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Antibiotic in endodontic
This document provides an extensive overview of antibiotics in endodontics, covering their classification, mechanisms of action, and specific applications in dental infections. It discusses historical development, selection criteria for antimicrobial agents, and various treatment regimens including dosages and complications. The text emphasizes responsible antibiotic use, potential resistance, and the significance of local drug delivery in endodontic therapy.
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Antibiotic in endodontic
- 1. 1 Good Morning MOHD.SIBGHATULLAH KHATIB 1STYEAR PG STUDENT
- 2.
- 3. CONTENTS • INTODUCTION • HISTORY •CLASSIFICATION OF ANTIBIOTICS • SELECTION OF ANTIMICROBIALAGENTS • BACETRIOLOGY • ODONTOGENIC INFECTION • COMMONLY USE ANTIIBIOTIC IN ORAL INFECTION • COMPLICATION OF ANTIBIOTIC THERAPY • FASCIAL SPACE INFECTION • MANAGEMENT OF ABSSCESS AND CELLULITIS • ANTIBIOTIC PROPHYLAXIS • RESISTANCE • ANTIBIOTIC DOSAGE • USE OF ANTIBIOTIC AS AN INTRA CANAL MEDICAMENT • MYTHS • CONCLUSION • REFRENCES 3
- 4. • Antibiotics-These aresubstances produced by microorganisms, which selectively suppress the growth of or kill other microorganisms at very low concentrations • Antimicrobial agent (AMA)-synthetic as well as naturally obtained drugs that attenuate microorganisms • Chemotherapy-Treatment of systemic infections with specific drugs that selectively suppress the infecting microorganism without significantly affecting the host 4
- 5. 3 phases: Empirical phaseEhrlich's phase The modem era of chemotherapy 5 History
- 6. Empirical phase • Mouldycurd by Chinese on boils • Chaulmoogra oil for leprosy, • Chenopodium by Aztecs for intestinal worms, • Mercury by Paracelsus (16th century) for syphilis, • Cinchona bark (17th century) for fevers. 6
- 7. Ehrlich's phase (1890-1935) •Ehrlich given the idea that if certain dyes could selectively stain microbes, they could also be selectively toxic to these organisms. He tried methyleneblue, trypan red, etc • He developed arsphenamine in 1906 and neoarsphenamine in 1909 for syphilis. • He coined the term 'chemotherapy' 7
- 8. Modern era • Domagk(1935) - The therapeutic effect of Prontosil. • Pasteur (1877) - Demonstrated the phenomenon of antibiosis : growth of anthrax bacilli in urine was inhibited by air-borne bacteria. 8
- 9. • Fleming (1929)- Discovered penicillin . • Chain and Florey (1941)- Clinical use of penicillin . • Waksman and his colleagues (1944)- Discovered streptomycin 9
- 10. 10 Golden era inantibiotic discovery
- 11. CLASSIFICATION OF ANTIBIOTIC 11 •Based on A. Chemical structure B. Mechanism of action C. Type of organism against which primarily active D. Spectrum of activity E. Type of action TRIPATHI 6TH EDITION
- 12.
- 13. • Inhibit cellwall synthesis – Penicillin – Cepholosporin – Vancomycin – Bacitracin • Cause leakage from cell membrane – Polypeptide: polymixin, Colistin – Polyenes:Amp-B,nystatin • Inhibit protein synthesis – Tetracycline – Chloramphenicol – Macrolides • Mis-reading of m-RNA – Aminoglycosides • Inhibit DNA gyrase – Fluoroquinolones • Interfere with DNA function – Rifampicin – Metronidazole • Interfere with DNA synthesis – Acylovir – Zidovudine – Idoxuridine • Interfere with intermediatory metabolism – Sulfonamide – Ethambutol 13 TRIPATHI 6TH EDITION
- 14. ANTIBIOTICS BACTERIOSTATIC • Sulfonamides •Erythromycin • Tetracyclines • Ethambutol • Chloramphenicol • Clindamycin BACTERICIDAL • Penicillins • Cephalosporins • Aminoglycosides • Vancomycin • Metronidazole • Cotrimoxazole 14 TRIPATHI 6TH EDITION
- 15. Spectrum of activity Narrow-spectrum • Penicillin G • Streptomycin • Erythromycin Broad-spectrum • Tetracyclines • Chloramphenicol 15 Extended-spectrum •Ampicillin •Amoxycillin Lippincotts pharmacology 5th edition
- 16. SELECTION OF ANTIMICROBIALAGENTS The organism’s identity Patient factors The site of the infection The organism’s susceptibility to a particular agent The safety of the agent The cost of therapy 16 Lippincotts pharmacology 5th edition
- 17.
- 18. • The pulpodentincomplex is sterile. • Bacterial invasion of dentinal tubules occurs more rapidly in nonvital teeth than in vital ones. 18 COHEN 10TH EDITION
- 19.
- 20. 20 Siquiera jr etal : update endodontic microbiology 2008
- 21. ODONTOGENIC INFECTION 21 PULPITIS Apical periodontitis PERIAPICALABSCESS PERIAPICAL GRANULOMA PERIODONTAL CYST OSTEOMYELITIS PERIOSTEITIS CELLULITIS ABSCESS ACUTE CHRONIC ACUTE CHRONIC ACUTE CHRONIC FOCAL DIFFUSE Reversible Irreversible
- 22. When do youneed the drugs to kill the bugs? • Fever > 100° F • Malaise • Lymphadenopathy • Trismus • Increased Swelling • Cellulitis • Osteomyelitis • Persistent Infection 22 American Association of Endodontists, 2006
- 23. Just say NO!Kill the bugs without the drugs Irreversible pulpitis, Acute apical periodontitis, Draining sinus tracts, After endodontic surgery, To prevent flare-ups, After incision for drainage of a localized swelling (without cellulitis, fever, or lymphadenopathy) 23 COHEN 10th edition
- 24. COMMONLY USED ANTIBIOTICIN ORAL INFECTION 24
- 25. Antibiotics for odontogenicinfections 25
- 26. DOSAGE 26 Antibiotic Dosage Duration PenicllinV 250mg/500mg Every4-6hours/5-7days Amoxicillin / Amoxicillin with clavulanate 250mg/500 mg Every 8 hours/5-7 days Clindamycin 300 mg/600mg Every 6 hours/5-7 days. Metronidazole 200mg/400 mg Every 8 hours/5-7 days. Azithromycin 250mg/500mg Once a day /5-7 days. American Association of Endodontists 2006
- 27.
- 28. COMPLICATIONS OF ANTIBIOTICTHERAPY • Hypersensitivity • Direct toxicity • Superinfections 28 lippincotts pharmacology 5th edition
- 29. THE FASCIAL SPACES Themandible and below The buccal vestibule Body of the mandible The mental space The submental space The sublingual space Submandibular space The cheek and lateral face The buccal vestibule of the maxilla The buccal space The submasseteric space The temporal space The pharyngeal and cervical areas The pterygo- mandibular space The para- pharyngeal spaces The cervical spaces The midface The palate The base of the upper lip The canine spaces The periorbital spaces 29
- 30. Management of Abscessesand Cellulitis • Correct diagnosis • Removal of the cause • Incision for drainage is indicated for any infection marked by cellulitis. It is important to provide a pathway of drainage to prevent further spread of the abscess and/or cellulitis. 30 COHEN 10th edition
- 31. Systemic Antibiotics forEndodontic Infections • Selection of antibiotics- – Empirical – based on the results of microbial susceptibility tests. • For diseases with known microbial causes, empirical therapy may be used. • Most of the bacterial species involved with endodontic infections, including abscesses, are susceptible to penicillins . 31 COHEN 10TH EDITION
- 32.
- 33. 33 • Managment Amoxicillin(500 mg, orally) at intervals of 8 h for 7 days and dexamethasone (4 mg, intramuscularly) at intervals of 24 h for 3 days 2% chlorhexidine gel applied with a 5- ml syringe
- 34. TOOTH AVULSION • Systemicadministration of antibiotics is generally recommended in order to prevent the harmful effects of bacterial contamination. • Antibiotics decrease the incidence of inflammatory root resorption but have a limited, or no, effect on the pulp 34 Australian Dental Journal Endodontic Supplement 2007
- 35. • Gram-negative obligateanaerobic rods – Porphyromonas spp. – Prevotella spp. • Prophylactic use of antibiotic to decrease incidence of flare up Controversy. Flare-Up’s Cohen pathways of pulp : 10 th edition 35
- 36.
- 37. Infective Endocarditis (IE) •A life threatening disease with substantial morbidity and mortality which affects individuals with underlying structural cardiac defects who develop bacteremia. 37
- 38. 38 JADA, Vol. 131,March 2000
- 39. 39 JADA, Vol. 131,March 2000
- 40. 40 JADA, Vol. 131,March 2000
- 41. • The Frenchagency for Health Product Health Safety advices against or contraindicates – Dental facial surgery, – Bone surgery, – Periodontal surgery, – Root canal treatment in these patients except under emergency situations, As these patients are prone to high risk of infection. 41 Asian Pac J Trop Biomed 2012; 2(9): 749-754
- 42. 42 American Heart Association,2007; 116: 1736-1754
- 43. PREGNANCY • Any drugused during pregnancy should be taken only under the supervision of the patient’s physician. 43 lippincotts pharmacology 5th edition
- 44. 44 CATEGORY DESCRIPTION DRUS ANo human fetal risk or remote possibility of fetal harm B No controlled studies show human risk; animal studies Suggest potential Toxicity β-Lactams,β-Lactams with inhibitors, Cephalosporins, Aztreonam , Clindamycin, Erythromycin, Azithromycin, Metronidazole Nitrofurantoin. Sulfonamides C Animal fetal toxicity demonstrated; human risk Undefined Chloramphenicol, Fluoroquinolones, Clarithromycin, Trimethoprim, Vancomycin Gentamicin, Trimethoprim-sulfamethoxazole D Human fetal risk present, but benefits Mayoutweigh Risks Tetracyclines, Aminoglycosides (except gentamicin) X Human fetal risk present but does not Outweigh benets; contraindicated in pregnancy United States FDA categories of antimicrobials and fetal risk. lippincotts pharmacology 5th edition
- 45. Partial List ofDrugs Usually Compatible With Both Pregnancy and Breast-Feeding • Local anesthetics including lidocaine , etidocaine , and prilocaine • Penicillins- 250mg/500mg(Every 8 hours) • Clindamycin- 300/600mg(6 hrs) • Azithromycin- 250/500mg(OD) • Acyclovir • Prednisone 45 COHEN 10TH EDITION
- 46.
- 47. Antibiotic Dosage Tradename Brand name Cost AMOXICILLIN 250mg/500mg (Every 8 hours) AMOXIL 500 mg CAP. ZYDUS CADILA Rs32.5 (10 cap) AMOXIL250 mg CAP. ZYDUS CADILA Rs20 (10 cap) NOVAMOX 500 mg CAP. CIPLA Rs105.68 (15 cap) WYMOX 500 mg CAP. PFIZER LTD Rs147.0 (15 cap) BLUMOX 500 mg CAP. BLUE CROSS LAB. LTD Rs70.0 (10 cap) CIPMOX 500 mg CAP. CIPLA Rs105.81 (10 cap) 47
- 48. Antibiotic Dosage Tradename Brand name Cost Amoxicillin With lactobacillus spores 250mg/500mg (Every 8 hours) NOVAMOX LB 500 CAP CIPLA Rs116.5 (6 cap.) NOVAMOX LB 250 CAP CIPLA Rs57.62 (10 cap) Amoxicillin and clavulanic acid 500mg+125mg AMOXYCLAV 500/125MG TAB. ABBOTT INDIA LTD Rs51.25 (6 tab) MOXIKIND-CV 625 TAB. MANKIND PHARMA LTD Rs82.76 (6 tab) CIPMOX CV 500/125 MG TAB. CIPLA LTD Rs79.68 (6 tab) AUGMENTIN 625 DUO TAB GSK Rs259.73 (10 tab) Amoxicillin and cloxacillin 250mg+250mg/ 125mg+125mg NATACLOX 250 MG CAP SUN PHARMA Rs31.37 (10 cap) 48
- 49. Antibiotic Dosage Tradename Brand name Cost CEFADROXIL 125mg/250mg/ 500mg (every 12 hrs) ODOXIL DT-250 LUPIN LTD Rs26 (10 tab) CEFADUR 250MG TAB CIPLA LTD Rs 26.0 (10 tab) CEFOXID 250 MG TAB ALKEM LAB. LTD Rs153.05 (10 tab) CEFUROXIME 125 mg (every 12 hrs) CEFAKIND 125MG TAB MANKIND PHARMA LTA Rs69.0 (10 tab) CEFIXIME 200mg (bid) TAXIM O 400MG TAB ALKEM LAB LTD Rs345 (10 tab) CEFIX 400MG CIPLA LTD Rs115.57 (4 tab) CLINDAMYCIN 300/600mg(6 hrs) DALCINEX 300MG CAP CIPLA LTD Rs176.0 (10 cap) CLINDAMITE 300MG CAP MANKIND PHARMA LTD Rs143.0 (10 cap) 49
- 50. Antibiotic Dosage Tradename Brand name Cost TETRACYCLINE 500mg (every 8 hrs) RESTECLIN 500mg CAP ABBOTT INDIA LTD Rs16.9 (10 CAP) NICOCYCLINE 500mg CAP ABBOTT INDIA LTA Rs16.25 (10 CAP) ALCYCLIN 500 mg CAP ALEMBIC PHARMA LTD Rs17.71 (10 CAP) DOXYCYCLINE 100mg (every 12 hrs) NICODOXY 100 mg CAP ABBOTT INDIA LTD Rs9.57 (10CAP) DOXICIP 100 mg CAP CIPLA LTD Rs10.87 (10 CAP) TATRADOX 100mg CAP RANBAXY LAB LTD Rs41.02 (10 CAP) 50
- 51. Antibiotic Dosage Tradename Brand name Cost Ciprofloxacin 250-750 mg (twice daily) CIPROBID 500 TAB ZYDUS CADILA Rs42.05 (10 TAB) CIPRACT 250 mg TAB RANBAXY LAB LTD Rs13.0 (10 TAB) CIPLOX 250 mg TAB CIPLA LTD Rs24.46 (10 TAB) Ciprofloxacin + Tinidazole 500/600 mg (twice daily) CIFRAN CT 500 mg/600mg TAB RANBAXY LAB LTD Rs107.0 (10 TAB) 51 Antibiotic Dosage Trade name Brand name Cost METRONIDAZOLE 200-400mg (every 8 hrs) FLAGYL 200 mg TAB ABBOTT INDIA LTD Rs6.77 (10 TAB) METROGYL 200 mg TAB JB CHEMICAL Rs6.77 (10 TAB)
- 52. 52 Good Morning MOHD.SIBGHATULLAH KHATIB 1STYEAR PG STUDENT
- 53.
- 54. RESPONSIBLE USE OFANTIBIOTICS IN ENDODONTIC THERAPY 54
- 55. LOCAL DRUG DELIVERY •Bacteria located inside dentinal tubules are protected from host defence cells, systemic antibiotics and chemomechanical preparation. • Therefore, endodontic medicaments must be able to penetrate into dentinal tubules and kill bacteria within them. 55 Australian Dental Journal Endodontic Supplement 2007;52:1.
- 56. Grossman Polyantibiotic Paste Tetracycline Ledermix SeptomixineForte MTAD Tetraclean Triple antibiotic Paste Clindamycin Odontopaste 56 LOCAL DRUG DELIVERY
- 57. Grossmann Poly AntibioticPaste • The first reported local use of an antibiotic in endodontic treatment was in 1951 • When Grossman used a polyantibiotic paste known as PBSC (penicillin, bacitracin, streptomycin, and caprylate sodium). Australian Dental Journal Endodontic supplement :2007 57
- 58. • All compoundswere all suspended in a silicone vehicle. • The composition was ineffective against anaerobic species 58 Australian Dental Journal Endodontic Supplement 2007;52:1. Penicillin Gram-positive organisms Bacitracin For penicillin-resistant strains Streptomycin Gram-negative organisms Caprylate sodium Yeasts
- 59. Septomixine Forte • Containstwo antibiotics – Neomycin Polymixin B sulphate 59 Gram-negative bacilli Neomycin X Bacteroides , fungi Gram-positive bacteria Polymyxin B sulphate International Journal of Pharmacy and Pharmaceutical Sciences Vol 6, Issue 3, 2014
- 60. Ledermix paste TRIAMCINOLONE • Anti-inflammatoryaction • Concentration of 1.0% • Inhibits clastic cells (osteoclasts, cementoclasts and dentinoclasts) DEMECLOCYCLINE • Anti microbial action • concentration of 3.21% 60 Australian Dental Journal Endodontic supplement :2007
- 61. • Ledermix: Effective inpreventing inflammatory resorption in avulsed teeth Pain management Australian Dental Journal Endodontic supplement :2007 61
- 62. Ledermix paste +Calcium hydroxide An intracanal dressing Pulp necrosis and infection with incomplete root formation Perforations Inflammatory root resorption Inflammatory periapical bone resorption The treatment of large periapical radiolucent lesions 62 Australian Dental Journal Endodontic supplement :2007
- 63. TRIPLE ANTIBIOTIC PASTE •Metronidazole + Ciprofloxacin + Minocycline. • Used in - The revitalization regeneration procedures 63 COHEN 10TH EDITION
- 65. Avulsion Application in largeperiradicular lesion Application in primary teeth Root fracture 65
- 66. DISADVANTAGES It may causebacterial resistance. Use of minocycline can cause tooth discoloration 66 COHEN 10TH EDITION
- 67. TETRACYCLINES To removethe smear layer from instrumented root canal walls Irrigation of apical root-end cavities during periapical surgical procedures As intracanal medicaments Mohammadi etal: An update on the antibiotic-based root canal irrigation solutions:IEJ 2008
- 68. MTAD • COMPOSITION- 3% Doxycyclinehyclate + 4.25% Citric acid+0.5% Polysorbate-80 (Tween 80) detergent. 68 COHEN 10TH EDITION
- 69. • MTAD iscapable of Removing the smear layer Disinfecting the root canal system. • Commercially available as BioPure MTAD 69 COHEN 10TH EDITION
- 70. • Tetraclean isanother combination product similar to MTAD. • The use of tetraclean was able to reduce 90% bacteric load after 5 minutes and 99.9% after 30 minutes of application. 70 MTAD TETRACLEAN DOXYCYCLINE 150mg/5ml 50mg/5ml Tween 80 Polypropylene glycol JOE-2007 COHEN 10TH EDITION
- 71. MTAD has bestantibacterial efficiency against E faecalis when compared to 2.5% Sodium Hypochlorite and 2% Chlorhexidine. MTAD was effective in killing E. faecalis up to 200 x dilution whereas NaOCl ceased to exert its antibacterial activity beyond 32 x dilution Torabinejad et al. (2003) 71 Journal of Dental and Medical SciencesVolume 5, Issue 3 (Mar.- Apr. 2013), PP 47-53
- 72. ODONTOPASTE • Zinc oxide-basedendodontic dressing • COMPOSITION Clindamycin hydrochloride- 5% Triamcinolone acetonide - 1% Calcium hydroxide- < 0.5% 72
- 73. Odontopaste is themost effective against Enterococcus faecalis. Propolis is partially effective against Candida albicans. 73 Journal of International Dental and Medical Research Volume ∙ 5 ∙ Number ∙ 1 ∙ 2012
- 74. BioPure (MTAD) iseffective in removing the smear layer. Ledermix help to reduce the periapical inflammatory reaction including clastic-cell mediated resorption. Clindamycin alone or in an ethylene vinyl acetate (EVA) vehicle can reduce the bacterial load inside the root canal system 74 International Endodontic Journal 2009
- 75. • The localapplication of antibiotics may be a more effective than systemic routes. • Tetracyclines – remove the smear layer from instrumented root canal walls for irrigation of apical root-end cavities during periapical surgical procedures intracanal medicament • Substantivity of tetracyclines has been shown for up to at least 12 weeks. • BioPure (MTAD) is effective in removing the smear layer. • Substantivity of MTAD has been shown to last for up to 4 weeks. 75 International Endodontic Journal 2009
- 76. YEA, BUT DOTHEY REALLY KILL THE BUGS? 76
- 77. Acquired resistance toPENICILLIN • Resistance to penicillin is usually by three mechanisms. Decreased bacterial cell wall penetration, Inability to bind to the penicillin binding proteins, Production of ß-lactamase. 77 JOURNAL OF ENDODONTICS, JANUARY 2003
- 78. Beta-lactamase production 78 • Black-pigmentedPrevotella • Nonpigmented Prevotella species • F. nucleatum, • P. acnes, • Actinomyces species, • Peptostreptococcus species • Capnocytophaga • Neisseria species COHEN 10TH EDITION
- 79. • Amoxicillin’s broadspectrum is more than is required for endodontic needs, and its use in a healthy individual may contribute to the global antibiotic resistance problem. 79 JAC 2013 Resistance Drugs F. nucleatum Penicillin, amoxicillin, and metronidazole P. intermedia Tetracycline and amoxicillin A. actinomycetemcomitans Amoxicillin and azithromycin Fusobacterium and nonpigmented Prevotella species Macrolides (erythromycin and azithromycin)
- 80.
- 81. MYTHS Antibiotics cure patients. Antibioticsare substitutes for surgical intervention. The most important decision is which antibiotic to use. Antibiotics increase the host’s defense to infection. 81 American Association of Endodontists, 2012
- 82. Multiple antibiotics aresuperior to a single antibiotic. Bactericidal agents are always superior to bacteriostatic agents. Antibiotic dosages, dosing intervals and duration of therapy are established for most infections. Bacterial infections require a “complete course” of antibiotic therapy. 82 MYTHS American Association of Endodontists, 2012
- 83. CONCLUSION • To sumup, the risk/benefit ratio should be always weighed before prescribing antibiotics. • Appropriately selected patients will benefit from systemically administered antibiotics. • A restrictive and conservative use of antibiotics is highly recommended in endodontic practice, but indiscriminate use is contrary to sound clinical practice • Future generations will thank us for today’s conscientious and judicious use of antibiotics. 83
- 84. REFERENCES • Cohen 10thedition • Tripathi 6TH EDITION • Lippincotts pharmacology 5th edition • Ingles endodontics - 6th ed. • Siquiera jr et al : update endodontic microbiology 2008 • Asian pac J trop biomed 2012; 2(9): 749-754 • J antimicrob chemother 2014 • American association of endodontists 2006 • International endodontic journal 2009 84
- 85. • JADA, vol.131, march 2000 • American heart association, 2007; 116: 1736-1754 • Australian dental journal endodontic supplement 2007;52:1 • American association of endodontics 2012 • Journal of International Dental and Medical Research Volume 5 Number 2012 • ADA council 1997 • Journal of dental and medical sciencesvolume 5, issue 3 (mar.- Apr. 2013), pp 47-53 • Journal of endodontics, january 2003 • International Journal of Pharmacy and Pharmaceutical Sciences Vol 6, Issue 3, 2014 85 REFERENCES
- 86.