To sum up, 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

1. 1
Good Morning
MOHD.SIBGHATULLAH KHATIB
1ST YEAR PG STUDENT

2. ANTIBIOTICS IN ENDODONTICS
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 are substances 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 phase Ehrlich's phase
The modem era of
chemotherapy
5
History

6. Empirical phase
• Mouldy curd 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 in antibiotic 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. MECHANISM OF ACTION
12

13. • Inhibit cell wall 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. BACTERIOLOGY
17

18. • The pulpodentin complex is sterile.
• Bacterial invasion of dentinal tubules occurs more
rapidly in nonvital teeth than in vital ones.
18
COHEN 10TH EDITION

19. 19
ENDODONTICS
INFECTION
INTRARADICULAR
PRIMARY SECONDARY PERSISTANT
EXTRARADICULAR
COHEN 10TH EDITION

20. 20
Siquiera jr et al : update endodontic microbiology 2008

21. ODONTOGENIC INFECTION
21
PULPITIS
Apical periodontitis
PERIAPICAL ABSCESS
PERIAPICAL GRANULOMA
PERIODONTAL CYST
OSTEOMYELITIS
PERIOSTEITIS
CELLULITIS ABSCESS
ACUTE CHRONIC
ACUTE CHRONIC
ACUTE CHRONIC
FOCAL DIFFUSE
Reversible Irreversible

22. When do you need 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 ANTIBIOTIC IN ORAL
INFECTION
24

25. Antibiotics for odontogenic infections
25

26. DOSAGE
26
Antibiotic Dosage Duration
Penicllin V 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. 27

28. COMPLICATIONS OF ANTIBIOTIC THERAPY
• Hypersensitivity
• Direct toxicity
• Superinfections
28
lippincotts pharmacology 5th edition

29. THE FASCIAL SPACES
The mandible 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 Abscesses and 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 for Endodontic 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. 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
• Systemic administration 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 obligate anaerobic 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. ANTIBIOTIC PROPHYLAXIS
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 French agency 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 drug used during pregnancy should be taken
only under the supervision of the patient’s
physician.
43
lippincotts pharmacology 5th edition

44. 44
CATEGORY DESCRIPTION DRUS
A No 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 of Drugs 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. ANTIBIOTICS AND DOSAGES
46

47. Antibiotic Dosage Trade name 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 Trade name 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 Trade name 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 Trade name 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 Trade name 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
1ST YEAR PG STUDENT

53. 53

54. RESPONSIBLE USE OF ANTIBIOTICS 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
Septomixine Forte
MTAD
Tetraclean
Triple antibiotic Paste
Clindamycin
Odontopaste
56
LOCAL DRUG DELIVERY

57. Grossmann Poly Antibiotic Paste
• 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 compounds were 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
• Contains two 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-inflammatory action
• 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 in preventing 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 large periradicular lesion
Application in primary teeth
Root fracture
65

66. DISADVANTAGES
It may cause bacterial resistance.
Use of minocycline can cause tooth discoloration
66
COHEN 10TH EDITION

67. TETRACYCLINES
 To remove the 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% Doxycycline hyclate + 4.25% Citric acid+0.5%
Polysorbate-80 (Tween 80) detergent.
68
COHEN 10TH EDITION

69. • MTAD is capable of
Removing the smear layer
Disinfecting the root canal system.
• Commercially available as BioPure MTAD
69
COHEN 10TH EDITION

70. • Tetraclean is another 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 best antibacterial 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-based endodontic dressing
• COMPOSITION
Clindamycin hydrochloride- 5%
Triamcinolone acetonide - 1%
Calcium hydroxide- < 0.5%
72

73. Odontopaste is the most 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) is effective 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 local application 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 DO THEY REALLY KILL THE
BUGS?
76

77. Acquired resistance to PENICILLIN
• 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-pigmented Prevotella
• Nonpigmented Prevotella species
• F. nucleatum,
• P. acnes,
• Actinomyces species,
• Peptostreptococcus species
• Capnocytophaga
• Neisseria species
COHEN 10TH EDITION

79. • Amoxicillin’s broad spectrum 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. 80

81. MYTHS
Antibiotics cure patients.
Antibiotics are 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 are superior 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 sum up, 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 10th edition
• 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. 86