2019-2020 4.

Class

DRUGS
USED IN
ENDODONTICS
ASSOC.PROF.DR.UMUT AKSOY
 PAIN
 BEFORE TREATMENT
 DURING TREATMENT AND/OR

 AFTER TREATMENT
SWELLING

CLINICAL MANAGEMENT Systemic medication

ANTIBIOTICS
ANTIBIOTICS

¿WHEN?
ANTIBIOTICS

Treatment of an
infection in the Prophylaxis
periapical region

1 2
Treatment of an
infection in the
periapical region

Only Pain

Localized Swelling

Symptomatic pulpitis

Chronic apical abscess

draining from the sinus tract
Treatment of an
infection in the
periapical region
 In Endodontics,
 Antibiotics are only used as adjuncts to
treatment with
Root canal treatment + Drainage
 In the presence of clinical manifestations
suggesting the possibility of
Systemic spread of the infection
or
In the presence of widespread and
unhealed infections.
Treatment of an
infection in the
periapical region

SYSTEMIC SYMPTOMS
The presence of symptoms such as fever, chills, chills
within the last 24 hours

Malaise, tiredness, fatigue, dizziness, rapid breathing

Trismus

Lymphadenopathy

Cellulitis (Non-localized widespread infection in soft

tissues)
Treatment of an
infection in the
periapical region

Acute apical abscess

When acute apical abscess is associated with
diffuse swelling leading to develop cellulites with
infectious process dissemination to other anatomic
spaces, or when acute apical abscess exhibits
evidences of systemic involvement, such as fever,
malaise, regional lymphadenitis or trismus,
antibiotics are necessary as adjuvant treatment to
drainage because the patient’s immune system is
incapable of stopping the infection advance
Treatment of an
infection in the
periapical region
Treatment of an
infection in the
periapical region

Antibiotic treatment may

be applied in the case of
"flare-up", which defines
pain and swelling after root
canal treatment, in
accordance with the
criteria stated.
Treatment of an
infection in the
periapical region

Antibiotics are
necessary in severe
traumatic injury cases
and after the
replantation of the
avulsed teeth.
Treatment of an
infection in the
periapical region
Treatment of an
infection in the
periapical region
Actinomyces israelii

Another condition requiring systemic

antibiotic use is periapical
actinomycosis, which is a
persistent periapical infection. In
these cases, it is necessary to apply
apical surgery with penicillin
application.
Treatment of an
infection in the
periapical region

If the sodium hypochlorite solution used for

irrigation is delivered to the periapical region,
or if it is accidentally injected instead of the
anesthetic solution as a more serious
complication, antibiotics should be given to
prevent secondary infection of the tissues,
which is likely to become necrotic, in addition
to emergency procedures.
Treatment of an
infection in the
periapical region
ANTIBIOTICS

¿Which
Antibiotic?
Which Antibiotic?

Detection of microorganisms

The severity of the infection

General health status of the

patient

These factors should be evaluated together!!!

Which Antibiotic?

Endodontic infections are

polymicrobial and most of
the isolated microorganisms
are obligate or facultative
anaerobic bacteria
Which Antibiotic?

Spectrum of the
antimicrobial
activity
is the range of bacterial types
against which the antibiotic is
effective
Which Antibiotic?

Select the narrowest

spectrum antibiotic
sensitive to the causative
microorganism!!!
Which Antibiotic?

Ideally, pre-treatment
specimens should be taken
to identify the causative
microorganism by culture
and to give the appropriate
antibiotic according to the
susceptibility test result.
Which Antibiotic?

Takes several
days to
weeks

We know approximately
the microorganisms
found in endodontic
infections.
Which Antibiotic?

Empiric
selection of
an Antibiotic
Which Antibiotic?

Persistent Cultivation
Infections methods
Which Antibiotic?

Peferred
Antibiotics for
endodontic
infections
Preffered Antibiotics for
Endodontic Infections:

Penicillin V

Amoxicillin

Clarithromycin and Azithromycin

Metronidazole

Clindamycin
Preffered Antibiotics for
Endodontic Infections:
Penicillin V

Penicillin V is a narrow-spectrum antibiotic for

infections caused by aerobic gram-negative cocci,
facultative and anaerobic microorganisms

It can be a good first option for endodontic

infections due to its effectiveness and low toxicity.
However, there is a risk of allergy.
A loading dose of 1000 mg of penicillin V should be
administered orally followed by 500 mg every 6 h to
achieve a steady serum level.
Preffered Antibiotics for
Endodontic Infections:
Penicillin V
Preffered Antibiotics for
Endodontic Infections:
Amoxicillin

Amoxicillin is an analogue of penicillin that is rapidly

absorbed and has a longer half-life. This is reflected
in higher and more sustained serum levels than
penicillin V. Amoxicillin is often used for antibiotic
prophylaxis of patients that are medically
compromised. Amoxicillin may be used for serious
odontogenic infections, however, its extended
spectrum may select for additional resistant strains
of bacteria. The usual oral dosage for amoxicillin is
1,000 mg loading dose followed by 500 mg every
eight hours for five to seven days.
Preffered Antibiotics for
Endodontic Infections:
Amoxicillin

The combination of amoxicillin with clavulanic acid

is the most effective antibiotic combination.

Clavulanic acid and sulbactam are competitive

inhibitors of the betalactamase enzyme produced
by bacteria to inactivate penicillin.
Preffered Antibiotics for
Endodontic Infections:
Amoxicillin

Amoxicillin
Preffered Antibiotics for
Endodontic Infections:
Amoxicillin

Amoxicillin+Clavulanic acid
combinations
Preffered Antibiotics for
Endodontic Infections:
Ampicillin

Ampicillin+sulbactam
combinations
Preffered Antibiotics for
Endodontic Infections:
Azithromycin and Clarithromycin

These are macrolide antibiotics such as erythromycin.

However, unlike erythromycin, they are effective on some
anaerobic species seen in endodontic infections.
In the cases of penicillin allergy, Azithromycin or
clarithromycin should be preferred for moderate infections.
They less likely to cause gastrointestinal side-effects than
erythromycin.
The oral dosage for clarithromycin is a 500 mg loading dose
followed by 250 mg every 12 hours for five to seven days. The
oral dosage for azithromycin is a 500 mg loading dose
followed by 250 mg once a day for five to seven days.
Preffered Antibiotics for
Endodontic Infections:
Azithromycin and Clarithromycin

Clarithromycin
Preffered Antibiotics for
Endodontic Infections:
Azithromycin and Clarithromycin

Azithromycin
Preffered Antibiotics for
Endodontic Infections:
Metronidazole

Metronidazole is a synthetic antimicrobial agent that

is bactericidal and has activity against anaerobes,
but lacks activity against aerobes and facultative
anaerobes.
Metronidazole may be used in combination with
penicillin or clindamycin.
If a patient’s symptoms worsen 48-72 hours after initial
treatment and the prescription of either penicillin or
clindamycin, metronidazole may be added to the
original antibiotic.
Preffered Antibiotics for
Endodontic Infections:
Metronidazole

It is important that the patient continue to take

penicillin or clindamycin, which are effective against
the facultative bacteria and those resistant to
metronidazole.

The usual oral dosage for metronidazole is a 1,000 mg

loading dose followed by 500 mg every six hours for
five to seven days.
Preffered Antibiotics for
Endodontic Infections:
Metronidazole
Preffered Antibiotics for
Endodontic Infections:
Clindamycin

Clindamycin is effective against gram-positive facultative

microorganisms and anaerobes. Clindamycin is a good
choice if a patient is allergic to penicillin or a change in
antibiotic is indicated. Penicillin and clindamycin have
been shown to produce good results in treating
odontogenic infections.
The oral adult dosage for serious endodontic infections is a
600 mg loading dose followed by 300 mg every six hours
for five to seven days.
Preffered Antibiotics for
Endodontic Infections:
Clindamycin
ANTIBIOTICS

Treatment of an
infection in the Prophylaxis
periapical region

1 2
Prophylaxis

Manipulation of
gingival tissues
Transient
bacteremia due
Manuplation of the
periapical region
to Viridans
group
All dental streptococci
procedures
involving oral
mucosa perforation
Prophylaxis

Dental antibiotic prophylaxis is the

administration of antibiotics to a dental
patient for prevention of harmful
consequences of bacteremia, that may be
caused by invasion of the oral flora into an
injured gingival or peri-apical vessel during
dental treatment.
Prophylaxis

It is used to prevent the

development of complications
such as infective endocarditis or
post-surgical infection in
dentistry.
Prophylaxis
 Prophylaxis

 Recommended:
 All dental procedures that involve manipulation of
gingival tissue or the periapical region of teeth, or
perforation of the oral mucosa
 Surgical procedures
 Periodontal procedures
 Endodontic procedures
 Intraligamenter anesthesia
 Reimplantation of avulsed tooth
 Dental implant procedures
 Prophylaxis

 Not Recommended:
 Routine anesthetic injections through noninfected tissue
 Taking dental radiographs
 Placement of removable prosthodontics or orthodontic
appliances
 Placement orthodontic brackets
 Shedding of decidious teeth
 Post placement
Prophylaxis
Prophylaxis

If several sessions are required, and if the practitioner uses

antibiotic prophylaxis, the sessions must be scheduled at
least 10 days apart if possible

A single prophylaxis can be planned for various dental

procedures within 6 hours.

If a prophylactic antibiotic was not administered by

mistake in a patient in need of treatment, the same dose
can be administered up to 2 hours after the procedure.

For patients who are taking antibiotics for another reason,

they should be taken with another class of antibiotics
before treatment (such as clindamycin if taking penicillin).
Analgesics
FIRST INTERVENTION

Should be directed to the source of the pain

DENTOALVEOLAR
ACUTE PULPITIS
ABSCESS

EXTIRPATION OF DENTAL PULP

DRAINAGE

OR ETRACTION OF THE TOOTH

Use of Analgesics

 Usually for postoperative pain

3D Approach for
Treating Acute Pain

DIAGNOSE
DEFINITIVE TREATMENT
DRUGS
Which Analgesics?

Narcotic
Non-narcotic
Which Analgesics?
Narcotic
Influences the central nervous system

Psychological and physical dependency characteristics.

Exp: Codein

Not Used in Dentistry Practice

Which Analgesics?

Non-narcotic
Most of the drugs in this group have both antipyretic
and antiinflammatory properties at the same time.

The most preferred drug group is non-steroidal

analgesic and anti-inflammatory drugs.
(NSAIDs).
NSAIDs
 NSAIDs inhibit the synthesis of prostaglandins
 Prostaglandin is the most important hyperalgesic
and inflammatory mediator
 Cyclooxygenase is the enzyme that mediates the
formation of prostoglandins (COX).
 NSAID inhibits the prostoglandin synthesis by
inhibiting the enzyme cyclooxygenase (COX).
PARACETAMOL

 Acetaminophen (Paracetamol):
 Unlike NSAIDs, the antiinflammatory
effect of acetaminophen is very weak.
 The antiinflammatory effect is minimal,
but it is safer in terms of side effects
 To be selected in cases where NSAIDs
are contraindicated
Paracetamol

is generally considered
safe during pregnancy
and while breastfeeding