Role of antibiotics in paediatric endodontics
Antibiotics have been extensively used for the management of odontogenic infections since their discovery.
n Commonly used drugs in endodontics4,5,8,9
edge6,7. If in doubt, recommended.
n Role of systemic antibiotics in endodontics5
by N ht
pyrig No Co t fo rP paediatrician consultation ub is lica tio n te ss e n c e
The child is not a miniature adult, thus paediatric dentists must consider their differences when making therapeutic choices for young patients, especially when treatment includes drug therapy. These include the following: t Young children tend to lack medical antecedents suggesting the possibility of drug allergies or adverse reactions. t The greater proportion of water in the tissues of children and their increased bone sponginess facilitate faster diffusion of infection; hence, adequate dose adjustment is recommended. t The gastrointestinal tract undergoes continuous developmental change from birth to old age. Infants and young children secrete low levels of acid due to immature gastric mucosa until 3 years of age; this favours absorption of weakly acidic drugs like penicillins and cephalosporins. Longer gastric emptying times combined with irregular peristalsis of infancy result in slower gastric drug absorption. t Alteration in drug metabolism due to deﬁciency of hepatic enzymes, i.e. they are at a higher risk of toxicity if not given the correct dose. t Drug metabolism and excretion are profoundly affected by the size of various body ﬂuid compartments. t Children need smaller drug doses to maintain therapeutic drug concentration, and those smaller doses are enough to produce toxicity. The ‘maximum safe dose’ listed in standard drug reference manuals is enough to overdose a paediatric patient, thus weight-based formulas are much safer in the paediatric population. t The severity of the infection has to be taken into account. Accordingly, antibiotics should be selected based on the assessment of the overall state of the patient’s health and most up-to-date microbiological knowl-
ENDO (Lond Engl) 2010;4(1):41–48
n Selecting an antibiotic
t Penicillin VK is effective against most aerobic and anaerobic bacteria associated with endodontic infections. t Erythromycin, which is commonly prescribed for penicillin-allergic patients, has been found to be ineffective against most of the anaerobes associated with endodontic infections. t Clindamycin is an appropriate substitute in patients allergic to penicillin. It is beta-lactamaseresistant and is highly effective against facultative and strict anaerobic bacteria associated with endodontic infections. It penetrates into abscesses and any other areas of poor circulation. t Clarithromycin has a more limited spectrum of activity than clindamycin but has some advantages over erythromycin. Clarithromycin is effective against facultative anaerobes and some of the obligate anaerobic bacteria associated with endodontic infections. It is also less likely than some other antibiotics to cause gastrointestinal problems. t Metronidazole is a synthetic antibiotic that is highly effective against obligate anaerobes but is ineffective against facultative anaerobic bacteria. If penicillin is ineffective after 48 to 72 hours, metronidazole is a valuable antimicrobial agent for combination antibiotic therapy. t Tetracycline kills the broadest spectrum of microbes. It is recommended in endodontics, since periodontal pathogens invade the root canal and periapical tissues. It is of limited use in children below 8 years of age, as it causes tooth discoloration, and can continue to do so beyond this age by becoming deposited in secondary dentine10.
n Root canal: To culture or not?5,11,12,13 The microﬂora of the necrotic pulps has been studied for more than 100 years by direct microscopy and cultivation. Although adjunctive antibiotic therapy for endodontic infections is based on the past knowledge of those organisms most likely to be associated
Bacteria have been implicated in the pathogenesis and progression of pulpal and periapical diseases.