group report 2009

8/3/2019 Group Report 2009

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“ Effectiveness of Systemic Antibiotic Therapy on Post-

treatment Symptoms Following Root Canal Therapy”

A Systematic Review

Group- A

Authors:

A mit Narwal

Hong Zhao

Mehdi Noroozi

Prabhjot Kaur

Preeya Chaly

Roya Khoshsar,



ABSTRACT

Objective: The purpose of this systematic review was to find a scientific and evidence based

answer to the effectiveness of systemic antibiotic therapy on prevention or reduction of post-

operative symptoms following root canal therapy/surgical endodontics. Methods: Literature search in Pub Med based on inclusion criteria (Randomized Control Trials,

Human studies, adults age 19 or older, English Language, Permanent teeth) followed by

systematic review of selected articles.

Results: Through literature search we identified 30 articles, then relevance to our study was

established by reviewing title/abstract in group and we identified 10 articles to be studied at full

text stage. Each article was read and scored in team and finally we selected 6 double blinded

placebo controlled randomized control trials for our evidence based report.

Recommendations/Conclusion: On the basis of evidence in this literature review:

1- We found no significant difference in the effectiveness of systemic antibiotics administered

either prophylactically or therapeutically in endodontic treatment/surgery in comparison to

placebo/no intervention.

2- There is a good level of evidence implying no significant advantage in the utilization of

systemic antibiotics in prevention/reduction of symptoms following endodontic treatment.

3 M d i d t ll d t i l ith t f l f f ll d li i ti th



Introduction

The administration of systemic antibiotics as preoperative and/or postoperative on a routine basis

in endodontic emergencies and endodontic surgeries has always drawn considerable attention1.

Seemingly there is limited empirical evidence to support the effectiveness of this approach and

questions have been raised about the safety of indiscriminate antibiotic prescription3.

Antibiotics should be prescribed on the basis of a defined need otherwise their use may presentmore of a risk to the patient than the infection being treated or prevented.

2Antibiotics can be

responsible for various adverse effects, including drug interactions, selection2 and overgrowth of

resistant microorganisms. This is validated by the fact that at least 60,000 to 100,000 deaths

occur annually in United States hospitals due to nosocomial infections caused by antibiotic

resistant microorganisms4, nausea, gastrointestinal upsets, potentially fatal allergic reactions and

antibiotic associated colitis. There is clear evidence that antimicrobials are being used

inappropriately by dentists for a variety of conditions.2

Postoperative pain and swelling following instrumentation and/or obturation is of concern for

endodontic patients, dentists, and dental staff. Investigators have reported varying frequencies of

postoperative complications commonly known as a flare-up that occurs in some patients

resulting in moderate-to-severe postoperative pain and/ swelling. The incidence of an endodontic

flare-up has been reported to be 1- 24% of the time5, 6

The main factors contributing to postoperative pain and discomfort can be classified as (a)host

factors,(b) idiopathic factors, and (c)flora of infected root canals.(5)Among the three major

elements the role of bacteria and their by products is well established Irritation of peri apical



This report deals with the evidence available concerning the efficacy of systemic antibiotics as

preoperative and/or postoperative care in endodontic emergencies and endodontic surgeries.

Only one Cochrane systematic review was found in the literature which has reviewed the use of

antibiotics for pain relief in patients with irreversible pulpitis undergoing no endodontic

treatment. They found no evidence to support the use of antibiotics for pain relief in irreversible

pulpits 3. This review sought to provide reliable evidence concerning the effectiveness of

prescribing systemic antibiotics for endodontic treatments/surgeries. Our key questions were

whether the antibiotic therapy reduces postoperative endodontic flare-ups? If yes, how effective

it is and whether the advantages of antibiotic administration outweigh the disadvantages?

Materials and methods

A systematic review of literature was carried out to identify, appreciate and critically appraise

the most relevant research to our topic of interest.

Stage 1: Search keywords in PubMed Database

We employed the following keywords to execute our research: Permanent teeth, Endodontic

treatment, Flare-up, Pain, Percussion pain, Swelling, Infection, Systemic Antibiotics. Following

outlining the keywords, we used the PubMed database to get needed articles. We used the

combination of PubMed and MESH to extract the scientific evidence. Experts from department

of Endodontics at the Toronto Faculty of Dentistry were consulted.

2- Inclusion and exclusion criteria setup

F ll i l i i h i h fi ld f d d i h i l i d



Exclusion Criteria: We did not consider the articles which had to do with:

Endodontic treatments on primary dentition.

Study designs other than RCT due to lower level of evidence.

Sources other than PubMed Database.

Following combination of key words and putting the limits in to place, the total numbers of 30

articles were retrieved.

Table 1: Search Strategy Table

Search Result

“endodontics "[MeSH Terms] OR "endodontics"[All Fields]OR "root canal therapy"[MeSH

Terms] OR "root canal therapy"[All Fields] OR endodontic[All Fields] OR"pulpectomy"[MeSH Terms] OR "pulpectomy"[All Fields] OR "pulpotomy"[MeSH Terms]

OR "pulpotomy"[All Fields] OR "endodontic surgery"[All Fields] OR "apicoectomy"[MeSH

Terms] OR "apicoectomy"[All Fields

24689

"anti-bacterial agents"[MeSH Terms] OR ("anti-bacterial"[All Fields] AND "agents"[All

Fields]) OR "anti-bacterial agents"[All Fields] OR ("antibacterial"[All Fields] AND

"agent"[All Fields]) OR "antibacterial agent"[All Fields] OR fluoroquinolones OR

"penicillins"[MeSH Terms] OR "penicillins"[All Fields] OR "penicillin"[All Fields] OR

"amoxicillin"[MeSH Terms] OR "amoxicillin"[All Fields] OR "metronidazole"[MeSH

Terms] OR "metronidazole"[All Fields] OR "clindamycin"[MeSH Terms] OR

519783



Stage 3: Study Preferences

We applied the title, abstract and full text screening Stages using the PICO-C model. Based onthe model, population, intervention, control or comparator, outcome and critical appraisal of each

study is assessed and evaluated. Each article reviewed by at least three members of the group for

screening. In cases of disagreement the consensus was established. Of 30 retrieved articles, 13

rejected in the title stage by virtue of the fact that topic was absolutely irrelevant to our topic of

interest. The remaining 17 articles were undergone the abstract screening stage which resulted in

rejecting 7 articles and approving 10 ones. Evaluating the result of Pubmed search did not

provide any additional citation.

Stage 4: Study Quality Appraisal

Based on the PICO-C model, each article approved at the abstract stage was thoroughly reviewed

in full text and appraised critically using “Checklist to Assess Evidence of Efficacy of Therapy

or Prevention 7 as a guideline by at least three members of the team to minimize the probability

of double standards. Regarding the checklist if the answer to question was positive, that question

was marked 1 and if the answer was negative, that question was scored 0 and the final score of

each study with the maximum possible score of 17 was calculated thereafter by adding theses

marks. Upon consultation with the experts in the field of endodontics, we retrieved 2 articles

which had been disapproved in the abstract stage. Moreover, 3 articles were rejected given the

fact that the intervention groups in the studies were compared with control groups originating

from past studies available for authors.



The following chart shows the number of articles approved and rejected in the 3 differentscreening stages based on our pre-defined inclusion and exclusion criteria.

Stage 1:

Pub Med Search ResultNo Further Article

17

10

Limits: Humans, Clinical Trial, Meta-Analysis,Randomized Controlled Trial, Trial, Phase IV, Controlled

Clinical Trial, English, All Adult: 19+ years

Pub Med30

Title Stage

13 rejected

17 accepted

Abstract Stage7 rejected;

10 accepted

Full Text Stage

3 rejected;7 accepted



#

Citation REASONS FOR

EXCLUSIONS

Score Stage of

Exclusion

1 Endodontics in the adult patient: The

role of

antibiotics.L.P.Longman,A.J.Preston,M

.V.Martin,N.H.F.Wilson

Journal of Dentistry 28(2000) 539-548

August 2000

The article was a review study.

The article discusses the

indication and contraindication of

antibiotics in healthy patient and

medically compromised patients,

which also includes use of topical

antibiotics.

10/17 Full text

2 A comparison of erythromycin and

cefadroxil in the prevention of flare-

ups from asymptomatic teeth with

pulpal necrosis and associated

periapical pathosis. Morse DR, Furst

ML, Lefkowitz RD, D'Angelo D,

EspositoJV. Oral Surg Oral Med Oral

Pathol.1990, May;69(5):619-30.

No control used in the current

trial.

A comparison was done with

control taken from another study.

11/17 Full text

3 A prospective randomized trial on

efficacy of antibiotic prophylaxis in

asymptomatic teeth with pulpal

necrosis and associated periapical

pathosis. Abbott AA, Koren LZ, Morse

DR, Sinai IH, Doo RS, Furst ML.

Oral Surg Oral Med Oral Pathol. 1988Dec; 66(6):722-33. Review.

No control group in the study, Not

blinded; Prophylactic Ab group of

this study was compared with

placebo control group of the other

study,

11/17 Full Text



Stage 5: Producing Evidence Table

We abstracted evidence from selected papers onto abstraction sheets and finally transferred thedata into the evidence table under PICOC‟s heading (Population, Intervention, Control, Outcome

and Critical appraisal)

Evidence based table was designed for 6 final randomized controlled trial, double blinded and

placebo controlled studies which had been systematically reviewed as follows:

1. Henry M, Reader A, Beck M.J Endod. 2001 Feb;27(2):117-2

2. Lindeboom JA, Frenken JW, Valkenburg P, van den Akker HP.Int Endod J. 2005

Dec;38(12):877-81

3. Walton RE, Chiappinelli J.J Endod. 1993 Sep;19(9):466-70.

4. Pickenpaugh L, Reader A, Beck M, Meyers WJ, Peterson LJ.J Endod. 2001Jan;27(1):53-6.

5. Torabinejad M, Dorn SO, Eleazer PD, Frankson M, Jouhari B, Mullin RK, Soluti

A. J Endod. 1994 Sep;20(9):427-31.

6. Torabinejad M, Cymerman JJ, Frankson M, Lemon RR, Maggio JD, Schilder H. J

Endod. 1994 Jul;20(7):345-54.

We complied with the guideline recommended by the Canadian Task Force on Preventive



Results

Our search strategy identified 30 articles. 13 papers were excluded on title stage, and 7 papers

were excluded on abstract stage. 4 papers were rejected on full text stage of which one paper was

systematic review, and three others did not have control group and were not blinded. Therefore,

totally 6 papers were included in this review, which were all double-blinded placebo controlled

randomized clinical trials.

Preoperative prophylactic antibiotics on post-endodontic treatment symptoms

Walton and Chiappinelli (1993) carried out a study to test the effect of the prophylactic penicillin

on post-endodontic treatment symptoms. They selected 80 patients with asymptomatic periapicalperiodontitis, and divided them into three groups. Group A (26 patients) received 2 g penicillin

before the treatment and 1 g 6 hours after the treatment. Group B (24 patients) received a placebo

with same regimen, and group C (30 patients) received no medication. Post treatment symptoms

such as pain and swelling were recorded at 4,8,12,24, and 48 hours. Only one flare-up was

reported which was in placebo group. 69% of the patients in group A (penicillin) had mild-

moderate pain, as compared with 79% in placebo group B and 70% in group C (no medication).

Statistics showed no significant difference (p=0.68) among these three groups as to posttreatment symptoms.



Another trial evaluated the value of clindamycin in the prevention of postoperative infection

(Lindeboom et al. 2005). 256 patients undergoing endodontic surgery were included. 1 hour

before surgery, 128 of them were given 600mg clindamycin orally, while another 128 patientsreceived placebo. Patients were assessed 1, 2 and 4 weeks after surgery. The infection rate in the

clindamyicn group was 1.6% (2 patients) and in the placebo group the infection rate was 3.2% (4

patients), which indicated no significant differences (p=0.448).

Post-treatment antibiotics on post-endodontic treatment pain:

Torabinejad et al. (1994) compared the effectiveness of penicillin and erythromycin on

postoperative pain for 72 hours following root canal instrumentation. Sample patients had

periapical periodontitis with varying levels of pain. Following complete root canal cleaning and

shaping, 57 patients received penicillin 500mg; 46 patients received erythromycin base 500mg,

and 53 patients were placebo group. All patients scored their levels of discomfort at each 6-hinterval for up to 72 hours after instrumentation. Patients‟ questionnaires were collected at the

obturation appointment. Data indicated that preoperative pain and apprehension had a strong

positive correlation with postoperative pain (p<0.0001, 0.012<p<0.047 respectively). In terms of

medications, penicillin and erythromycin base were significantly more effective in reducing

moderate and severe pain than placebo within the first 48 hours after instrumentation (p<0.05).

Whereas in patients with no or mild pain no statistical significant difference was showed

between the effectiveness of antibiotics and placebo.

Torabinejad et al. (1994) continued this study to further compare the effectiveness of antibiotics



Discussion

In this evidence based report, we have tried to gather the best studies available, in order to findan answer as to whether or not antibiotics should be taking into consideration in preventing any

flare up, pain, swelling or pain on percussion after endodontic treatment of asymptomatic teeth

with necrotic pulp and periapical pathology.

After a detailed database search, we came out with six articles that might answer our concern.

All these articles were randomized clinical trials.

The reason for selecting randomized controlled trials for our study was due to the highest level of

evidence they provide as the gold standard. They are generally accepted as the most valid

method for determining the efficacy of therapeutic intervention, because the biases associated

with other experimental designs can be avoided.9

The articles subject to full-text consideration were included. Only articles approved that the

antibiotics were administered to relieve post endodontic treatment flare ups. Articles representing

antibiotic prophylaxis to only prevent heart diseases or to treat a tooth abscess were discarded.

Furthermore, the studies were critically appraised based on the checklist to assess evidence of

efficacy of therapy adapted from Fletcher and Wagner7.

Action of antibiotic in preventing flare up in endodontically treated teeth:

The use of prophylactic antibiotics to prevent an infection is based on work of Burke and Miles.

They demonstrated in animal models for the antibiotics to be effective, they must be in tissue or

wound site prior to the beginning of infections Any delay of 3-4 hours resulted in infections



dosage were standardized for both the groups appropriately and the patients were assessed first,

second and fourth week post-operatively. Although, there was no significant difference in the

rate of infection, the randomization of surgical site was not ideal. More molars were treated inclindamycin group while more maxillary pre-molars and maxillary anterior teeth, were treated in

placebo patients.

In a randomized double-blind study Walton et al. 1993, studied the use of antibiotics in

preventing flare up between patients receiving penicillin V either 2g single dose(AHA

recommendation 1994) at the beginning of treatment and an additional of 1g six hours after the

appointment, an inert placebo control or receive no medication at all.

A single visit conventional root-canal cleaning and shaping was performed following which the

symptoms of flare-ups were self-evaluated by patients using visual pain analog at 4, 8, 12, 24

and 48 hours post-treatment. However, this study has its own drawbacks with small sample size,

treatment being rendered by undergraduates and the important factor which we thought that the

occlusion was not adjusted, which might be one of the co-factors for flare-ups.

Leigh Pickenpaugh t al. 2001, performed a study to determine the effect of prophylactic

amoxicillin on the occurrence of flare-up in asymptomatic, necrotic teeth with periapical legion

measuring 3x3 mm. They give patients either 3g dosage of amoxicillin orally 1hour before the

treatment or an inert placebo. The flare-up was defined as moderate to severe post-operative pain

or moderate to severe swelling that began 12-48 hours after the treatment and lasted for at least

48 hours. Pickenpaugh et al. 2001, claims that their results „disagree with the work of Morse and

co-authors

9

. Unfortunately their study didn‟t come without drawbacks such as a lack of samplesize, occlusion was not adjusted and its power value was 0.08.

In the double-blind study by Torabinejad et al. 1994, using a sample size of 411 patients reported



less than 20%, instrument steps were not standardized in certain emergency appointments

because of time constraints and also there was no reporting on occlusal adjustment.

Research supporting the use of antibiotics in preventing flare-up following endodontic treatment

has come from investigators at the School of Dentistry at Temple University.

“Mata et al. 1985 used a randomized control trial to test the incidence of flare-up between the

patients receiving either penicillin V or a placebo control. The antibiotic dosage schedule was

250mg tablet of penicillin V every hour for the first 24 hours followed by one tablet every six

hours until all tablets were used. Flare-up was defined as pain and or swelling that necessitatedan unscheduled emergency visit. After treatment patients were asked to complete a pain and

swelling questionnaire for 2 days. It was found that the incidence of flare-up was less in

penicillin group as compared to the control group.

Amongst the articles in our evidence table all provided highest level of evidence I and

only one article favoured the use of antibiotics after complete instrumentation prior to obturation

(Torabinejad, M et al. 1994). The other articles did not find any statistically significant

difference between the effectiveness of various antibiotics versus placebo in controlling adverse

outcomes of flare-ups subsequent to the endodontic treatment.

Despite the conclusion drawn from the above papers, there are numerous limitations

before any clinician arrives to a decision.

A) Factor related to endodontic procedure:

i) Difference in clinicians‟ expertise: General dentist v/s Endodontists or

undergrad students v/s Postgrad students.



adjusted it is impossible to determine if flare-up is due to infection or due

to excessive occlusal contacts.10

B) Definition of flare-up: Different studies have different definitions of flare-ups which

render it difficult to compare the results concerning efficacy of antibiotics at reducing

flare-up.9

C) Use of Analgesics: Many researchers have given their patients analgesics, which they

might have used to control their pain and swelling. As in the study of Pickenpaugh et

al (2001), Tylenol 3 and Ibuprofen was used to control flare-up. Ibuprofen is bothanalgesic and anti-inflammatory agent, while Tylenol 3 is purely analgesic. This

difference will make it difficult to standardize the definition of flare-up.10

D) Non-standardized measurement of flare-up:

i) Difference in period of flare-up evaluation.

ii) Problems associated with report of pain

Walton et al (1993), instructed patients to assess pain using a questionnaire at strict time, while

Pickenpaugh et al (2001)instructed patients to keep a diary of pain assessed before going to bed

on the day of the treatment, then on arising and before bedtime each for five days . The duration

in different studies does not monitor the pain adequately, which might affect the standardization

of the study.

iii) It is believed that individual tolerance and reaction to pain differed greatly

from person to person (Marieb, 2001). This inherited difference make it10



Recommendations/Conclusion

At present, good level of evidence prevail to conclude that Antibiotics DO NOT play a crucialrole in subsiding post-treatment symptoms e.g. pain, percussion pain, swelling and discomfort.

Based on this systematic review, we found no significant difference in the effectiveness of

systemic antibiotics administered either prophylactically or therapeutically on post treatment

flare-ups following endodontic treatment/surgery in comparison with placebo/no intervention;

however, we need more conclusive evidence to support or refute the administration of systemic

antibiotics as a must following endodontic treatments. (Based on the CTFPHC system8, the level

of evidence is 1 and the grade of recommendation is E).

A protocol adoption for the prescription of systemic antibiotics in endodontics may be

advantageous to both patients and clinicians in the future. (Longman etal 2000)

RECOMMENDATIONS FOR FUTURE RESEARCH:

1- There is a good level of evidence implying no significant advantages in the utilization of

systemic antibiotics on prevention/reduction of symptoms after endodontic treatment

2-Studies need to be carried out more globally taking in consideration different races and

sections of population throughout the world and not merely one country.

3- The factors impacting on post treatment symptoms such as patients condition before

treatment, definition of flare-ups, quality of flare-up measurements, endodontic procedure



References:

1- Lindeboom JAH, Frenken JWH, Valkenburg P,van den Akker HP. International Endodontic

Journel, 38, 877-881, 2005.

2- Longman L.P, A.J. Preston, M.V. Martin, N.H.F. Wilson. Endodontics in the adult patient:the

role of antibiotics. Journal of Dentistry ;28(2000)539-548

3- Keenan J .V, Farman AG, Fedorowicz Z, Newton JT. A conchrane Systematic Review No

Evidence To support the use of Antibiotics for pain relief in irreversible pulpitis Journal of

Endodontics;2006,32,no.2,1-14

4-Krishnan G,.The endodontic dilemma-rationale behind antibiotic

usage,Endodontology;2001,vol:13,19-23

5- Torabinejad M, Cymerman JJ, Frankson M, Lemon RR, Maggio JD, Schilder H.J.

Effectiveness of various medications on postoperative pain following complete

instrumentation.Journal of Endodontics;1994,20,no.7, 345-354

6- Pickenpaugh L, Reader A, Beck M, Meyers WJ, Peterson LJ. Effect of prophylactic

amoxicillin on endodontic flare-up in asymptomatic necrotic teeth. J Endod. 2001 Jan;27(1):53-6

7- Adapted from: Fletcher, Fletcher and Wagner. Clinical epidemiology – the essentials. 3rd

ed.

1996, and Sackett et al. Evidence-based medicine: how to practice and teach EBM. 1997

8- Canadian Task Force on Preventive Health Care evidence. http://www.ctfphc.org/

http://www.ctfphc.org/

http://www.ctfphc.org/



Appendix1: Technology Assessment Table

Compared toplacebo,

Antibiotictherapy costs

Compared to the placebo/ no medication,Antibiotic therapy works

Better The same Worse

Less

The same

More X

Appendix2: CTFPHC Grades of Recommendations and Quality of Published Evidence

A. The CTF concludes that there is good evidence to recommend the clinical preventive action

B. The CTF concludes that there is fair evidence to recommend the clinical preventive action

C The CTF concludes that there is conflicting evidence neither recommending nor favoring the clinical

preventive action.

D The CTF concludes that there is fair evidence to recommend against the clinical preventive action.

E The CTF concludes that there is good evidence to recommend against the clinical preventive action.

I The CTF concludes that there is insufficient evidence to make a Recommendation



Appendix 3:

Checklist to Assess Evidence of Efficacy of Therapy or Prevention

Citation: ____________________________________________________

____________________________________________________

1. Was the study ethical? ___

2. Was a strong design used to assess efficacy? __

3. Were outcomes (benefits and harms) validly and reliably measured? ___

4. Were interventions validly and reliably measured? __

5. What were the results?

Was the treatment effect large enough to be clinically important? ___

Was the estimate of the treatment effect beyond chance and relatively precise? ___

If the findings were “no difference” was the power of the study 80% or b etter ___

6. Are the results of the study valid?

Was the assignment of patients to treatments randomised? ___



Author,

Date

Study

Design

Population InterventionEndodontic

Control Outcome Criticalappraisal

comment

s/scores

Conclusion,Strength of

evidence

andclassification

n Medication Regimen Time Procedure n Placebo

A s s e s s m e n t

F l a r e - u p

I n c i d e n c e

P v a l u e

HenryM,Reader

A, Beck M,2001

Randomizedcontrolled

Trial/ Double blind

Sample Size:41emergency adults

Age:Penicillin:37+/- 16.5

Placebo:38+/- 18.8F:20, M:21Location: The Ohio

State University

Symptomatic(spontaneous pain)/ necroticpermanent teeth with

periapical radiolucency

19 Penicillin V 500mgq.i.d

Oral7 days

Post Treatment Treatmentby

seniorEndodontic

graduatestudentsStep back

technique

22 Lactosepackaged

bypharmacy

7-dayDiary to

record pain.

Pain: Percussion

pain

Swelling,

# of analgesics

taken P >

0 . 0

5

P = 0 . 2

2

P =

0 . 8

Score:16.5/17

No significant

reduction inpain ,

sensitivity topercussion,

swelling andnumber of analgesic

medications

taken byadministrationof penicillin

postoperatively

Level of Evidence: Ι

Lindeboom

et al. 2005.

Randomized

ControlledTrialDouble-blind

placebo-controlled

trial.

Sample size: 256

Mean Age: 44.4 yrs,Range : 18-42 yrsM: 109(42.6%)

F: 147(47.4%)Location: University of

AmsterdamNon Vital Teeth withapical periodontitis,

adequate root canalfilling and free of acutesymptoms for periapical

surgery.

128 Clindamycin 600 mg

1h before

endodonticsurgery (Prophylactic)

Endodontic

Surgery,The sameduration of

surgery fortwo groups.

128 Oral

Placebo,1h beforesurgery

Pts

Assessed 1,2 and 4weeks

postoperatively

Post-op

woundinfection

intervention : 2 cases 1.6%;

95% CI: 0.48-4.72control: 4 cases 3.2%95%CI: 0.42-1.33

P = 0 . 4

4 8

Score:

14.5

Randomiz

ation insurgicalsites is not

ideal.

No statisticallysignificant

evidence of differencebetween

preoperativeclindamycin

prophylaxisand placebo inprevention of

postoperativeinfection inendodontic

surgery.

Level of

Evidence: Ι

Walton RE,Chiappinell

i J et al.

1993

RandomizedControlled

Trial

Double blind

Sample size: 80Age: 17-78 years old.

F:32, M:48,

divided in 3 groups:Group A: 26,Group B: 24,

Group C:30Location: University

of IowaPermanent teeth withnecrotic pulp & chronic

apical periodontitis

26

Penicillin V

Penicillin V

2grsSingle

dose (AHA

recomme

ndations-

1984)

6grsSingle

dose (AHA

recomme

ndations-

1984)

At thebeginning of

treatment

6 hours after

the appointment

Single Visit

Standard

endodontictreatment,No

intracanaldressing

24

30

group B:Placebo

same

regimen

Group C:No

Medication

Ptsassessed

at 4, 8, 12,

24, and 48

hours.

Flare-up:group A:0

group B:1

Mild to

moderatepain:A: 69%

B:79%C:70%

Swelling:A: 1 caseB: 1case

P = 0 . 6

8

P > 0 . 0

5 Score:

14/17

smallsamplesize;

Pts undertreatment

by Endograduatesand

undergraduates. Skills

varied

Administration

of penicillin

prophylactically

was unrelated to

post treatment

signs &

symptoms.

following canal

preparation

Using penicillin

prophylactic ally

to control Post-

op symptoms not

recommended

Level of

Evidence: Ι



Author,

Date

Study

Design



comment

s/scores


evidence

andclassification

n Medication Regimen Time Procedure n Placebo

A s s e s s m e n t

F l a r e - u p

I n c i d e n c e

P v a l u e

LeighPickenpaug

h, et al.

2001

RandomizedControlled

Trial,double-blind

Placebo-controlled

Sample size : 70healthy adults

Location: The OhioState University

Asymptomaticpermanent teeth with

necrotic pulp associated

with periapical lesions3*3

34 Amoxicillin Oral3grams,

1 hourbefore

Endo Tx

Pretreatment1 h before

Two-visitstep back

technique,k type files,

2.62%sodium

hypochlorite,

sterile cottonpellet,Temp filling:

Cavit

36 3grams,one hour

beforeEndo Tx

5 1/2 – daydiary to

record Pain,percussion

pain,swelling,

number and

type of painmedicationtaken

moderate-to-

severepostoperative

pain orswelling that

began 12-48h after

endodontic

treatmentand persistedfor an

average of 48h

Intervention:4 casesControl: 3

P = 0 . 8

0

Score :14

Prophylacticdose of

amoxicillinbefore

endodontictreatment of

asymptomatic

necrotic teethhad no effecton the

endodonticflare-up.

Level of evidence: Ι

Torabinejad

et.al,1994

Randomized

control Trial

Doubleblinded

study

Sample Size:588

Range of age :18-79 yrs

F:52% M:48%

Location: Loma Lindauniversity

Permanent Symptomatic

or asymptomatic teeth

with pulpal or periapical

pathosis.

57

46

Penicillin

Erythromycin

Base

2*250mgEvery 6 hrfor 72hrs

2*250mg

Every 6 hr

for 72hrs

Drugs given

post

operativelyafter completeinstrumentatio

n beforeobturation

Multiple -

visit Endo

Treatment,StandardRCT;complete

instrumentati

-on but noobturation by

10 endo

practices and4 endo gradprogram.

Irrigation:

Sodiumhypochlorite1.5-5.25%

Intracanal

medicaments

used

53

inert-

excipients

Post

operativepainassessedby visual

analog

scaleevery 6hrs

for 72 hrs

followinginstrumentation

1-Increase

in.Pre-

operativepainassociatedwith increase

in post

operativepain.

P <

0 . 0

0 0 1

Loss to

follow upwas present

(<20%)

Score: 13.5

Penicillin and

erythromycinmore effectivein controllingmoderate to

severe post

operative painwithin first 48

hours

compared toplacebo.Penicillin and

erythromycinmight preventsevere

postoperative

complicationsin patientswith no ormild

preoperative

pain. Level of

Evidence: Ι

Apprehensio

n associated

with increasein postoperative

pain

P < 0 . 0

4 7

Greater

decrease inpost-op pain

withpenicillin

and

erythromycinthan placeboin first 48hours in pts

with

Moderate &sever pre-oppain.

P =

0 . 0

0 3



Author,

Date

Study

Design


procedure


comment s

/scores


evidenceand

classification

n Medication Regimen Time n Placebo

A s s e s s m e n t

F l a r e - u p

I n c i d e n c e

P v a l u e

TorabinejadM etal,1994

Randomizedcontrol Trial

Double

blindedstudy

Range of age :18-79 yrs

Sample Size:411

F: 52%, M:48%

Location: Loma Linda

university

Permanent Symptomaticor asymptomatic teeth

with pulpal or periapicalpathosis.

46

33

Penicillin

Erythromycin

Base

2*250mg

Every 6 hrfor 72hrs

2*250mg

Every 6 hrfor 72hrs

Drugs givenpost operatively

after completeobturation

Multiplevisits of EndoTreatment,

Standardobturation

with GuttaPerchaperformed.

Irrigation:

Sodium

hypochlorite1.5-5.25%

Intracanalmedicaments

used

41 inert-excipients

Postoperative

painassessedby visual

analogue

scale of 0to 9 every

6hr for 72

hrs

Post operativepain at various

time intervalsafterobturation is

lower than

that followingcomplete

instrumentatio

n (5.83% vs.21.76%)

P < 0 . 0

0 0

1

Loss tofollow up

was present(<20%)

Score: 13.5

No significantdifference

between theeffectivenessof various

antibiotics and

placebo incontrolling

postoperative

painfollowing

obturation Level of evidence: Ι

Erythromycinwas more

effective than

placebo onlyat 6 hour s

P = 0 . 0

2 0 6

group report 2009

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