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We are all familiar with the expression "Chicken soup…may not help but wouldn’t hurt". We should all be alarmed with the tendency for clinicians to prescribe antibiotics, like chicken soup, without understanding their proper usage. It is understandable that dentists wish to provide relief for their symptomatic emergency patients with the least interruption of their practice day. However, wholesale use of antibiotic prescriptions as an effortless method of "getting the patient out of the office" or "dealing with the symptomatic telephone call" must be condemned.
Understanding pulp pathology precludes the use of antibiotic therapy in vital cases. It is ironic that clinicians who prescribe antibiotics for thermally sensitive "sick pulps", do not recognize that part of the pathology involves compromise of circulation to this organ. Antibiotic therapy is of NO value in the case of pulpitis with a vital pulp. Antibiotics rely on the attainment of an adequate concentration of the medication via the circulation. When pulpal circulation is compromised by inflammation, there is no way for this medication to reach the affected area i.e./ the most coronal or radicular pulp. The most critical management decisions facing the clinician dealing with pulpitis, are whether or not periapical symptoms are present and how to deal with a diseased or dying pulp.
(1) The Thermally Sensitive Tooth with NO Periapical Symptoms – Vital Tooth
The problem is the coronal pulp. Treatment is pulpotomy (or pulpectomy if there is sufficient time). This will relieve the thermal symptoms and allow the patient to be rescheduled for completion of endodontic treatment when time allows. Antibiotics are contraindicated.
(2) The Periapically Involved Tooth – May be Partially Vital or Non-vital
Teeth with periapical involvement will have signs that include slight percussive sensitivity, periapical palpation sensitivity and/or swelling and sometimes visible radiographic periapical pathology. Relief will be most predictably obtained by pulpectomy. Canals should be broached, irrigated and cleaned to approximately size #15 or #20 instrument (if possible) with electronic confirmation of working length. In this way, the minimal remaining pulp remnants have little possibility of increasing the periapical inflammation. Antibiotics are not required as long as you have good instrument length control and do not push canal contents into the periapex . The occlusion is relieved and the patient is placed on anti-inflammatory medication. Routine prescription of antibiotics "just in case", is not supported by the literature.
(3) Post Treatment Exacerbation - (Blow Up)
In rare cases, you may need to place the patient on antibiotics if they develop post pulpectomy blow up. This usually occurs 48 hours after treatment and is due to pushing debris out of the apex. It is more often associated with necrotic or retreatment cases. Pathology is due to inoculation of the periapical area with pulp content and bacteria, inadvertently introduced into this area by a file. When placing instruments in canals, working lengths must be accurate. Use an electronic apex locator (EAL) to prevent being long with files. (See Apex Location Techniques in the next months Endo Fax or the opinions section of www.endoexperience.com for hints on working with an EAL) Confirm working lengths with images (x-ray film or digital radiography).
If the case blows up, there will be PDL inflammation. The tooth will extrude. Pain and periapical palpation sensitivity and swelling will occur. Relief of the occlusion is important for comfort. The first 48 hours post-treatment are the most critical. Good communication with patients prevents cases from getting out of control. Antibiotics should be given immediately in those cases where post operative swelling is reported. It is important to start the medication early and to ensure that the patient does NOT apply heat to the area externally. THERE IS NO SCIENTIFIC BASIS FOR GIVING ANTIBIOTICS AS A "PROPHYLAXIS" IN THE CASE OF THE SINGLE APPOINTMENT TREATMENT OF AN ASYMPTOMATIC NECROTIC TOOTH.
Clinicians considering Antibiotic therapy should read : Baumgartner JC, and Falkner WA. Bacteria in the apical five mm of infected canals JOE 1991;17:380. This article categorizes various antibiotics used in treatment as well as indications for their use.
The continued irrational use of antibiotics as "do something" treatment, contributes to the proliferation of antibiotic resistance. The consequences will probably not be apparent to clinicians in their middle or late career years. The problem will no doubt escalate in the future, as bacteria become more resistant and we are left with fewer effective drugs. Those of us prescribing in a haphazard manner may well be responsible for a situation where our children and grandchildren have fewer and fewer alternatives for treating serious bacterial infection in other, more critical areas of the body. |
