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Endodontics Pharmacology

What is the best antibiotic to prescribe for irreversible pulpitis?

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This question was submitted by a general dentist: What is the best antibiotic to prescribe for irreversible pulpitis?

Dr. Mary Dabuleanu, from Dabuleanu Dental,  in collaboration with Dr. Suham Alexander, Oasis Clinical Editor, provided this quick initial response

What is irreversible pulpitis?

Irreversible pulpitis is essentially a diagnosis based on both objective and subjective clinical findings which determines that the pulpal tissue has become inflamed but is not capable of healing. The following description(s) apply to teeth diagnosed with irreversible pulpitis.

  • ASYMPTOMATIC -tooth has no symptoms or pain but, left untreated with a deep carious lesion or significant tooth structure loss, the tooth will be come painful and/or nonvital
  • SYMPTOMATIC -tooth has spontaneous and intermittent pain, exposure to cold or extremes of temperature causes intense and prolonged pain after the stimulus is removed-usually an emergency situation

Emergency Dental Management

Antibiotics are not recommended in the treatment of irreversible pulpitis!

There is insufficient scientific research to ascertain whether the use of antibiotics is helpful, studies show that antibiotics do not have any significant effect of reducing the pain from a toothache.

  • Symptomatic irreversible pulpits – remove infected pulp and clean the root canal system. If there are time constraints at the emergency visit, then a pulptomy may be performed. The patient would then be re-appointed soon after to complete root canal treatment.
  • NSAIDs and acetaminophen are commonly used to manage endodontic pain. NSAIDs are very effective in managing pain due to inflammation. As organic acids, NSAIDS have low PKa values which aid in the penetration of the active drug into the acidic environment of inflamed tissue. Moreover, there is enhanced delivery of these drugs into inflamed tissues via extravasation of NSAID-bound plasma proteins.

References

  1. Fedorowicz Z, van Zuuren EJ, Farman AG, Agnihotry A, Al-Langawi JH. Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev. 2013;12:CD004969.
  2. Greenwood M, Corbett I, editors. Dental Emergencies. Wiley-Blackwell; 2012.
  3. Hargreaves KM, Cohen S. Cohen’s Pathways of the Pulp. 10th ed. Mosby Elsevier; 2011.
  4. Ingle JI, Bakland LK, Baumgartner JC, editors. Ingle’s Endodontics 6. Hamilton (ON): BC Decker Inc.; 2008.
  5. Graf P, Glatt M, Brune K. Acidic nonsteroid anti-inflammatory drugs accumulating in inflamed tissue. Experientia. 1975;31(8):951-3.

 

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7 Comments

  1. Dr. Robert Kaufmann February 24, 2014

    This question hints to a fundamental lack of understanding of endodontic pathology and the proper use of antibiotics in treatment of endodontically related disease.
    Use of antibiotics to treat pulpitis is not only unsupported on the literature, it actually may contribute to proliferation of antiobiotic resistant pathogens.
    See my article for more information: http://www.endoexperience.com/pro_newsFeb01.html

    and these publications, created by the AAE
    https://www.aae.org/uploadedfiles/publications_and_research/endodontics_colleagues_for_excellence_newsletter/ss95ecfe.pdf
    (Note “antibiotics” is not mentioned in the entire article)

    and
    http://www.aae.org/uploadedfiles/publications_and_research/endodontics_colleagues_for_excellence_newsletter/ecfewinter12final.pdf

    Reply
  2. VR February 25, 2014

    I’m wondering why, after all this research, that antibiotics still seem to give a temporary relief; especially in those with visible apical lesions or fistulas? I still give it, NOT as a final solution (which I’m not sure is or isn’t the intent of the question and answer) but as a way of reducing pain and bacterial load until or through the full treatment time.

    Despite what you say, I ALWAYS find that my patients get at least SOME relief from antibiotics AND are extremely grateful that they can sleep at night till treatment is done. Rarely do I see that I must perform an immediate pulpotomy unless there is severe pain. AND when doing so, I find that freezing that patient is generally not easy.

    Perhaps the question was meant to be along these lines? I’m pretty sure that any trained dentist understands that the ultimate treatment is root canal therapy or extraction.

    I also understand the overall concern of antibiotic resistance which is the exact reason I use Penicillin as my first line of defence and only use others such as clindamycin or metronidazole as indicated for worse or spacial infections.

    Reply
    1. Dr. Robert Kaufmann February 26, 2014

      VR, the science simply does not support your position and your perceptions are not evidence based.

      Firstly, the question was directed toward cases of symptomatic irreversible pulpitis. It may be symantics but these terms are important if we are to describe the situation accurately.Your mention of visible periradicular findings or sinus tracts ( fistula is not the correct term) implies that the cases you are discussing are associated with non-vital pulps. The original question asked about treatment of irreversible pulpitis cases, not necrotic cases . The stage of pulpal inflammation directly affects how we manage these cases.

      Secondly, ask any endodontist and they will tell you what happens because they see it daily and they understand the pathology : The tooth presents at the Dentist’s office in acute distress with elevated thermal symptoms and toothache(irreversible pulpitis). Many times the patients are dismissed with Rx for analgesics and antibiotics and are scheduled with the endodontist ASAP. With no emergency treatment perfromed, the patient frequently has 48 hrs or so of discomfort ( sometimes severe) that is sometimes managed with analgesics and then the pulp becomes necrotic. As long as there is no severe periradicular involvement, the patient then goes through a “quiescent” period where the antibiotics appear to have helped. This is mere coincidence. The truth is that the pulp tissue has become necrotic and no longer is capable of transmitting pain sensation in the original manner. That is what makes the original pain go away, not the antibiotic. It is only when the pulp breakdown products leak into the periapex that we get PDL inflammation, percussive sensitivity and periradicular involvement that is characteristic of acute periraadicular periodontitis that is of endodontic etiology.

      Lastly, the point is this: Antibiotics are NOT effective in the cases of irreversible pulpitis and this has clearly been shown in the literature.
      Antibiotics are not “chicken soup” and they should not be used as a stopgap method to “tide patients over” or “just in case” until they can be properly treated. We all graduated from dental school and we SHOULD have the clinical ability to perform a pulpectomy (in a single rooted tooth) or pulpotomy (in a multi-rooted tooth) that can very easily, quickly and relatively inexpensivley relieve the patient’s symptoms. If you are uncomfortable with this procedure, then emergency referral (without and antibiotic prescription) to an endodontist is the best course of action.

      The chances of patients undergoing a fatal acute (anaphylactic) response to antibiotics is very small. But, should it occur to YOUR patient in such a circumstance, such a prescription would be difficult to defend, being that there is no support for it, scientifically.

      If we must prescribe a drug, its use needs to be supported by science and an understanding of endodontic pathology, not simply “it works for me”.

  3. Terry February 26, 2014

    Excellent, Dr.Kaufmann.

    Reply
  4. JCDA Oasis February 27, 2014

    On behalf of Dr. Ken Miller

    I just read the discussion about symptomatic irreversible pulpitis. I find most teeth that are in this state are so hypersensitive they don’t freeze all the way and they have some periapical radiolucency on a radiograph. After 2 or 3 carpules of anesthetic the tooth is still not numb and if I drill into it to remove the pulp the patient experiences excruciating pain. After one week on Amoxil the tooth freezes more easily and I can work on the patient without them suffering a lot of pain. I’ve tried both ways. Both the patient and I like option 2.

    I have previously heard the statement the authors say about pulpectomy over antibiotics. Whenever I try to do a pulpectomy on a “hot” tooth like this the patient feels a lot of pain. How do the authors get complete local anesthesia on a tooth like this? When your schedule is full and an emergency patient like this comes in, if there is not time for a pulpectomy and you do a pulpotomy, are you putting formocresol on cotton pellets and then closing with a zinc-oxide and eugenol temporary filling? What’s the recommended pulpotomy procedure? How many days does it take for the pain to disappear after a pulpotomy treatment on a tooth with irreversible pulpitis? Thank you for your answers,

    Reply
    1. Anonymous February 27, 2014

      “Hot” teeth ( especially Mandibular Molars) are sometimes difficult to anesthetize. Adjunctive methods should be used when conventional IAN blocks are insufficient. These include (1) the “Supplemental” ( Mylohyoid/Lingual ) infilotration, placed just distal to the lingual aspect of the the tooth in question (2) PDL injections ( which are in essence “intraosseous” injections given though the 4 corner PDL sites of the molar. Research has shown that you do not need a dedicated “PDL Gun” to do this but it MUST be done with significant pressure into the PDL to diffuse the solution.) (3) True intraosseous techniques such as using the X-Tip or Stabident or dedicated handpiece driven anesthesia.

      Lastly, if you are doing mandibular molar endo on a routine basis, you will need to know how to give a quick, efficient , “kindly administered” intrapulpal anesthetic in those cases where no other techniques work adequately.

      http://www.endoexperience.com/pro_opinions_intrapulpal.html

      The Amoxil “perception” is an error. All you are doing by waiting the extra time ( no matter what drug you give) is waiting for the pulp to break down further and be less responsive to stimulus. The medication has no effect.

      Formocresol and phenol derived (toxic, sometimes carcinogenic) medicaments are no longer used in modern endodontics. Calcium Hydroxide (CaOH2) is the medicament of choice. The tooth is closed with either a bonded restoration or Cavit/IRM sandwich. IRM tends to shrink when it sets and we need a better seal for the chamber which is provided by the interior layer of Cavit (which is a better seal but has lesser compressive strength).

      Pulpectomy in a single canal tooth of reasonable diameter (not calcified) can be easily and quickly accomplished within a few seconds by selecting an appropriately sized barbed broach and broaching the majority of pulp in one motion. ( Note: a GOOD selection of broaches from xxxfine to Coarse is required so you can select the proper size for the canal. The pulp is “entangled” in the broach and removed. The broach is NOT used around difficult curves or to “blenderize” the pulp.)

      The pulpotomy is only used when there are NO PERIRADICULAR symptoms. ( i.e./ the tooth is strictly thermally sensitive ( carious exposure/deep restoration etc.) The tooth has NO periradicular findings on a radiograph or PDL/perussive or apical palpation sensitivity. The CHAMBER pulp is the source of the patient’s symptoms. To obtain relief from the toothache/ thermal/sweet sensitivity, all we need to do is remove the pulp to the level of the orifices if you do not have the time to do a complete pulpectomy. ( It is always preferable to remove the entire pulp if possible during the emergency appointment.) In that case, the procedure is similar to that of a Pedo pulpotomy but WITHOUT the Formocresol medication. After removing teh chamber pulp down to teh level of teh orifices, rinse the chamber with Na0CL. Control bleeding of the stumps(if necessary) by applying H2O2 on a cotton pellet and applying pressure until teh bleding ceases. The remaining tissue with become “frosted” (escerotic) and bleading will stop. Apply Ca(OH)2 in the chamber and close. ( There is NO value in leaving vital teeth open and it only serves to introduce oral flora into teh chamber and contaminate the case. )

      When properly performed in a vital tooth, these methods provide instant relief from the initial symptoms. Patients should be advised to use NSAIDs to counter any inflammatory symptoms and to call if the acute symptoms do not resolve or they develop periradicular symptoms.

      Efficient treatment of Endodontic emergencies can be some of the most gratifying and efficient practice building tools for the general practitioner. It can:

      1. Elevate Daily production levels – One of two quick pulpotomies or pulpectomies during the day (in a hygiene or “extra” chair) can increase the profitability of a practice without causing disruption in the scheduled office procedures.

      2. Create Great Public Relations – Patients in discomfort are very appreciative of prompt emergency endodontic care. Proving efficient relief for the patient who has been up all night with a toothache is a wonderful way to help publicize your practice. They tell EVERYONE how great you are and how you helped them!

      3. Expand your practice base – Patients who present with carious exposures frequently have other areas that require treatment. They often have been neglectful of their mouths, which is why many require acute care. Performing efficient, comfortable emergency procedures can convince these patients that you are the Dentist they should be seeing for their other treatment.

  5. Anonymous February 28, 2014

    Thank you Dr. Kaufmann for saying what we are all thinking. I am wondering why is this question even being asked?

    Reply

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