Endodontic%20Emergencies%20and%20Antibiotics[1].pdf

8/14/2019 Endodontic%20Emergencies%20and%20Antibiotics[1].pdf

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EndodonticEndodontic EmergenciesEmergenciesand Antibioticsand Antibiotics

Dr Zuryati AbDr Zuryati Ab--GhaniGhani

BDS, Grad DipBDS, Grad Dip ClinClin Dent, FRACDS,Dent, FRACDS,

DD ClinClin Dent (Pros)Dent (Pros)28.06.0628.06.06


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Topics to be coveredTopics to be covered

EndodonticEndodontic emergenciesemergencies

Systemic antibioticsSystemic antibiotics

Indication for using systemic antibioticsIndication for using systemic antibiotics

Strategies for using antibioticsStrategies for using antibiotics Which antibiotic should be usedWhich antibiotic should be used

Specific indications for antibiotics inSpecific indications for antibiotics in

endodonticsendodonticsTopical antibioticsTopical antibiotics

IntracanalIntracanal medicamentsmedicaments


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EndodonticEndodontic emergenciesemergencies

Require careful handlingRequire careful handling Difficult to spend time with patientDifficult to spend time with patient

due to busy scheduledue to busy schedule

Types of emergencies:Types of emergencies:

AcuteAcute pulpitispulpitis, acute apical, acute apical

periodontitisperiodontitis or acute apical abscessor acute apical abscess


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Basic principles of managementBasic principles of management

Correct diagnosisCorrect diagnosis Remove the cause of painRemove the cause of pain

Provide drainage (if necessary)Provide drainage (if necessary)

Correct medication if necessary (local andCorrect medication if necessary (local and

systemic)systemic)

Rest (general andRest (general and occlusalocclusal))


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AcuteAcute pulpitispulpitisIf irreversible:If irreversible:

LA, rubber damLA, rubber dam

Remove all caries, gain access, extirpateRemove all caries, gain access, extirpatepulppulp

Canal preparation not essential if timeCanal preparation not essential if timelimitedlimited

LedermixLedermix paste dressing, temporarypaste dressing, temporaryrestorationrestoration

RoutineRoutine endoendo treatment carried out attreatment carried out atconvenient timeconvenient time


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Acute apicalAcute apical periodontitisperiodontitis

Pain is caused by inflamed dental pulpPain is caused by inflamed dental pulpor infected canalor infected canal

Treatment: as for acuteTreatment: as for acute pulpitispulpitis


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Acute apical abscessAcute apical abscessSevere pain, swelling, feverSevere pain, swelling, fever

Treatment: As for acuteTreatment: As for acute pulpitispulpitis PLUSPLUS

Establish drainage (if required)Establish drainage (if required)-- via rootvia rootcanal or via incision of mucosa.canal or via incision of mucosa.

Canal should not be left open. Better to seeCanal should not be left open. Better to seepatient after 12 to 24 hrs for furtherpatient after 12 to 24 hrs for furtherdrainagedrainage

AntiobioticAntiobiotic systemicallysystemically AnalgesicsAnalgesics

Rest (occlusion and sleep)Rest (occlusion and sleep)


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Systemic antibiotic inSystemic antibiotic in

endodoticendodotic

EndodonticsEndodontics

: largely concerned with apical: largely concerned with apical

periodontitisperiodontitis with source of infection fromwith source of infection fromtooth.tooth.

Thos can be treated with removal of theThos can be treated with removal of theinfected canal contentinfected canal content

Should only be considered as an adjunct toShould only be considered as an adjunct to

endoendo RxRx Should not be used as a means ofShould not be used as a means of

providing pain reliefproviding pain relief


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Indication for usingIndication for using

systemic antibioticssystemic antibiotics

MalaiseMalaise Elevated body temperatureElevated body temperature

Lymph node involvementLymph node involvement

SupressedSupressed or compromised immuneor compromised immunesystemsystem

CellulitisCellulitis or a spreading infectionor a spreading infection Rapid set of a severe infection (i.e.Rapid set of a severe infection (i.e.

less than 24 hoursless than 24 hours


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Contra indication ofContra indication of

systemic antibioticssystemic antibiotics

No systemic illnessNo systemic illness Chronic alveolar infections associatedChronic alveolar infections associated

withwith pulplesspulpless teethteeth

Inflammatory pulp conditionInflammatory pulp condition

Acute alveolar condition whereAcute alveolar condition where

adequate drainage,adequate drainage, debridementdebridement andandintraintra--canal medication have beencanal medication have beenachieved.achieved.


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Systemic antibiotics notSystemic antibiotics not

indicatedindicated

PulpitisPulpitis andand periapicalperiapical periodontitisperiodontitisSystemic antibiotics will not remove theSystemic antibiotics will not remove thecause of the problem nor remove thecause of the problem nor remove the

bacteria present in the tooth as thebacteria present in the tooth as theconcentration is lowconcentration is low

Necrotic pulp orNecrotic pulp or pulplesspulpless toothtooth-- nonoblood supply thus antibiotic will notblood supply thus antibiotic will notreach the root canal systemreach the root canal system


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Which antibiotic shouldWhich antibiotic should

be usedbe used

Bacterial involved inBacterial involved in endodonticendodonticinfection:infection:

BacteroidsBacteroids vulgarisvulgaris

FusobacteriumFusobacterium necrophorumnecrophorumPeptostreptococcusPeptostreptococcus sppspp..

PrevotellaPrevotella sppspp..At least 70 different bacterial speciesAt least 70 different bacterial species

have been isolatedhave been isolated


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Which antibiotic shouldWhich antibiotic should

be usedbe used

Penicillin VPenicillin V First choice of oral antibioticsFirst choice of oral antibiotics

Narrow but appropriate antibacterialNarrow but appropriate antibacterialspectrumspectrum

Loading dose of 1000mg, followed byLoading dose of 1000mg, followed by

500mg taken every 6 hrs for 5500mg taken every 6 hrs for 5--7 days7 days


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MetronidazoleMetronidazole

Second choiceSecond choice espesp if anaerobic bacteria areif anaerobic bacteria aresuspectedsuspected

Very narrow spectrumVery narrow spectrum-- ineffective againstineffective againstaerobic and facultative anaerobic organismsaerobic and facultative anaerobic organisms

Can be used with Pen VCan be used with Pen V

Loading dose of 800mg, followed by 400mgLoading dose of 800mg, followed by 400mgtidtid, 5, 5--7 days or7 days or

Loading dose of 400mg, followed by 200mgLoading dose of 400mg, followed by 200mg


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ClindamycinClindamycin

First choice in patients allergic toFirst choice in patients allergic topenicillinpenicillin

Appropriate spectrumAppropriate spectrum

Loading dose of 300mg, followed byLoading dose of 300mg, followed by

150mg150mg tidtid 55--7 days7 days

Erythromycin is another alternative inErythromycin is another alternative in

these patients, but the spectrum is notthese patients, but the spectrum is not

appropriate forappropriate for endoendo infectioninfection


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AmoxycillinAmoxycillin

Very popularVery popular Broad spectrumBroad spectrum

Should not be used for routine Rx ofShould not be used for routine Rx of

endoendo infectioninfection Recommended asRecommended as antiobioticantiobiotic

prophylaxis in pts at risk forprophylaxis in pts at risk fordeveloping infectivedeveloping infective endocarditisendocarditissingle 3 gm dose 1 hr presingle 3 gm dose 1 hr pre--opop


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TetracyclineTetracycline

Has an inappropriate spectrum ofHas an inappropriate spectrum ofantibacterial activity for mostantibacterial activity for most

endodonticendodontic infectionsinfections


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IdealllyIdeallly a microbiological analysisa microbiological analysisshould be done when antibiotics areshould be done when antibiotics are

being considered as part of the Rxbeing considered as part of the Rx

plan in order to identify the bacteriaplan in order to identify the bacteria

Some anaerobes are resistant toSome anaerobes are resistant to

penicillin and thus serious infection ispenicillin and thus serious infection istreated with combination oftreated with combination of

metronidazolemetronidazole and penicillinand penicillin


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Specific indications forSpecific indications for

antibiotics inantibiotics in endodonticsendodontics

ProphylaxisProphylaxis For patients at risk of developingFor patients at risk of developing

infectiveinfective endocarditisendocarditis

Following trauma to preventFollowing trauma to prevent

inflammatory rootinflammatory root resorptionresorption andand

replacementreplacement resorptionresorption Prior to some surgical situationsPrior to some surgical situations


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TreatmentTreatment FacialFacial cellulitiscellulitis

Acute apical abscessAcute apical abscess Rapidly spreading infectionRapidly spreading infection

ImmunoImmuno--compromised patientscompromised patients


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IntracanalIntracanal medicamantsmedicamants

AntisepticsAntisepticsAntibioticsAntibiotics


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Calcium hydroxideCalcium hydroxide

AntisepticAntiseptic Bactericidal due to high pH of 12.2Bactericidal due to high pH of 12.2

Stimulates calcificationStimulates calcification IrritantIrritant--avoid use as initial dressing inavoid use as initial dressing in

teeth associated with pain, or whenteeth associated with pain, or when

the inhibition of inflammation orthe inhibition of inflammation orinflammatory rootinflammatory root resorptionresorption isis

necessarynecessary


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AntibioticsAntibiotics Commercial preparations containing antibiotics alsoCommercial preparations containing antibiotics also

contain corticosteroidscontain corticosteroids Corticosteroids reduce inflammation, pain andCorticosteroids reduce inflammation, pain and

initiate healinginitiate healing

Preparations:Preparations:LedermixLedermix pastepaste ((demeclocyclinedemeclocycline 3.21%,3.21%,triamcinolonetriamcinolone))

SeptomixineSeptomixine ForteForte (Neomycin,(Neomycin, polymixinepolymixine BBsulphatesulphate,, dexamethasonedexamethasone))

PulpomixinePulpomixine ((framycetinframycetin,, polymixinepolymixine BB sulphatesulphate,,dexamethasonedexamethasone))


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LedermixLedermix pastepaste-- material of choice.material of choice.The concentration of tetracycline isThe concentration of tetracycline is

high enough to inhibit the commonhigh enough to inhibit the common

bacteria.bacteria.


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Recommended materialsRecommended materials

LedermixLedermix paste (a corticosteroidpaste (a corticosteroidantibiotic paste)antibiotic paste)

PulpdentPulpdent paste (calcium hydroxide inpaste (calcium hydroxide in

methyl cellulose paste)methyl cellulose paste)

50:50 mixture of50:50 mixture of LedermixLedermix paste andpaste and

PulpdentPulpdent pastespastes


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The use of medicamentsThe use of medicamentsMedicamentMedicament Min timeMin time Max timeMax time

LedermixLedermix pastepaste 1010--14 days14 days 66--8 wks8 wks

PulpdentPulpdent pastepaste 33--4 wks4 wks 33--55 mthsmths

50:5050:50

Ledermix/PulpdLedermix/Pulpd

entent

33--4 wks4 wks 33--44 mthsmths


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THANK YOUTHANK YOU

ReferencesReferences

1. Cohen S, Burns RC. (1998). Pathways1. Cohen S, Burns RC. (1998). Pathways

of the pulp. 7th edition. Mosby Inc. St Louisof the pulp. 7th edition. Mosby Inc. St Louis2.2. EndodonticsEndodontics and dentaland dental traumatoloogytraumatoloogy..

An overview of modernAn overview of modern endodonticsendodontics. A. Ateaching manual sponsored by the Educationteaching manual sponsored by the Education

Committee of the International Federation ofCommittee of the International Federation ofEndodonticEndodonticAssociationsAssociationsAustralia.Australia.

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