contains two antibiotics –
Neomycin
Polymixin B sulphate
59
Gram-negative bacilli Neomycin X Bacteroides , fungi
Gram-positive bacteria Polymyxin B sulphate
International Journal of Pharmacy and Pharmaceutical Sciences Vol 6, Issue 3, 2014
60. Ledermix paste
TRIAMCINOLONE
• Anti-inflammatory action
• Concentration of 1.0%
• Inhibits clastic cells
(osteoclasts, cementoclasts and
dentinoclasts)
DEMECLOCYCLINE
• Anti microbial action
• concentration of 3.21%
60
Australian Dental Journal Endodontic supplement :2007
61. • Ledermix:
Effective in preventing inflammatory resorption in
avulsed teeth
Pain management
Australian Dental Journal Endodontic supplement :2007
61
62. Ledermix paste + Calcium hydroxide
An intracanal dressing
Pulp necrosis and infection with incomplete root formation
Perforations
Inflammatory root resorption
Inflammatory periapical bone resorption
The treatment of large periapical radiolucent lesions
62
Australian Dental Journal Endodontic supplement :2007
63. TRIPLE ANTIBIOTIC PASTE
• Metronidazole + Ciprofloxacin + Minocycline.
• Used in - The revitalization regeneration procedures
63
COHEN 10TH EDITION
66. DISADVANTAGES
It may cause bacterial resistance.
Use of minocycline can cause tooth discoloration
66
COHEN 10TH EDITION
67. TETRACYCLINES
To remove the smear layer from instrumented root canal walls
Irrigation of apical root-end cavities during periapical surgical
procedures
As intracanal medicaments
Mohammadi etal: An update on the antibiotic-based root canal irrigation solutions:IEJ 2008
69. • MTAD is capable of
Removing the smear layer
Disinfecting the root canal system.
• Commercially available as BioPure MTAD
69
COHEN 10TH EDITION
70. • Tetraclean is another combination product similar to
MTAD.
• The use of tetraclean was able to reduce 90%
bacteric load after 5 minutes and 99.9% after 30
minutes of application.
70
MTAD TETRACLEAN
DOXYCYCLINE 150mg/5ml 50mg/5ml
Tween 80 Polypropylene glycol
JOE-2007
COHEN 10TH EDITION
71. MTAD has best antibacterial efficiency against E faecalis
when compared to 2.5% Sodium Hypochlorite and 2%
Chlorhexidine.
MTAD was effective in killing E. faecalis up to 200 x
dilution whereas NaOCl ceased to exert its antibacterial
activity beyond 32 x dilution
Torabinejad et al. (2003)
71
Journal of Dental and Medical SciencesVolume 5, Issue 3 (Mar.- Apr. 2013), PP 47-53
73. Odontopaste is the most effective against Enterococcus
faecalis.
Propolis is partially effective against Candida albicans.
73
Journal of International Dental and Medical Research Volume ∙ 5 ∙ Number ∙ 1 ∙ 2012
74. BioPure (MTAD) is effective in removing the smear layer.
Ledermix help to reduce the periapical inflammatory reaction
including clastic-cell mediated resorption.
Clindamycin alone or in an ethylene vinyl acetate (EVA)
vehicle can reduce the bacterial load inside the root canal
system
74
International Endodontic Journal 2009
75. • The local application of antibiotics may be a more effective
than systemic routes.
• Tetracyclines –
remove the smear layer from instrumented root canal walls
for irrigation of apical root-end cavities during periapical surgical
procedures
intracanal medicament
• Substantivity of tetracyclines has been shown for up to at
least 12 weeks.
• BioPure (MTAD) is effective in removing the smear layer.
• Substantivity of MTAD has been shown to last for up to 4
weeks.
75
International Endodontic Journal 2009
77. Acquired resistance to PENICILLIN
• Resistance to penicillin is usually by three
mechanisms.
Decreased bacterial cell wall penetration,
Inability to bind to the penicillin binding proteins,
Production of ß-lactamase.
77
JOURNAL OF ENDODONTICS, JANUARY 2003
78. Beta-lactamase production
78
• Black-pigmented Prevotella
• Nonpigmented Prevotella species
• F. nucleatum,
• P. acnes,
• Actinomyces species,
• Peptostreptococcus species
• Capnocytophaga
• Neisseria species
COHEN 10TH EDITION
79. • Amoxicillin’s 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.
79
JAC 2013
Resistance Drugs
F. nucleatum Penicillin, amoxicillin, and metronidazole
P. intermedia Tetracycline and amoxicillin
A. actinomycetemcomitans Amoxicillin and azithromycin
Fusobacterium and nonpigmented Prevotella
species
Macrolides (erythromycin and azithromycin)
81. MYTHS
Antibiotics cure patients.
Antibiotics are substitutes for surgical intervention.
The most important decision is which antibiotic to
use.
Antibiotics increase the host’s defense to infection.
81
American Association of Endodontists, 2012
82. Multiple antibiotics are superior to a single antibiotic.
Bactericidal agents are always superior to
bacteriostatic agents.
Antibiotic dosages, dosing intervals and duration of
therapy are established for most infections.
Bacterial infections require a “complete course” of
antibiotic therapy.
82
MYTHS
American Association of Endodontists, 2012
83. CONCLUSION
• To sum up, the risk/benefit ratio should be always weighed
before prescribing antibiotics.
• Appropriately selected patients will benefit from
systemically administered antibiotics.
• A restrictive and conservative use of antibiotics is highly
recommended in endodontic practice, but indiscriminate
use is contrary to sound clinical practice
• Future generations will thank us for today’s conscientious
and judicious use of antibiotics.
83
84. REFERENCES
• Cohen 10th edition
• Tripathi 6TH EDITION
• Lippincotts pharmacology 5th edition
• Ingles endodontics - 6th ed.
• Siquiera jr et al : update endodontic microbiology 2008
• Asian pac J trop biomed 2012; 2(9): 749-754
• J antimicrob chemother 2014
• American association of endodontists 2006
• International endodontic journal 2009
84
85. • JADA, vol. 131, march 2000
• American heart association, 2007; 116: 1736-1754
• Australian dental journal endodontic supplement 2007;52:1
• American association of endodontics 2012
• Journal of International Dental and Medical Research Volume
5 Number 2012
• ADA council 1997
• Journal of dental and medical sciencesvolume 5, issue 3 (mar.-
Apr. 2013), pp 47-53
• Journal of endodontics, january 2003
• International Journal of Pharmacy and Pharmaceutical
Sciences Vol 6, Issue 3, 2014
85
REFERENCES