Antibiotics in Endodontics: A Clinical Guide
As dentists we treat patients with oral infections every day.
At times those infections can overwhelm a host’s immune response and bacteria can extend into the periapical tissue and eventually into the facial spaces in the head and neck. Antibiotics are not curative, however a sound knowledge of which medications to prescribe and more importantly when to prescribe these medications help in our everyday patient care.
In endodontics, removing the source of infection will almost always prevent the need for antibiotic therapy. Complete debridement of the root canal system without over instrumentation will allow the body’s immune system to overcome and resolve the infection. The majority of endodontic infections will not require an antibiotic when the root canal system is properly cleaned. Even in the cases where an apical lucency is present in conjunction with a necrotic pulp, as long as the patient remains comfortable, the body’s inflammatory process prevents the bacteria from spreading into the periapical tissue.
However, when a patient presents with significant discomfort or diffuse facial swelling, an antibiotic will help ease a patient’s pain and aid in resolving the infection. Most endodontic infections are a combination of Gram-positive and Gram-negative anaerobic bacteria. The following table can be used as a guide as to which antibiotics to prescribe for an endodontic infection:
1. Pen VK, is still the number one choice. A cycle of 500 mg, 2 stat, and one tab four times a day for seven days is recommended. Pen VK is a narrow spectrum antibiotic that effectively targets polymicrobial infections of the mouth. PenVK is a more efficient antibiotic for endodontic infections than Amoxicillin.
2. Clindamycin, 300 mg, 2 stat, 1 tab, three times a day; is recommended for those patients allergic to PenVK. Clindamycin can cause stomach problems with some patients and we always recommend a pro-biotic in conjunction with this antibiotic. If a patient has a history of stomach problems, we may prescribe a lower dose of the medication, 150mg, three times a day.
3. For those infections that are non-responsive to PEN VK, we add Flagyl (Metronidazol), 500 mg, 2 stat, 1 tab four times a day. Flagyl strictly targets anaerobic bacteria and should be used in combination with Pen VK if possible. We usually reserve Flagyl for those infections that have not responded after several days of Pen VK.
**Clindamycin can also be used in conjunction with PVK (as opposed to Flagyl) for refractory infections.
The latest evidence also recommends monitoring a patient with an acute infection daily. If we see that the patient’s infection has resolved and symptoms are minimal the antibiotic can be stopped even before the full seven day cycle is complete. With growing resistance to antibiotics and in order to provide effective treatment of bacterial infections we try to prescribe antibiotics judiciously and only when indicated.
I hope this blog can help serve as a guide to the management of acute infections with oral antibiotics.
Thanks for visiting us at Tri City and Fallbrook Micro Endodontics, serving the greater San Diego, CA area.