ANTIBIOTICS IN

ENDODONTICS

1
HISTORY
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.

2
EHRLICH’S PHASE ( 1890 – 1935)

• Paul Ehrlich, a German physician, noted that certain

chemical dyes coloured some bacterial cells but not others.

• He concluded that they could also be selectively toxic to these organisms.

• In 1909, he discovered - arsphenamine was an effective treatment for syphilis - the

first modern antibiotic.

• Ehrlich himself referred to his discovery as 'chemotherapy'

3
MODERN PHASE

• 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.
• Fleming (1929) - Discovered penicillin .
• Chain and Florey (1941)- Clinical use of penicillin .
• Waksman and his colleagues (1944)- Discovered streptomycin from
Actinomycetes
4
CLASSIFICATION
I . Based on chemical structure

1. Sulfonamides : Sulfadiazine, Dapsone 10. Glycopeptides : Vancomycin

2. Diaminopyrimidines : Trimethoprim 11. Oxazolidinone : Linezolid

3. Quinolones: Norfloxacin, Ciprofloxacin 12. Nitroimidazoles: Metronidazole, Tinidazole
4. β-lactam antibiotics: Penicillins, 13. Nitrofuran derivatives : Nitrofurantoin
Cephalosporins 14. Nicotinic acid derivatives : Isoniacid,
5. Tetracyclines: Tetracycline, Doxycycline Ethionamide
6. Aminoglycosides: Streptomycin, Gentamicin 15. Polyene antibiotics: Nystatin, Amphotericin-B
7. Nitrobenzene derivatives: Chloramphenicol 16. Azole derivatives : Miconazole, Clotrimazole
8. Macrolides: Erythromycin, Azithromycin 17. Others : Clindamycin, Ethambutol
9. Polypeptides : Polymyxin B, Colistin
5
CLASSIFICATION
II. Based on spectrum of activity

NARROW
SPECTRUM BROAD EXTENDED
SPECTRUM SPECTRUM
Eg :
Eg : Eg :
Natural penicillins
Tetracyclins Ampicillin
Streptomycin
Chloramphenicol Amoxycillin
Erythromycin

6
CLASSIFICATION
III. Based on type of action

Bactericidal Bacteriostatic
Penicillin(s)
Cephalosporin(s) Chloramphenicol
Aminoglycosides Clindamycin
Vancomycin Tetracyclines
Metronidazole Erythromycin
Imipenem

7
CLASSIFICATION

IV. Based on the source of antibiotics

Fungi : Penicillin, Cephalosporin, etc.

Bacteria : Poly myxin B, Bacitracin, etc.

Actinomycetes : Aminoglycosides, Tetracyclines, Chlorampheniol, Macrolides, etc.

8
CLASSIFICATION Based on mechanism of action

9
Beta-Lactam Antibiotics

 These have a β-lactam ring.

 Two major groups:

Penicillins Cephalosporins
Also,
• Monobactams
• Carbepenems
10
 Penicillins

• The so-called wonder drug discovered in 1928 by

Alexander Fleming
• First antibiotic to be used in 1941.
• Obtained originally from the fungus Penicillium
notatum.
• Presently obtained from P.chrysogenum.

11
CLASSIFICATION
1. Natural Penicillin: Penicillin G (Benzyl Penicillin)

2. Semi synthetic Penicillin:

 Acid resistant alternative to Penicillin G: Phenoxymethyl penicillin (Penicillin V)

 Penicillinase resistant penicillins: Methicillin, Cloxacillin

 Extended spectrum penicillins,

⁕ Aminopenicillins : Ampicillin, Amoxicillin

⁕ Carboxypenicillins: :Carbenicillin

⁕ Ureidopenicillins: Piperacillin

⁑ β-lactamase Inhibitors: Clavulanic acid, Sublactam, Tazobactum 12

MECHANISM OF ACTION

The synthesis of cell wall of bacteria is

completely depended upon an enzyme
named as transpeptidase.
Primarily, Penicillin inhibits the cell wall
formatiom of bacteria by blocking
transpeptidase after binding to penicillin-
binding protein (PBP) and prevents its
synthesis
Cell wall deficient bacteria undergo lysis 13
RESISTANCE

 Also altered target proteins on the bacterial cell wall

14
ADVERSE DRUG REACTIONS
1. Hypersensitivity

 Most important adverse effect.(1-10 %)

 Penicilloic acid, a metabolite reacts with proteins and serves as hapten to causes immune reaction

2. Diarrhea

3. Jarisch-Herxheimer reaction

 Penicillin injected in a syphilitic patient (secondary syphilitic) may produce shivering, fever,

myalgia, exacerbation of lesion.

 This is due to sudden release of spirochetal lytic products which lasts for12-72 hours.
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AMPICILLIN
 Sensitive to all organisms sensitive to PnG + many gram negative bacilli
Eg. H.influenza, E.coli, Proteus.
 Rapid development of resistance.
 Good oral absorption, but not complete.
 Food interferes with absorption.
AMOXYCILLIN
Similar to ampicillin except :
• Better oral absorption
• Lesser incidence of diarrhoea
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USES IN DENTISTRY

 Amoxicillin is the most frequently prescribed drug for infections of dental origin.

 It is administered orally, which is the safest, most convenient and least expensive mode
of drug administration.

 In infections associated with both gram +ve and –ve aerobic and anaerobic organisms,
amoxicillin combined with metronidazole is the agent of choice.

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CEPHALOSPORINS

 Semisynthetic antibiotics derived from Cephalosporin-C

obtained from the fungus Cephalosporium.

 Chemically related to penicillins.

 Bactericidal drugs.

 Inhibit cell wall synthesis.

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CLASSIFICATION
5 th Gen.

Effective against
MRSA

Ceftobiprole
Ceftaroline
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PHARMACOKINETICS

 IV/IM administration.
 Good distribution into body fluids.
 Good penetration into bones.
 Eliminated through tubular secretion and glomerular filtration.

ADR:
1. Allergic manifestations: It should be avoided in those allergic to penicillin.
2. Disulfiram like effect
3. Bleeding
20
 MACROLIDES
Erythromycin
 Used as an alternative to penicillin in individuals who are allergic to β-lactam antibiotics.
Newer Macrolides:
 Roxithromycin
 Clarithromycin
 Azithromycin

Mechanism of Action
 Bacteriostatic at low concentration and bactericidal at high concentration.

 Macrolides bind irreversibly to a site on the 50S subunit and interferes with translocation, thus
inhibiting protein synthesis.
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MACROLIDES
Antibacterial spectrum:
 Narrow, includes mostly gram +ve and few gram –ve bacteria.
 Effective against many of the organisms as penicillin G.

Resistance:
 Serious clinical problem.
 Most staphylococci stains in hospital isolates are resistant to this drug.
1. Inability of the drug to take up the antibiotic.
2. Decreased affinity of the 50S ribosomal subunit for the antibiotic.
3. Presence of plasmid associated erythromycin esterase.
22
METRONIDAZOLE

 Synthetic nitroimidazole.
 Antiprotozoal drug.
 Used extensively for the treatment of anaerobic bacterial infections.

Mechanism of action
 Bactericidal drug.
 Affects DNA synthesis.
 It enters into the cell and reduces into its nitro group to produce metabolites that
damage DNA, eventually inducing cell death.

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Pharmacokinetics Adverse drug reactions

 Completely absorbed from the GIT.  Nausea and vomitting

 Peripheral neuropathy on prolonged

 Widely distributed in the boby.
usage
 Excellent CNS penetration.
 Metallic taste
 Metabolised in liver.  Dark or red brown urine
USES
• 200-400 MG TDS ( 15-30 MG/KG/DAY)
• Used extensively to treat orodental infections and drug of choice for Acute necrrotising
ulcerative gingivitis
• Mostly combined with penicillin, cephalosporin or macrolides 24
SULFONAMIDES
 Were the first agents effective against pyogenic bacteria, and were extensively used in the
subsequent years.
 Limited use currently, due to rapid development of bacterial resistance.
Mechanism of action:

PABA (p-aminobenzoic
acid)

- Sulfonamides

Folic acid

Humans also require folic acid, but they utilize preformed FA supplied in diet. 25
CLASSIFICATION
1. Short acting (4-8 hrs) : Sulfadiazine
2. Intermediate acting (8-12 hrs) : Sulfamethoxazole
3. Long acting(⁓7days) : Sulfadoxine
4. Special purpose sulphonamides : Silver Sulfadiazine

ANTIBACTERIAL SPECTRUM
Primarily bacteriostatic against gram-positive and gram negative bacteria.

26
Resistance
 Enhanced production of PABA.
 Decreased cellular permeability to sulfa drugs.
 Alternative pathway in folate metabolism.

Pharmacokinetics:
 Well absorbed orally.
 Crosses BBB and placenta easily.
 Metabolised in the liver.
 Excreted by glomerular filtration.

27
Uses
 Topically used to prevent infection on burn surfaces.
 Combined with trimethoprim for many bacterial infections.
 Not used to treat dental infections.
Adverse effects
 Crystalluria; nephrotoxicity may result.
 Hypersensitivity
 Hematopoietic disturbances in patients with G6PD deficiency.
 Kernicterus, may occur in newborn.
Contraindications:
 Newborns and infants < 2months.
 Pregnancy
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COTRIMOXAZOLE

• Trimethoprim + Sulfamethaxazole = Cotrimoxazole

• Greater antibacterial activity.
Mechanism of action:
PABA
Sulfonamide - - -
Dihydrofolate
(DHFA)
Trimethoprim - - -
Tetrahydrofolate
(THFA)
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Antibacterial spectrum
 Broader spectrum of action.
 Effective in treating UTIs, and Pneumocystis pneumonia (in AIDS).

Adverse effects
 Nausea, vomitting, stomatitis
 Megaloblastic, anemia, leukopenia, thrombocytopenia (can be reversed by
administration of folinic acid).
 High incidence of fever, rash, bone marrow hypoplasia in AIDs patient.
 Renal toxicity.

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 QUINOLONES

 Active primarily against gram - bacteria.

 Newer compounds also inhibit gram + bacteria.
 Flourination of quinolone structure at position 6 and introduction of a piperazine
substitution at position 7 resulted in derivatives called fluoroquinolones.
 Have high potency.
 Expanded spectrum.
 Slow development of resistance.
 Better tissue penetration.
 Good tolerability.
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Mechanism of action
 They inhibit the replication of bacterial DNA by interfering with the action of DNA
gyrase.
 DNA gyrase nicks double stranded DNA, introduces negative supercoils and then
reseals the nicked ends.
 Fluoroquinolones interferes with the strand cutting and resealing function.

 Bactericidal drugs.
 Slow development of resistance.

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CIPROFLOXACIN

 Prototype.
 Most frequently used.
 Active against a broad range of bacteria.

Pharmacokinetics
 Rapid oral absorption, but food delays absorption.
 Rapid first pass metabolism.
 High tissue permeability, good concentration in lung, sputum, muscle, bone,
prostate.
 Excreted in urine by glomerular filtration and tubular secretion.
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Adverse drug reactions
 Hypersensitivity: rash, pruritis, utricaria
 GIT: nausea, vomitting, bad taste.
 CNS: headache, restlessness, anxiety
 Phototoxicity

Contraindicated in pregnancy, cautious use in children.

Interactions:
 NSAIDs enhance the CNS toxicity of fluoroquinolones.
 Interaction with theophylline, caffeine and warfarin: toxicity of these drugs may occur.

Not indicated for any dental infections unless dictated by culture and sensitivity tests.

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 TETRACYCLINS
 These are a class of antibiotics having a nucleus of four cyclic rings.

Mechanism of Action:
 Bacteriostatic agent.
 Inhibit protein synthesis by binding to 30S ribosomes thereby blocking access to the
amino acyl-tRNA to the mRNA-ribosome complex at the acceptor site.

Resistance:
 Inability of the organism to accumulate the drug.
 Production of bacterial proteins that prevent tetracyclines from binding to the ribosome.
 Enzymatic inactivation of the drug 35
Pharmacokinetics

 Adequately but incompletely absorbed after oral ingestion.

 Simultaneous ingestion of dietary products decreases absorption due to formation
of non absorbable chelates of the tetracycline and calcium ions.
 High concentration in liver, kidney, spleen and skin.
 Binds to tissue undergoing calcification (teeth and bone).
 Crosses the placental barrier and concentrates in fetal bones and dentition.
 Excreted in urine by glomerular filteration.

36
 Adverse drug reactions
 Gastric discomfort: epigastric pain, nausea, vomitting, diarrhoea.
 Effects on calcified tissue: calcium tetracycline chelate gets deposited in developing teeth
and bone.
 Fetal hepatotoxicity
 Phototoxicity
 Vestibular toxicity
 Superinfections
 Nephrotoxicity

 Not recommended for the treatment of infections of dental origin.

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AMINOGLYCOSIDES
 All are bactericidal and more active at alkaline pH.
 They act by interfering with bacterial protein synthesis.
 Do not penetrate brain or CSF.
 All are excreted unchanged in urine by glomerular filtration.
 All are active primarily against aerobic gram –ve bacilli and do not inhibit anaerobes.
 There is only partial cross resistance among them.
 All exhibit ototoxicity and nephrotoxicity.

 Streptomycin
 Gentamycin
 Tobramycin
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SELECTION OF ANTIMICROBIAL AGENTS
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

Lippincotts pharmacology 5th edition

39
When do you need the drugs to kill the bugs?

• Fever > 100° F

• Malaise
• Lymphadenopathy
• Trismus
• Increased Swelling
• Cellulitis
• Osteomyelitis
• Persistent Infection
American Association of Endodontists, 2006
40
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)

COHEN 10th edition 41

ANTIBIOTIC RECOMMENDATIONS FOR SYMPTOMATIC ENDODONTIC PATIENTS

VITAL PULP PULP NECROSIS PULP NECROSIS

ACUTE APICAL PERIODONTITIS ACUTE PERRADICULAR ABSCESS

ANTIBIOTICS
NOT LOCALIZED SPREADING
RECOMMENDED

ANTIBIOTICS RECOMMENDED TO SUPPLEMENT LOCAL TREATMENT

ANTIBIOTICS NOT RECOMMENDED (CONSIDER PENICILLIN V OR AMOXYCILLIN 500mg qid,
CONSIDER ANTIBIOTICS IF MEDICALLY OR CLINDAMYCIN 300 mg qid FOR PATIENTS ALLERGIC TO
COMPROMISED PENICILLIN

CONDITION CONDITION DOES CONDITION

RESOLVES NOT RESOLVE DETERIORATES

CONSIDER CULTURE SWITCH TO CLINDAMYCIN, CONSIDER PROMPT

& SENSITIVITY MACROLIDE OR REFERRAL TO
TESTING CEPHALOSPORIN OR ADD SURGICAL
METRONIDAZOLE SPECIALIST
42
 ANTIBIOTIC SELECTION SUMMARY
DRUG INDICATIONS NOTES
Penicillin V Drug of choice for mild to moderate Bactericidal
odontogenic infections Appx 3% of patient population allergic
Clarithromycin Mild odontogenic infections in Bacteriostatic
immunocompressed patients allergic to
penicillin
Cephalosporins Allergic to penicillin Bactericidal
( caution : 5-15 % shows allergy to Broader spectrum than penicillin
cephalosporins)
Tetracyclins Allergic to penicillins and cephalosporins Bacteriostatic
and cannot tolerate erythromycin like
drugs
Fluroquinolones Mild infections and allergy to penicillin Bactericidal

Clindamycin Chronic low grade infections resistant to Bacteriostatic

penicillins or erythromycin
Metronidazole Chronic infections by anaerobic bacteria. Bactericidal
Very effective in combination with No action against facultative anaerobes
43
penicillin in mixed infections. like streptococci.
 PRINCIPLES OF MANAGING ODONTOGENIC INFECTIONS
STEP SUBSTEPS
1. Determine severity Assess the history of onset and progression
Perform physical examination of the area;
i) Determine character and size of the swelling
ii) Establish presence of trismus
2. Evaluate host defenses Evaluate ;
i) Diseases that compromise the host
ii) Medications that may compromise the host
3. Perform surgery Remove the cause of infection
i) Drain pus
ii) Relieve pressure
4. Select antibiotic Determine ;
i) Most likely causative organism based on history
ii) Host defence status
iii) Allergy history
iv) Previous drug history
5. Follow up Confirm treatment response
Evaluate for side effects and secondary infections 44
45
ANTIBIOTIC ALLERGY TESTS
•NO SINGLE TEST FOR ANTIBIOTIC ALLERGY.
•Except Penicillin, immunoreactive drug metabolites rarely identified.

SKIN TESTING -
•Amoxycillin side chain–specific immune reactions warrant specific amoxycillin skin
testing.
•Intradermal skin testing is difficult to do in children under 10 years of age.
•Most nonpruritic maculopapular rashes will not be predicted by skin testing.

46
 PRINCIPLES OF SKIN TESTING
allergen is introduced into the skin
contact with cutaneous mast cells
Binding of the allergen occurs
patient's mast cells are coated with IgE recognizing that specific allergen.
then adjacent allergen-specific IgE -cross-linked on the mast cell surface & activated
Positive skin test
•transient "wheal-and-flare" reaction (15 to 20 min)
•central area of superficial skin edema (wheal) surrounded by erythema (flare) pruritic
reaction represents the immediate phase.
•cutaneous mast cells are not activated, (no edema or erythema develop & the test is
negative)
47
BLOOD ALLERGY TESTING

• (ImmunoCAP) is available for penicillin G, penicillin V, amoxicillin and Cefaclor

• Most accurate when measured close to the time of the event.
• Tryptase elevation on a sample collected within 1–4 hours after a reaction is consistent with
mast cell degranulation.
• Blood count (looking for eosinophilia) and biochemistry (looking for raised liver enzymes)
Eosinophilia and/or abnormal liver function tests -T-cell/non-IgE-mediated reactions.
• Results of allergy testing may become negative with time.
• For IgE-mediated antibiotic allergy, antimicrobial introduction is used where skin and
intradermal tests are negative, or H/O of low risk and alternative drugs are clearly inferior.
Under medical supervision (clinical immunology/allergy specialist)
48
 Folic acid

Methotrexate, Warfarin

49
DRUG INTERACTIONS

50
51
52
53
Antibiotics in Endodontics Uses
Triple antibiotic paste Intracanal medicament, Regenerative
endodontics
MTAD Irrigant
Tetraclean Irrigant
Ledermix paste Pulp capping and intracanal medicament
Odontopaste Intracanal medicament
Pulpomixine Pulp capping
MTAD Irrigant
Septomixine forte Intracanal medicament
Medicated gutta percha Iodoform and tetracycline impregnated GP,
Recent- nanosilver and nanodiamond
coated Gutta percha
54
 TRIPLE ANTIBIOTIC PASTE
RATIO

Metronidazole (nitroimidazole) -a broad spectrum against

3 protozoa &anaerobic bacteria.

Minocycline (semisynthetic tetracycline) with a

3 similar spectrum of activity

1 Ciprofloxacin, a synthetic fluoroquinolone, has

a bactericidal mode of action

BY WEIGHT 55
 MTAD

• Mixture of 3% doxycycline (Tetracycline), Citric Acid and a Detergent

polysorbate
• To remove the smear layer without affecting or altering the structure of a
dentinal tubules

56
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).

SEPTOMIXINE FORTE
• Contains two antibiotics – Neomycin Polymixin B sulphate

57
LEDERMIX PASTE

TRIAMCINOLONE DEMECLOCYCLINE

• Anti-inflammatory action • Anti microbial action

• Concentration of 1.0% • Inhibits • concentration of

clastic cells (osteoclasts, 3.21%
cementoclasts and dentinoclasts)

Effective in preventing inflammatory resorption in avulsed teeth

Pain management

58
 ODONTOPASTE
• Zinc oxide-based endodontic dressing
• COMPOSITION
Clindamycin hydrochloride- 5%
Triamcinolone acetonide - 1%
Calcium hydroxide- < 0.5%
Odontopaste is the most effective against Enterococcus faecalis.

59
ANTIBIOTIC REGIMENS FOR DENTAL PROCEDURES
(single dose administered 30 min to 60 min before the procedure)

Situation Agent Adults Children

Able to take oral Amoxicillin 2g 50 mg/kg
medication
Unable to take oral Ampicillin 2 g IM or IV 50 mg/kg IM or IV
medication Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV

Allergic to penicillin or Cephalexin 2g 50 mg/kg

ampicillin Clindamycin 600 mg 20 mg/kg
Azithromycin or 500 mg 15 mg/kg
clarithromycin
Allergic to penicillin or Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
ampicillin and unable to Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
take oral medication
Infective endocarditis: Updated guidelines ; U Allen
60
Canadian Journal of Infectious Diseases and Medical Microbiology
PROPHYLAXIS INDICATED PROPHYLAXIS NOT INDICATED

• Prosthetic cardiac valves

Ventricular septal defects
• Previous infective endocarditis
Patent ductus arteriosus
• Unrepaired cyanotic congenital heart disease, including
Mitral valve prolapse
palliative shunts and conduits
Previous Kawasaki disease
• Completely repaired congenital heart defect with
Hypertrophic cardiomyopathy
prosthetic material or device, during the first six
Previous coronary artery bypass graft surgery
months after the procedure
Cardiac pacemakers (intravascular and epicardial)
• Repaired congenital heart disease with residual defects
and implanted defibrillators
at the site or adjacent to the site of a prosthetic patch or
Bicuspid aortic valves
prosthetic device (which inhibit endothelialization)
Coarctation of the aorta
• Cardiac transplant recipients with cardiac valvulopathy
Calcified aortic stenosis
• Rheumatic heart disease if prosthetic valves or
Pulmonic stenosis
prosthetic material used in valve repair 61
DENTAL PROCEDURES REQUIRING ANTIBIOTIC COVERAGE

• Dental extractions
• Periodontal procedures, including surgery, subgingival placement of antibiotic fibers/ strips, scaling and root
planing, proving, recall maintenance
• Dental implant placement
• Replantation of avulsed teeth
• Endodontic instrumentation only if beyond the root apex and endodontic surgery
• Initial placement of orthodontic bands (not brackets)
• Intraligamentary and intraosseous local anesthetic injections
• Postoperative suture removal (in selected circumstances that may create significant bleeding)
• Prophylactic cleaning of teeth or implants where bleeding is anticipated

Use and abuse of antibiotics Author_Steven G. Morrow 62

LOW RISKS

 Routine anesthetic injections through noninfected tissue,

 Taking dental radiographs,
 Placement of removable prosthodontic or orthodontic appliances,
 Adjustment of orthodontic appliances,
 Placement of orthodontic brackets,
 Shedding of deciduous teeth, and
 Bleeding from trauma to the lips or oral mucosa.

Infective endocarditis: Updated guidelines ; U Allen

Canadian Journal of Infectious Diseases and Medical Microbiology
63
CONCLUSION
Antibiotics and antimicrobials have become a critical and integral part of the dental

practice.

It is apparent that antibiotics are used widely In dentistry, often unnecessarily.

Dental practitioners must become better educated about the prudent use of antibiotics

and the dangers and cost of their overuse and misuse.

So it is important to understand the drugs , their actions and the development of

resistance.
64
JOURNAL REVIEWS

65
Susceptibility of Endodontic Pathogens to Antibiotics
in Patients with Symptomatic Apical Periodontitis
Neringa Skucaite,Vytaute Peciuliene JOE
AIM :
The aim of this study was to evaluate susceptibility of predominant endodontic pathogens isolated from
teeth with symptomatic apical periodontitis to most commonly prescribed antibiotics.
METHODS
Among 58 patients with symptomatic apical periodontitis, 47 and 11 cases were caused by primary and
secondary root canal infection, respectively. The microbial samples were taken either from the root canals
(35 cases) or by aspiration from apical abscesses (23 cases). Culture methods were used to identify the
microorganisms present in the samples. Antibiotic susceptibilities of all isolates were evaluated by using the
E-test method.

66
RESULTS
Microorganisms were isolated from 49 of the 58 samples studied and included facultative and obligate
anaerobes. Streptococci and obligate anaerobes were the predominant microorganisms in cases of primary
infection. Enterococcus faecalis dominated in cases of secondary infection. All tested microorganisms
were highly sensitive to penicillin G, amoxicillin, and ampicillin. Susceptibilities to clindamycin and
erythromycin were 73.8% and 54.7%, respectively. About 40% of the isolates were resistant to
tetracycline. More than 50% of all anaerobes were resistant to metronidazole. All E. faecalis isolates were
resistant to clindamycin.
CONCLUSIONS
Based on the study results, penicillin and amoxicillin are suitable antibiotics for treatment of endodontic
infection when conventional root canal treatment alone is insufficient. Clindamycin could be advised for
penicillin-allergic patients with primary endodontic infections.

67
Infection Control in Teeth with Apical Periodontitis Using a Triple
Antibiotic Solution or Calcium Hydroxide with Chlorhexidine: A
Randomized Clinical Trial
Marcia E.F. Arruda, Monica A.S. JOE
AIM : To compare the antibacterial effectiveness of treatment protocols using either a triple antibiotic
solution (1 mg/mL) or calcium hydroxide/chlorhexidine paste as interappointment medication in
infected canals of teeth with primary apical periodontitis.
Methods: The root canals of single rooted teeth with apical periodontitis
were prepared by using a reciprocating single-instrument technique with 2.5% sodium hypochlorite
irrigation then medicated for 1 week with either
1. a triple antibiotic solution (minocycline, metronidazole, and ciprofloxacin) at 1 mg/mL (n = 24) or
2. a calcium hydroxide paste in 2% chlorhexidine gluconate (n = 23).

68
• Samples were taken from the canal at the baseline (S1), after chemomechanical preparation
(S2), and after intracanal medication (S3).
• DNA extracts from clinical samples were evaluated for total bacterial reduction using a 16S
ribosomal RNA gene-based quantitative polymerase chain reaction assay.

Results:
• All S1 samples were positive for the presence of bacteria, and counts were substantially reduced
after treatment procedures (P < .01).
• Bacterial levels in S2 and S3 samples did not significantly differ between groups (P > .05). S2
to S3 reduction was 97% in the antibiotic group and 39% in the calcium
hydroxide/chlorhexidine group; only the former reached statistical significance (P < .01).
69
Conclusions:
• Interappointment medication with a triple antibiotic solution at the concentration of 1
mg/mL significantly improved root canal disinfection, and its effects were at least
comparable with the calcium hydroxide/chlorhexidine paste.
• Effectiveness and easy delivery of the antibiotic solution make it an appropriate
medicament as part of a disinfecting protocol for conventional nonsurgical endodontic
treatment and possibly regenerative endodontic procedures.

70
Facial antibioma formation: A case report.
Haydar Mahdey,1 Danish Muzaffar : J Oral Res 2018

• 26 year old female patient attended the SEGi Oral Health Centre with the chief complaint of a
swelling in the right lower posterior region of the mandible present for two weeks.
• The patient was in general good health and reported no systemic illness.
• Intraoral examination revealed a swelling on the oral
mucosa and a temporary restoration on the occlusal surface
of a mandibular first molar (tooth 46).
• Extraoral examination revealed well-marked swelling (2x2cm)
at the lower border of the mandible near the tooth 46 area

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• The dental history revealed that tooth 46 was under for root canal treatment that had not been
yet completed by the dentist.
• The patient reported a history of repeatedly and prolonged use of antibiotics including
amoxicillin and metronidazole.
• Etoricoxib was used in conjunction with the antibiotics as a analsegic.
• The preoperative intra-oral periapical radiographs showed periapical lesion of tooth 46.
• The patient abandoned root canal treatment following the development of the swelling.
• Considering the patient history and clinical presen-tation, various treatment options, their
possible outcomes and related complications were explained to the patient.
• The agreed treatment plan comprised the surgical removal of tooth 46 and associated antibioma
under local anesthesia followed by restoration of the lost tooth.

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DISCUSSION
• In this case, to eradicate the infection, the patient was
treated for root canal treatment.
• However, insufficient cleaning and shaping of the root
canal lead to poor drainage and accumulation of
biological material in the affected tooth.
• The prolonged use of antibiotics to treat the residual
infection and lack of proper postoperative follow-up led
to the formation of the antibioma.
• This clearly illustrated the importance of mechanical instrumentation (cleaning and shaping) and
chemical disinfection of canals during root canal treatment.
• The negligence regarding judicious antibiotic usage during the management of odontogenic
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infections may result in serious consequences.
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