antibiotics used in dentistry

1. ROLE OF ANTIBIOTICS IN DENTISTRY
DR.AJAY BABU GUTTI
1ST YR PG
DEP OF CONS & ENDO

2. CONTENTS
 INTRODUCTION
 HISTORY OF ANTIBIOTICS
 CLASSIFICATION OF ANTIBIOTICS
 SYSTEMIC USES OFANTIBIOTICS IN
ENDODONTICS
 ANTIBIOTICPROPHYLAXIS

3. CONTENTS
TOPICAL USES OF ANTIBIOTICS IN
ENDODONTICS
 ANTIBIOTICS IN MEDICALLY
COMPROMISED PATIENTS
ANTIBIOTIC RESISTANCE
SUMMARY
REFERENCES

4. Introduction
 Antibiotics are substance produced by the
microorganism that act against another
microorganism.
 Term derived from greek word ANTI means
AGAINST and BIOTIKOS means
CONCERNING LIFE.

5. Introduction
 Endodontic disease can be primary or
secondary infections characterized by a
polymicrobial nature which lends to biofilm
formation.
 Microbial biofilms in the root canal are
highly complex, multi-species entities that
amplify the difficulty in eradication of the
microbial biomasses.

6. Estimates suggest that pulpal disease may affect up to
30% of the world’s population. When left
unchecked,pulpal disease lends itself to a reduced quality
of life by means of increased pain, loss of physiologic
function and compromised anatomical form of the
affected dentition. Scientific literature consistently
highlights the undeniable benefits of antibiotic use in
treatment of disease control, more specifically
odontogenic bacterial infections

7. HISTORY
The first antibiotic penicillin was discovered by
ALEXANDER FLEMING
Took a decade before pencillin was introduced as treatment
for bacterial infection
Florey and chain –purify the antibiotics and scale up the
production

8. BRIEF HISTORY OFANTIBIOTICS

9.  .
An ANTIBIOTIC is a low molecular substance
produced by a microorganism that at a low
concentration inhibits or kills other microorganisms.
An ANTIMICROBIAL is any substance of
natural, semi synthetic or synthetic origin that
kills or inhibits the growth of microorganisms but
causes little or no damage to the host

10. Classification of antibiotics


11. CLASSIFICATION OF
ANTIBIOTICS
ON THE BASIS OF MECHANISM OF
ACTION
ON THE BASIS OF SPECTRUM OF
ACTIVITY
ON THE BASIS OF MODE OF ACTION

12. Cell Wall Synthesis inhibition Penicillin
Cephalosporin
Vancomycin
Beta-lactamase Inhibitors
Carbapenems
Aztreonam
Polymycin
Bacitracin
Protein Synthesis
Inhibitors
Inhibit 30s Subunit:Aminoglycosides,Tetracyclines
Inhibit 50s Subunit:Macrolides,Chloramphenicol
Clindamycin,Linezolid,Streptogramins.
DNA Synthesis Inhibitors Fluoroquinolones
Metronidazole
RNA synthesis Inhibitors Rifampin
Mycolic Acid synthesis
inhibitors
Isoniazid
Folic Acid synthesis inhibitors Sulfonamides
Trimethoprim
1.Based on mechanism of action

13. Based on mechanism of action

14. CELL WALL SYNTHESIS INHIBITION

15. RESISTANCE
Organism like staphylococcus produce pencillinase(beta
lactamase)
Opens beta lactam ring and inactivate pencillins
Altered target proteins on bacterial cell reduces affinity for
pencillin also leading to resistance

16. PROTEIN SYNTHESIS INHIBITION

17. RESISTANCE
LOW AFFINITY OF RIBOSOMES ACQUIRED BY MUTATION
DECREASE IN PERMEABILITY TO THE ANTIBIOTIC
PLASMID MEDIATED BY INACTIVATING ENZYMES
DECREASE PERMEABILITY OF MICROORGANISM
RIBOSOMAL INSENSITIVITY
ACQUIRED THROUGH PLASMID
LOW PERMEABILITY OF BACTERIA TO THE ANTIBIOTIC
LOW AFFINITY OF RIBOSOME TO MACROLIDE
AMINOGLYCOSI
DES
TETRACYCLI
NES
MACROLI
DES

18. DNA Synthesis Inhibitors

19. RESISTANCE OF FLUOROQUINOLONES
 NOT VERY FREQUENT
RESISTANCE IS DUE TO MUTATION IN THE TARGET
ENZYME OR A CHANGE IN PERMEABILITY OF ORGANISM
RESISTANCE OF SULFONAMIDES
MUTATION RESULTING IN OVER PRODUCTION OF
PABA
USING ALTERNATIVE METABOLIC PATHWAY FOR
FOLIC ACID SYNTHESIS
LOW PERMEABILITY TO SULFONAMIDE

20. 2.Based on spectrum of activity
Narrow spectrum Broad spetrum
Penicillin G
Streptomycine
Erythromycine
Tetracyclines
Chloramphenicol

21. Broad spectrum antibiotic
 An antibiotic that is effective against a wide
range infectious organisms that include both
gram positive and gram negative.
DISADVANTAGES
Resistance
Children taking this
mediation in first year of
life develop asthma
ADVANTAGES
Broad spectrum of activity
Less need to identify
infecting pathogen with
certainity before
commencing treatment.

22. Narrow spectrum antibiotic
 An antibiotic that are effective against
selected group of bacterial types.
DISADVANTAGES
Can be used only if
causative organism is
identified.
Should be usedwith
utmost care
ADVANTAGES
Do not kill as many normal
micro organisms as broad
spectrum do.
Less resistance.
Less ability for super
infection

23. 3.Based on mode of action
BACTERIOSTATIC
Tetracycline
Chloramphenicol
Erythromycin
Clindamycine
BACTERICIDAL
Cephalosporin
Pencillin
Ciprofloxacine
Aminoglycosides
CotrimoxazolE

24. ANTIBIOTICS USED IN ORAL INFECTION
 PENCILLIN/AMOXYCILLIN
 CEPHALEXIN
 TETRACYCLINE
 CLINDAMYCIN
 METRONIDAZOLE
 AZITHROMYCIN
 CIPROFLOXACIN

25. penicillins
Natural
penicillin Acidresistant
penicillin
penicillinase-
resistant
penicillins
Extended
spectrum
penicillins
Aminopenicillins--
Ampicillin
-Amoxicillin
Carboxy penicillins
-Carbenicillin,
-Ticarcillin
Ureido penicillin
-piperacillin
Cloxacillin
Dicloxacillin
Oxacillin
Nafcillin
Methicillin
Penicillin G
(Benzylpenicillin)
Classification
Penicillin
V(phenoxy
methyl penicillin)
• Pencillin/inhibitor combination
Ampicillin/sulbactam
Tiracillin/clavulanate
Piperacillin/tazobactam
Amoxicillin/clavulanate

26. PENCILLIN V
.
 BETALACTAM ANTIBIOTIC
 Phenoxymethylpenicillin, also known as penicillin V
and penicillin VK, is an antibiotic useful for the
treatment of a number of bacterial infections.
 First line of defense in odontogenic infections
 Good effectiveness, low toxicity, as well as low cost,
bactericidal.
 Penicillin V potassium comes as a tablet and as an
oral solution (liquid) to take by mouth.

27.  Narrow antimicrobial spectrum, cover most bacteria
associated with odontogenic infections.
 In culture and sensitivity testing on 94 patients with
odontogenic abscesses, penicillin V was the least effective
antibiotic for eradicating bacterial isolates. Despite this,
more than 95% of patients treated with surgical incision
and drainage in conjunctionwith penicillin V recovered
satisfactorily.
 DOSAGE:A loading dose of 1,000 mg of penicillin VK
should be orally administered, followed by 500 mg every
four to six hours for three to seven days .

28. AMOXICILLIN
CHEMICAL STRUCTURE
 Broad spectrum activity is associated with the presence of
alpha hydrophilic group on the acyl side chain of pencillin
 Semisynthetic aminopencillin are active against a variety of
gram negative bacilli
 Extra phenol group is present on amoxicillin
 Acid resistant due to the –NH2 group and therefore orally
active
 Sensitive to beta lactamase

29. USES
TYPHOID ,BRONCHITIS,URINARY
INFECTION,SABE,GONORRHEA
DENTAL INFECTIONS,ODONTOGENIC
INFECTIONS
DOSAGE-0.25-1g TDS oral/i.m
METABOLISM-Hepatic
EXCRETION-Through kidney
SIDE EFFECTS –Hypersensitivity &diarrohea
BREAST FEEDING-Enters breast milk

30. CEPHALOSPORINS
 Semi synthetic antibiotics obtained from
fungus cephalosporium.
Chemically nucleus consists of beta lactum
ring fused to dihydrothiazine ring.
 Bactericidal
Divided in to 4 generations.

31. CEPHALOSPORIN
FIRST
GENERATION
CEFAZOLIN
CEPHALEXIN
CEPHRADINE
CEFADROXIL
CEPHALOTHIN
SECOND
GENERATION
CEFUROXIME
CEFOXITIN
CEFACLOR
CEFUROXIME
AXETIL
THIRD
GENERATION
CEFOTAXIME
CEFTIZOXIME
CEFTRIAXONE
CEFTAZIDINE
CEFOPERAZO
NE
CEFIXIME
CEFPODOXIM
E PROXETIL
CEFDINIR
CEFTIBUTEN
FOURTH
GENERATION
CEFEPIME
CEFPIROME
spectrum of antibacterial coverage against gram-negative bacteria
5THGENERATION
CEFTOBRIPOLE
CEFTAROLINE
CEFTOLOZANE

32. CEPHALEXIN
 First generation cephalosporin
 High activity against gram positive but weaker
against gram negative
PHARMACOKINETICS
 Little bound to plasma protein and attain high
concentration in bile
 t1/2-60minutes

33. DOSAGE- 0.25-1g 6to8 hourly
CEPHACILLIN 250,500mg capsules
SPORIDEX,ALCEPHIN,CEPHAXIN 250,500mg ,125mg/5ml dry
syrup
METABOLISM-hepatic
EXCRETION-kidney
SIDE EFFECTS-diarrhoea,nausea
PREGNANCY- category B antibiotic drugs
BREAST FEEDING-enters the breast milk and to be used with
caution

34. USES
 In dental infection instead of amoxicillin
 Good penetration into alveolar bone(tooth socket)
 Removal of aerobic organism improves oxygen
availability at local site and indirectly checks growth of
anaerobes
 Specially valuable for oro dental infection caused by
klebsiella though rare occur in neutropenic patients
 Cephalexin is more commonly used for sinus
communications and for antibiotic prophylaxis in
patients with prosthetic joints.

35. TETRACYCLINES
Have a nucleus of four cyclic rings
Obtained from soil actinomycetes
Broad spectrum antibiotic
Weakly water soluble but hydrochlorides are more
soluble

36. CLASSIFICATION OF
TETRACYCLINES
Group 1
Tetracyclines
Oxytetracycline
Group 2
Demeclocyclines
• Group 3
Doxyclyclines
Minocyclines

37. PHARMACOKINETICS
Absorption is better if taken in empty stomach
 Have chelating property
 Widely distributed in the body
 They are concentrated in the liver ,spleen and gingival
tissues and bind to connective tissue in bone and teeth

38. DOSAGE
✔Oral capsules that should be taken half an hour before
or 2hr after food
✔Dry syrups and liquid oral preparation discontinued
✔Not recommended intramuscular route
✔Slow injection given rarely
✔Topical preparation
availableACHROMYCIN,HOSTACYCLINE,RES
TECLIN 250,500mg capsules;3%skin
ointment,1%eye/ear drops and ointment

39. SIDE EFFECTS
Irritative effect-pain
nausea
vomiting,diarrhoea,oesophageal ulceration
DOSE RELATED TOXICITY
Liver damage
Kidney damage
Phototoxicity

40. Teeth and bones –calcium chelate gets deposited in
developing teeth and bones
Mid pregnancy to 5 months of extrauterine life:deciduous
teeth are affected brown discoloration ,ill formed
teeth,more susceptible to caries
 3months to 6 years of age: affect the crown of the
permanent teeth
 Late pregnancy or early childhood :causes temporary
suppression of bone growth

41. Antianabolic effect
Increased intracranial pressure
Diabetes inscipidus
Vestibular toxicity
Hypersensitivity
Super infection
INDICATIONS
Acute dental infection
Management of chronic periodontitis
Refractory periodontal disease-

42. EXCRETION-kidney/fecal
PREGNANCY-Category D antibiotic drug
BREAST FEEDING –AAP considers drug to be compatible

43. CLINDAMYCIN
Lincosamide antibiotic
It is narrow spectrum includes mostly gram
positive(staphylococcus but not MRSA,C.diptheria ,Nocardia
Actinomyces, Toxoplasma) and few gram negative
High activity against variety of anaerobes(BACTERIA
FRAGILIS)

44. PHARMACOKINETICS
Oral absorption is good
Penetrated into most skeletal and soft tissue but not
brain and CSF
Accumulates in neutrophils and macrophages
METABOLISM& EXCRETION
Largely metabolised and metabolites are excreted in
urine and bile
t ½ is 3 hours

45. SIDE EFFECTS
Rashes, utricaria, abdominal pain ,diarrhoea and pseudomemberanous
enterocolitis due to Clostridium Difficle super infection
Therefore clindamycin is restricted to anaerobic and mixed infection
Combined with Aminoglycosides and Cephalosporins
USES
Anaerobic streptococcal and Clostridium perfigens and those
involving bone and joint respond well
Prophlaxis for colorectal /pelvic surgery
Infected acne vulgaris(topical application)
Good choice for the treatment DENTOALVEOLAR ABCESS
Alternative antibiotic for the prophylaxis of endocarditisdue to post
extraction bacteraemia
Potentiate neuromuscular blockers

46. DOSAGE
150-300mg QID oral
200-300mg i.v 8 hourly
SIDE EFFFECTS
Diarrhoea and pseudo membraneous colitis
PREGNANCY-category B group of antibiotic drugs
BREAST FEEDING-AAP suggest that it is fairly safe

47. ANTIAMOEBIC DRUGS -
CLASSIFICATION

48. METRONIDAZOLE
NITROIMIDAZOLE DRUG
 PROTOTYPE was introduced for trichomonas
vaginitis1959
Broad spectrum anti protozoal drug against entamoeba
histolytica and giardia lamblia
Congeners of metronidazole are produced of which
tinidazole secnidazole ornidazole is of now in clinical use
Anaerobic bacteria are susceptible to metronidazole
It does not affect aerobic bacteria

49. PHARMACOKINETICS
Completely absorbed from the small intestine
Little unabsorbed drug reaches the colon
Widely distributed in the body with therapeutic concentration
in vaginal secretion,semen saliva,CSF.

50. METABOLISM AND EXCRETION
metabolised liver by oxidation and glucoronide conjugation
excreted in urine ,T1/2 =8hours
SIDE EFFECTS
Anorexia ,nausea,bitter metallic taste, abdominal
cramps,looseness of stool is occasional,
seizures on high doses
So metronidazole is contraindicated in neurological
disease,blood dyscrasias

51. USES
ORODENTAL INFECTION(anaerobic organism not
responding to amoxicillin)
Drug of choice for acute necrotizing ulcerative gingivitis
were it is always combined with amoxicillin,erythromycin
and tetracycline
5 days course is always sufficient.
 It provides excellent anaerobic coverage used in
conjunction with penicillin..

52. DOSAGE
DOSAGE
FLAGYL,METROGYL.METRON,ARISTOGYL,ALDEZOL
E 200mg,400mg,200mg/5ml
suspension;500mg/100ml i.v infusion
UNIMEZOL-200,400mgtablets,200mg/5ml
suspension
PREGNANCY-category B group of drugs (avoid in first trimester)
BREAST FEEDING-AAP rates it as CONCERN..

53. AZITHROMYCIN
Has a macrocyclic lactone ring with attached sugars
Newer azalide congener of erythromycin
More active against H.influenzae and certain anaerobes like
peptostreptococcus and less active against gram positive
cocci
Higher activity is on respiratory pathogens
Not active against erythromycin resistant bacteria

54. PHARMACOKINETICS
Acid stability, rapid oral absorption,marked tissue
distribution and intracellular penetration
Absorption is decreased by food
Concentration in most tissues exceed than of
plasma
High concentration is achieved inside macrophage
and fibroblast

55. Slow release from intracellular sites contributes to long
terminal t ½ more than 50 hours
USES
Oro dental infection.
Alternative for the antibiotic prophylaxis of post dental
surgery wound infection ,endocarditis in predisposed patients.
Higher efficacy, better gastric tolerance and convenient one
day dosing.

56. DOSAGE-500mg once daily 1 hour before or 2hours after food
to be taken for 3days
SIDE EFFECTS-
Gastric upset ,abdominal pain ,headache,dizziness
PREGNANCY-category B antibiotic drugs
BREAST FEEDING-enters the breast milk so should be used
with caution

57. CLASSIFICATION
FLUROQUINOLONES
FIRST GENERATION
NORFLOXACIN
CIPROFLOXACIN
OFLOXACIN
PEFLOXACIN
SECOND
GENERATION
LOMEFLOXACIN
SPARFLOXACIN
LEVOFLOXACIN
GATIFLOXACIN
MOXIFLOXACIN

58. CIPROFLOXACIN
FIRST generation fluroquinolones active against a broad range of
bacteria
Aerobic gram negative bacilli
Highly susceptible
E.coli
K.Pneumoniae
Neisseria gonorrhoea
N.Meningitidis
Enrobacter
Salmonella typhi
H.Influenzae
H.Ducreyi
Shigella
Proteus
Yersinia enterocolitica
Vibrio cholerae
Moderately susceptible
Staphylocococcus aureus
legionella
Brucella
Enetrobacter
listeria
Salmonella typhi
Bacillus anthracis
H.Influenzae
Mycobacterium
tuberculosIS

59. MICROBIOLOGICAL FEATURES
Rapidly bactericidal activity and potency
Low frequency of mutational resistance
Active against beta lactam and aminoglycosides resistant
bacteria
Less active at acidic Ph
PHARMACOKINETCIS
Absorbed orally ,food delays the absorption
High tissue penetrability
Concentration in lung ,sputum ,muscle,prostrate
exceed that in plasma

60. EXCRETION
Excreted in urine
Urinary and biliary concentration are 10-50 fold higher than plasma
SIDE EFFECTS
CNS-dizziness ,headache ,restlessness and anxiety , insomnia
GIT- nausea, vomiting, bad taste and anorexia
SKIN-hypersensitivity
Plasma concentration of caffeine theophylline and warfarin is increased
due to inbition of metabolism-toxicity of drugs can occur
NSAIDS can enhance CNS toxicity
ANTACIDS &SUCRALFATE AND IRON SALTS give reduced absorption of
ciprofloxacin

61. USES
 Dental:It is not effective against anaerobic bacteria
usually foundin endodontic infections It should be
considered as a second line therapy to penicillin V,
metronidazole and clindamycin if an infection is
persistent and bacterial culture shows bacterial
susceptibility
SYSTEMIC INFECTION-urinary tract infection ,bacterial
gastroenteritis, typhoid fever , gonorrhoea
In combination with other drugs it can be used for
septicaemia and meningitis
chemotherapy for multi drug resistant tuberculosis

62. • DOSAGE
CIFRAN,CIPLOX,CIPROBID,QUINTOR,CIPROLET
250mg,500mg,750mg tablets;200mg/100ml i.v
infusion
3mg/ml eye drop
PREGNANCY-category B antibiotic drugs
BREAST MILK-enters breast milk hence not
recommended

63. Antibiotics commonly
available-dosage

64. Recommended antibiotics and dosages in endodontics

65. Systemic uses
of antibiotics in endodontics

66. ENDODONTIC INFECTION
 .
 The bacterial microflora of the root canal is initially
dominated by aerobes and facultative anaerobes .
 As disease progresses, the ecology within the root canal
system changes and is largely characterized by anaerobic
bacteria in primary infections.
 The most common species of bacteria isolated in odontogenic
infections are the anaerobic gram-positive cocci
Streptococcus milleri group and Peptostreptococcus.
Anaerobic gramnegativerods, such as Bacteroides (Prevotella)
also play an important role.

67. .
 The microbial flora found in secondary infections,
typically are able to survive harsh conditions such as a
wide pH range and nutrient-limited conditions.
 The microbial phenotypes of secondary infections, is
predominated by gram-positive bacteria.

68.  .Generally, an accurate diagnosis coupled with effective
endodontic treatment will decrease microbial flora
sufficiently for healing to proceed.

69.  Evidence based reviews highlight very specific indications
for prescribing antibiotics preoperatively or
postoperatively to prevent endodontic infection or pain;
moreover when the infection becomes systemic.

73.  Before starting patients on antibiotic therapy,
dentists need to consider various factors to
determine the benefit-to-risk ratio that
includes
 clinical diagnosis
 patient’s medical and oral health status,
 patient’s current medication,
 results of microbiological analysis,
 When prescribing, dentists should use the
shortest effective course of a narrow-spectrum
antibiotic

74.  Amoxicillin and penicillin VK -first line of therapeutic
antibiotics
 Amoxicillin + clavulanic acid - unresolved or
recalcitrant infection
 Amoxicillin+clavullanic acid-produce adverse effects such
as gastrointestinal and hepatic disturbances .

75.  Metronidazole – only -odontogenic infections
when in combination with a penicillin provides
excellent gram-positive + gram-negative coverage.
 Allergy to penicillin, clindamycin next choice risk of
colitis and clostridium difficile associated diarrhoea
Azithromycin should be first considered

76. Systemic antibiotics in traumatic
injuries of teeth
(SAP)
The value of systemic administration of antibiotics in human
after replantation -questionable as clinical studies have not
demonstrated its value.
Experimental studies have however, usually shown positive
effects upon both periodontal and pulpal healing especially when
administered topically.. .
International Association of Dental
Traumatology DENTAL TRAUMA
GUIDELINES Revised 2012

77. SYSTEMICANTIBIOTICS USED IN
TRAUMATIC INJURIES OF THE TEETH
MEDICAL STATUS OF THE
PATIENT MAY REQUIRE
ANTIBIOTIC ADMINISTRATION
BUT WHEN THE INJURIES IS
ACCOMPANIED BY SOFT
TISSUE INJURY ANTIBIOTIC
ADMINISTATION IS DONE
IADT GUIDELINES DONOT
RECOMMEND USE OF
SYSTEMIC ANTIBIOTICS IN
THE MANAGEMENT OF
LUXATION INJURIESOR IN
TEETH WITH ROOT
FRACTURES
NOT DEMONSTRATED BY
CLINICAL STUDIES

78.  For systemic administration tetracycline is the first choice
in appropriate dose for patient age and weight the first
week after replantation. (risk of discoloration of
permanent teeth ,tetracycline is not recommended for
patients under 12 years of age.
 A penicillin phenoxymethylpenicillin (Pen V,) or
amoxycillin, -alternative to tetracycline.

79. Segura‐Egea JJ, Gould K, Şen BH, Jonasson P, Cotti E, Mazzoni A, Sunay H, Tjäderhane L,
Dummer PM. European Society of Endodontology position statement: the use of antibiotics in

80. Endocarditis Prophylaxis Recommendations
 Prosthetic cardiac valves, including transcatheter-
implanted prostheses and homografts.
 Prosthetic material used for cardiac valve repair,
such as annuloplasty rings and chords.
 Previous IE.

81. 4 Unrepaired cyanotic congenital heart disease or repaired
congenital heart disease, with residual shunts or valvular
regurgitation at the site of or adjacent to the site of a
prosthetic patch or prosthetic device.
5. Cardiac transplant with valve regurgitation due to a
structurally abnormal valve.

82. Additional Considerations
 Clinical recommendation should be integrated with the
practitioner’s professional judgment in consultation with
the patient’s physician, and the patient’s needs and
preferencesThese considerations include, but are not
limited to:
 Patients with previous late artificial joint infection
 Increased morbidity associated with joint surgery (wound
drainage/hematoma)
 Patients undergoing treatment of severe and spreading oral
infections (cellulitis)
 Patient with increased susceptibility for systemic infection

83.  Congenital or acquired immunodeficiency
 Patients on immunosuppressive medications
 Diabetics with poor glycemic control
 Patients with systemic immunocompromising
disorders(e.g. rheumatoid arthritis, lupus erythematosus)
 Patient in whom extensive and invasive procedures are
planned
 Prior to surgical procedures in patients at a significant
risk for medication-related osteonecrosis of the jaw

86. TOPICAL USES
OF ANTIBIOTICS IN ENDODONTICS

87. Rationale of using topical antibiotics
 Systemic antibiotics -potential risk of various
sideeffects ,development of resistantance
 Antibiotics systemically relies on patient compliance.
 A normal blood supply to the infected area is needed not
possible with a necrotic pulp, a pulpless and infected
root canal system (RCS), or a root-filled tooth that
becomes infected.
 Hence, in RCS, local application of antibiotics is a more
effective mode for delivering the drug.

88. locally used antibiotic agents
 Advantages
Efficient and predictable
disinfection
A high drug concentration
at the local site
Reducing systemic
complications of
antibiotic medication.
 Disadvantage
Possible development of
bacterial resistant strains
(antimicrobial resistance)
Allergic reactions
Inhibition of angiogenesis
Tooth staining or
discoloration.

89. Antibiotics can be used in various modalities in endodontics. First
local use of Antibiotics in endodontics was by Grossman - Father
of Endodontics.

90. ANTIBIOTICS AS
INTRACANAL MEDICAMENTS

91.  Grossmans paste
 Ledermix paste
 Triple antibiotic paste
 Odontopaste
 Septomyxine

92. GROSSMANS PASTE
 First reported use of antibiotic as intracanal
medicament was in 1951.
 Introduced by Grossman as polyantibiotic paste
PBSC.

93. .
PBSC
POLYANTIBIOTIC PASTE
SUSPENDED IN SILICON VEHICLE
PENCILLIN
BACITRACIN
STREPTOMYCIN
CAPRYLATE SODIUM
NOT EFFECTIVE AGAINST ANAEROBIC SPECIES AND
ALLERGIC REACTION NOT USED
PBSCN
NYSTATIN SUBSTITUTED CAPRYLATE SODIUM

94. -Triamcinolone(steroid)1%+demethylchlortetracycline3.2%(antibiotic)
Avaliable :paste and cement
Paste form is preffered in exposed pulp as it contain one third more
steroid than cement form.
Also helps in control of Tooth preparation
Emergency management of irreversible pulpitis
Pulp capping agent in small pulp exposure
Subliner for deep cavities were no exposure but hypersensitivity is
present
Pulp capping agent not recommended as it is also cause pulp irritatio
Can be removed easily.
LEDERMIX

95. ODONTOPASTE
Released in feb.2008
Zinc oxide based root canal paste with 5% clindamycin
hydrochloride and 1%triamcinolone acetonide
 Clindamycin is effective against streptococci,peptostreptococcus
actinomyces,fusobacterium eubacterium,propionobacterium
microaerophilic,peptococcus porphyromona prevotella
 Clindamycin paste has good antibacterial paste but does not
have a antiresorptive property

96. Bacteriostatic property and interim dressing
Corticosteroid can temporary reduce inflammation and post
operative pain
No bleaching required as they donot stain tooth
Contain calcium hydroxide 0.5%optimal for preservation of
corticosteroids

97. SEPTOMIXINE FORTE
Gram negative bacilli neomycine X bacteria and fungi
Gram positive bacteria Polymyxicne B Sulphate
Contains two antibiotics
Neomycine
Polymyxicne B Sulphate

98. SEPTOMIXINE FORTE
Contain dexamethasone halethazole tartrate,neomycin
sulfate,polymyxin b sulfate and tyrothricin
No longer in use as antibiotic are unsuitable for use
against endodontic bacteria(neomycin and polymyxin b)
Inappropriate spectra of activity

99. PULP CAPPING

100.  LEDERMIX PASTE
 PULPOMYXINE

101. LEDERMIX
-
TRIAMCINOLONE(STEROID)+DEMETHYLCHLORTETR
ACYCLINE(ANTIBIOTIC)
AVALIABLE :PASTE AND CEMENT
PASTE FORM IS PREFFERED IN EXPOSED PULP AS IT
CONTAIN ONE THIRD MORE STEROID THAN
CEMENT FORM
EMERGENCY MANAGEMENT OF IRREVERSIBLE
PULPITIS
PULP CAPPING AGENT IN SMALL PULP EXPOSURE
SUBLINER FOR DEEP CAVITIES WERE NO EXPOSURE
BUT HYPERSENSITIVITY IS PRESENT
PULP CAPPING AGENT NOT RECOMMENDED AS IT
IS ALSO CAUSE PULP IRRITATION
PULPOMYXINE
DEXAMETHASONE
POLYMYXIN B SULFATE
FRAMYCETIN SULFATE
NOT USED IN PATIENTS ALLERGIC TO THESE
INGRDIENTS
APPLIED IN FLOOR OF THE DEEP CAVITIES
WITHOUT PULP EXPOSURE,ACUTE
PULPITIS,RECENT PULP EXPOSURE WITH
RECENT PULPITIS
PREPARATION CONTAINING
ERYTHROMYCIN ESTOLATE AND
VANCOMYCIN
PROVED TO BE INEFFECTIVE

102. IRRIGANTS CONTAINING
ANTIBIOTICS

103. BioPure MTAD
Root canal irrigant MTAD commercialized as BioPure MTAD
was introduced by Torabinejad and Johnson in 2003.
 Powder-Liquidsystem.

104.  Part A - liquid containing
 4.25% citric acid&0.5% detergent (Tween 80)
(polyoxyethylene sorbitan mono-oleate (non-
ionic )
 Part B powder –
 3% doxycycline hyclate,
The powder and liquid are mixed by following
the manufacturer’s instructions to obtain the
final ready to use MTAD.
clinically effective and biocompatible, and has
proved its antimicrobial effectiveness against E.
faecalis and over standard IRRIGANTS.

105.  . Study by Newberry et al. demonstrated the
antimicrobial efficacy of MTAD against 8 strains of
E. Faecalis. Here MTAD was used as a final rinse for
5 mins after irrigating the canals initially with 1.3%
Naocl. This showed complete elimination of 7 out of
8 strains of bacteria .
 Tong et al. showed by adding nisin to MTAD, it
enhanced its effectiveness against E. Faecalis biofilm
 .

106. TETRACLEAN
 A mixture of an antibiotic ,acid and detergent but
differ in the concentration of doxycycline
(50mg/ml)and the type of detergent (polypropylene
glycol)
 Against anaerobic and facultative anaerobic bacteria
and removes the smear layer
 Has low value of surface tension when compared to
17%EDTA,smear clear 5.25%NaOCL and MTAD.
 Tetraclean is more effective than MTAD against
E.FAECALIS

107. OBTURATION WITH MEDICATED
GUTTA PERCHA POINTS

108.  Howard Martin developed medicated guttapercha(MGP)
 10% iodoform and tetracycline impregnated gutta percha
(TGP)
 10% tetracycline which intent to retard the growth of
bacteria inside the obturated root canal.
Obturation with medicated gutt a
percha points

109.  TGP -antimicrobial reservoir, inhibiting colonization of
bacteria on the gutta percha points and within the root
canals
 Advocated as an inter-appointment intracanal medicament
and final obturating material.
 Gutta Percha points containing metronidazole for root
canal disinfection have been investigated, an ideal method
for clinical application.
 This concept needs in-vivo studies.

110. MEDICATED SEALER
 Prevent re-infection and impart antimicrobial property
for extended period of time.
 Hoelscher et al. found that, except for metronidazole,
amoxicillin, penicillin, clindamycin and doxycycline
enhanced the antimicrobial efficacy of Kerr Pulp Canal
Sealer (PCS) against E. faecalis.

111. TOOTH REIMPLANTATION
Avulsed teeth with immature root are subjected to root
resorption
But it also has potential for pulp revascularisation
Bacterial contamination occur during the extraoral time
that could inhibit the healing of recently reimplanted
teeth ,so topical treatment of exposed root with
doxycycline before reimplantation.
The tooth has been kept in a physiologic storage medium or
osmolality balanced medium and/or stored dry, the extraoral dry
time has been less than 60 minute.

112. Avulsed teeth with open apex-soaked for 5minutes in
1mg/20ml doxycycline solution
This improves over 60%pulp vascularisation and reduce
the risk of external replacement resorption , ankylosis,
external inflammatory resorption
 Recommended to prescribe oral antibiotic therapy to
avoid infection and external root resorption. The
antibiotic choice is amoxicillin.

113. ANTIBIOTIC IN REGENERATIVE
ENDODONTICS

114. TRIPLE ANTIBIOTIC PASTE
Sterile environment is required for success of any regenerative
procedure
Triple antibiotic paste(TAP) IS COMMONLY USED
It was first used by Sato et al
Metronidazole + ciprofloxacin + minocycline
Commercially available as 3 MIX MP
Combination dosage recommended is 1:1:1 ratio
The carrier - propylene glycol and macrogol ointment at the ratio
1:1

115.  Hoshino et al. recommended metronidazole
(500 mg), minocycline (100 mg) and ciprofl oxacin (200
mg) at a ratio of 1:1:1 for the 3Mix formulation.[ This was
modified by Takushige et al recommended
metronidazole+minocycline+ciprofloxacin at the ratio
3:3:1
This was mixed with ROOT CANAL SEALERS(NOT
RECOMMENDED)

116.  Metronidazole
 broad spectrum and strong antibacterial activity
 against anaerobic cocci, as well as gram-negative and gram-
positive bacilli. (excellent activity against anaerobes isolated
from odontogenic abscesses (Roche & Yoshimori 1997).
 low induction of bacterial resistance (Slots 2002).
 Minocycline
 bacteriostatic and broad-spectrum antimicrobial.
 It is effective against both gram-positive and gram-
negative microorganisms,
 used in periodontal therapy, available in many topical
forms

117. Ciprofloxacin
potent activity against gram-negative pathogens , activity
is limited against gram-positive bacteria,
and most anaerobic bacteria are resistant to ciprofloxacin

118.  intra-coronal use of TAP containing
minocycline is dentine discolouration (Sato
1996, Hoshino et al. 1996, Kim et al. 2010,
Miller et al. 2012, Rodríguez-Benítez et al.
2015). Thibodeau & Trope (2007) suggested
substituting minocycline for cefaclor in the tri-
antibiotic formula to avoid dentine
discolouration, and Miller et al. (2012)
confirmed that the incorporation of cefaclor
into TAP, instead of minocycline, avoided
discolouration.


119. Antibiotics and Stem cells
 preservation of host residual cells is essential for favourable
REP outcomes. Stem cells must survive to contribute to
tissue regeneration (Diogenes et al. 2013).

 TAP is well tolerated by vital pulp tissues (Ayukawa 1994,
Paryani et al. 2012).
 It is biocompatible (Gomes-Filho et al. 2012, Wigler et al.
2013). The TAP concentration used in regenerative
endodontic procedures (100 μg/mL each antibiotic) is
highly effective against endodontic bacteria and is non-toxic
to stem cells of the apical papilla (SCAP

120.  The recent review and ESE position
statement on revitalization procedures
advocate the use of calcium hydroxide
instead of antibiotics to avoid
discolouration (ESE 2016, Galler et al.
2016).

121. DRAWBACKS OF TAP-
DISCOLOURATION
RADIOLUCENT
PROPYLENE GLYCOL USED AS A VEHICLE IS DIFFICULT
TO REMOVE FROM THE DENTIN SURFACE
• AUGMENTIN PASTE –
• 5 WEEKS AS AN INTRACANAL MEDICAMENT
• EXCELLENT INFECTION CONTROL
• COMPLETE OSSEOUS HEALING OF PERIAPICAL LESION AND FORMATION OF
ROOT APEX

122.  Polymer based antibiotic containing electrospun scaffolds
act as a biologically safe antimicrobial drug delivery system for
regenerative endodontics.
 Improve drug delivery system due to high surface area
fibers arranged in an interconnecting structure -allow
controlled drug release , improve drug adaptation to the canal
wall in the regeneration procedure .
As the scaffold degrades not required to remove and thus
reduces the appointment and risk of bacterial contamination .

123.  Although a local antibiotic medication in endodontics
offers, this mode has some drawbacks,
 development of bacterial resistant strains, allergic
reactions,
 inhibition of angiogenesis,
 tooth staining or discoloration.

124. Can Intracanal Antibiotics be
Substituted?
 Hockett et al showed that the apical negative pressure
eradicated biofilms of Enterococcus faecalis within 48
hours, not only from the walls of the rootcanal system, but
also from the dentinal tubules.
 Various other studies have also shown that apical
negative pressure with sodium hypochlorite irrigation
results in similar bacterial reductions and equivalent repair
process resulted
 avoids the risk of drug resistance, tooth discoloration, and
allergic reactions.

126. Overview on the Current Antibiotic Containing Agents Used in Endodontics
Ramta Bansal, Aditya Jain1

127. Antibacterial resistance
 Systemic antibiotics and their benefits in combating
bacteria and infection also carry risk of morphing the
same bacteria they are primed to target into “super bugs”
that resist the therapeutic effects of the drug

128. ANTIBIOTIC CONTAINING
SCAFFOLDS
 TAP has its own drawbacks.
 It is radiolucent
 May be difficult to remove from the
dentin and re-opening the tooth to remove TAP introduces a
risk of recontamination.
 Antibiotic containing scaffolds can solve the problems

129.  Altered cell wall permeability
 confers resistance to tetracyclines,
quinolones, trimethoprim and β lactam
antibiotics
 Creation of biofilm barrier
 provides an environment where offending
bacteria can multiply safe from the hoste
immune system
 Salmonella
 Staph epidermidis

130.  Active efflux pumps
 confers resistance to erythromycin and tetracycline
 e.g. msrA gene in Staph
 Altered peptidoglycan subunit (altered D-alanyl-D-
alanine of NAM/NAG-peptide)
 confers resistance to vancomycin
 e.g. vancomycin resistant enterococcus (VRE)
 Ribosome alteration
 erm gene confer inducible resistance to MLS (macrolide
lincosamide streptogranin) agents via methylation of 23s
rRNA
 demonstrate using D zone test
 for inducible clindamycin resistance in Staph and beta
hemolytic Stre

131. Antibiotics in pregnancy

133. Conclusion
Odontogenic infections are polymicrobial in nature. Astute
diagnosis with appropriate treatment, including elimination
of the causative factor, is crucial for successful management
of dental infections. Antibiotics are a useful adjunct in the
treatment of odontogenic infections, but should not replace
removal of the etiologic agent .

134.  Identifying factors contributing to antibiotic resistance
through the use and abuse of these drugs is paramount. All
dentists should know if and when to prescribe antibiotics
and the respectable time for referral to a specialist.
Prudent antibiotic stewardship needs to be embraced by
the dental community with prescribing patterns reflective
of current best habits and practices.

135. References
 1. Beringer PM, Wong-Beriner A, Rho JP. Economic
aspects of antibacterial adverse effects.
Pharmacoecomonics 1999; 13-35-59.)
 2. Foaud AF, Rivera EM, Walton RE. Penicillin as a
supplement in resolving the localized acute apical
abscess. Oral Surg 1996;81(5): 590-595
 3. Fedorowicz Z, van Zuuren Ejj, Farman AG, Agnihotry
A, Al-Lanawi JH. Antibiotic use for irreversible pulpitis.
Cochrane Database Syst Rev. 2013;12: CD004969
 4. World Health Organization. Global action plan on
antimicrobial resistance. Available at:
http://www.who.int/antimicrobial-resistance/global-
action-plan/en/. Accessed August 5 2019

136.  Outpatient Settings, 2017 CDC https://www.cdc.gov/antibiotic-
use/community/programs-measurement/state-local-activities/outpatient-
antibiotic- prescriptions-US-2016.html
 6. AAE Guidance on the use of Systemic Antibiotics in Endodontics 2017
 7. Marra F, George D, Chong M, et al. Antibiotic prescribing by dentists has
increased: why? JADA. 2016; 147(5): 320-327
 8. Durkin MJ, Feng Q, Warren K, Lockhart PB, Thornhill MH, Munshi KD,
Henderson RR, Hsueh K, Fraser VJ; Centers for Disease Control and
Prevention Epicenters. Assessment of inappropriate
 antibiotic prescribing among a large cohort of general dentists in the
United States. J Am Dent Assoc. 2018 May;149(5):372-381.e1. doi:
10.1016/j.adaj.2017.11.034.
 9. American Association of Endodontists. AAE guidelines on the use of
systemic antibiotics in endodontics: AAE position statement. Available at
https://www.aae.org/specialty/wp- content/uploads/
 sites/2/2017/06/aae_systemic-antibiotics.pdf Accessed June 5,2019.