B;, Ih Paul F Ahbolt, Endodontist. 3 Wesllc;, .benuc. Iwnhw. 1ictoria.
3079
Mnior Fello~.School ol' lkntal Scicncc. 'I'hc Ilniwrsitj of Hclbourne
Selective And Intelligent Use Of
Antibiotics In Endodontics
Editor's Note:
Based on a lecture presented to the Australian
Society of Endodontology (Victorian Branch) on 18th
August 1999.
Abstract
Antibiotics have been used extensively for the
management of odontogenic infections since their
discovery early this century. Although they have been
invaluable in the management of acute and severe
infections, many members of the dental and medical
professions have unfortunately used these drugs
inappropriately for the management of dental pain
when "local" dental treatment would have sufficed.
This. and the general over-use of antibiotics in other
situations such as for growth enhancement in animals
for human consumption, is leading to the widespread
development of strains of bacteria that are resistant
to antibiotics - hence, their effectiveness is being
reduced at a rapid rate. The dental profession has a
responsibility to patients and to the community as a
whole to restrict the use of antibiotics to those
situations that actually require them. This philosophy
should also be extended to other professions who
may be called upon to manage dental pain at times.
Introduction
Antibiotics have been an extremely valuable addition to the
armamentarium available to health practitioners for the
management of bacterial infections There is no doubt that they
have often been used to save lives that would otherwise have been
lost if antibiotics had not been available However. the general
public have unfortunately developed high. and often unrealistic.
expectations about when and why antibiotics should be used The
health professions have also been guilty of this. which has led to the
over-use, ma-use and abuse of these drugs during the last few
decades ( I , 2). The purpose of this review is to outline some of the
problems associated with the incorrect use of antibiotics and to
demonstrate situations where antibiotics should be used as an
adjunct to enddontic treatment
History
Antibiotics were first discovered in 1928 but they were not
routinely used clinically until the early 1940s during the Second
t0
World War Prior to this. most wartime deaths were due to
bacterial infection of wounds. rather thdn the wounds themselves
The use of antibiotics was popularised as a result of the rapid
recoveiy of wounded militaiy personnel and this populmty
continued after the end of the war ( I ) Initially. these drugs were
used in a relatively unconti-olled manner as few countries had any
government regulations controlling them and prescriptions were
not required Antibiotics could be purchased as "over the counter"
medication. a situation that still applies in many countries tday
especially in South East Asia
Antibiotics were labelled as "miracle drugs"- and after about 10
years of this uncontrolled use. the medical profession began to
become aware of some of the problems associated with their over-
use Patients would often demand antibiotics for all types Of
infections. including viruses such as the common cold and influenza
unfortunately. it was common for practitioners to succumb to
these demands (I) Antibiotics were also often prescribed for the
"prevention" of post-surgical infections. even though there was no
scientific evidence to support this use and in spite of evidence of an
increase in the frequency of infections when they were used in this
way. particularly in hospital settings
In the late 1960's. there was a euphoric perception that humans
had conquered bacteria and in 1969 the Surgeon General of the
United States of America told their Congress that it was "time to
close the book on infectious diseases" ( I ) This statement has had
dramatic long-term consequences as the US Government
drastically reduced its funding for research and development of new
antibiotics in the late 1970's Since then. little research has been
conducted and very few new antibiotics have been developed as
the commercial pharmaceutical companies turned their attention to
developing drugs to manage other diseases. In addition. infectious
disease research attention turned to viruses. such as the life
threatening HIV and Ebola viruses. during the 1980s ( I ).
Now. in the late 1990s. there are about I 58 antibiotics available
for human therapeutic use but no new antibiotics are being
developed (3) It is simply too expensive and takes too long for
commercial companies to undertake this work without government
subsidies.
Non-Medical 1Jse Of Antibiotics
In addition to their therapeutic use in humans, antibiotics are also
widely used in veterinary practice to control infections in animals
This has an indirect effect of further, and regularly. exposing humans
to antibiotics in addition to the problems associated with the
development of resistant strains of bacteria in the animals ( I ).
Antibiotics are also used in the human food chain because one of
their side effects (especially with chlortetracycline and penicillin) is
the ability to enhance growth of animals Initiallyonly small amounts
were needed and this use was classified as being "nutritional". rather
than "therapeutic" Hence, the direct sale of antibiotics was allowed
to farmers for animal feed, particularly for cattle. pigs. lambs and
A U S T W I A N ENDODONTICIOURNAL VOLUME 26 No I APRIL 2000
poultry It has been estimated that up to I7 million pounds (about
8 million kilograms) of antibiotics are used every yeai in the USA for
this purpose ( I)
As a result of the long-term use of low doses of antibiotics. their
effectiveness as growth enhancers is reducing and therefore higher
doses are required to achieve the same effect Over several
decades. this has become dramatic with up to 10-20times more
antibiotic now being required for the same growth effect as that
achieved in the 1950's (I) An alarming fact is that this dose is
approaching the therdpeutic doses required for treating bacterial
infections. which will have futther effects on the development of
resistant strains and thus further reduce the effectiveness of these
drugs ( I ) Fortunately. most western European countries now ban
antibiotics for growth enhancement in animals but many countries.
including the USA, have yet to do likewise
The non-medical use of antibiotics in the human food chain is
significant because the small amounts used for months and even
years promotes the dcvelopment of bacterial resistance Resistant
strains. resistant genes and small doses of the antibiotics pass from
animals to humans through ndtural processes either directly by
human ingestion of animal meat. or indirectly &cause animal
matter is used as fertiliser for food crops and these ale subsequently
eaten by other animals and humans ( I ) Agricultural ( rops and fruit
trees are often sprayed with antibiotics to protect them from
bacterial diseases (4) and. because humans eat food crops even
people who nevei eat meat are being regularly exposed to small
doses of antibiotics. resistant strains of bacteria and the resistant
genes ( I . 4)
Bacterial Resistance
Since the introduction of antibiotics. bacterid have been
developing resistant strains and genes Initially this was 7ot
considered to be significant but it has now developed to be a major
concei n as the number of fatalities fi.oni bactet id infections is
increasing Even bacterial infections that were once considered to
be eliminated or controlled have begun to ie-emerge as life
tht eatening problems Some examples of re-emerging infections
ai e gonorrhoea. pneumonia. tuberculosis. meningitis. dysentery
and septicaemia ( I , 3)
There are several nossible mechanisms by which bacte-ial
resistance can develop l3acteria may produce enzymes to inactiv,ite
Table I
Some 01 the i'esults of a survey of American dentists and endodontists regarding the use of antibiotics to treat various pulp m d pei.iapicd
diseases from Whitten et nl(8).
Patient's presenting clinical condition
Irreversible Pulpitis with:
Chronic Apical Pewdontitis (no/mild symptomsj
Acute Apical Periodontitis (moderatekeveresymptoms)
Pulp Necrosis with:
Chronic Apical Pet iodontitis (no/mild symptoms, no swelling)
Acute Apical Periodontitis (moderate/severe symptoms, no swelling!
Chronic Apical Abscess (no/mild symptoms. draining sinus)
Acute Apical Abscess (moderatekeveresymptoms, swelling)
the drug, they may synthesize modified targets against which the
drug has no effect, or they may alter their permeability so an
effective intracellular antibiotic concentration is not achieved Once
resistance has developed it is then passed on to future generations
of the species through mutation and genetic transfer As most
bacterial species have very rapid reproduction rates (eg E coli
produces 10 generations every 3 hours), an infection can easily
continue despite the use of antibiotics A further complicating factor
is the ability of bacteria to pass resistance to different species and
between different host animals ( I )
Bacterial mutation is especially likely to occur if the challenging
agent is of limited strength and applied over a long time
Unfortunately.this is the typical manner in which antibiotics are used
both as a theiapeutic agent and in nonmedical situations such as
for growth enhancement - and therefore resistance can spread at
an exponential rate The use of antibiotics creates "selective
pressure" whereby the more susceptible organisms die and the
more resistant ones survive inadequate dose regimens enhance
this "selective pressure" phenomenon which in turn increases
resistance ( I ) Therefore. when being used therapeutically, the
antibiotic dose must be high enough and not be used for any longer
than necessaty in cmler to avoid these problems A Idige "loading
dose" is recommended to rapidly elevate the blood levels and lo
expose the bacteria to high concentration of the drug before
Iesistance can develop ( I . 5 )
Bacterial resistance to antibiotics was first noted in large hospitals
in the late 1940's It boon spread to smaller hospitals and even to
people that had never hdd direct contact with the hospitals or the
antibiotics ( I ) At the time. new drugs were being developed so the
problem was not as critical as it is now Howevei. with the lack of
iesearch and development of new drugs, the effects of resistance
dre becoming more and more critical
Resistance to antibiotics should be considered at foul levels
The individual bacterial species
Othei bacterial species
The individual person
Othei people locally. nationally and globally
it is important to iemembei these four levels when considei ing the
use of antibiotics as eveiy prescription that is written has the
potential to cause damage at each and eveiy one of these levels
The oveiall long-term consequence is that eventually the curl ent
mtibiotics may not 3e effective at all and there may be 110 new
Percentage of respondents that WOULD prescribe
antibiotics
General Dentists Endodontists
23% 9%
51% 2 5%
35% 35%)
62% 67%
62% 29%
95% 97%
 Table 2
The most common "first choice" antibiotics used by the respondents in the survey of American dentists and endcdontists by
Whitten et 01 (8)

No Allergy to Penicillins History of Allergy to Penicillins

alternatives to use In 1994. the American Society of Microbiology
(6) reported that over 90% of Stoph oureus were resistant to
penicillin and beta-lactam antibiotics. the incidence of voncomycin-
resislont enterococci in the USA had increased 20-fold from I989 to
1993, and the number of ontibiotic-resistantStrep pneumonio was
increasing dramatically. In I998, the arrival of "supermicrobes"was
reported when a strain of vancomycin-intermediote-resisront Stoph
ailreus was isolated in a New York hospital and currently there is
NO known antibiotic that can control this organism (3).
Use And Abuse Of Antiobiotics
Antibiotics have failed to eliminate any single bacterial pathogen
and their effectivenessnow appears to be decreasing In a series of
two articles reviewingthe use and abuse of antibiotics. Harrison and
Svec ( I . 2) posed the question of "Why are bacteria winning?"the
fight against antibiotics Their answer (I) to this contained two
reasons:
I. The remarkable genetic plasticity of bacteria to develop
resistance to antibiotics. and
2 The abuse and misuse of the "miracle" antibiotics
Antibiotics are one of the most frequently used medications
throughout the world although it is impossible to quantify the
amount used due to the lack of regulations in many countries and
the non-medicaluses outlined above They are the most frequently
prescribed medication for dental pain even though this use is very
often completely inappropriate and unnecessary (I, 4. 5. 7)
Antibiotics are generally not required for the management of most
cdontogenic infections such as those associated with pulp and
periapical diseases as there are simple and effective local treatment
measures that can be used However, there are some specific
circumstances when antiobotics are indicated and these are
discussed below
In 1996. Whitten et ol (8) published the results of a survey of
general dentists and endodontists in the USA This survey
questioned practitioners about many aspects of their endodontic
treatment regimens. including their use of antibiotics Some of the
results of this survey are summarised in Table I and they strongly
support the above statement regarding the inappropriate use of
antibiotics to manage pain in endodontics Particularly alarming is the

Table 3
Relative proportion of use of some antibiotics prescribed by Australian dentists. Data for 1982-83 from Woods ( lo) whilst data for 1997-
98 represents the overall community use combining PBS. RPBS. private prescribing and survey estimates supplied by the Pharmaceutical
Benefits Branch of the Australian Commonwealth Department of Health and Aged Care (9)

Antibiotic 1982-83 1997-98

Amoxycillin 56.6% 78.9%

Penicillin V 13.1% 4.1%

Metronidazole 4.4% 0.03%

Augmentin Not Available 3.7%

Erythromycin 12.1% 6. I%

Total antibacterialprescriptions 326,264 458,759

12 AUSTRALIAN ENDODONTIC IOURNAL VOLUME 26 No I APRIL 2000

 Antibiotic Number of Prescriptions Percentage of all Antibiotics Prescribed

Amoxycillin 4.876.899 20 I %

Penicillin V 798.565 3 3%

Metronidazole 24. I93 0 I%

Auginentin 2.344.878 9 6%

Erythiomycin I .7 15.440 7 I%

Total antibacterial prescriptions 24,308, I74

Table 5
Diagnosis of the presenting pain condition and the use of antibiotics amongst a series of I29 new patients referred to the author during a
three-month period from September until November I998

I
Antibiotics Antibiotics NOT
Number PreSCribed. P*exribCd
Diagnosis (% of all cases) (% of condition) (% of condition)

Pulpitis 50 (38.7%) 38 (76%) I 2 (24%)

Infectedcanals t
apical periodontitis 70 (54.3%) 52 (74%) I 8 (26%)
~~

Non-endodontic pain 9 (7 0%) 9 ( I00%) 0 (0%)

Total 129 (100%) 99 (76.7%) 30 (23.3Oh)

* The antibiotics were prescribed by either the referringdentist or by the patient's medical practitioner prior to seeing the endodontist

use of antibiotics to treat pulpitis and apical periodontitis
conditions that are inflammatory in nature. and not infections. This
survey shows that antibiotics were more commonly used if the
patient had pain and general dental practitioners weie more likely
to use antibiotics than endodontists These fndings could be
interpreted as an indication of a general lack of understandingof the
disease processes that these practitionerswere treating
The antibiotics commonly prescribed by the respondents in the
study by Whitten el d (8) are shown in Table 2 The prescribing
patterns for general dentists and endodontists in the USA were
similar for patients with no history of allergy to penicillin. although
slightly more general dentists than endodontists would use
clindamycin. and significantly more endodontists would use
penicillin V as their first choice In contiast. there was A noticeable
difference between the general dentists and endodontlsts for
patients with a reported allergy to penicillin - in this situation. the
specialists were much more likely to use clindamycin but the most
common choice for both groups was eiythromycin
What Happens In Australia?
There have not been any similar studies of Australian dentists'
use of antibiotics during endodontic treatment, so direct
comparisons can not be made. However, estimates of drug
prescribing patterns of doctors and dentists are available from
the Phdrmaceutical Benefits Branch of the Commonwealth
Department of Health and Aged Care (9). Some of the figures for
overall community use are shown in Tables 3 and 4 although these
figures should not be regarded as absolute numbers since they are
a compilation of information obtained from the Pharmaceutical
Benefits Scheme (PBS). the Repatriation Pharmaceutical Benefits
Scheme (RPBS). private prescribing and survey estimates These
estimates are used because drugs supplied under the PBS and RPBS
are only recorded by the Department if their cost exceeds d
nominated amount which varies from time to time
Table 3 also shows dentists' prescribing patterns for antibiotics in
1982-83 (lo) Amoxycillin appears to be the most common
antibacterial drug prescribed by both doctors and dentists and it is
interesting to note that the proportional use of amoxycillin by
dentists has dramatically increased (by 22 3%) over the I 5-yeat
period from 1982-83 to 1997-98. while the use of the more
appropriate penicillinV has dropped considerably (9% less) This is
pi.obably a result of recommendations by Woods ( I I - 13) for the
use of amoxycillin. based on the claimed better patient compliance
and some disputed microbiological testing methods ( 14, 16) This
inciease in the use of amoxycillin is also in contrast to other
recommendations that phenoxymethylpenicillin(penicillin v) is the
drug of first choice for odontogenic infections (3. 4. 5. 16). and

/\US1 I W I A N LND01KIN IIC. I( )URNAI V( )IUMI 26 No I APRll 2000

quite different to dentists' usage patterns from other countries such
as the USA (see Table 2)
Since there were no data available concerning Australian dentists'
use of antibiotics for the management of pain that they thought was
of endodontic origin. a survey of I29 new patients referred to the
author. who is an endodontist in private practice. was conducted
over a three-month period from September until November I998
A detailed history was taken of the patients' signs and symptoms,
and patients were questioned about whether antibiotics were being
taken and who had prescnbed them After a thorough clinical and
radiographic examination. a diagnosis was formulated to reflect the
status of the pulp. the root canal and the periapical region - for the
purposes of this survey. the endodontic diagnoses were grouped
into broad categories of either pulpitis. infected canals with apical
periodontitis. or "non-endodontic pain" The latter were assessed
as not being caused by any pulp or periapical diseases and their true
origin was recorded Appropriate treatment was provided to
relieve the patients' pain and the need for antibiotics with this
treatment was recorded If the pain was not of endodontic origin.
then the patient was referred to an appropriate practitioner for
further assessment and treatment
The results of this survey are summarised in Tables 5-9 They
show some alarming trends and emphasise the popularity of
amoxycillin over penicillin amongst the referring dentists and
doctors (Table 8) The results also demonstrate that antibiotics are
being over-used and ma-used by both dentists and doctors for the
management of dental pain rather than for the management of
infections (Tables 5-7) The medical profession could perhaps be
excused to some extent as they do not have the knowledge, skills.
equipment or experience with dental diseases to make an accurate
diagnosis - however, if this is the case, then they should be advising
the patients to seek urgent dental care rather than prescribing an
inappropriate medication that could have detrimental short and
long-term effects In this survey, every patient that had seen their
general medical practitioner for the dental pain had been prescnbed
an antibiotic
Dentists were also guilty of mis-using antibiotics to control pain.
as demonstrated by the high frequency of antibiotics being
prescribed for pulpitis and for other pain problems that were not
caused by an infection - such as cracked cusps. temporomandibular
dysfunction, invasive resorption. mouth ulcers, and maxillary
sinusitis due to an allergy Although the dentists were willing to
prescribe antibiotics. they did not appear to be so willing to provide
local dental treatment to relieve the pain - only 24% of both pulpitis
and apical periodontitis cases had treatment commenced, even
though this is far more likely to result in rapid resolution of the pain

Table 6
Details of the causes of "non-endodontic" pain and the prescribers of antibiotics in nine new patients referred to the author for endodontic
treatment during a three-month period from September until November 1998.

Diagnosis Number Antibiotics Prescribed b y

Cranio-mandibulardysfunctiodmuscle pain 3 I x Doctor, 2 x Dentists

Periodontal pain I Dentist

Cracked cusp 2 2 x Dentists

lnvasive cervical resorption I Dentist

Mouth ulcer I Dentist

Maxillary sinusitis (allergy) I Dentist

Total 9 8 Dentists, I x Doctor

Table 7
Details of the use of antibiotics. the origin of the prescriptions and whether treatment was commenced by the referring dentists in a series
of I 29 new patients referred to the author during a three-month period from September until November 1998.

I
Antibiotics Referring dentists
Antibiotics Prescribed b y Antibiotics started treatment:
Diagnosis P*exribed Needed#
Dentist Doctor. YeS No

Pulpitis 76% 56% 20% 0 24% 76%

I Infectedcanals+
apical periodontitis 74% 56% 18% I I% 24% 76%

* EVERY patient who saw a medical practitioner received a prescription for antibiotics
#As assessed by the author on presentation

34 AUSTRALIAN ENDODONTICJOURNALVOLUME 26 No I APkL 2000


Frequency of use of each type of mtibiotic by the referring dentists and doctors in a series of I 29 new patients referred to the author
during a three-month period from September until November I998
(Note Five patients had used more than one course of antibiotics)
Antibiotic Used
Amoxycillin
Penicillin V
Metronidazole
Amoxycillin t Metronidazole
Erythiomycin
Total
Reasons for use of antibiotics by the author during a three-monthperiod from September until November 1998.
Reason for use of antibiotic
Prophylaxis-
Patients "at risk" of Idective Endocarditis
Post trauma (pi.evention of inflammatory resorption)
Treatment-
Acute Apical Absces.,
Facial Cellulitis
E xtra-radicular infection
(dtei. intracanal medicaments not resolving
the infection)
Total
It was also interesting to note that the vast majority of patients
iepoited that they had "m abscess" even though there were only
two cases of acute apical abscesses even patients with pulpitis had
been told they "had an abscess and needed antibiotics" An abscess
is defined as a "localised collection of pus" ( 17) and this does not
occur with every infection or in eveiy case of dental pain
Data was also collected about the author's perception of the
need for antibiotics for these same I29 new patients (Table 7)
five patients presented with an acute apical abscess and two others
had facial cellulitis which required antibiotic therapy in conjunction
with endodontic treatment These seven patients comprised only
5 4% of all new patients and 10% of the patients with infected
canals These figures are much lower than the 76 7% of all new
patients and 74% of those with infected canals that actually had
mtibiotics prescribed by their medical 01' dental practitioners
Thi.oughout the three-month sutvey period. the cndcdontist
prescribed antibiotics for only I0 patients (see Table 9).which is an
AU5 IIWI I A N [ NI )OIX )NTK (( WHNAL VOI UMI 26 No I APRll 20'K)
Table 8
Number of Patients Percentage of Prescriptions
73 70 2%
4 3 9%
8 7.7%
I2 I I 5%
7 6 7%
104 100%
Table 9
No. of Cases Antibiotics Used
3 Amox ycillin
I Penicillin V
2 Penicillin V
2 Penicillin V i Meti.oniddzole
2 Penicillin V t Metronidazole
10
average of less than one prescription each week Most 01 these
piesci iptions (40%) were for prophylactic purposes (either foi-
patients "at risk" of developing infective endocarditis. or following
trauma to prevent external inflammatory root resorption) Others
were for acute abscesses (2 cases), cellulitis ( 2 cases), or an attempt
to control extra-radiculdrinfections where symptoms had persisted
following routine canal preparation and sevei al intracanal
medicaments (2 cases) In the latter situation. one of the two cases
resolved but the other required surgery for a periapical curettage
Tible 9 also shows the antibiotics prescribed for each of these
situations
The general conclusions that can be drawn from this simple
siirvey is that dentists and doctors are using antibotics as a "pain
relief" measure rather than providing the appropriate local dental
treatment The survey results also suggest that either a diagnosis is
not made prior to prescribing the drugs or the wrong diagnosis IS
often made In addition. it appears as though the practitioneis have
a pwt' understdnding of the pathological processes involved in pulp
and periapical diseases.
'l'hc Nature Of Pulp And Periapical
Diseases
Most patients presenting with pain of endodontic origin are
suffetmgpain due to acute inflammation of either the pulp or the
periapical tissues. and sometimes from both Although it is
I ecognised that these conditions are commonly caused by the
presence of bacteti,t in tooth. it must be remembered that the
mere presence of bacteria does not imply an infection Infection
only exists when the microorganisms begin to adversely affect the
local host defenses dnd cause damage to the tissues (4)
In the case of pulpitis. the bactetia may be contained within d
cai'tous lesion or they may entet the tooth through leaking
iestot ation mat gins and/ot clacks In the case of apical peridontitis.
the bacteria ai'e present within the necrotic pulp or within the
pulpless root canal system In these situations. the bacteria have
usually entered the tooth through the same pathways as for pulpitis
(that is. via caiies. leaking restorations. or cracks) It is rare to find
bacteria within the periapical tissues and histological studies have
clearly shown that the most common periapical "lesion" is a
granuloma ( 18). which is essentially a normal response to irritation
rather than b e q a "lesion" Only a small proportion of pel iapical
I adiolucencies are abscesses or infected cysts and these conditions
cannot usually be clinically distinguished from granulomas, except in
the case of dn acute apical abscess or cellulitis with severe pain and
swelling However. even if one of these lesions is suspected. it is
unlikely to be cured with antibiotic therapy as the antibiotics will not
penetrate into the abscess 01' into the site of the infection which
is in the root canal system ( 19. 20)
When treating pulpitis and apical periodontitis. the use of
systemic antibiotics will not remove the cause of the problem nor
will they destroy the bacteria present in the tooth because the
concentration of antibiotic that can be achieved in a pulp is
extremely low and well below the Minimal Inhibitory
Concentration (MIC) required to kill the bacteria (20) If the pulp
has necrosed or been removed by the bacteria to create a pulpless
canal, then the blood supply has been lost and therefore it is
expected that none of the antibiotic will reach the root canal system
which contains the reservoir of bacteria causing the apical
periodontitis or abscess ( 19)
Managing thdodontic Pain And
Infections
The first priority for managing endodontic pain and infections is
to identify the cause of the presenting problem that is, diagnose
the disease and its aetiology This includes an assessment of the
status of the pulp, root canal and penapical tissues. which tooth is
involved. and what has caused the problem
The second priority for managing endodontic pain and infections
is to remove the cause of the presenting problem - in endodontics.
this will invariably be caries. cracks, a leaking restoration. or
combinations of these This implies that the entire existing
restoration should be removed from all teeth being endodontically
treated in order to remove the aetiological factors ( 2 I) A further
advantage of removing the restoration is to allow accurate
assessment of the feasibility of restoring the tooth again (22) Other
possible causes such as trauma, periodontal disease. occlusion. etc
should also be managed, if present
36
The third priority for managing enddontic pain and infections is
to manage the effect of the disease that is. the pain. swelling.
reduced function. etc This is largely achieved by cleaning and
medicating the toot canal. sealing the tooth to prevent further
bacterial ingress. relieving the occlusion. obtaining drainage when
necessary, and perhaps the use of anti-inflammatory systemic
medication to control periapical inflammation (16) In a small
number of cases. systemic antibiotics may be required although
they are usually far more effective if placed within the root canal
that is. in the site of the infection where they can have direct effects
on the bacteria ( 16)
Drainage is only required when pus is present and it is under
pressure that is an acute abscess (4. 17) Conditions such as
apical periodontitisdo not require drainage because there is no pus
present to be drained Any attempts to achieve drainage by passing
enddontic instruments through the apical foramen will only cause
an acute exacerbation of the periapical inflammationthat is already
present. which will then cause increased pain for the patient
Facial cellulitis is a diffuse spreading of the pus throughout the
fascia1 planes between the various facial muscles and hence it is
unlikely that drainage will occur. except for any pus in the periapical
region If drainage is required. it can be achieved through the root
canal (which is the usual first choice approach) or by a soft tissue
incision Drainage will usually be spontaneous once a pathway is
established and it will stop once the fluid is no longer under
pressure. It should not be forced and canals should never be "left
open to drain" as this only allows more bacteria to enter the tooth
and continue the infectious process It is far more effective to place
an antibacterial dressing within the root canal and a temporary
restoration to seal the tooth If the patient continues to have
symptoms with signs of further pus production. then the tooth can
be re-entered to allow more drainage either later the same day or
on the following day
The effectiveness of each phase of treatment largely relies on
having an accurate diagnosis and recognising the aetiology of the
disease Once these have been identified. the treatment becomes
very obvious. especially if the general principle of treating any
disease is followed - that is. remove the cause and do not just
"treat" the effect In endodontics. the indiscriminate use of anti-
biotics and analgesics without providing any local dental treatment is
a classic example of managing the effect rather than treating the
cause of the disease (4. 17) Studies have shown that patients with
localised periapical pain or swelling recover very rapidly with local
dental treatment and there is no demonstrable benefit from
supplementing this treatment with systemic penicillin (7)
Possible Complications Arising From
Dental Infections
The vast majority of dental infections only cause local problems
such as pain. swelling. trismus. and reduced function. However, on
occasions. dental infections may progress very rapidly or the
patients may ignore the early waming signs and not seek treat-
ment until the infection has advanced considerably. Although
complications from dental infections are rare, it is important to be
aware that there are some severe, and at times even life
threatening. complications that can arise ( 16) - the following
complications have all been reported in the dental literature from
time to time ( 16)
Bacterial endocarditis
Cavernous sinus thrombosis
Orbital cellulitis
Ludwig's angina
AUSTRALIAN ENDODONTIC JOURNAL VOLUME 26 No. 1 APRIL 2000
 Brain abscess
Mediastinitis
Osteomyelitis
If the patient presents with one of these conditions. then immediate
(and aggressive) treatment is iequired ideally. intravenous
antibiotics and local dental treatment to remove the cause 01 the
infection(that is. endodontic treatment or extraction)
These complicatiors are more likely to occui if the patient is
immuno-compiomised or if their general resistance has been
affected by conditions such as old age. drugs alcoholism.
malnourishment anxiety, systemic diseases. or other infections ( 16.
17) These factors shoidd always be considered when assessing the
need for systemic antibiotics as an adjunct to endodontic or other
dental treatment
Indications For Using Syst.cmic
Antibiotics
There are very few REAL indications for the use of antibiotics in
conjunction with endodontic treatment Antibiotics should not be
used ds a means of providing pain relief and they should only be
considered as an ADJUNCTto endodontic treatment. with their
use being reserved for special circumstances as outlined below
Antibiotics should be used only to treat infections that are likelv to
respond to them and they should not be used to treat inflammatory
conditions such as pulpitis and apical periodontitis (5 I 6 I 7. 2 3 )
Antibiotics do not CURE infections.they only ASSIST the body’s
defense mechanisms to overcome the bacterial attack (5. 17)
Therefore, they are only needed when the body’s efforts at fighting
the bacteria are failing The clinical signs of such a failure are feder
malaise. cellulitis. trismu. and progressive swelling ( I 7 ) Hence the
systemic use of antibiotics should be limited to patients showing
signs of (5. 16. 17)
Malaise
Elevated body temperature
Lymph node involvement
Suppressed or compromised immune system
Cellulitis or a spreading infection
Rapid onset of severe infection (I e less than 24 hours)
In general, orofacial infections can be effectively treated by
physically removing as many organisms as possible. and by doing
this as soon as possible This reduces the demand on the body’s
defense mechanisms and reduces the number of resistant strains
that can develop Draining pus from an abscess is an essential part
of this treatment for two reasons firstly, it helps to remove some
organisms. and secondly it helps to encourage blood ‘low into the
region Abscesses reduce the blood flow to the infected area which
reduces the body‘s ability to fight the bacteria and limits distribution
of the antibiotic to the region This. in turn. makes the antibiotic
therapy less effective and creates a higher chance of allowing
resistant strains to develop and survive (5) The immediate effect is
to allow the infection to progress and spread further
Strategies For Using Antibiotics
In order to maximise the effect of antibiotics and to minimise the
chances of resistant strains developing. a high initial (or loading) dose
should be given (5) - this is typically double the standard oral dose
used for most antibiotics Patients should be instructed to
commence the course of antibiotics as soon as possible and an
appropriate narrow spectrum drug should be chosen (5. 23) The
use of broad spectrum antibiotics is contra-indicatedas this leads to
the development of resistance The patient should be monitored
AUSTRALIAN tNOODONTIC IOURNALVOLUMt 16 No I A W L ;OM)
daily foi the first few days in order to deteimine whethei the
prescribed drug is being effective and to ensuie that the patient’s
condition is improving (5. 17) An alternative dntibiotic should be
considered if there is no improvement seen within 24-48 houis of
commencing the therapy (4) Repeat presci iptions of the sane
antibiotic are not recommended and an alternative drug should
be chosen if the infection has not completely resolved by the time
the course of the originally prescribed drug has been completed
In this case, the local dental treatment has piobably not k e n
sufficient. or appropriate. and it should be reassessed repedted or
extended (4. I 7)
Some controversy exists regarding how long antibiotics should
be used for The correct time is the time it takes foi the host’s
defense mechanisms to regain control of the situation and this can
be evidenced by subsiding of the systemic manifestations that were
present prior to treatment (5. 23) The antibiotics should be
continued for only 1-2 days after the signs of the infection hwe
diminished (5). even if there are still some tablets or capsules
remaining in the prescribed packet Many years ago. it was
consideied necessary to “complete the course of tablets‘ but there
is no evidence to justify this approach and the prolonged use of
antibiotics only leads to the development of more resistant strain>.
which may then allow more symptoms to develop Patient
compliance also drops markedly after several days dnd especi‘illy
once symptoms subside The subsequent use of an occdsiondl
tablet when the patient remembers to take it lowers the effective
dose being applied to the infected area and extends the time of
“treatment” - all these scenarios lead to a highei chance of iesistmt
strains developing ( I ), as outlined above
Cessation of the drug therapy also enables the effectiveness 01
the local dental treatment to be assessed Oro-facialinfections will
rarely rebound if the source of the bacteria is reduced (5. 17. 2 3 )
and this is usually easily achieved by doing the local dental treatment
to remove the bacteria and their pathway of penetration. as
outlined dbove Patients should be educated that the typically
prescribed course of seven days of antibiotics is arbitrary dnd it is
not always necessary to “complete the course’ Any unused
tabletskapsules should be disposed of immediately and patients
jhould not keep them for self-administration if they have further
problems in the future
Severe infections. cases with rapid onset. and cases with rapid
spreading of the infection should be treated with intramuscular
or intiavenous administration of the antibiotics (I 7) In these cases.
the assistance of appropriate medical practitioners and even
hospitalisation is recommended Oral antibiotics may need to be
used after the initial control of the infection and the local dental
treatment should be Commenced as soon as pi-actid as this will
Aow more effective and rapid removal of the bacteria
Which Antibiotic Should Be Ilsed?
If systemic antibiotics are required in conjunction with
endodontic treatment of an infected tooth, then
phenoxymethylpenicillin(penicillinV) is the first choice oral antibiotic
that should be used where there is no history of allergy to the
penicillins (4. 5, 16, 23). It has a narrow but appropriateantibacterial
spectrum and can be commenced with a loading dose of I000mg.
followed by 5Wmg taken every 6 hours on an empty stomach (thdt
is. I hour prior to meals and last thing at night). Relief is usually
rapidly noticed and the drug can be withdrawn after 5-7 days in
most cases
Metronidazoleis the second choice oral antibiotic for endodontic
infections. especially if ,inaerobic bacteria are suspected to be the
iI
major pathogens ( 16) However metronidazole has a very narrow
spectrum of antibacterial activity. and is ineffectiveagainst aerobic and
facultative anaerobic organisms Most, if not all, odontogenic
infections are mixed infections with representatives from the
anaerobic. aerobic and facultative anaerobic groups of organisms
Hence, the use of metronidazole alone may allow proliferation of
the aerobic and facultative anaerobic organisms with the result of
ongoing infection However, fortunately, metronidazole has a
synergistic reaction with phenoxymethylpenicillin and therefore they
can be used concurrently to increase the effectiveness of therapy
This combined approach should only be used in severe infections
(4. 16. 17) or where the use of penicillin alone has not resolved the
infection (after appropriate local treatment also) Metronidazolecan
be used with a loading dose of 800mg. followed by 400mg every
8 hours for 5-7 days Alternatively. a loading dose of 400mg.
followed by 200mg can be used Patients must be instructed to
avoid alcohol. even for a few days after cessation of the drug
Clindamycin is the first choice oral antibiotic for the management
of endodontic infections in patients with a history of allergy to the
penicillins It has an appropriate spectrum of antibacterial action for
endodontic bacterial infections and it can also be used in patients
without a history of penicillin allergy as the second choice antibiotic
ifphenoxymethylpenicillinand local dental treatment have not been
effective ( 5 . 17) The usual loading dose is 300mg. followed by
I50mg every 8 hours for 5-7 days Erythromycin has traditionally
been used as the alternative antibiotic for patients allergic to the
penicillins However. its spectrum of antibacterial activity is not very
appropriate for endodontic infections and, whilst it may have some
effect in reducing signs and symptoms, it is not the most effective
drug available Hence. it should be considered only as an alternative
for patients allergic to penicillin if clindamycin is not effective
Amoxycillin is very popular amongst Australian dentists. as
outlined above However, its spectrum is broader than required
and hence resistance is likely to occur This antibiotic should not be
used for routine treatment of endodontic infections but is the
currently recommended drug for pre-operative prophylactic
antibiotic cover for patients who are "at risk" of developing infective
endocarditis In these cases, a single 3gm dose, taken one hour pre-
operatively. is recommended and readers should refer to the
current published guidelines for further details
Tetracycline has an inappropriatespectrum of antibacterial activity
for most endodontic infections but it has some useful non-
antimicrobial properties that can be advantageous to dental
treatment (24) It can help with healing of hard tissues and may
prevent resorption of bone and tooth substance (24) Some other
recent research suggests that it may be the antibiotic of choice for
prevention of resorption after dental trauma as it inhibits both
inflammatory(25) and replacement resorption (26) More research
is needed to confirm this systemic application of tetracyline
Ideally, a microbiological analysis should be done for all cases
when antibiotics are being considered as part of the treatment plan
in order to identify the bacteria and to test their susceptibility to
antimicrobialagents (4, 5. 16. 17, 23) However,there are practical
problems associated with this which preclude such analyses being
done The sampling and growth techniques are quite complex and
must involve techniques to grow and identify anaerobic bacteria
Experienced laboratory staff are required for accurate identification
and this expertise is not available in commercial pathology
laboratories in Australia ( I 6) The time involved is lengthy and the
local dental treatment will usually resolve the infection before
cultunng results can be obtained In addition. the costs of these teds
are very high and difficult to justify. particularly when the local
treatment is so effectiveand very predictable
38
Women of child bearing age that are taking one of the combined
oral contraceptive pills should be warned to use alternative
contraceptive methods whilst taking antibiotics and for an additional
seven days after they stop taking the antibiotics as there is an
association between the use of antibiotics and unplanned
pregnancies ( 17. 27) This is especially so for the broad spectrum
antibiotics and there are several possible mechanisms for this effect.
This warning should be explained verbally to women and it should
also be provided in writing with the prescription
Specific Indications For Antibiotics In
Endodontics
In summary, systemic antibiotics may be used in endodontics as
either a prophylactic measure ( I 6. 25-28) or as part of the
treatment (4. 5. 16. 17. 23) They are indicated in the following
situations. as an adjunct to the endodontic treatment
Prophylaxis for patients "at risk" of developing infective
endocarditis
- following trauma to prevent inflammatory
root resorption and possibly replacement
resorption
- prior to some surgical situations where the risk
of spread of infection is high
Treatment - facial cellulitis
- acute apical abscess (especially if drainage
cannot be achieved)
- rapidly spreading infection
- immuno-compromisedpatients
Antibiotics can also be used locally, as opposed to systemically. as
part of endodontic treatment (16) That is. they can be placed
within the root canal as part of an intracanal medicament This
should be the preferred approach as they are far more likely to be
effective when used locally because the drug is applied to the actual
site of the infection This allows an effective inhibitory or bactericidal
concentration to be readily achieved and maintained for an
appropriate period of time The onset of action is also rapid as
there is no lag time between writing a prescription and arrival of the
drug at the site of required action Furthermore. the use of
intracanal antibiotics does not rely on patient compliance to take the
drug as directed and it reduces the costs and the chances of
developing potential complications such as allergies. toxicity,
resistance. yeast infections (especially in women), and super-
infection (23)
Conclusions
Antibiotics were initially considered to be "miracle diugs" but
their over-use in medicine. dentistry, veterinary practice and the
agricultural industries has led to the development of many resistant
strains of bactena. The dental profession has an obligation to limit
the use of antibiotics to those situations that actually require them
and to situations where patients will benefn from their use. They
should not be used as pain relief medications in the absence of local
dental treatment. Most patients with pain of endodontic origin are
suffering pain due to inflammationand therefore antibiotics are not
indicated even though the inflammationmay be caused by bacteria
in the tooth. The presence of bacteria does not necessarily imply
that there is an infection. An accurate diagnosis and assessment of
the aetiology will lead to identification of the appropriate treatment
which should be based on operative and endodontic treatment, in
conjunction with analgesic or anti-inflammatory medication.
Antibiotics will not help to resolve pulpitis. they will not prevent
AUSTRALIAN ENDODONTIC JOURNALVOLUME 26 No. I APRIL 2000
post-operative pain or "flare-ups". and they will not help "Fst in
case" there are problems. Patients, dentists and doctors need to be
educated and diligent about the role of antibiotics and the long-term
consequences of their misuse and abuse.
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39