Use of Antibiotics in endodontic therapy: Review analysis

Endodontic infections are usually polymicrobial, involving a combination of Gram-positive and Gram-negative facultative anaerobes and strictly anaerobic bacterial flora. (1) Bacterial invasion results in pulpal necrosis, which becomes a reservoir of infection. When the dead microbes and their products reach the peri-radicular region, peri-radicular inflammation follows, leading to abscess and cellulitis(2). Such systemic involvement warrants for concomitant use of antibiotics, as an adjunct to endodontic treatment(1,2,3), helping in the elimination of bacteria and creating an aseptic environment (3)

⮚ Role of systemic antibiotics in managing endodontic infections-Systemic antibiotics can be used as an adjunct to endodontic clinical treatment whenever the host response cannot contain the infection(1), such as in cases of persistent or systemic infections and immunocompromised patients. It has been documented that antibiotics are indicated when there are signs of clinical spread of infection such as fever, cellulitis, lymphadenopathy, and swelling as well as a prophylactic treatment to prevent endocarditis, prosthetic joint infection among high-risk patients/ immuno-suppressed patients. (1,3)

Because antibiotics are one of the most commonly prescribed drugs by dentists, (1) it is imperative that the dental fraternity is on a continuous lookout to implement the most beneficial drug therapy in day-to-day clinical practice. Systemic pharmacotherapy with amoxicillin has exhibited time-tested and unprecedented promise in the successful management of infected root canals (1).

⮚ Role of amoxicillin in root canal therapies: Analyzing the Mechanism of action of amoxicillin-

Amoxicillin, a synthetic analog of penicillin, acts via the Inhibition of biosynthesis of cell wall mucopeptide during bacterial multiplication(3). Regarded to be a β-lactam bactericidal drug, they kill susceptible bacteria by inhibiting the synthesis of the bacterial peptidoglycan cell wall and leading to the formation of new peptidoglycan chains that are not cross-linked and lack tensile strength. Once weak points develop in the growing cell wall, it results in cell rupture due to osmotic lysis (4). In addition, there are more targets for the action of penicillins, which are collectively termed penicillin-binding proteins (PBP), structures that all bacteria possess. (4)

Production of synthetic penicillins like amoxicillin has enhanced the antimicrobial specter of the drug, against Gram-negative as well as Gram-positive bacteria. With a moderate spectrum of activity directed against specific bacteria, increased stability in oral and stomach acids, and increased absorption, resulting in lower dosages necessary to establish therapeutic levels, amoxicillin scores far better than its natural predecessor. (4)

⮚ Which antibiotics are preferred as 'first line' antibiotics by endodontists?

Investigating the worldwide pattern of antibiotic prescription in endodontic infections, researchers from a major study have highlighted that Amoxicillin was preferred as the drug of choice for endodontic infections in most countries. The team elaborated that Amoxicillin is the preferred prescribed antibiotic of choice for endodontic infections across Europe, Africa, and Asian countries including India, Pakistan, and Saudi Arabia. (1)

Having said that, the responsible and rational use of antibiotics must be encouraged among dentists to avoid the growing issue of over-prescribing patterns and antibiotic abuse. (3)

⮚ Quoting studies –

● Studies (5) have been documented that medically compromised patients are more susceptible to complications arising from odontogenic infections and antimicrobials have a more specific role in their treatment. Therefore, antibiotics should be considered in patients having systemic diseases, with compromised immunity, or in patients with a localized congenital or acquired altered defense capacity, such as patients with infective endocarditis, prosthetic cardiac valves, or with recent prosthetic joint replacement.

● A major study by Baumgartner & Xia et al highlighted that among the commonly used antibiotics for root canal therapies, amoxicillin exhibited a remarkably high susceptibility of 91 %, to a panel of bacteria isolated from endodontic infections. (5) This reaffirms the fact that the majority of microorganisms have susceptibility to amoxicillin; therefore, it can be a good first option for the adjunctive treatment for lesions of endodontic origin.

● Study reviews by Matthews et al. and Aminoshariae & Kulild et al have concluded that infection must be systemic or the patient must be febrile or immunocompromised to justify the need for antibiotics. (5)

● According to Andreasen et al., a logical approach to contain microbes in a dental traumatic injury requiring endodontic therapy is to limit the bacterial load during the healing phase. Resonating with the above observation, International Association of Dental Traumatology (IADT) guidelines recommend the use of systemic antibiotic therapy in the replantation of avulsed teeth. (5)

⮚ Recommended dosages and duration of antibiotic therapy in endodontics- Antibiotics should be prescribed at the correct frequency, dose and duration so that the minimal inhibitory concentration is surpassed and so that side effects and the development of resistant bacteria are prevented. (6)

⮚ The recommended oral dosage of amoxicillin is 1000 mg loading dose, followed by 500 mg every 8 hours. (5)

The American Association of Endodontists recommends that when there is ample clinical evidence that the symptoms are resolving or resolved, antibiotic therapy should be ceased. There is a general tendency among dentists to administer an antibiotic for 3 to 7 days, though there is a lack of a standard consensus (7).

⮚ Common Indications for the use of systemic antibiotics in endodontics-Systemic antibiotics are generally used in the indications like (i) acute periapical abscesses with signs of systemic involvement; (ii) acute periapical abscesses in immuno-suppressed patients; (iii) prophylaxis of infection associated with tooth avulsion; (iv) treatment of persistent symptomatology and/or exudation after the performance of all available options to control inter-radicular infection; (v) prophylaxis against bacteremia caused by endodontic treatment in immunosuppressed patients or patients susceptible to bacterial endocarditis; (vi) abscess dissemination; and (vii) endodontic flare-ups, etc.(2)

Highlighters-

● The main goal of endodontic treatment is the removal of commonly found microorganisms ( Gram-negative anaerobic rods, E.Faecalis), and their by-products from the root canal space by using various antimicrobial agents to provide an environment free of microorganisms (8). This goal can be fulfilled by the use of supplemental antibiotic therapy in conjunction with regular root canal treatment.

● Cases with evidence of systemic involvement as well as high-risk groups (immunocompromised) call for the obvious use of antibiotics. (3,5)

● Global studies have affirmed that Amoxicillin is the preferred prescribed antibiotic in endodontic infections with systemic effects. (5)

On a concluding note- Taking into account that approximately 10% of all commonly used antibiotics are prescribed by dentists(1), it is high time that appropriate and rational antibiotic prescribing habits are inculcated and adhered to by the dental fraternity.

Amoxicillin is the first line of antibiotics chosen as adjunct therapeutic agents in endodontics in the United States of America and Europe. It is highly effective against isolates from infected root canal systems that are composed primarily of facultative and obligate anaerobes(9). With extensive evidence supporting the superior efficacy of systemic amoxicillin therapy in the successful management of endodontic therapies, it is needless to say that judicious use of this time-tested drug has been and will continue to be a major game-changer for dentists worldwide.

References

1. Segura-Egea, J. J., Martín-González, J., del Carmen Jiménez-Sánchez, M., Crespo-Gallardo, I., Saúco-Márquez, J. J., & Velasco-Ortega, E. (2017). Worldwide pattern of antibiotic prescription in endodontic infections. International dental journal, 67(4), 197-205.

2. Jagadish B and Aswathy K. (2020). Use of antibiotics in endodontics: A critical review. World Journal of Advanced Research and Reviews, 5(3), 38-43.

3. Balasubramaniam, R., & Jayakumar, S. (2017). Antibiotics in endodontics-A concise review. Int J Appl Dent Sci, 3(4), 323-329.

4. Soares, Geisla Mary Silva et al. Mechanisms of action of systemic antibiotics used in periodontal treatment and mechanisms of bacterial resistance to these drugs. Journal of Applied Oral Science [online]. 2012, v. 20, n. 3 [Accessed 3 March 2022], pp. 295-309. Available from: . Epub 31 July 2012. ISSN 1678-7765.

5. Segura‐Egea, J. J., Gould, K., Şen, B. H., Jonasson, P., Cotti, E., Mazzoni, A., &Dummer, P. M. H. (2017). Antibiotics in Endodontics: a review. International endodontic journal, 50(12), 1169-1184.

6. Bax R (2007) Development of a twice daily dosing regimen of amoxicillin/clavulanate. International Journal of Antimicrobial Agents 30(Suppl 2), S118–21.

7. Dr. SmridhiBhanot, Dr. Sonali Talwar1, Dr. Pinki Narwal, Dr. Amit Sood, Dr. Pratibha Marya and Dr. Pardeep Mahajan.(2021) Antibiotics and Analgesics in Endodontics- A review. IAR Journal of Medical Sciences.

8. Mirza MB, Alhedyan FS, Alqahtani AM. Antibiotics in endodontics. J Dent Res Rev 2019;6:65-8.

9. Mazumder P. Use of antibiotics in endodontics. J West Bengal Univ Health Sci. 2021; 1(4):53-61.