Antibiotics Role In Endodontics

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1 : Antibiotics In Endodontics Dr. Navin Mishra Saturday, December 24, 2011
2 : Table Of Contents Introduction Classification Role and Rationale of its use Advantages Disadvantages Conclusion Saturday, December 24, 2011
3 : Antibiotics ---------? Chemotherapeutic Agents Now Antimicrobials Agents (AMA) Saturday, December 24, 2011
4 : Introduction Antibiotic (from the Ancient Greek – anti, "against", and – bios, "life") is a substance or compound that kills, or inhibits the growth of, bacteria. Antibiotics belong to the broader group of antimicrobial compounds, used to treat infections caused by microorganisms, including fungi and protozoa. The term "antibiotic" was coined by Selman Waksman in 1942 to describe any substance produced by a microorganism that is antagonistic to the growth of other microorganisms in high dilution. Saturday, December 24, 2011
5 : Antimicrobials drugs are the greatest contribution of the present century to therapeutics. There advent changed the outlook of the doctors about the power drugs can have on the diseases. Chemotherapy mean ‘ treatment of systemic infections with specific drugs that selectively suppress the infecting microorganism without significantly affecting the host’. Saturday, December 24, 2011
6 : History of chemotherapy The history of chemotherapy is divided into three phases. A. The period of empirical use of ‘mouldy curd’ by chinese on boils, chaulmoogra oil by Hindus in leprosy, chenopodium by Aztecs for intestinal worms, mercury by Paracelsus for syphilis, cinchona barks for fevers. ( 16 – 17th century) B. Ehrlich’s phases of dyes and organometallic compounds ( 19th century) : with the discovery of microbes in later half of 19th century Ehrlich toyed with idea that if certain dyes could selectively stain microbes, they could also be selectively toxic to these organisms, and tried methylene blue , tryptan red etc. Saturday, December 24, 2011
7 : C. The modern era of chemotherapy was ushered by Domagk in 1935 by demonstrating therapeutic effect of Prontosil, a sulfonamide dye, in pyogenic infection. Flemming in 1929 found that diffusible substance was elaborated by penicillium mould which could destroy Staphylococcus on the culture plate. Chain and Florey in 1941 followed up this observation and purified penicillin for its clinical use. Past 70 years emphasis has shifted from searching new antibiotics producing organisms to developing semisynthetic derivatives of older antibiotics with more desirable properties. Saturday, December 24, 2011
8 : Classification Of Antibiotics Although there are several classification schemes for antibiotics, based on bacterial spectrum (broad versus narrow) or type of activity (bactericidal vs. bacteriostatic), the most useful is based on chemical structure. Saturday, December 24, 2011
9 : Classification On Chemical Structure Sulfonamides : They are derivatives of Sulfanilamide ( p-aminobenzene sulfonamide) Short acting ( 4-8 hrs) ----- Sulfadiazine, Sulfisoxazole Intermediate acting ( 8-12 hrs) ---- Sulfamethoxazole, Sulfamoxole Long acting ( 7 days) -----Sulfadoxine, Sulfamethopyrazine Special purpose sulphonamides ----- Sulfacetamide sodium, Sulfasalazine, Mafenide, Silver sulphadiazine. Saturday, December 24, 2011
10 : Beta lactam Antibiotics These are antibiotics having beta lactam rings. The two major groups are Penicillin and Cephalosporins. Monobactams and Carbapenems are the newer additions. Penicillins 1. Natural penicillin --- Penicillin G 2. Semisynthetic Penicillin: Acid resistant alternative to Penicillin G------ Penicillin v Penicillinase resistant penicillin------ Methicillin, Oxacillin, Cloxacillin Saturday, December 24, 2011
11 : Extended spectrum penicillin ----- A. Aminopenicillins: Ampicillin, Amoxycillin, Bacampicillin. B. Carboxypenicillin---- Carbenicillin, Carbenicillin indanyl, Ticarcillin. C. Urediopenicillin ---- Mezlocillin, Piperacillin. Beta-lactamase inhibitors---- Clavulanic acid, Sulbactam. Saturday, December 24, 2011
12 : Cephalosporins These are groups of semisynthetic antibiotics derived from ‘Cephalosporin- C’ obtained from a fungus Cephalosporium. They are chemically related to Penicillins; the nucleus consists of a Beta lactam ring fused to dihydrothiazine ring. First generation: Parenteral: Oral Cephalothin Cephalexin Cefazolin Cefradine Cephaloridine Cefadroxil Saturday, December 24, 2011
13 : Second generation: Parenteral Oral Cefuroxime Cefaclor Cefoxitin Cefuroxime axetil Third generation: Parenteral Oral Cefotaxime Cefixime Ceftizoxime Ceftriaxone Ceftazidime Cefoperazone Saturday, December 24, 2011
14 : Fourth generation: Cefipime Cefpirome Cefquinome Cefozopran Fifth generation: Ceftobiprole Monobactam ---------- Aztreonam Carbapenem----------- Imipenem Saturday, December 24, 2011
15 : Tetracycline's These are class of antibiotics having nucleus of Four cyclic rings. All are obtained from soil actinomycetes. Group 1 Group 2 Group 3 Chlortetracycline Demeclocycline Doxycycline Oxytetracycline Methacycline Minocycline Tetracyclines Lymecycline Saturday, December 24, 2011
16 : Chloramphenicol It has nitrobenzene substitution which is responsible for bitter taste and antibacterial activity. It was initially obtained from Streptomyces venezuelae in 1947, later it was synthesized chemically and now all commercial products are synthetic. Saturday, December 24, 2011
17 : Aminoglycosides These are group of natural and semisynthetic antibiotics having polybasic amino groups linked glycosydically to two or more aminosugars residues ( Streptidine, 2- deoxy streptamine). They are : Streptomycin Gentamycin Kanamycin Tobramycin Amikacin Sisomycin Netilmycin Neomycin Framycetin Saturday, December 24, 2011
18 : Macrolides The macrolide antibiotics are derived from Streptomyces bacteria, and got their name because they all have a macrocyclic lactone chemical structure. The macrolides are bacteriostatic, binding with bacterial ribosomes to inhibit protein synthesis The most commonly prescribed macrolide antibiotics are: Erythromycin Clarithromycin Azithromycin Dirithromycin Roxithromycin Troleandomycin Saturday, December 24, 2011
19 : Flouroquinolones The quinolones also referred to as fluoroquinolones are a family of synthetic broad-spectrum antibiotics. The term quinolone(s) refers to potent synthetic chemotherapeutic antibacterials the first generation of which was derived from an attempt to create a synthetic form of chloroquine, which was used to treat malaria during World War II. Quinolones are synthetic chemotherapeutic agents which have a broad spectrum of antimicrobial activity as well as a unique mechanism of action resulting in inhibition of bacterial DNA gyrase and topoisomerase IV. Quinolones inhibit the bacterial DNA gyrase or the topoisomerase IV enzyme, thereby inhibiting DNA replication and transcription.
20 : For many gram-negative bacteria DNA gyrase is the target, whereas topoisomerase IV is the target for many gram-positive bacteria. It is believed that eukaryotic cells do not contain DNA gyrase or topoisomerase IV. However, there is debate concerning whether the quinolones still have such an adverse effect on the DNA of healthy cells, in the manner described above, hence contributing to their adverse safety profile. This class has been shown to damage mitochondrial DNA(Am J Health Syst Pharm 2007)
21 : 1st generation Cinoxacin (Removed from clinical use) Flumequine (Genotoxic carcinogen) Nalidixic acid (Genotoxic carcinogen) Oxolinic acid (Currently unavailable in the United States) Piromidic acid (Currently unavailable in the United States) Pipemidic acid (Currently unavailable in the United States) Rosoxacin (Restricted use, currently unavailable in the United States
22 : 2nd generation The 2nd generation class is sometimes subdivided into "Class 1" and "Class 2". ciprofloxacin Enoxacin (Removed from clinical use) Fleroxacin (Removed from clinical use) lomefloxacin (Discontinued in the United States) Nadifloxacin (Currently unavailable in the United States) Norfloxacin (restricted use) Ofloxacin (Discontinued in the United States) Pefloxacin (Currently unavailable in the United States) Rufloxacin (Currently unavailable in the United States
23 : 3rd generation Balofloxacin (Currently unavailable in the United States) Gatifloxacin (removed from clinical use) Grepafloxacin (Removed from clinical use) Levofloxacin Moxifloxacin (restricted use). Sometimes reported as 4th generation. Pazufloxacin(Currently unavailable in the United States) Sparfloxacin (restricted use) Temafloxacin (Removed from clinical use) Tosufloxacin(Currently unavailable in the United States)
24 : 4th generation Clinafloxacin (Currently unavailable in the United States) Gemifloxacin (Currently unavailable in the United states) Sitafloxacin (Currently unavailable in the United States) Trovafloxacin (Removed from clinical use) Prulifloxacin (Currently unavailable in the United States) In development Garenoxacin (Application withdrawn due to toxicity issues) Delafloxacin (Am J Health Syst Pharm 2007)
25 : Antibiotics are also classified as Primarily bacteriostatic ( slow acting) primarily bactericidal (fast acting). Bacteriostatic: sulfonamides, tetracyclines, macrolides, chloramphenicol. Bactericidal: penicillins, cephalosporins, fluorquinolones, vancomycin. Metronidazole, secindazole, tinidazole. Saturday, December 24, 2011
26 : Mechanism Of Action Of Antibiotics Saturday, December 24, 2011
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28 : Rationale Behind Antibiotic Usage
29 : To serve in the best interest of our patients and profession, it is imperative that we not only know which antibiotic has to be employed, but more importantly we should be judicious enough to realize whether there is any need for one at all? Thus rationale behind use of antibiotic in endodontic should be based on the following three criteria:
30 : 1. whether antibiotics is indicated in a given endodontic infection? 2. when to advocate prophylactic antibiotic coverage? 3. which antibiotic is the best to resolve infections of endodontic origin?
31 : Is antibiotic necessary? “The desire to take medicine is perhaps the greatest feature, which distinguishes Man from Animal” ( William Osler) Antibiotics are designed primarily to control active microbial infections, not for preventing the possibility of infections, unless the person is medically compromised. The common notion behind prescribing antibiotics during endodontic infections is to quell the infection present in the pulp space and the periapical area. Many of us fail to understand that for antibiotics to kill the susceptible bacteria, the systemic antibiotic has to be carried by the blood circulation to the pulp space to come in direct contact with the bacteria.
32 : In an infected or necrosed pulp this doesn't happen as the blood supply is highly constrained and restricted. In case of periapical pathoses, it is very important to appreciate that most chronic endodontic periapical lesions are not infected lesions but are inflammatory lesions ( JOE , 1992) The inflammation in the periapical area is mostly caused by bacterial toxins, their harmful metabolic by products or disintegrating pulp tissue from root canal. Hence elimination of irritants, especially pathogenic bacteria in the root canal by careful chemomechanical debridement is far more effective than antibiotics in preventing flare-ups and treating endodontic periapical lesions
33 : Moreover, the incidence of bacteremia associated with nonsurgical root canal treatment is essentially negligible as long as the endodontic instruments are confined within the root canal system ( J Endod 1997)
34 : When Are Antibiotics Indicated? The only indications for usage of antibiotics in endodontics are: Active microbial infections with manifestations of local and systemic signs and symptoms such as diffuse swelling with sinus discharge, fever, malaise, lymphadenopathy and elevated White Blood cell count. Preventing the possibility of any infection following bacteremia in high risk patients. Patients having ludwig’s angina, fascial or space infection, cavernous sinus thrombosis due to endodontic infection. The rationale behind advocating prophylactic antibiotic coverage in endodontics is to prevent the inadvertent bacteremia following chemomechanical debridement of pulp space in high risk patients.
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37 : Administration of antibiotics is usually recommended when a traumatically avulsed tooth is replanted, in order to prevent bacterial contamination It was found that after systemic antibiotic treatment at the time of replantation there was no inflammatory root resorption. (Dental Traumatology Volume 2 Issue 2, Pages 51 - 57) Ellis class II, Ellis class III Initiate antibiotics with coverage of intraoral flora (eg, penicillin, clindamycin). (Treatment & Medication: Fractured Teeth eMedicine Specialties , Clinical Procedures ,Otolaryngologic and Dental Procedures)
38 : Antibiotic As Anti inflammatory Agent A number of studies have been conducted to explain the mechanisms whereby macrolides exert these anti-inflammatory actions. Using the rat carrageenin paw edema model, roxithromycin given prophylactically suppressed edema produced by injecting carrageenin into the paw at levels comparable to those of the non-steroidal anti-inflammatory drug nimesulide Azithromycin and clarithromycin also had potent anti-inflammatory effects in that study while erythromycin had the least anti-inflammatory effects. These macrolides also reduced prostaglandin E2 and TNF-alpha. (J Antimicrob Chemother 1998: 41: 47–50).
39 : Conditions Warranting Prophylactic Antibiotics Coverage Uncontrolled Diabetes Mellitus Prosthetic cardiac valves Previous bacterial endocarditis Complex, cyanotic congenital heart disease Surgically constructed systemic shunts Rheumatic heart disease Addison's disease Mitral valve prolapse and valvular regurgitation Total joint replacement AIDS Heart, liver, Kidney, Transplant Dialysis ( Heamo, CAPD) Harrison's principle and practice of medicine
40 : It is advisable to give prophylactic antibiotic to the patients in 1. Any conditions, which causes immunosuppression in the patient. 2. Any conditions which creates an ideal breeding ground for infections in a patient.
41 :
42 : Endodontic Topics 2002, 3, 52–66
43 : Choosing The Right Antibiotics An endodontist’s motto when it comes to prescribing antibiotics should always be “caution”, and this duty can be expressed by this couplet- “ Be not the first by whom the new are tried nor yet the last to lay old aside.” (Pope Alexander)


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Role of antibiotics in endoontics
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