EndodonticEndodontic Emergencies Emergencies and Antibioticsand Antibiotics

Dr Zuryati AbDr Zuryati Ab--GhaniGhaniBDS, Grad Dip BDS, Grad Dip ClinClin Dent, FRACDS, Dent, FRACDS,

D D ClinClin Dent (Pros)Dent (Pros)28.06.0628.06.06

Topics to be coveredTopics to be covered

EndodonticEndodontic emergenciesemergenciesSystemic antibioticsSystemic antibiotics

Indication for using systemic antibioticsIndication for using systemic antibioticsStrategies for using antibioticsStrategies for using antibioticsWhich antibiotic should be usedWhich antibiotic should be usedSpecific indications for antibiotics in Specific indications for antibiotics in endodonticsendodontics

Topical antibioticsTopical antibioticsIntracanalIntracanal medicamentsmedicaments

EndodonticEndodontic emergenciesemergencies

Require careful handlingRequire careful handlingDifficult to spend time with patient Difficult to spend time with patient due to busy scheduledue to busy scheduleTypes of emergencies:Types of emergencies:Acute Acute pulpitispulpitis, acute apical , acute apical periodontitisperiodontitis or acute apical abscessor acute apical abscess

Basic principles of managementBasic principles of management

Correct diagnosisCorrect diagnosisRemove the cause of painRemove the cause of painProvide drainage (if necessary)Provide drainage (if necessary)Correct medication if necessary (local and Correct medication if necessary (local and systemic)systemic)Rest (general and Rest (general and occlusalocclusal))

Acute Acute pulpitispulpitis

If irreversible:If irreversible:LA, rubber damLA, rubber damRemove all caries, gain access, extirpate Remove all caries, gain access, extirpate pulppulpCanal preparation not essential if time Canal preparation not essential if time limitedlimitedLedermixLedermix paste dressing, temporary paste dressing, temporary restorationrestorationRoutine Routine endoendo treatment carried out at treatment carried out at convenient timeconvenient time

Acute apical Acute apical periodontitisperiodontitis

Pain is caused by inflamed dental pulp Pain is caused by inflamed dental pulp or infected canalor infected canal

Treatment: as for acute Treatment: as for acute pulpitispulpitis

Acute apical abscessAcute apical abscess

Severe pain, swelling, feverSevere pain, swelling, feverTreatment: As for acute Treatment: As for acute pulpitispulpitis PLUSPLUS

Establish drainage (if required)Establish drainage (if required)-- via root via root canal or via incision of mucosa.canal or via incision of mucosa.Canal should not be left open. Better to see Canal should not be left open. Better to see patient after 12 to 24 hrs for further patient after 12 to 24 hrs for further drainagedrainageAntiobioticAntiobiotic systemicallysystemicallyAnalgesicsAnalgesicsRest (occlusion and sleep)Rest (occlusion and sleep)

Systemic antibiotic in Systemic antibiotic in endodoticendodotic

EndodonticsEndodontics: largely concerned with apical : largely concerned with apical periodontitisperiodontitis with source of infection from with source of infection from tooth.tooth.Thos can be treated with removal of the Thos can be treated with removal of the infected canal contentinfected canal contentShould only be considered as an adjunct to Should only be considered as an adjunct to endoendo RxRxShould not be used as a means of Should not be used as a means of providing pain reliefproviding pain relief

Indication for using Indication for using systemic antibioticssystemic antibiotics

MalaiseMalaiseElevated body temperatureElevated body temperatureLymph node involvementLymph node involvementSupressedSupressed or compromised immune or compromised immune systemsystemCellulitisCellulitis or a spreading infectionor a spreading infectionRapid set of a severe infection (i.e. Rapid set of a severe infection (i.e. less than 24 hoursless than 24 hours

Contra indication of Contra indication of systemic antibioticssystemic antibiotics

No systemic illnessNo systemic illnessChronic alveolar infections associated Chronic alveolar infections associated with with pulplesspulpless teethteethInflammatory pulp conditionInflammatory pulp conditionAcute alveolar condition where Acute alveolar condition where adequate drainage, adequate drainage, debridementdebridement and and intraintra--canal medication have been canal medication have been achieved.achieved.

Systemic antibiotics not Systemic antibiotics not indicatedindicated

PulpitisPulpitis and and periapicalperiapical periodontitisperiodontitisSystemic antibiotics will not remove the Systemic antibiotics will not remove the

cause of the problem nor remove the cause of the problem nor remove the bacteria present in the tooth as the bacteria present in the tooth as the concentration is lowconcentration is lowNecrotic pulp or Necrotic pulp or pulplesspulpless toothtooth-- no no blood supply thus antibiotic will not blood supply thus antibiotic will not reach the root canal system reach the root canal system

Which antibiotic should Which antibiotic should be usedbe used

Bacterial involved in Bacterial involved in endodonticendodonticinfection:infection:BacteroidsBacteroids vulgarisvulgarisFusobacteriumFusobacterium necrophorumnecrophorumPeptostreptococcusPeptostreptococcus sppspp..PrevotellaPrevotella sppspp..

At least 70 different bacterial species At least 70 different bacterial species have been isolatedhave been isolated

Which antibiotic should Which antibiotic should be usedbe usedPenicillin VPenicillin V

First choice of oral antibioticsFirst choice of oral antibioticsNarrow but appropriate antibacterial Narrow but appropriate antibacterial spectrumspectrumLoading dose of 1000mg, followed by Loading dose of 1000mg, followed by 500mg taken every 6 hrs for 5500mg taken every 6 hrs for 5--7 days7 days

MetronidazoleMetronidazoleSecond choice Second choice espesp if anaerobic bacteria are if anaerobic bacteria are suspectedsuspectedVery narrow spectrumVery narrow spectrum-- ineffective against ineffective against aerobic and facultative anaerobic organismsaerobic and facultative anaerobic organismsCan be used with Pen VCan be used with Pen VLoading dose of 800mg, followed by 400mg Loading dose of 800mg, followed by 400mg tidtid, 5, 5--7 days or7 days orLoading dose of 400mg, followed by 200mgLoading dose of 400mg, followed by 200mg

ClindamycinClindamycin

First choice in patients allergic to First choice in patients allergic to penicillinpenicillinAppropriate spectrumAppropriate spectrumLoading dose of 300mg, followed by Loading dose of 300mg, followed by 150mg 150mg tidtid 55--7 days7 daysErythromycin is another alternative in Erythromycin is another alternative in these patients, but the spectrum is not these patients, but the spectrum is not appropriate for appropriate for endoendo infectioninfection

AmoxycillinAmoxycillin

Very popularVery popularBroad spectrumBroad spectrumShould not be used for routine Rx of Should not be used for routine Rx of endoendo infectioninfectionRecommended as Recommended as antiobioticantiobioticprophylaxis in pts at risk for prophylaxis in pts at risk for developing infective developing infective endocarditisendocarditis ––single 3 gm dose 1 hr presingle 3 gm dose 1 hr pre--opop

TetracyclineTetracycline

Has an inappropriate spectrum of Has an inappropriate spectrum of antibacterial activity for most antibacterial activity for most endodonticendodontic infectionsinfections

IdealllyIdeallly a microbiological analysis a microbiological analysis should be done when antibiotics are should be done when antibiotics are being considered as part of the Rx being considered as part of the Rx plan in order to identify the bacteriaplan in order to identify the bacteriaSome anaerobes are resistant to Some anaerobes are resistant to penicillin and thus serious infection is penicillin and thus serious infection is treated with combination of treated with combination of metronidazolemetronidazole and penicillinand penicillin

Specific indications for Specific indications for antibiotics in antibiotics in endodonticsendodonticsProphylaxisProphylaxis

For patients at risk of developing For patients at risk of developing infective infective endocarditisendocarditisFollowing trauma to prevent Following trauma to prevent inflammatory root inflammatory root resorptionresorption and and replacement replacement resorptionresorptionPrior to some surgical situationsPrior to some surgical situations

TreatmentTreatmentFacial Facial cellulitiscellulitisAcute apical abscess Acute apical abscess Rapidly spreading infectionRapidly spreading infectionImmunoImmuno--compromised patientscompromised patients

IntracanalIntracanal medicamantsmedicamants

AntisepticsAntisepticsAntibioticsAntibiotics

Calcium hydroxideCalcium hydroxide

AntisepticAntisepticBactericidal due to high pH of 12.2Bactericidal due to high pH of 12.2Stimulates calcificationStimulates calcificationIrritantIrritant--avoid use as initial dressing in avoid use as initial dressing in teeth associated with pain, or when teeth associated with pain, or when the inhibition of inflammation or the inhibition of inflammation or inflammatory root inflammatory root resorptionresorption is is necessarynecessary

AntibioticsAntibiotics

Commercial preparations containing antibiotics also Commercial preparations containing antibiotics also contain corticosteroidscontain corticosteroidsCorticosteroids reduce inflammation, pain and Corticosteroids reduce inflammation, pain and initiate healinginitiate healingPreparations:Preparations:LedermixLedermix pastepaste ((demeclocyclinedemeclocycline 3.21%, 3.21%, triamcinolonetriamcinolone))SeptomixineSeptomixine ForteForte (Neomycin, (Neomycin, polymixinepolymixine B B sulphatesulphate, , dexamethasonedexamethasone))PulpomixinePulpomixine ((framycetinframycetin, , polymixinepolymixine B B sulphatesulphate, , dexamethasonedexamethasone))

LedermixLedermix pastepaste-- material of choice. material of choice. The concentration of tetracycline is The concentration of tetracycline is high enough to inhibit the common high enough to inhibit the common bacteria.bacteria.

Recommended materialsRecommended materials

LedermixLedermix paste (a corticosteroid paste (a corticosteroid ––antibiotic paste)antibiotic paste)PulpdentPulpdent paste (calcium hydroxide in paste (calcium hydroxide in methyl cellulose paste)methyl cellulose paste)50:50 mixture of 50:50 mixture of LedermixLedermix paste and paste and PulpdentPulpdent pastespastes

The use of medicamentsThe use of medicaments

MedicamentMedicament Min timeMin time Max timeMax time

LedermixLedermix pastepaste 1010--14 days14 days 66--8 wks8 wks

PulpdentPulpdent pastepaste 33--4 wks4 wks 33--5 5 mthsmths

50:50 50:50 Ledermix/PulpdLedermix/Pulpdentent

33--4 wks4 wks 33--4 4 mthsmths

THANK YOUTHANK YOUReferencesReferences1. Cohen S, Burns RC. (1998). Pathways 1. Cohen S, Burns RC. (1998). Pathways of the pulp. 7th edition. Mosby Inc. St Louisof the pulp. 7th edition. Mosby Inc. St Louis2. 2. EndodonticsEndodontics and dental and dental traumatoloogytraumatoloogy. . An overview of modern An overview of modern endodonticsendodontics. A . A teaching manual sponsored by the Education teaching manual sponsored by the Education Committee of the International Federation of Committee of the International Federation of EndodonticEndodontic Associations Associations –– Australia.Australia.