Endodontic intervention verses oral antibiotic therapy in the management of endodontically compromised situations Two case reports.

Transcription

1 Endodontic intervention verses oral antibiotic therapy in the management of endodontically compromised situations Two case reports. Dabas U* and Dabas VK* ABSTRACT Since many years, antibiotics in different forms have got definite application in the fields of Medicine and Dentistry to heal various superficial and deepseated body and dental and oral infections. Nevertheless, lack of sound scientific knowledge regarding judicious application of antibiotics, tradition, mentality or common trend of prescribing antibiotics for each and every patient with endodontic involvement, especially without emphasizing the need for an endodontic treatment planning, too often culminate into untoward consequences and many failures. This in turn, raises dubiety in the psyche of a patient regarding the professional skill of a surgeon, with often loss of faith in the profession as well. Being an Endodontist or even a Dental Surgeon, it is imperative that one must stress the importance of appropriate endodontic intervention in all the involved cases, with oral antibiotic administration used only as an adjunct. Moreover, one must be aware of all the pros and cons of antibiotic therapy and of course, the very fact that whether they are needed or not in a particular case in the first place. In this article, two cases have been reported where injudicious and irrational use of antibiotics did not yield any positive result; instead added further woes to the patients agony. Eventually, with careful Endodontic intervention, it became possible to not only provide prompt and permanent pain relief to the patients but also salvage the natural teeth while bringing back the smile and the lost faith of the patients towards the profession. Introduction In the field of human health care, the advent of antibiotic constitutes one of the greatest revolutionary advancements. Being the life saving drugs and as therapeutic agents, the role and value of antibiotics in the field of Dentistry to curb dental and oral infections is * Assistant Professors Dept. of Conservative Dentistry and Endodontics, K M Shah Dental College & Hospital, Vadodara, India. indeed inestimable 1. Nevertheless, certain misconceptions and notions regarding their usage in the clinical practice of Endodontics have culminated into undesirable sequel and end results. There prevails a common notion and misbelief like heavy doses of any broad spectrum antibiotic or last generation antibiotics can heal any kind of endodontic infection and hence, may postpone or retard the very requirement of an endodontic procedure. Such assumptions, too often not 2

2 Dabas U and Dabas VK Endodontic intervention Vs. oral antibiotic therapy... Fig. 1. Intra-oral periapical x-ray of # 45 showing distal curvature of root. only result in antibiotic abuse but terminate into drastic consequences like persistence or proliferation of existing problem, severe, acute exacerbation of chronic infections, development of resistant strain, drug toxicity, allergic and hypersensitivity reactions, photo toxicity etc. In all the endodontic pathologies, be pulpal or periapical, some are infected yet few others are only inflammatory lesions 2. Hence, elimination of irritants, especially pathogenic bacteria from the pulp space or root canal by careful and appropriate endodontic procedures is far more effective therapy over prescribing solely oral antibiotics and recommending no elective dental treatment in a particular case. Following two case reports adequately document these points. Case report- 1 A woman, aged 32 years, reported to a private clinic with the chief complaint of severe pain and extra oral swelling on lower right side, fever and diminished mouth opening. Patient gave history of oral medication, which chiefly composed of various groups of antibiotics including ampicillin, cloxacillin, sparfloxacin and ciprofloxacin for the past days without any relief. She had initially visited a local dentist about 2 years back with the complaint of moderately decayed # 45, with hypersensitivity to cold and sweets. She was prescribed some antibiotics and analgesics 3 Fig. 2. RVG scan of # 45 showing obturated canal. and no further definitive treatment was given. Again after few months, she started having pain and severe sensitivity with hot and cold with increasing size and depth of the carious lesion. When she visited a local hospital, few antibiotics and anti-inflammatory analgesics were prescribed, topical application of eugenol was done and significantly no adequate dental treatment was advised. After that, since last days she was suffering from excruciating, radiating pain with massive swelling on her lower right side. When she visited the local hospital, an intra oral periapical x- ray of the affected side was taken and again different types of antibiotics were prescribed (firstly, combination of amoxycillin and cloxacillin 500 mg t.d.s. for 4 days and then ciprofloxacin 500 mg t.d.s. for 6 days). The patient was discharged after local application of some sedative agent. Even after taking antibiotics for more than 20 days, the problem went on worsening. Moreover, due to prolonged oral antibiotic consumption, she developed severe indigestion, gastric problems, and loss of taste, allergy and phototoxicity. Hence, she decided to go for another opinion and permanent solution to her problem. The clinical examination revealed presence of intraoral swelling with prominent sinus formation in lower right buccal vestibule. Tooth no. 45 was deeply carious distoproximally. Intraoral periapical X-ray and RVG scan

3 Fig. 3. Intra oral periapical radiograph of # 37 showing a large carious lesion involving the pulp. suggested deep pulpal involvement in tooth # 45 with periapical pathology and periodontal involvement. There was a single, distally curved root with root canal terminating approximately 1.7 mm short of apex (Fig. 1). On the same visit, endo-perio treatment was administered. Abscess was incised, drained and the area was irrigated with metronidazole suspension. Root canal was opened, irrigated with metronidazole and subsequent NaOCl solution and distilled water along with usual biomechanical preparation. Occlusion was relieved subsequently and the patient was discharged with considerable pain relief. All antibiotics were discontinued and the patient was advised to take anti-inflammatory (Tab. Rofecoxib 50 mg OD) only in case of pain. On subsequent sittings, thorough scaling with deep curettage was performed along with routine endodontic procedure in # 45. The patient was relieved of all her symptoms within a week. Root canal was finally obturated with gutta percha and Sealapex (Fig.2). The tooth was restored with full cast ceramic crown. Case report- 2 A 38-year-old woman visited a dental clinic with chief complaint of severe pain in 37 and difficulty in chewing on that side. There was a history of chewing suddenly on a very hard substance in the food 3-4 months back that gave her instant severe pain and feeling of something broken down. Subsequently she 4 Fig. 4. Showing obturated root canals of # 37. developed pain and hypersensitivity in the same tooth with cold. When she visited a local hospital, she was prescribed antibiotics- Ampicillin and Cloxacillin, 500 mg thrice daily for 5 days. No dental treatment was advised. Hypersensitivity with cold continued and gradually increased with hot foods also. Since past 4-5 days, the pain started increasing and became almost continuous without any provocation. Again she visited the same hospital, but instead of opting for any appropriate dental treatment, she was prescribed Amoxicillin + Clavunimic acid 625 mg. twice daily for 5-6 days and Tab. Diclofenac sodium 50 mg. thrice for 5 days and was advised to report again. Nevertheless, after taking all the medicines, she did not get any relief. Since previous night she was keeping cold water in her mouth to get pain relief. She came to the clinic for permanent management of her problem. Intraoral examination revealed tooth # 37 was having occlusal breakdown. Old silver amalgam restoration in 37 had exfoliated and there was a big, open cavity. Recurrent caries was also found below the exfoliated restoration. RVG scan of #37 suggested deep pulpal involvement and less significant periapical lesion (Fig 3.). The tooth was tender on percussion and was giving exaggerated response to thermal test. The condition was diagnosed as initial hyperemia transformed into acute pulpitis. Immediately under local

4 Dabas U and Dabas VK Endodontic intervention Vs. oral antibiotic therapy... anesthesia, root canals were opened in #37, routine chemo mechanical preparation was done, occlusion was relived and the patient was discharged after sedative dressing. Oral antibiotics were discontinued and antiinflammatory (Tab. Roficoxib 50 mg once or twice as per the severity of pain) was prescribed for 2-3 days. Within 2 days, the patient was relieved of much of her pain. Routine endodontic procedure was done after that and finally the canals were obturated using Endoflas- FS (Fig. 4). Coronal restoration was done after completion of the endodontic treatment. Discussion Although antibiotics constitutes the bulk of all the drugs and medicines employed in the fields of medicine and dentistry in the modern era of science 3, ironically they constitute the single most abused group of drugs in health care today. The tragic fact attributes to indiscriminate, irrational and insane usage of various antibiotics to curb any infection without appropriate knowledge of antibiotic therapy. Nevertheless, there are certain systemic conditions warranting prophylactic antibiotic coverage prior to attempting any endodontic or exodontic procedures like rheumatic heart disease, bacterial endocarditis, prosthetic cardiac valves, congenital heart defects, AIDS etc. where the rationale behind advocating prophylactic antibiotic coverage is to prevent the inadvertent bacteraemia as a consequences of chemo mechanical debridement in the canal in high risk patients 2. The fact is that antibiotics control active microbial infection if present, but cannot prevent the possibility of infection. One cannot prevent occurrence of any endodontic infection with oral antibiotic therapy alone and avoid endodontic procedure. As per the fundamental principle of Conservative Dentistry, any carious lesion should be treated at once with proper restorative procedure, which could have been done in the first reported case and all subsequent agonies of the patient could have 5 very well been averted. Here, prescribing oral antibiotics to cure sensitivity was simply not justified! Not only that, once diagnosed with dental caries approximating pulp and signs like hyperemia or pulpitis got developed, instead of prescribing antibiotics, endodontic procedures like pulp-capping, pulpotomy or root canal therapy etc. should have been carried out immediately. Moreover, in this case, purposelessly prescribing various antibiotics was simply experimenting with the situation. The patient suffered from untoward reactions like severe, continued indigestion, allergy and even phototoxicity, which are sometimes observed with ciprofloxacin or sparfloxacin group of antibiotics. Even if an antibiotic is to be used to control periapical infection, it is mandatory to have the knowledge of microbiology of pulp infection, as more than % bacteria in the infected pulpspace are anaerobes, so is the case with lesions of periodontal pathosis. Moller 4 isolated anaerobes in 74% of his samples of endodontic cases. Also Sundqvist in his study on endodontically involved conditions isolated 88 strains of which about 90% were anaerobes 5. Metronidazole is a highly effective antibiotic in the management of anaerobic infection; hence it worked well in the first case, where it was both, endodontic and periodontal involvement. In cases of sinus with pulsating and pointing intra-oral abscess, it is always advisable to incise and drain the abscess followed by subsequent, appropriate endodontic and periodontal treatment. In case of periapical pathology, majority of lesions are inflammatory in nature and need not necessarily be infected. As the possibility of bacterial presence in the periapical tissues is negligible, antibiotics are often unnecessary in such conditions. In the second case, there was no infection periapically during the initial stages. Any carious lesion or tooth with exfoliated restoration without periapical pathology could have been restored immediately with due precautions. From the

5 history of the patient, signs, symptoms and clinical observation, the condition could have been diagnosed as hyperemia at the initial stage, which later developed into acute pulpitis. As these are inflammatory lesions and can be easily treated endodontically, antibiotics play no role in such conditions. It is usually when the drainage becomes difficult to obtain or host resistance is reduced or virulence of organisms is more, that the antibiotics are required 6. Hence, after discontinuing antibiotics at once and performing root canal therapy worked best in the second case. Conclusion To render professional services in the bestdesired manner to our invaluable patients, we the dental surgeons must possess sound knowledge of rationale behind the usage of antibiotics in routine endodontic practice. Endodontic therapy now emphasizes the importance of debridement procedures and elimination of microorganisms and their substrate. For any endodontically compromised tooth, be it pulpal or periapical pathology, an appropriate endodontic procedural intervention at the right time is the only eventual solution. Judicious and rational application of relevant antibiotics for any desired length of period in appropriate dosage can very well be a thoughtful adjunct. However, it certainly cannot be the sole and ultimate mode of the treatment modality in Endodontics. References: 1. Holroyd SV. Clinical pharmacology of antibiotics of dental importance, Dent. Clin. North Am. 1970; 14: Gopikrishna and Parmeshwaran. Role of antibiotics in Endodontics J. Ind. Dent. Assoc. 2001: Miles M: Anesthetics, Analgesics, Antibiotics & Endodontics, Dent Clin North Am 1984; 28: Moller A J.R: Microbiological examination of root canals and periapical tissues of human teeth. Goteborg, Akademiforlaget, Sundqvist G. Bacteriological Studies of Necrotic Dental Pulps. Umea, Sweden, University of odontology Dissertations, Weine FS. Endodontic Therapy 1996; 5th Edition, Harcourt Brace & Company Asia Pvt. Ltd. 6