Acta Scientific Pharmaceutical Sciences

Volume 1 Issue 2 2017

Review Article

Pharmacology in Endodontics-Revisited

Prashanth Kumar Katta*

Department of conservative dentistry and endodontics, Bapuji Dental College and Hospital, Karnataka

*Corresponding Author: Prashanth Kumar Katta, Department of conservative dentistry and endodontics, Bapuji Dental College and
Hospital, Karnataka.

Received: May 17, 2017; Published: June 23, 2017

Abstract
Antibiotics are very useful to treat microbial infections. But sound knowledge is important as to which antibiotic should be pre-
scribed for a particular situation. Also, whether it is prudent to prescribe antibiotic also should be gauged before advising them.
With the emergence of resistance strains to number of antimicrobials indiscriminate use of them must be avoided. The drugs are not
without their side effects. Hence a collective approach is must before using them.

Keywords: Antibiotics; Antimicrobials; Prophylaxis; Special conditions

Introduction and gram negative rods like bacteroides and fusobacterium.

The dental infections may be either primary due to odontogenic a. Systemic condition: People who are immunocompromised
or secondary to systemic diseases. The clinician should diagnose need antibiotics.
the case thoroughly and appropriate antibiotics should be recom-
b. Severity of the condition: Swelling, cellulitus, or fever that es-
mended to treat them. But the dentist should also be careful not to
calates with time may indicate that an infection is spreading.
indis-criminately use the antibiotics which can lead to resistance
development in the patient. The antibiotics should be used at times c. Benefits versus risks: The side effects and drug interactions
prophy-lactically to control the infection during the treatment pro- must be addressed before prescribing antimicrobials. The
cedures. The doctor should be well versed with drug interactions side effects can vary from minor rash to life threatening ana-
and the side effects. There is no hard and fast rule that antibiotics phylactic reaction. Drugs prescription must be the last resort.
should be prescribed for all the patients. Proper clinical and radio- In case of endodontic treatment, the cleaning and shaping
graphic diagnosis is must before prescribing drugs [1,2]. procedure is more important that antibiotics.

In daily practice we come across various patients like pregnant Other factors like vital or non-vital teeth, sinus and past history
patients, patients who are already taking drugs for other systemic of drugs taken is also important.
reasons, pediatric patients, prophylaxis, etc.
Bacteria commonly detected in odontogenic infections [4]
Many factors should be considered before prescribing antibiot- Based on Harbison H, Rose HS, Coen DM, Golan DE. Principles
ics. These include the following [3]: of antibacterial and antineoplastic pharmacology. In Golan DE,
Tashji-an, Jr. AH, Armstrong EJ, Armstrong AW. Ed. Principles of
Microbiology of odontogenic infections: Often the causative
pharmacology. The pathophysiologic basis of drug therapy. 2nd ed.
is indigenous bacteria and mixed infection. Both aerobic (e.g., strep-
2008. Wolters Kluwer/Lippincott Williams & Wilkins. Baltimore,
tococci) and anaerobic bacteria are present. The most commonly
MD
found gram positive cocci are streptococci and peptostreptococci

Citation: Prashanth Kumar Katta. “Pharmacology in Endodontics-Revisited”. Acta Scientific Pharmaceutical Sciences 1.2 (2017): 02-08.
Pharmacology in Endodontics-Revisited

03

a. Inhibitors of Bacterial Cell Wall Synthesis: Penicillin Antibiotic Choice

b. Inhibitors of DNA Synthesis or Integrity: Metronidazole Narrow Spectrum Antibiotics Broad Spectrum Antibiotics
c. Inhibitors of Transcription or Translation: Tetracyclines a. Specific for the particular a. Both Gram positive and
strain of microbe. Gram negative bacteria are
b. Less harmful to other sensitive, appropriate for
Gram staining and Facultative Obligate anaerobes microbes. mixed infections.
morphological anaerobes c. Minimal side effects. b. Sometimes effectiveness
characteristics d. Quick effect seen in case of for Gram positive is lost to
Gram positive cocci Streptococcus Streptococcus sensitive strains. gain effectiveness for Gram
enterococcus Peptostreptococcus e. E.g.: Pen VK, Pen G, negative.
Gram positive bacilli Actinomyces Actinomyces Erythromycin c. E.g.: Amoxicillin,
lactobacillus Lactobacillus Ampicillin
Proprionibacterium
Bifidobacterium Principles of Antibiotic Therapy
Eubacterium
Gram negative cocci Neisseria Viellonella 1. Therapeutic effectiveness Clinical indications Pharmcodynam-
Gram negative bacilli Capnocytophaga Porphyromonas ics, pharmacokinetics Age and extent of infection
Eiknella Prevotella
Fusobacterium Patient factors
Campylobacter
Bacteroides 1. Age, allergies, compliance, pregnancy risk
spirochetes Treponema
2. Patient function Renal, hepatic, immunosuppresion, route ap-
Crescent shaped Selenomonas
plicability

3. Cost Brand name, length of course, alternatives?

Management of odontogenic infections

Uncomplicated odontogenic infections which primarily mani-

fest as dental caries, reversible pulpitis or periapical periodontits.
Symptoms of such conditions include pain, erythema, edema, and
difficulty chewing.

Complicated odontogenic infections: when an uncomplicat-

Figure 1: Mechanisms of action of antibacterial agents [5]. ed condition not properly intervened at right time the symptoms
aggravate with the disease extending to surrounding tissues re-
sulting in cellulitis, osteomyelitis, and space infections. There may
Antibiotic Strategies also be trismus, lymphadenitis, and difficulty in breathing and
swallowing [6,7].
a. Use the most suitable drug.

b. Prescribe the appropriate dose. Reversible pulpitis: NSAIDs’.

c. Recommend the correct dosing schedule and duration.

Irreversible pulpitis: In case of vital teeth NSAIDs’ are sufficient.
d. precribe a loading dose to quickly achieve therapeutic levels
in the blood. Acute Apical Periodontitis [1]
e. Avoid combinations of both bacteriostatic and bacteriocidal
drugs. Apical periodontitis lesions originating from pulp are precipi-
tated by the immune system and are consequent to intraradicular

Citation: Prashanth Kumar Katta. “Pharmacology in Endodontics-Revisited”. Acta Scientific Pharmaceutical Sciences 1.2 (2017): 02-08.
Pharmacology in Endodontics-Revisited

04

infections. In most cases, this inflammatory process successfully 5 days course of antibiotics. the starting loading dose is followed
removes the microbes enter in the periapical region thorough the by maintenance doses for the remaining period. It is wise to re-
canal and stops them from spreading in the periapical region. This view the patient after 2 to 3 days. This will enable the clinician to
process is initially mediated by the polymorphonuclear leukocytes assess patient’s response to treatment. Hypersensitivity reactions
which kill bateria by phagocytosis. Asymptomatic apical periodon- are potentially the most serious adverse drug effects.
titis originating from pulp do not routinely require systemic antibi-
otic therapy for complete resolution and healing. Proper cleaning Indications for Adjunctive Antibiotics
and shaping with thorough irrigation using copious amount of irrig-
a. Fever > 100°F
ant is enough from healing. Once the source of infection is removed
b. Malaise
prescribing antibiotics no longer have any benefit. NSAIDs’ must be
prescribed to reduce the recovery time. c. Lymphadenopathy

d. Trismus
Acute Apical Abscess: NSAIDs’.
e. Increased Swelling
Draining Sinus Tract: Thorough cleaning and shaping elimi-
f. Cellulitis
nates most of the infection. NSAIDs’ are recommended to shorten
the recovery time. g. Osteomyelitis

h. Persistent Infection
Gingival Abscess: It is most commonly due to secondary to food
lodgment. Removal of the etiology is first line of treatment. Fol- Conditions where Adjunctive Antibiotics are not recommend-
lowed by topical anesthetic application and periodic warm water ed
gargling. Routine antibiotic therapy is of no use.
1. Pain without signs and symptoms of infection
Necrotizing Ulcerative Gingivitis: First, gentle irrigation with a. Symptomatic irreversible pulpitis
warm saline is recommended. Followed by meticulous curetting of
b. Acute periradicular periodontitis
ne-crotizing ulcerative lesion and root surfaces is done. Patients
should be advised to rinse their mouth with warm saline and repeat 2. Teeth with necrotic pulps and radiolucency
curet-ting of lesion if needed during the next visit. Antibiotics are of 3. Teeth with a sinus tract (chronic periradicular abscess)
no use. For severe lesions, gingivoplasty is recommended [8]. 4. Localized fluctuant swellings

Concomitant antibacterial Chemotherapy: Timely interven-

A small localized swelling with no systemic signs and symp-
tion and proper first line of treatment including removal of etiology
toms of infection or spread of infection regimen of antibiotics is
and cleaning and shaping where necessary reduces most of the in-
not indicated in an otherwise healthy patient.
fection. When these interventions are not done at right time, antibi-
otics may be needed. Also in case of immunocompromised patients Antibiotics are not a substitute for surgical procedures like
it is recommended. endodontic treatment, extraction, incision and drainage and scal-
ing and curettage. Only when the infection is diffuse, the source
Penicillin VK or ampicillin, single or along with metronidazole
can’t be identified and a situation where immediate treatment is
and clindamycin are acceptable empirical choice to consider for
not possible to control the spread of infection antibiotic is admin-
treating complicated odontogenic infections. Azithromycin is also
istered [11].
an empirical option in some cases. Lastly, the empirical drug of
choice must be an effective formula with the most narrow spectrum There is no hard and fast rule that bactericidal drugs are al-
and the least side effects due to drug intake. ways better than bacteriostatic drugs. Bactericidal drugs are
useful in case of immunocompromised patients. Post antibiotic
First Line of Antibacterial Chemotherapy [9,10] effects (PAEs-persistent inhibition of bacterial growth after pre-
The empirical drug of initial choice for treating dental infections vious exposure to antibiotics) are more predictable and reliable
is narrow spectrum penicillin V K. Majority infections need atleast with bacteriostatic agents (erythromycin, clindamycin) than with

Citation: Prashanth Kumar Katta. “Pharmacology in Endodontics-Revisited”. Acta Scientific Pharmaceutical Sciences 1.2 (2017): 02-08.
Pharmacology in Endodontics-Revisited

05

bactericidal agents (betalacatamase) because the clinical effects of Indications Adult dosages
bacteriostatic agents are less dose-dependent. First line of treatment Penicillin V potassium 500
No history of allergy to beta Initial loading dose of 1000 mg
Proper Use of Antibacterial Drugs clinically [12] lactum antibiotics followed by three
times a day for 5 days
1. The drug dosage should be optimum. The patient should be
administered the required drugs only for the required number Patient did not respond Metronidazole 500 mg tablets
favorably to Penicllin VK in 2-3
of days. Four times a day
days
2. The minimal inhibitory concentration of drug for a particular
2nd line of treatment Azithromycin 250 mg tablets
causative organism should be attained at the site of infection.
Patient allergic to beta lactum Initial loading does of 500 mg
3. Antibiotic therapy should be started with a loading dose that is antibiotics followed by one tablet
more than needed for maintaining the drug later.
250 mg for five days
4. Oral antibiotic should ideally be administered at dosing inter- 3rd line of treatment Clindamycin 300 mg capsules
vals of three to four times its serum half-life, particularly if Patient allergic to beta lactum Initial loading dose of 600 mg
antibiotics followed by 300mg
5. When steady-state blood levels are desired, the antibiotic
should be administered orally for at least 3 to 4 times in peri- Infection not resolved after daily for five days.
taking beta lactum antibiotics
odic intervals corresponding to its serum half life.
Empirical drug initially for
treating serious infections
Endodontic conditions where antibiotics are not recommend-
Pediatric dosage Penicillin V Potassium 25-50 mg/kg day divided
ed [13,6]
quarterly 6-8h, metronidazole 30 mg/kg/day divided quarterly 6h,
Azithromycin 5-10 mg once daily, Clindamycin 10 mg/kg, quarterly
a. Vital pulp
8h, pediatric dosage must not be more than adult dosage.
b. Pulp necrosis with acute apical periodontitis Metronidazole is added in addition to Penicillin V regimen.

c. Pulp necrosis with acute periradicular abscess (localized, anti- Table 1: Empirical antibacterial drugs for the treatment of
biotic recommended in medically compromised patients) complicated odontogenic infections [14].

Endodontic conditions where antibiotics are recommended Drugs for pediatric patients

Pulp necrosis with acute periradicular abscess (spreading): Calculation of pediatric dosage:
Amoxicillin 500 mg every 8 hors or Clindamycin 300 mg every 8 Child’s weight lb (or kg) × adult dose = child’s dose 150 lb (or 70
hours for 5-7 days is recommended for adults. If condition doesn’t kg)
subside, change antibiotic to macrolide or include Metronidazole
500 mg every 12 hours for 5 days. Infection type Preferred antibiotic
Early (first 3 days of Penicillin VK
Drugs for pregnant patients [4] infection) Amoxycillin
Cephalexin (or other first
a. Antibiotics must be the last resort. As the side effects are more generation cephalosporins) 1
than the desired effects especially during pregnancy. No improvement in 24-36 Beta lactamase stable antibiotic
hours Clindamycin or amoxicillin/
b. Drugs must not be prescribed during first trimester clavulanic acid combination
Penicillin allergy Clindamycin
c. Only time tested drugs must be prescribed
Cephalexin (if penicillin allergy is
not anaphylactoid type)
d. Only the minimum required dose must be prescribed
Clarythromycin2
e. Above all, thorough endodontic treatment is primary and piv- Late (> 3 days) Clindamycin
otal. If cleaning and shaping is done well using copious amount Penicillin VK-Metronidazole,
of irrigants and calcium hydroxide intracanal dressing is placed Amoxycillin- Metronidazole
antibiotics are not needed. Penicillin allergy Clindamycin

Citation: Prashanth Kumar Katta. “Pharmacology in Endodontics-Revisited”. Acta Scientific Pharmaceutical Sciences 1.2 (2017): 02-08.
Pharmacology in Endodontics-Revisited

06

Table 2: Empiric Antibiotics of Choice for Odontogenic Infections [6]. inter-vention, for the first 6 months after the treatment.

f. Repaired Cngential heart disease with defects not completely

For better patient compliance, 2nd generation cephalosporin (ce-
healed at the site or next to the surgical region where pros-
faclor, cefuroxime), at twice daily dose has been recommended. A
thetic part or prosthetic equipment (which retard endotheli-
macrolide is useful for patients who are sensitive to penicillin, rec-
alization) is present.
ommended two times a day for better patient compliance [8].
g. patients with cardiac transplantation who eventually grow
Antibiotic Pediatric dosage < 12 Adult dosage >12 cardiac valvulopathy.
years years
Penicillin V 250 mg orally every 250-500 mg orally Prophylaxis recommended Prophylaxis not
potassium 8-12hr for 10 days every 6hr for 5-7 recommended
days
• Procedures that include • Routine anesthetic injection at
Amoxicillin 15 mg/kg every 8h for 500 mg every 8h for manipulation of gingival, the site where infection is absent
5-7 days 5-7 days periapical tissues of teeth
Maximum dose per day Maximum dose per or repair of perforation • Radiographic procedures
2 grams day 2 grams
Amoxicillin + 45 mg/kg every12h 875 mg every 12g • Orthodontic appliance placement
clavulanic acid every 8h for 5-7 every 8h for 5-7 days and removable prosthesis insertion
days Maximum dose per Maximum dose per
day 2 grams day 2 grams • Orthodontic bracket placement

cephalexin 25 to 50 mg/kg in Dosage ranges from 1 • Orthodontic appliance adjust-

divided doses to 4 g daily in ment
total daily dose may be divided doses.
divided and 250 mg every 6 • Primary teeth shedding
administered every 12 hours. • Lip and tongue trauma resulting
hours
in bleeding
For 10 days maximum.
clindamycin 10 mg/kg every 8h 150-300 mg every
At least 10 days 8h for Drugs that should be part of a medical emergency kit
At least 10 days
1. Albuterol ( one metered dose inhaler and a spacer for chil-
Table 3: Antibiotics of Choice for Odontogenic Infections [10]. dren, if applicable)

Anitbiotic Prophylaxis Recommendations 2. Aspirin(two packets of powdered aspirin {325 mg})

prophlyxactic chemotherapy is recommended for cardiac dis- 3. Diphenhydramine (two 1 ml ampules or vials of 50 mg/ml)
eases that may arise due to intial endodocarditis who undergo 4. Epinephrine1:1000 (two preloaded, self injecting suringes
dental treatment [5] for patients weighing more than 66 lbs, 0.3 mg, and two pre-
a. Prosthetic cardiac valve or prosthetic material used for cardiac loaded, self injecting syringes for patients weighing between
valve repair 33 lbs and 66 lbs, 0.15 mg, if applicable)

b. Previous infective endocarditis 5. Glucose(one tube of glucose gel)

6. Nitroglycerine (one boottle of the metered dose spray or one

c. Congenital heart disease (CHD)
bottle of sublingual tablets, 0.4 mg/spray or tablet)

d. Unrepaired cyanotic CHD, including palliative shunts and con-

Immunocompromised patients
duits
Immunocompromised patients may not be able to resist tran-
e. Completely repaired heart defect that are congeital repaired sient bacteremia following invasive dental procedures. These
with prosthetic material or device by surgery or by catheter non-cardiac causes can make patient vulnerable for distant-site

Citation: Prashanth Kumar Katta. “Pharmacology in Endodontics-Revisited”. Acta Scientific Pharmaceutical Sciences 1.2 (2017): 02-08.
Pharmacology in Endodontics-Revisited

07

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Citation: Prashanth Kumar Katta. “Pharmacology in Endodontics-Revisited”. Acta Scientific Pharmaceutical Sciences 1.2 (2017): 02-08.
Pharmacology in Endodontics-Revisited

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14. Ashraf f Fouad. “Are antibiotics effective for endodontic pain?

An evidence-based review”. Endodontic Topics 3.1 (2002): 52-
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Volume 1 Issue 2 June 2017

© All rights are reserved by Prashanth Kumar Katta.

Citation: Prashanth Kumar Katta. “Pharmacology in Endodontics-Revisited”. Acta Scientific Pharmaceutical Sciences 1.2 (2017): 02-08.