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rev port estomatol med dent cir maxilofac . 2017;58(4):205-211 209

odontic infections, it is not more effective than either amoxi-
Discussion
11
cillin or clindamycin. Due to its action spectrum and excel-
Endodontic infections typically have a rapid onset and a lent penetration in the bone tissue, clindamycin is the
short duration of up to 2 to 7 days, particularly if the cause is first -choice antibiotic for the treatment of endodontic infec-
treated or eliminated. 16,17 In our study, the average length of tions in patients allergic to penicillin and cases of resistance
antibiotic prescriptions was 7.81 days, with a range of 5 to 10 to these drugs. 11
days. Comparing to the average treatment duration reported The majority of chronic or even acute dental infections can
in other similar studies, 9,10,12,15 the respondents in this study be successfully treated by eliminating the source of infection
prescribed for longer periods. by pulp extirpation, drainage of abscess or tooth extraction,
The proper dose and duration of an antibiotic treatment without the need for antibiotics. Thus, to justify the use of
25
are enough when there is sufficient evidence that the patient’s antibiotics, an infection must be persistent or systemic, i.e.,
host defenses have gained control of the infection. When the cause fever, swelling, lymphadenopathy, trismus, or malaise
infection is resolving or has resolved, the drug treatment in a healthy patient. 12
should be terminated. 12,16,17 A 6 - to 7 -day course would prob- In our study, in cases of irreversible pulpitis with moderate/
ably be appropriate for most endodontic infections. Accord- severe symptoms without and with an acute apical periodon-
10
ing to Epstein, The majority of endodontic infections resolve titis component, 16% and 44% of the respondents prescribed
18
in 3 -7 days; thus, the 83.1% of respondents who routinely pre- antibiotics, respectively. In these cases, the pulps are still vital
scribe antibiotics for more than 7 days should reassess how and there is no infection or signs of systemic involvement.
they prescribe antibiotics. Thus, antibiotics are not indicated in either situation. The
26
A higher dose of antibiotics given for a shorter duration findings indicate that the scientific basis for prescribing anti-
has been advocated in recent years 19,20 . Traditionally, beta- microbial agents was neglected by most of the respondents.
29
-lactam antibiotics have been used as the first -line therapy for Another study reported that more than 60% of respondents
odontogenic infections. In our study, amoxicillin, either alone prescribed antibiotics for these two cases.
10
or associated with clavulanic acid, was the most prescribed In cases of necrotic pulp, chronic apical periodontitis, no
antibiotic for patients who were not allergic to penicillin. How- swelling and none or mild symptoms, in a healthy patient,
ever, according to some authors, 9,11 the amoxicillin’s antimi- there is no indication for antibiotic use, and treatment should
crobial activity against some bacteria involved in odontogenic be limited to nonsurgical root canal therapy. However, in this
infections is decreasing as a result of the increasing emer- survey, 15.8% of the respondents prescribed antibiotics in
gence of beta -lactamase -producing bacteria. Consequently, these cases. Other studies 15, 27 have reported prescription per-
the combination of a beta -lactam antibiotic with a beta- centages of less than 5% in that situation; however, at the op-
-lactamase inhibitor, such as amoxicillin and clavulanic acid, posite end, percentages higher than 30% have been found in
has been considered. 21 recent studies. 10, 28
The association of amoxicillin with clavulanic acid is a In situations of necrotic pulp, acute apical periodontitis, no
first -line treatment option for odontogenic infections due to swelling and moderate/severe symptoms, the proper treat-
its broad spectrum, low incidence of resistance, pharmacoki- ment is debridement of the root canal space and analgesics.
netic profile, tolerance and dosage. 9,22,23 In our study, amoxi- However, 41.1% of our sample prescribed antibiotics for this
cillin associated with clavulanic acid was prescribed by 83.2% clinical situation, which is a very high percentage of inappro-
of respondents.However, in other studies, 9,15 amoxicillin was priate prescription. Interestingly, several other studies 9,10,12,28
considered as the first -choice antibiotic in patients without also described higher percentages of antibiotic overuse in this
penicillin allergies, followed by amoxicillin associated with situation. On the other hand, in the study by Jayadev et al., 27
clavulanic acid. s olely 7.2% of the respondents prescribed antibiotics in this
On the other hand, in the USA, amoxicillin is prescribed by situation.
only 27.5% of AAE (American Association of Endodontists) In asymptomatic cases of necrotic pulp and chronic apical
members, 12 P enicillin is a narrow -spectrum antibiotic for in- periodontitis, and cases with sinus tracts, 45.3% of the dentists
fections caused by aerobic gram -negative cocci and anaer- in our study still prescribed antibiotics. If there are no signs of
12
obes. Among the group of penicillins, penicillin VK, amoxi- systemic involvement, treatment of a chronic apical abscess
cillin alone and amoxicillin associated with clavulanic acid is done similarly to other periapical pathological entities, by
have been advocated for the treatment of odontogenic infec- eliminating the etiological source present within the root ca-
tions. Kuriyama et al. did not find differences between their nals. 11,29 However, if the patient is medically compromised and
24
19
clinical evolution. the sinus tract does not close within a few weeks, or the pa-
In our study, the most reported drug of choice for patients tient experiences a flare up with systemic involvement, then
with sensitivity to penicillin was clarithromycin (34.7%). Other antibiotics would be indicated. 9,12 More encouraging results
studies 9,10 reported percentages higher than 60% for clinda- were described by other studies, with percentages below
mycin as the first -choice antibiotic. In our study, the second 20%. 12,27
antibiotic most prescribed for patients allergic to penicillin In the presence of necrotic pulp, acute apical periodontitis
was 500 -mg azithromycin (33.7%), which is in accordance with (abscess), swelling, and moderate -to -severe symptoms of an
De -Bem et al.. According to the literature, azithromycin and infection, previous studies 9,27 described an antibiotic prescrip-
15
clarithromycin have several advantages over erythromycin, tion rate between 92% and 99%. The results of our study were
and, although azithromycin has the potential for use in end- comparable, at 91.6%, and appropriately so. If systemic involve-