Antibiotic prophylaxis in endodontics
The use of broad-spectrum antibiotics in dentistry is common, on the rise, and problematic. Prescriptions are written too often when not indicated (for example, for symptomatic irreversible pulpitis, necrotic pulps, and localized acute apical abscesses), said the authors of an article who sought to recommend more judicious applications of antibiotics in endodontics.
In an article published January 16 in International Endodontic Journal, the European authors examined the current literature regarding the indications and use of antibiotics in dentistry with the aim of providing guidance to endodontists. The authors declared that dentists generally prescribe about 10% of antibiotics dispensed in primary care and “it is important not to underestimate the potential contribution of the dental profession to the development of antibiotic-resistant bacteria ... .”
The authors examined antibiotic prophylaxis as an adjunct to endodontic therapies (irreversible pulpitis, acute apical periodontitis, and progressive infections) and for treatment of traumatic injuries to teeth (luxation injuries and replantation of avulsed tooth). They also examined the use of topical antibiotics in pulp capping, root canal treatments, regenerative endodontic procedures, and replantation of avulsed tooth.
They determined that antibiotics were to be avoided as adjuncts in favor of other approaches, specifically when treating symptomatic irreversible pulpitis, pulp necrosis, acute apical periodontitis, chronic apical abscess, and acute apical abscess with no systemic involvement.
They examined 5 types of traumatic injury. The only 1 for which antibiotic prophylaxis was indicated was replantation of avulsed teeth. In those cases, antibiotics should be prescribed for the shortest, most effective time and not as substitutes for endodontic treatment.
“The key to obtaining a successful result in an endodontic infection is the chemomechanical removal of the infecting agent from the root canal system as well as drainage of pus,” wrote the authors. “The indications for antibiotic administration should be considered very carefully and only as an adjunct to endodontic treatment, which is the major and indispensable procedure for obtaining the optimum outcome in lesions of endodontic origin.”
The authors concluded that endodontists can avoid overprescription of antibiotics by limiting them to instances in which infection is persistent, progressive, or systemic or when the patient is medically compromised in specific ways, including having infective endocarditis, immune system deficiencies, and certain prosthetics. The authors recommended the use of certain antibiotics. “Although penicillin VK, possibly combined with metronidazole to cover anaerobic strains, is still effective in most cases, amoxicillin (alone or together with clavulanic acid) is recommended because of better absorption and lower risk of side effects,” they wrote. “In case of confirmed penicillin allergy, lincosamides, such as clindamycin, are the drug of choice.”
Read the original article.
Consulting Editor: Susan Wood, DDS
Diplomate, American Board of Endodontics
Coconut milk and probiotic milk storage for avulsed teeth
The outcomes of replanted teeth are associated with the survivability of periodontal ligament cells (PDL), which form the tissue for alveolar attachment apparatuses, say researchers in an article published online December 12 in Dental Traumatology.
Keeping avulsed teeth protected until attempted replantation needs to happen quickly to save the PDL cells. In addition to Hank’s balanced salt solution (HBSS), milk can be used as a storage medium during extraalveolar periods. Researchers from the Department of Pedodontics and Preventive Dentistry at M.S. Ramaiah University of Applied Sciences in Bangalore, India, compared the efficacy of coconut milk and probiotic milk separately with HBSS in preserving the viability of PDL cells in an avulsed tooth.
In the in vitro study, the researchers obtained 69 noncarious human premolars that were extracted from patients owing to orthodontic reasons. The researchers randomly divided the newly extracted teeth into 3 sets of 23—1 for storage in coconut milk, 1 for storage in probiotic milk, and 1 for an HBSS control group.
After extraction, the teeth were dry stored for 20 minutes and then immersed for 30 minutes in their assigned storage media. The teeth then underwent collagenase-dispase assay and were labeled with 0.5% trypan blue staining solution to determine cell viability. The researchers counted the number of viable cells using a light microscope and statistically analyzed the data using analysis of variance and post hoc Tukey test.
The authors found that probiotic milk was a safer storage medium than coconut milk. Probiotic milk, however, kept pace with HBSS. “The ability of probiotic milk to maintain PDL cell viability may be considered almost comparable to that of HBSS,” the authors said.
Read the original article.
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Nonsteroidal anti-inflammatory drugs and antibiotic effects on calcium hydroxide paste
Nonsteroidal anti-inflammatory drugs (NSAIDs) or an antibiotic in conjunction with calcium hydroxide (CH) paste can fight Enterococcus faecalis, according to an article published in the January issue of Journal of Endodontics.
To determine how effective the combinations were against E. faecalis, which is often involved with endodontic failures despite CH therapy, researchers explored whether the NSAIDs diclofenac sodium and ibuprofen or the antibiotic ciprofloxacin would help or harm the pH and limited antimicrobial benefits of CH paste. They combined them over various time intervals and applied the combinations to biofilm colonized on bovine incisors.
The tested combinations were:
- CH paste with propylene glycol;
- CH paste with propylene glycol plus 5% diclofenac sodium (a NSAID);
- CH paste with propylene glycol plus 5% ibuprofen (a NSAID);
- CH paste with propylene glycol plus 5% ciprofloxacin (an antibiotic);
- a positive control (without medication).
The researchers sterilized 30 bovine incisor dentin blocks before inducing E. faecalis biofilm in them and confirming the purity of the microorganism.
The authors found that the association of NSAIDs or antibiotic did not interfere with the pH of calcium hydroxide paste and it increased the antimicrobial action of calcium hydroxide paste against the biofilm of E. faecalis. In addition, the 2 NSAIDs offered the additional benefit of potentially preventing the use of an antibiotic to fight E. faecalis.
Another potential plus the authors noted—with the caveat that further studies are needed to confirm the findings—was that “the association of anti-inflammatory drugs with calcium hydroxide paste would be a topical action in the control of inflammation, which could reduce postoperative pain in patients after endodontic intervention.”
Read the original article.
Nonsteroidal anti-inflammatory drugs and preoperative, postoperative pain
In a systematic review and meta-analysis of scientific literature, researchers found unclear evidence regarding the most effective analgesic for treating postoperative pain in patients who seek treatment for preoperative pain.
In an article published in the January issue of Journal of Endodontics, the authors compared the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) alone or combined with other analgesics with a placebo or nonnarcotic analgesics in reducing postoperative pain and the incidence of adverse events in patients with preoperative pain who underwent initial orthograde endodontic treatment.
The authors of the most recently published systematic review on the use of NSAIDs for treating postoperative endodontic pain, published in 2002, found that the most effective analgesics were a combination of flurbiprofen and tramadol or a combined regimen of preoperative and postoperative flurbiprofen. The systematic review authors proposed to update the 2002 findings using studies published over the past 14 years.
Through electronic and manual searches of select databases—Ovid MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials—the reviewers identified 2,284 studies and included 15 articles pertaining to postoperative endodontic pain management with NSAIDs. All of the included studies had a moderate to high risk of bias.
Although they found that some NSAIDs alone and when combined with other nonnarcotic analgesics and drugs provided greater pain relief than a placebo, they also found that the literature often lacked clarity in its results.
The systematic review’s findings included the following:
- 600 milligrams of ibuprofen provided greater pain relief than a placebo;
- 600 mg of ibuprofen and 1,000 mg of acetaminophen provided greater pain relief than a placebo;
- 500 mg of naproxen and 50 mg of ketoprofen may have been more effective than ibuprofen.
The researchers deduced that 600 mg of ibuprofen was more effective at relieving pain than a placebo 6 hours after endodontic treatment and that 600 mg of ibuprofen combined with 1,000 mg of acetaminophen was significantly more effective than a placebo at 6 hours.
However, the researchers found that the strength of the evidence recommending ibuprofen or ibuprofen plus acetaminophen over placebo was low. Based on preliminary information, 50 mg of ketoprofen and 500 mg of naproxen might be more effective than 600 mg of ibuprofen 6 hours after surgery.
The authors found that the literature was lacking and that more studies with larger sample sizes are needed that analyze endodontic pain to increase statistical power.
The researchers concluded that, “At this time, there are insufficient data to recommend the most effective NSAID, dose amount, or dose interval for relieving postoperative endodontic pain in patients with preoperative pain.”
Read the original article.
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Evaluators and users tout this endodontic irrigating solution
Facts about Irritrol:
• Disinfection rate of 99.99%.*
• Against Enterococcus faecalis better than 2% CHX alone.*
• Removes the smear layer less aggressively than conventional irrigants, therefore causing less demineralization of the dentin.*
* See below link for citations.
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What is Specialty Scan?
This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on endodontics, the first in the series on this topic for 2017. Other specialty scan issues are devoted to oral pathology, oral and maxillofacial radiology, orthodontics, pediatric dentistry, periodontics and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome your feedback on this and all specialty scan issues.
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