doi:10.1111/iej.
12823
Antibiotic prescription for endodontic infections: a
survey of Brazilian Endodontists
M. R. Bolfoni1, F. G. Pappen1 , T. Pereira-Cenci1
1
Graduate Program in Dentistry, Federal University of Pelotas/UFPel, Pelotas; and 2Department of Restorative Dentistry, School
of Dentistry, S~ao Paulo State University (Unesp), Aracßatuba, Brazil
Abstract
Bolfoni MR, Pappen FG, Pereira-Cenci T, Jacinto
RC. Antibiotic prescription for endodontic infections: a
survey of Brazilian Endodontists. International Endodontic
Journal, 51, 148–156, 2018.
Aim To investigate antibiotic prescribing habits
reported by Brazilian endodontists in specific clinical
situations.
Methodology Brazilian endodontists (n = 13 853)
were invited to answer an online questionnaire.
The questionnaire consisted of two parts: the first
part contained personal data such as age, gender,
years of experience and location of endodontic prac-
tice; the second part included questions regarding
their behaviour when prescribing antibiotics in den-
tal practice. The subjects provided their registration
number in the Regional Council of Dentistry (RCD)
to prevent duplication of data. Data were collected
and analysed by SPSS 17.0 (SPSS, Inc., Chicago,
IL, USA). Chi-square and Fisher’s exact tests were
used to test the significance of possible associations
(P < 0.05).
Introduction
Antimicrobial resistance is the ability of a microor-
ganism to withstand the effect of antibiotics (Rodri-
nez et al. 2009, Segura-Egea et al. 2010),
guez-Nu~
which may occur due to certain bacterial species
Correspondence: Fernanda Geraldo Pappen, Graduate Pro-
gram in Dentistry, Faculty of Dentistry, Federal University of
Pelotas, RS, Brazil – Goncßalves Chaves, 457/507, Pelotas,
RS, CEP: 96015-560, Brazil (e-mail: ferpappen@yahoo.
com.br).
148 International Endodontic Journal, 51, 148–156, 2018
& R. C. Jacinto2
Results From the 13 853 questionnaires, a total of
615 were answered (4.44%). The first-choice antibi-
otic was amoxicillin (81.5%), followed by amoxi-
cillin + clavulanic acid (30.7%). For acute apical
abscesses with intra- and extraoral diffuse swelling,
fever and trismus, 90.1% reported they would pre-
scribe antibiotics, whilst 88.1% reported they would
prescribe antibiotics even without extraoral swelling,
fever and trismus, and 20.5% would prescribe antibi-
otics in cases of chronic apical periodontitis, and sinus
tract. The first-choice antibiotics varied by age of den-
tist (P < 0.001) and time elapsed since their endodon-
tic graduation (P = 0.001).
Conclusions Many endodontists reported prescrib-
ing antibiotics in situations where they would not be
indicated. Likewise, the general administration of
antibiotics was longer in duration than necessary,
reinforcing the need of continuous education regard-
ing the use of antibiotics.
Keywords: antibiotics, endodontic infections, pre-
scription habits, questionnaire.
Received 21 September 2016; accepted 20 July 2017
developing resistance to antibacterial agents shortly
after they are used (Jacinto et al. 2008). Moreover,
inappropriate prescription and use of antibiotics have
been identified as major factors in the emergence of
antibiotic resistance (Segura-Egea et al. 2010, Eur-
opean Society of Endodontology 2018).
In endodontics, it is recommended that antibiotics
should be used only as an adjunct to definitive non-
surgical or surgical endodontic therapy (Rodriguez-
Nu~ nez et al. 2009). Antibiotic therapy should be
reserved for patients who have systemic signs and
symptoms associated with endodontic infections,
patients with progressive infections or patients who
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

are immunocompromised (Jacinto et al. 2008, Eur-
opean Society of Endodontology 2018). Consequences
of resistance are higher treatment costs, longer hospi-
tal care time, health complications, mortality and
ineffectiveness of antibiotics. This problem has empha-
sized the need for rationalization of antibiotic use in
treatment of infections (Palmer et al. 2001, Kaptan
et al. 2013).
In Brazil, antibiotics could be bought without
prescription until 2010, when a government reso-
lution (RDC 44/2010) determined that antibiotics
could only be acquired with prescription. Gomes
et al. (2011) observed that the antimicrobial resis-
tance of anaerobes isolated from primary endodon-
tic infections in a Brazilian population increased
throughout a period of 9 years. An increase in the
resistance to benzylpenicillin and clindamycin was
observed in this population, and erythromycin had
a decrease in its effectiveness against all species
analysed.
Surveys about general dental practitioners prescrib-
ing habits have raised awareness of the quality of pre-
scriptions. Whilst some surveys have emphasized that
dental prescriptions do not follow clinical guidelines,
other authors have concluded that there was a lack
of scientific information about appropriate and effec-
tive prescription (Palmer et al. 2001, Nabavizadeh
et al. 2011, Kaptan et al. 2013). However, there are
no reports regarding the antibiotic prescribing pat-
terns of Brazilian endodontists in the treatment of
endodontic infections. Hence, the aim of this study
was to investigate antibiotic prescribing patterns
related to endodontic treatment by endodontists in
Brazil.
Material and methods
The research was approved by the Research Ethics
Committee of Piracicaba Dental School, UNICAMP,
Universidade Estadual de Campinas (Piracicaba, SP,
Brazil (#066/2011). An online questionnaire was
sent to Brazilian endodontists through e-mail. The
mailing list of Brazilian endodontists (n = 13 853)
was obtained from the Endodontic Associations of
each Brazilian State. Questions were adapted from
previously published surveys (Yingling et al. 2002,
Mainjot et al. 2009, Segura-Egea et al. 2010, Skucait_e
et al. 2010, Kumar et al. 2013). Sample size calcula-
tion considered a confidence interval of 4%, confi-
dence level of 95%, resulting in a minimum sample
size of 575 (surveysystem.com).
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Bolfoni et al. Antibiotic prescribing in Brazil
The questionnaire was divided into two parts: the
first part was a register of personal data such as age,
gender, years of experience in endodontic practice,
location and (public or private) of dental practice; the
second part included questions regarding the beha-
viour of endodontists when prescribing antibiotics in
dental practice. After responding to the questionnaire,
the subjects were requested to provide their registra-
tion number in the Regional Council of Dentistry
(RCD) to prevent duplication of data. Before being
applied, the questionnaire was reviewed by the
endodontic faculty of Federal University of Pelotas
(Pelotas, RS, Brazil), for appropriateness and clarity
(Fig. 1).
Statistical analysis
Data were collected and analysed by SPSS 17.0
(SPSS, Inc., Chicago, IL, USA). Chi-square and Fish-
er’s exact tests were used to test the significance of
possible associations. A value of P < 0.05 was consid-
ered statistically significant.
Results
From the 13 853 questionnaires sent, a total of 615
were answered (4.44%). The mean age of respondents
was 38.5 years. Twenty-six per cent of respondents
were less than 30 years old, and 18% were more
than 45 years old. Female respondents accounted for
58% (357) and males 42% (258) of the total. Most
respondents had graduated in endodontics in the last
10 years (68.5%).
The percentage of respondents by regions of Brazil
was 142 (23.1%) from the south, 236 (38.4%) from
the south-east, 96 (15.6%) from the north-east, 74
(12%) from the mid-west, 50 (8.1%) from the North
and 17 (2.8%) from the Federal District. Regarding
clinical practice, most respondents worked only in pri-
vate practice (60.2%); whilst 3.3% worked exclusively
in public practice. A total of 114 respondents (18.5%)
taught in undergraduate or postgraduate courses.
Most endodontists confirmed they would prescribe
antibiotics for 7 days (67.5%) (Table 1), and there
was an association between duration of antibiotic pre-
scription and the age of the endodontist (P = 0.014)
as well as the time elapsed since the completion of
endodontic graduation (P = 0.011). Most of respon-
dents (83.5%) chose amoxicillin as the first-choice
antibiotics for nonallergic patients, followed by amoxi-
cillin and clavulanic acid in combination (9.1%).
International Endodontic Journal, 51, 148–156, 2018 149
 Antibiotic prescribing in Brazil Bolfoni et al.

Antibiotic prescription in endodontic infections: survey with Brazilian Endodontists

Gender: ( ) Female ( ) Male

Year of birth -- Select --
When did you complete your Endodontic graduation course? -- Select --
In which Brazilian state do you live? -- Select --
Where is your dental practice located?

( ) Private Practice ( ) Teaching – Undergraduation course

( ) Public Practice ( ) Teaching – Graduation course

Which one is your first choice antibiotics for non-allergic-patients? Which is your second choice antibiotics for these
patients? (Mark #1 for your first choice and #2 for your second choice). Which are your choices for allergic
patients? Mark #3 for your first choice and #4 for your second choice.

( ) Amoxicillin ( ) Cefalexyn ( ) Metronidazole

( ) Amoxicilin with Clavulanic acid ( ) Ciprofloxacin ( ) Penicillin

( ) Ampicillin ( ) Clarithromycin ( ) Tetracycline

( ) Azithromycin ( ) Clindamycin ( ) Others

( ) Cefaclor ( ) Erythromycin

When you prescribe antibiotics, how long is the duration of treatment?

( ) 3 days ( ) 10 days

( ) 5 days ( ) Until symptoms disappear

( ) 7 days

Ocasionally, do you use a loading dose when you prescribe antibiotics?

( ) No ( ) Yes, a loading dose of three times the maintenance dose

( ) Yes, in the maintenance dose ( ) Yes, a loading dose of four times the maintenance dose

( ) Yes, a loading dose of twice the maintenance dose

In which situations do you prescribe antibiotics? * More than one answer is allowed (use checkboxes)

( ) Irreversible pulpitis
( ) Irreversible pulpitis with acute apical periodontitis
( ) Necrotic pulp with acute apical periodontitis; no swelling, with pain
( ) Necrotic pulp with chronic apical periodontitis; with fistula; no pain
( ) Acute apical abscess; located intraoral swelling, with pain
( ) Acute apical abscess; diffuse intraoral swelling, fever and trism
( ) Acute apical abscess; diffuse intraoral and extraoral swelling, fever and trism
( ) Post-operative pain
( ) Endodontic retreatment
( ) Perforation
( ) Root-end surgery

Figure 1 Questionnaire sent to Brazilian endodontists.

150 International Endodontic Journal, 51, 148–156, 2018 © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Bolfoni et al. Antibiotic prescribing in Brazil

Azithromycin was prescribed as the first-choice antibi-
otic by 2.3% of respondents (Table 2). Amoxicillin
and clavulanic acid combination was cited by 30.9%
of respondents as the second-choice antibiotics, fol-
lowed by azithromycin (23.9%) and metronidazole
(14.5%) (Table 3). The first-choice antibiotics varied
in accordance with professional age (P < 0.001) and
time elapsed since the completion of endodontic grad-
uation (P = 0.001). The age of the endodontist was
also associated with the second choice for antibiotic
prescription (P = 0.05). However, there was no asso-
ciation between the endodontic graduation year and
the second choice of antibiotics (P = 0.101). Half of
the professionals used a loading dose and 36% used
twice the regular concentration, 1 h before treatment.
The first drug of choice for patients with allergy to
penicillin was clindamycin (33.0%), followed by azi-
thromycin (29.2%), erythromycin (15.7%), cepha-
lexin (9.4%) and metronidazole (4.5%).

Table 1 Treatment duration frequently recommended by Brazilian endodontists and its association with respondents’ age and
time since the end of endodontic graduation course

Until
symptoms
disappear n (%) 7 days n (%) 3 days n (%) 5 days n (%) 10 days n (%) P value

Age
25–30 9 (5.5) 119 (72.6) 11 (6.7) 19 (11.6) 6 (3.7) 0.014
31–45 18 (5.3) 236 (69.8) 18 (5.3) 50 (14.8) 16 (4.7)
>45 years 11 (9.9) 61 (55.0) 3 (2.7) 25 (22.5) 11 (9.9)
Total 38 (6.2) 416 (67.9) 32 (5.2) 94 (15.3) 33 (5.4)
Endodontic graduation
≤10 years ago 20 (4.8) 302 (71.9) 23 (5.5) 55 (13.1) 20 (4.8) 0.011
>10 years ago 18 (9.3) 114 (59.1) 9 (4.7) 39 (20.2) 13 (6.7)
Total 38 (6.2) 416 (67.9) 32 (5.2) 94 (15.3) 33 (5.4)

Table 2 First-choice antibiotics prescribed by Brazilian endodontists to patients’ nonallergic to penicillin

Amoxicillin with
Amoxicillin Azithromycin clavulanic acid Others P value

Age
25–30 148 (90,2) 5 (3.0) 6 (3.7) 5 (3.0) <0.001
31–45 292 (85.9) 5 (1.5) 28 (8.2) 15 (4.4)
>45 years 71 (64.0) 4 (3.6) 22 (19.8) 14 (12.6)
Total 511 (83.1) 14 (2.3) 56 (9.1) 34 (5.5)
Endodontic graduation
≤10 years 369 (87.6) 8 (1.9) 27 (6.4) 17 (4.0) 0.001
>10 years 142 (73.2) 6 (3.1) 29 (14.9) 17 (8.8)
Total 511 (83.1) 14 (2.3) 56 (9.1) 34 (5.5)

Table 3 Second-choice antibiotics prescribed by Brazilian endodontists to patients nonallergic to penicillin

Amoxicillin with
clavulanic acid Azithromycin Metronidazole Amoxicillin Cephalexin Clindamycin Others P value

Age
25–30 43 (26.4) 41 (25.2) 34 (20.9) 12 (7.4) 16 (9.8) 12 (7.4) 5 (3.1) 0.005
31–45 119 (35.2) 78 (23.1) 43 (12.7) 39 (11.5) 24 (7.1) 18 (5.3) 17 (5.0)
>45 years 27 (24.3) 27 (24.3) 12 (10.8) 13 (11.7) 10 (9.0) 7 (6.3) 15 (13.5)
Total 189 (30.9) 146 (23.9) 89 (45.5) 64 (10.5) 50 (8.2) 37 (6.0) 37 (6.0)
Endodontic graduation
≤10 years 123 (29.4) 103 (24.6) 70 (16.7) 41 (9.8) 34 (8.1) 28 (6.7) 20 (4.8) 0.101
>10 years 66 (34.2) 43 (22.6) 19 (9.8) 23 (11.9) 16 (8.3) 9 (4.7) 17 (8.8)
Total 189 (30.9) 146 (23.9) 89 (14.5) 64 (10.5) 50 (8.2) 37 (6.0) 37 (6.0)

© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 51, 148–156, 2018 151
 Antibiotic prescribing in Brazil Bolfoni et al.

Table 4 Number and percentage of positive response for prescribing antibiotics in specific situations

Age Endodontic graduation

Clinical situation Total 20–35 36–45 >45 P value ≤10 years >10 years P value

Irreversible pulpitis 7 (1.1) 4 (2.4) 1 (0.3) 2 (1.8) 0.424 5 (1.2) 2 (1.0) 1.000
Irreversible pulpitis with acute 38 (6.2) 10 (6.1) 18 (5.3) 10 (9.0) 0.369 27 (6.4) 11 (5.7) 0.857
apical periodontitis
Necrotic pulp with acute apical 71 (11.5) 15 (9.1) 39 (11.5) 17 (15.3) 0.291 43 (10.2) 28 (14.4) 0.136
periodontitis; no swelling, with
pain
Necrotic pulp with chronic apical 126 (20.5) 37 (22.6) 69 (20.3) 20 (18.0) 0.652 96 (22.8) 30 (15.5) 0.036
periodontitis; with fistula; no pain
Acute apical abscess; located 440 (71.5) 124 (75.6) 232 (68.2) 84 (75.7) 0.129 308 (73.2) 132 (68.0) 0.211
intraoral swelling, with pain
Acute apical abscess; diffuse 541 (88.1) 146 (89.0) 294 (86.7) 101 (91.0) 0.443 371 (88.1) 170 (88.1) 1.000
intraoral swelling, fever and
trismus
Acute apical abscess; diffuse 554 (90.1) 150 (91.5) 302 (88.8) 102 (91.9) 0.507 383 (91.0) 171 (88.1) 0.310
intraoral and extraoral swelling,
fever and trism
Postoperative pain 30 (4.9) 11 (6.7) 17 (5.0) 2 (1.8) 0.178 23 (5.4) 7 (3.6) 0.321
Endodontic Retreatment 35 (5.7) 11 (6.7) 18 (5.3) 6 (5.4) 0.806 26 (6.2) 9 (4.6) 0.575
Perforation 48 (7.8) 20 (12.2) 24 (7.1) 4 (3.6) 0.025 42 (10.0) 6 (3.1) 0.003
Root-end surgery 277 (45.0) 87 (53.0) 148 (43.5) 42 (37.8) 0.032 202 (48.0) 75 (38.7) 0.036

Table 4 lists the percentage of respondents who
prescribed antibiotics for various clinical situations.
For acute apical abscesses with intra- and extraoral
diffuse swelling, fever and trismus, 90.1% reported to
prescribe antibiotics, whilst 88.1% prescribed antibi-
otics in cases of acute apical abscesses with diffuse
intraoral swelling, fever and trismus. Even in cases of
acute apical abscesses with localized intraoral swel-
ling, without fever and trismus, 71.5% of respondents
prescribed antibiotics. A total of 20.5% of the
endodontists prescribed antibiotics in cases of chronic
apical periodontitis and fistula. Also, younger
endodontists prescribed antibiotics more frequently
than older endodontists in cases of necrotic pulp with
chronic apical periodontitis, with fistula and no pain
(P = 0.036). The prescription of antibiotics in cases of
perforation and root-end surgery was reported by
7.8% and 45% of respondents, respectively. The
respondents’ age and time elapsed since graduation
were associated with the prescription of antibiotics
after root canal perforation and after root-end surgery
(P < 0.05).
Discussion
The present observational study based in question-
naires answered by 615 professionals investigated the
habits of endodontists from Brazil in prescribing
antibiotics. Studies using a similar questionnaire in
different countries obtained 158, 589 and 552
responses (Rodriguez-Nu~ nez et al. 2009, Kaptan et al.
2013, Garg et al. 2014). An online questionnaire was
prepared with questions adapted from previously pub-
lished surveys (Yingling et al. 2002, Mainjot et al.
2009, Segura-Egea et al. 2010, Skucait_e et al. 2010,
Kumar et al. 2013). This is the first study to investi-
gate antibiotic prescribing habits of endodontists in
Brazil, and responses from all regions of the country
were obtained.
Although this is one of the few reports regarding
antibiotic prescribing patterns in the treatment of
endodontic infections, there are important limitations
of this type of study; as with all questionnaire-based
surveys, there is the risk in relation to the consistency
of responses and the problem of nonresponse bias.
Thus, caution must be applied in interpreting the
results, as there is the potential for those who pre-
scribe antibiotics differently to have not responded
(nonresponder bias). The study response rate should
be emphasized, considering that although low
response rates are common in surveys, response rates
higher than 80% are undoubtedly more reliable than
those found in the present study, with a response rate
of less than 10%. However, it is important to high-
light that two reminders were sent via e-mail as
described previously (Dillman et al. 2009).

152 International Endodontic Journal, 51, 148–156, 2018 © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

Unfortunately, there were no other possibilities to
encourage nonresponders to complete the survey,
especially considering the number of endodontists and
the continental size of Brazil.
Antibiotic resistance patterns might vary according
to geographic locations. Zadik & Levin (2008) evalu-
ated the influence of geographic locations (Israel,
Eastern Europe, Latin America) on decision-making
regarding management of dental caries, periapical
lesions and antibiotic prescribing routines. Latin
American graduates prescribed more antibiotics fol-
lowing endodontic treatment and retreatment.
Castilho et al. (1999) carried out a survey in Brazil
analysing the prescription pattern of systemic medica-
tion by dentists and found that antibiotics were the
drugs most frequently prescribed by dentists in Brazil.
Bacterial resistance to antibiotics is a serious public
health problem. A major contributing factor for the
development of this problem is the excessive use of
antibiotics (Yingling et al. 2002, Gomes et al. 2011).
Among several reasons for the development and
spread of antimicrobial resistance, their overuse in
animal food production systems, where these agents
are growth promoters in cattle, poultry and hog farm-
ing, fish farming and honeybee hives is prominent.
Some estimates affirm that antibiotic use in animals is
at least 1000-fold greater in terms of absolute ton-
nage compared with the use in humans (World
Health Organization 2010, Chioro et al. 2015,
Lekshmi et al. 2017). In endodontics, antimicrobial
drugs are prescribed during treatment of specific clini-
cal situations related to acute apical infections as an
adjunct to local treatment. Evidence exists that the
resistance of oral microflora to antibiotics has
increased over the past decades (Gomes et al. 2011),
and both misuse and overuse of antibiotics in dental
practice have been observed (Kakoei et al. 2007,
Mainjot et al. 2009, Kumar et al. 2013).
Generally, b-lactam antibiotics are used as a first
option for treatment of endodontic infections. In the
present study, amoxicillin was the most prescribed
antibiotic for patients without allergy to penicillin,
corroborating studies performed in Lithuania
(Skucait_e et al. 2010) and Brazil (Castilho et al.
1999). Amoxicillin’s broad spectrum is more than is
required for endodontic needs. Therefore, the use of
amoxicillin should decrease as a function of increas-
ing the production of b-lactamase (Kuriyama et al.
2007, Montagner et al. 2014).
Penicillin V should be the antibiotic of choice to
treat acute infections (Fouad et al. 1996,
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Bolfoni et al. Antibiotic prescribing in Brazil
Baumgartner & Xia 2003), as it is effective against
aerobic and anaerobic bacteria, strict and facultative,
and have low toxicity. However, in Brazil, there is a
technical problem with this drug: it is marketed at a
concentration of 325 mg, and the necessary dose for
the treatment of oral infection is 500 mg, correspond-
ing to 1.5 tablets, increasing the cost of treatment.
Another difficulty is that to achieve stable blood levels
of the drug, to remain above the minimum inhibitory
concentration, it is necessary to administer it every
4–6 h, increasing the number of intakes, increasing
the cost and decreasing the compliance and comfort
of patients. For these reasons, penicillin V is not used
by Brazilian endodontists and was not cited as an
antibiotic option by the respondents, whilst 69% of
Americans had reported to prescribe penicillin as the
first choice, followed by amoxicillin at 28% (Yingling
et al. 2002).
The combination of amoxicillin and clavulanic acid
was considered to be the second antibiotic of choice
for patients without allergy to penicillin (30.9%). The
use of clavulanic acid is, normally, prescribed because
amoxicillin is susceptible to degradation by b-lacta-
mase producing bacteria. However, as the amoxicillin
and clavulanic acid combination is characterized by a
much broader spectrum of activity compared to peni-
cillin and amoxicillin, it carries a risk of the develop-
ment of bacterial resistance (Barcelona et al. 2008,
Montagner et al. 2014).
The first choice for patients allergic to penicillin was
clindamycin (33%), in contrast with the responses of
Spanish endodontists (63%) (Rodriguez-Nu~ nez et al.
2009). The second choice for patients with penicillin
allergy was azithromycin with 29.2%. Other antibi-
otics prescribed for this reason were erythromycin,
cephalexin and metronidazole. Erythromycin, a
macrolide, has similar activity spectrum to penicillin,
so it is also considered an option for patients allergic to
penicillin. Resistance to erythromycin has been
observed in species isolated from a Brazilian popula-
tion (Gomes et al. 2011). Another study demonstrated
that Fusobacterium and Prevotella strains had shown
resistance to azithromycin and erythromycin from
dentoalveolar infections (Kuriyama et al. 2007). This
drug was the most prescribed for penicillin-allergic
patients in studies conducted in India (Kumar et al.
2013, Garg et al. 2014) and also in Iran (Kakoei et al.
2007). Metronidazole is an effective antibiotic against
anaerobic bacteria, but not against facultative anaero-
bic or aerobic bacteria, so it needs to be used in associ-
ation with another agent (combination of antibacterial
International Endodontic Journal, 51, 148–156, 2018 153
 Antibiotic prescribing in Brazil Bolfoni et al.
agents) for chemotherapy of oral infections. If amoxi-
cillin is not effective after 2 or 3 days of administra-
tion, metronidazole is recommended as a
supplementary medication, which was the response of
40.5% of the participants, whilst this combination was
the first choice of antibiotic therapy for patients with
no history of medical allergies, followed by amoxicillin
alone in the study of Kumar et al. (2013).
The optimal dosage of antibiotics should be enough
to eliminate the pathogens, with minimal adverse
effects on the physiology of the host and microbial
ecology. As most oral bacterial infections have rapid
onset, there is no way to establish in a short time the
minimum inhibitory concentration of a particular
drug. Therefore, it is recommended to start treatment
with a loading dose, generally twice the maintenance
doses. In the present study, 50% of respondents use
loading dose, and 36% prescribed double the regular
concentration 1 h before treatment. The use of a
loading dose was reported by 85.14% of the members
of the American Association of Endodontists (Yingling
et al. 2002).
Acute oral infections have relatively rapid onset
and short duration when the cause of the infection is
eliminated, 2–7 days or less, particularly if the cause
is treated or eliminated. Brazilian endodontists often
prescribe antibiotics for 7 days (67.9%), whilst 20.5%
prescribed a shorter period. The average duration of
antibiotic therapy has been reported to be
4.8  2.1 days (Mainjot et al. 2009) and 4.26 
1.26 days (Garg et al. 2014), whilst in another study,
the average duration of antibiotic therapy was
7.58 days (Yingling et al. 2002). The ideal duration
of antibiotic treatment is the shortest capable of pre-
venting both clinical and microbiological relapse.
Most acute infections are resolved within 3–7 days
(Oberoi et al. 2015). Prescription of antibiotics should
be made initially for a 2-, 3- or 5-day period. A
higher serum concentration of the antibiotic in con-
tact with infected tissues might provide better results
than prolonged antimicrobial therapies. Also, short
duration of therapy reduces risk of antibiotic-induced
toxicity and/or allergy, and reduces risk of developing
resistant microorganisms. At the same time, use of
antibiotics with a wide spectrum of activity, which
could include many species of bacteria found else-
where in the body, also increases the risk of selecting
resistant bacteria outside the oral cavity (Baumgart-
ner & Xia 2003).
Before completing the 72 h of treatment, a
reassessment of the clinical picture should be made to
154 International Endodontic Journal, 51, 148–156, 2018
provide sufficient evidence that the patient host
defences have gained control of the infection. Based
on the signs and symptoms, the physician must deter-
mine whether to maintain or stop the antibiotic ther-
apy. When local treatment is successful, the duration
of treatment should not exceed 7 days (Jacinto et al.
2008). The prolonged use of antibiotics or an ineffec-
tive dose without the full coverage of the microbial
spectrum can contribute to the development of resis-
tant microbial species. If resistant species are already
present, it will not matter how long the antibiotic is
used; it will still be ineffective (Yingling et al. 2002).
In irreversible pulpitis with acute apical periodonti-
tis, the pulp remains vital; there is no infection or
signs and symptoms of systemic involvement; thus,
antibiotics are not indicated. Yet, 6.2% of the respon-
dents reported they would prescribe antibiotics in this
situation. Questionnaires also reported a low percent-
age for this situation in Lithuania (Skucait_e et al.
2010) and Belgium (Mainjot et al. 2009), whilst this
percentage was higher in studies carried out in
Kuwait (19.6%), Iran (80.6%) and India (71.6%)
(Salako et al. 2004, Nabavizadeh et al. 2011, Garg
et al. 2014). These differences might be related to the
fact that in the present study, only endodontists were
included in the sample, whilst in the other studies
(Salako et al. 2004, Nabavizadeh et al. 2011, Garg
et al. 2014) general practitioners were investigated. It
is important to point out that the administration of
antibiotics does not reduce pain, percussion pain or
the number of analgesic medications taken by
patients with untreated irreversible pulpitis (Nagle
et al. 2000). Therefore, antibiotics should not be pre-
scribed for this situation.
Asymptomatic cases of pulp necrosis with apical
periodontitis associated with sinus tract should be
treated by removal of the cause of the infection by
root canal treatment, with the aid of intracanal medi-
cation (Mittal & Gupta 2004, Wray 2011). In this
study, 20.5% of respondents prescribed antibiotics for
this situation corroborating to another report (11.9%)
(Yingling et al. 2002), with both studies conducted
among endodontic specialists. Conversely, a higher
percentage of antibiotic prescribing in those cases was
reported among general dentists – 58% (Nabavizadeh
et al. 2011) and 59.8% (Segura-Egea et al. 2010).
In cases of pulp necrosis and acute apical periodon-
titis, with pain but without swelling, 11.5% of the
respondents would prescribe antibiotics. However, the
recommended treatment for this situation is limited to
root canal treatment (Yingling et al. 2002). In cases
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

of endodontic abscesses, without local signs of infec-
tions spread, after root canal treatment, the host
defences should be able to control these infections
(Siqueira & R^oßcas 2013). Therefore, the use of antibi-
otics in addition to analgesics for pain and local
decontamination does not provide benefits to the
patient. However, if the patient was systemically com-
promised and the sinus tract did not close or the
patient experienced a flare up with systemic involve-
ment, then antibiotics would be indicated (Yingling
et al. 2002).
Antibiotic therapy should be reserved for cases
when signs such as cellulitis, lymphadenitis, limita-
tion of mouth opening, associated with symptoms
such as fever, loss of appetite and general malaise,
suggesting that the immune system of the patient is
not able to control the infection, which could dissemi-
nate to other regions, causing serious health problems
(Whitten et al. 1996, Siqueira & R^ oßcas 2013, Mon-
tagner et al. 2014). Most respondents indicated the
use of an antimicrobial for this situation, which is in
agreement with previous reports (Yingling et al.
2002, Rodriguez-Nu~ nez et al. 2009, Segura-Egea
et al. 2010).
Conclusions
A number of endodontists reported prescribing antibi-
otics in situations where they would not be indicated.
Younger endodontists prescribed antibiotics more fre-
quently in cases of perforation, root-end surgery and
necrotic pulps with chronic apical periodontitis, with
fistula and no pain, which could be explained by lack
of experience. Therefore, there is a need of further
education, as excessive and incorrect prescription of
antibiotics in endodontics contributes to the global
increase of microbial resistance. Likewise, the general
administration of antibiotics was longer than neces-
sary, reinforcing the need of continuous education
regarding the use of antibiotics.
Conflict of interest
The authors have stated explicitly that there are no
conflict of interests in connection with this article.
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