While the most important step in managing endodontic infections is prompt treatment by general dentists or endodontists, use of antibiotics when indicated may be necessary in managing certain endodontic emergencies. The American Association of Endodontists (AAE) has recently updated the guidelines for the use of systemic antibiotics for the urgent management of dental infections. The full article can be viewed here.
- antibiotics are NOT indicated in immunocompetent patients who have no evidence of lymphadenopathy, fever, malaise, fascial space involvement
- first line of effective antibiotics in endodontic infections: amoxicillin 500mg
- in resistant infections: amoxicillin combined with metronidazole 500mg
- in patients with true allergy to penicillin (i.e., history of anaphylaxis, angioedema or hives): azithromycin 500mg
- in patients with reported allergy to penicillin (i.e. not true allergy): oral cephalexin 500mg
- if patient cannot take azithromycin: clindamycin 300mg
- clindamycin now has U.S. FDA black box warning for C. difficile infection, which can be fatal.
- antibiotic treatment is discontinued as soon as definitive treatment and improvement of the condition occurs (as short as three days).
Inappropriately prescribing antibiotics is one of the main contributing factors in the development of antibiotic resistant microorganisms.
The most effective treatment of endodontic infections are: removal of the source of infection through endodontic treatment, incision for drainage, or extraction. Antibiotics are used in addition to appropriate treatment to aid the host defenses in the elimination of remaining bacteria.
Antibiotics are INDICATED when there is systemic involvement or evidence of spread of infection. Signs and symptoms include: fever >100F, malaise, cellulitis, unexplained trismus, lymphadenopathy, rapid onset swelling. Antibiotic prophylaxis should also be considered for medically at-risk patients, for prevention of infective endocarditis and delayed prosthetic joint infection.
Antibiotics are NOT INDICATED in: teeth with signs of irreversible pulpitis (hot teeth, cracked teeth, teeth with large decays, etc.), teeth with necrotic pulps and a radiolucency, teeth with a sinus tract, and teeth with localized fluctuant swellings.
What to use? Pen-V-K is the antibiotic of choice for endodontic infections. Metronidazol should be used in combination with Pen-V-K or clindamycin if patient’s symptoms worsen 48-72 hours after the initiation of treatment. Amoxicillin is often used for antibiotic prophylaxis cases. Clindamycin is the antibiotic of choice for patients allergic to penicillins or when a change in antibiotic is indicated. Amoxicillin-Clavulanate should be reserved for unresolved infections and patients who are immunocompromised.
[AAE Colleagues for Excellence – Summer 2006]