Claudia Hoffman
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 DEALLY,
we would love to be able to culture the bacteria in every infection and
do susceptibility testing before prescribing antibiotics, but that is unrealistic.
Therefore, we must use our own experience and research when prescribing
antibiotics.
When treating a patient, if the case is vital
the use of antibiotics afterwards is not indicated. In a nonvital case,
the decision is more challenging. I prescribe antibiotics to patients with
nonvital teeth that are swollen or draining, or to patients who present
in terrible pain. (These are just my personal guidelines; you can find
many practioners with different guidelines). If a patient has a nonvital
tooth under treatment and does not have any symptoms, I usually give the
patient a prescription for antibiotics and tell him or her to start the
antibiotics if they begin to have swelling or pain. I always have patients
call me if symptoms make them decide that they need to start the antibiotics,
and I will usually see them.
It is always best to be careful when giving
antibiotics. Antibiotics should be given until two or three days after
resolution of major clinical signs and symptoms, usually six to ten days.
A high-dose regimen for a short period of time is better than a low-dose
for longer; this regimen helps prevent resistance. A loading dose is recommended;
that is, for drugs that can take a long time to reach a therapeutic level
you start with a high dose.
Antibiotics Used in Endodontics
Penicillin V Potassium (penicillin VK, or PVK) has a comparatively
narrow spectrum of microbial activity that includes most of the bacteria
associated with endodontic infections, both facultative and anaerobic.
Therefore, PVK remains the antibiotic of choice because of its efficacy
and low toxicity. The one drawback is that there is a 10 percent allergy
rate. An oral loading dose of 1000 mg should be followed by 500 mg every
six hours for six to ten days. For serious infections, the PVK can be prescribed
every four hours to maintain a higher serum level.
Amoxicillin (“amox”) is often used as a first choice now because
of its broader spectrum of activity, which includes other bacteria not
associated with endodontic infections. Amoxicillin is absorbed more swiftly
and gives a higher and more continuous serum level. Because of its broader
spectrum, amox will select for more resistant organisms; therefore, it
is good for medically compromised patients. An oral loading dose of 1000
mg should be followed by 500 mg every eight hours.
Augmentin is amoxicillin with clavulanate potassium. It is recommended
for endodontic infections containing beta-lactamase-producing bacteria.
Clindamycin is recommended for patients with serious cellulitic
infections and patients allergic to PVK or amox. It is effective against
facultative infections and strict anaerobes. Pseudomembrane colitis is
a possible side effect from Clindamycin. The research says that it is rare,
but I find that some colitis is a more common problem with this antibiotic.
Z-Pak azithromycin: I have seen this prescribed a lot lately
for dental infections, probably because it is so user-friendly. Like erythromycin,
it is a macrolide. Z-Pak may be considered for a mild infection, and is
only effective against some of the anaerobic species associated with endodontic
infections. I personally have not found Z-Pak particularly effective against
dental infections, but I have found it very effective with sinus infections.
April - June 2007
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We
must use our own experience and research when prescribing antibiotics.
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