INTRODUCTION:

The main aim of the endodontic intervention or the root canal is to adequately remove the debris from the canal by proper biomechanical preparation and eradication of pathogenic endodontic microbiota there by leading to proper compaction of the guttapercha and hence better obturation of the radicular system¹. But the procedure of root canal is rendered incomplete without the use of deployment of pharmacological drugs, which can exponentially contribute to the healing of periapical lesions².

Dental caries occurrence and its lateral spread towards Dentino Enamel Junction (DEJ) and its proximity to pulp chamber allows ingress of microorganisms leading to pulpal involvement leading to inflammation of pulp with symptomatic changes³. Patients who are suffering from medically compromised disorders like diabetes mellitus or undergone cardiac procedures like angioplasty, stent or pacemaker alignment in the cardiac chamber would require the antibiotic prophylaxis before proceeding ahead with root canal treatment^4,5.

An endodontist should and always know the pharmacokinetics and pharmacodynamics of the given drug, amount of dosage of drugs prescribed for the patient, its systemic side effects. This article rightly describes the importance of correct antibiotics, analgesics prescribed for patients undergoing root canal treatment.

Control of infection- Paramount importance for the endodontic treatment:

The pathogenicity of the microbes or micro-organisms which then clinically lead to the involvement of the mesenchymal connective tissue called as pulp was recognized way back in 1965. The main aim and objectives of the root canal treatment is to eliminate occurrence of existing endodontic infections and pathogens inside the root canal and prevent the re contamination of the root canal by different species having capacity to cause endodontic re-infection. Hence the process of eliminating infection is the penultimate goal in the field of endodontics.

Endodontist being the practicing clinicians should always take proper measures to make sure that there is no spread of the disease from endodontist to the patient or patient to the endodontist or from one patient to another patient. Proper cleansing and cleaning of the hands by antimicrobial handwash before and after clinical examination of the patient irrespective of the dental procedure the patient has undergone to restore occlusal and neuromuscular harmony is a must. Proper use of protective gear such as headcaps, mouth masks and eye wear prevent any transmission of infection from dentist to the patient. Protective eye wear is highly useful in preventing any contact with splatter from the patient's oral cavity. Rubber dam isolation is imperative isolation tool to perform all the restorative and endodontic procedures and for its clinical longevity and better outcome of the treated lesions^6,7.

Strictly following the schematics of sterilizing the instruments is mandatory which is a basic perquisite in primary oral health care management between the endodontist and the patient. A survey was conducted right across many parts of India, and it came to be known that due to the customized complex design of the endodontic rotary files, it was getting tedious to sterilize the endodontic rotary files which amounted to the less than 100% efficiency sterilization status of the endodontic rotary files.

Recently different modalities of sterilization methods have been introduced to sterilize the endodontic rotary files like laser and gamma sterilization in order to prevent cross contamination⁸.

Role of antibiotics in endodontic management of the tooth:

Antibiotics are the class of antibacterial agents which kills the bacteria. They are used as alternatives in root canal treatment. They are prescribed either as single entity or in multiple combination with other class of drugs. They function as bacteriostatic (prevent the reproduction of the bacteria otherwise not killing them, preventing the growth of the bacteria) or bactericidal (killing of the bacteria). The main indication of the antibiotics in endodontic therapy becomes clinically important when the infection is persistent or systemic.Antiobiotics should only be prescribed when there is absolute clinical need. Dosage of antibiotics along with appropriate prescription of antibiotics is vital for the endodontic therapy.

Table 1: Antibiotics and their mode of action

S. No	Name of the prescribed drug	Prescribed drug action
1	Penicillin	Bactericidal
2	Cephalosporins	Bactericidal
3	Metronidazole	Bactericidal
4	Fluoroquinolones	Bactericidal
5	Macrolides	Bacteriostatic
6	Clindamycin	Bacteriostatic
7	Tetracycline	Bacteriostatic

1. Penicillin:

Penicillin being the main drug of choice for endodontists, it is considered as one of pivotal drugs in endodontic treatment^9,10. Oral suspension of the drug includes its variants like Penicillin V, Amoxicillin, Ampicillin. In these group of penicillin drugs, amoxicillin is commonly prescribed by many dentists and endodontist to minimize the endodontic infection. Because of its action it is effective against gram positive cocci like staphylococci, streptococci and gram-positive bacteria like clostridium, corynebacterium and oral anaerobic bacteria like pepto-streptococci, actinomyces and eubacterium. These drugs have got short half-life, better absorption of the drug with minimal toxic effects and excreted via urine with no prevalent change^11,12. Side effects of penicillin groups of drugs are less pronounced, but cross-sectional study conducted in community groups proved that 3 to 7% of the population is allergic to penicillin. The range of side effects or level of toxicity can vary from common rashes on the cutaneous surface to severe life endangering anaphylactic episodes. Few of the patients have even encountered symptoms like lower gastrointestinal disorders with secondary infections. Severe toxic effects like allergy and anaphylactic reactions are prevalent in few of the patients which can lead to symptoms like hypothermic upper and lower limbs, difficulty in breathing, spasm of the upper respiratory tract, circulatory collapse. Patients having renal disorders, exercise caution in prescribing penicillin group of drugs, in such patient's (renal) dosage should drastically be reduced.

2. Cephalosporins:

Cephalosporins are generally categorized as beta lactam group of antibiotics which are prescribed alternative to penicillin group of antibiotics, and they are very similar structurally to penicillin. There are different generations of cephalosporins which are used to control endodontic infections¹³. Primarily, first generation group of cephalosporins are extensively used for eradicating oral microorganisms and are widely considered by many dentists for dental infections. Second and third generations of cephalosporins are used after the culture reports are verified from laboratory. Of all classes and generations of cephalosporins, predominantly cefaclor, cefuroxime and cefprozil are highly effective against infective oral microbial pathogens. Pharmacologically it's important to understand that concentration of cephalosporins is higher in the hard tissues like alveolar bone on oral administration and widely used to treat periapical infections.¹⁴

3. Metronidazole:

Metronidazole is the most important bactericidal drug which causes inherent damage to bacterial Deoxyribonucleic acid (DNA). Its action is on obligate anaerobic bacteria's except on facultative bacteria¹⁵.It doesn’t act on facultative bacteria. It is an important tool for treating endodontic- periodontal lesions as it acts against many groups of periodontal pathogens like pervotella, porphyromonas, eubacterium, fusobacterium, veilonella, campylobacter, clostridium, treponema, and peptpstreptococcus. Patients should be highly advised that one should not intake alcoholic beverages while ingesting, Metronidazole half-life is about 8 hours. Side effects of metronidazole include metallic unpleasant taste and brown color of the urine discharge.

4. Fluoroquinolones:

Fluoroquinolones are class of drugs which are bactericidal and alter the state of DNA replication. But they are not at all effective against the strains of microorganisms which are seen in endodontic infections. Use of Fluoroquinolones should be confined to cases where results of culture and sensitivity are rightly indicated. Of all the groups of Fluoroquinolones, Ofloxacin has better mode of action against oral pathogens and microorganisms¹⁶

5. Macrolides:

Erythromycin's mode of action is by preventing bacterial protein synthesis. These classes of drugs become the prime dosage of regimen to the patients who are allergic to penicillin groups of drugs. They have a pronounced action against gram positive bacteria, but less effect is seen in groups of gram-negative bacteria. Newer drugs under macrolides like Azithromycin and Clarithromycin show better state of pharmacological action and attain higher concentration in the tissues.Ill effects includeallergy and gut mobility. The ester variant of the erythromycin is capable of causingcholestatic hepatitis. Ill effects are seen after 10 to 20 days of treatment and symptoms of this drug are prevalent after the discontinuation of the drug¹⁷.

6. Tetracyclines:

It exhibits better action against many variants of oral microbes and microorganisms and has a better longer half-life. It binds to 30 S- Subunit of the ribosomes and prevents the occurrence of bacterial protein synthesis¹⁸. Although there is always the higher chance of developing resistance against these groups of drugs, still its uses as drug in the field of dentistry is on the rise as it exhibits better spectrum of action. It has certain side effects like brownish black staining of the teeth and occurrence of photosensitivity, as the concentration of these groups of drugs are paramount in gingival fluids, they are recommended to treat periodontal infections.

7. Codeine:

It is a derivative of methyl morphine and is natural opium alkaloid¹⁹. Its action is less pronounced than morphine, as it has low manifested abuse potential it is recommended choice of pain killer by many endodontists for the symptomatic pain ranging from intensity from moderate pain to severe pain. Its pronounced mode of action is due to production of morphine by procedure called as “Demethylation”. Its pharmacokinetic and pharmacodynamic action is much more efficient when given through oral mode of administration. When being given through oral route, its action is viable for 5 to 6hours. Its degree of analgesia given in 60mg is comparable to non-steroidal anti-inflammatory drugs such as Aspirin when given in 600mg as dosage, it induces constipation which manifest as side effects.

8. Tramadol:

It is centrally acting opium alkaloid which is used to treat symptomatic pain having intensity as comparable as moderate pain. Its state of affinity for µ is more pronounced and that of receptors such as δ receptors are less responsive. Its mode of action by preventing the flow of noradrenaline and 5 HT (5-hydroxytryptamine) there by leading to the activation of mono aminergic spinal inhibition of pain. It has better pharmacodynamic action when being administered through oral route and half-life of the drug is 3 to 5 hours and its action lasts for about 7hours. Its side effects include minimal respiratory depression, constipation and urinary retention than in comparison to morphine. It is considered to be safe drug of choice in patients suffering from cardiac anomalies. Minor side effects like nausea and dizziness are reported.

9. Propoxyphene:

It is chemically linked to methadone but has a similar mode of action like codeine. It is metabolized in liver and has a half-life of 4 – 11hours. If there is over dosage of this drug, then it causes confusion and delirium. But one of the derivatives of propoxyphene called “Demethylated” causes massive cardiac toxicity to the patients. Its use as an analgesic should be very minimal given in doses of 50 to 100mg as a substitute for codeine in combination with aspirin and paracetamol²⁰

Use of antibiotics as a prophylactic measure in the field of endodontics:

Use of antibiotics as a prophylactic therapy is a measure which is checked and updated periodically and annually for maintaining medical health and rendering anatomic site of oral cavity for dental treatments. Earlier studies have indicated that the occurrence of bacteremia is clinically at a lower level in endodontic treatment. Few of the authors were of the opinion that in the root canal therapy, prescribing the usage of antibiotics can be avoided clinically by advising the patients for proper Chlorhexidine mouth washes which can be rinsed in oral cavity, which can exponentially reduce the load of bacteria to a greater extent. As the use of endodontic instruments in the canal can predispose to bacteria and would then require the use of antibiotics in such cases for proper periapical resolution of the lesion.

Few of the studies have indicated that the use of antibiotics in a healthy patient is not recommended who is undergoing the root canal treatment. Antibiotic prophylaxis becomes highly perquisite and imperative when there is perforation in the maxillary antrum, or the floor of the nose and its dosage can reduce the occurrence of infection. Antibiotics prophylaxis is advised when the patient is undergoing the procedure called “Re-implantation of the avulsed tooth” and this is done in order to prevent the occurrence of the invasion of bacteria in pulp and to eliminate root resorption.

Proper protocols and approach should be followed while one tries to advise the course of particular antibiotics for the root canal treatment. Most of the clinicians and endodontists recommend the use of broad-spectrum antibiotics as it is highly effective against facultative and anerobic pathogenic microorganisms. In terms of dosage regimens for a patient undergoing endodontic intervention, short term high dosage would be highly recommended than a prolonged 4 to 6 days of intensive antibiotic therapy

According to the study and research done by the American Heart Association, antibiotics should be administered 1 hour in case of oral administered dose or 30 minutes in case of intravenous mode of administration before the procedure of the root canal treatment. Most preferred choice of the antibiotics is “Amoxicillin”, 2 grams and the patients who are allergic to penicillin groups of drugs can then be prescribed Clindamycin 600mg.

Control of pain as an important measure for endodontic therapy:

Pain control in the patient is of utmost importance in patients undergoing endodontic therapy^19.Non-steroidal anti-inflammatory drugs (NSAIDS) are advised during endodontic intervention as a measure to reduce the symptomatic response of the patient. Most of the cases expressing pain of varying intensity are advised NSAIDS, based on the research done by the clinicians and endodontist, non-opioid drugs were used more often than opioid drugs for treating the symptomatic response of patients undergoing endodontic therapy. Some of the recommended pain killers advised in endodontic treatment are mentioned below.

Table 2: Pain killers in endodontic treatment

S. No	Name of the prescribed analgesics
1	Codeine
2	Tramadol
3	Propoxyphene
4	Aspirin and other NSAIDS

Aspirin and other non-steroidal anti-inflammatory drugs:

It is the most prescribed analgesic to patients who undergo endodontic intervention. It has potential to bind irreversibly with enzyme “Cyclooxygenase” and block the arachidonic acid pathway there by prevent the action of prostaglandins which are mediators of the inflammation²¹Patients who have history of cardiac disorders like stroke or history of an episode of atherosclerosis, would first be needing a clearance from their respective cardio thoracic surgeon and a proper authentication letter stating the status of dental treatments which one can safely undergo without any post operative complications.

It is always safe to enquire about the status of medical disorders in patients undergoing endodontic treatments knowing which a concerned clinician and endodontist can then under proper medicated prophylaxis or medications can perform the desired root canal treatment without any post operative complications and to make sure that proper clearance for dental treatments are being written by general physicians for the patients who are medically compromised.

REFERENCES:

1. Cohen S, Hargreaves K. Pathways of the Pulp 9th ed. Mosby, St. Louis, MO, 2006.

2. Aggarwal A, LuthraV. Role of pharmacological agents in endodontic therapy-A mini review. J Adv Med Dent Scie Res. 2015; 3(4): 96-98.

3. Kakehashi G, Stanley HR, Fitzgerald R. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg. 1965; 20: 340.

4. Seltzer S. Pain in endodontics: Journal of Endodontics. 2004; 30(7): 501-503.

5. Systemic medication applied to endodontic treatment: a literature review: Nanete de Menezes Silva Avenida Murilo Dantas, 2014.

6. Infection control in endodontic clinic: Rahmatullahkhan, Chandanprabhakar: Pakistan Oral and Dental Journal. 2015; 35(1).

7. Kohn WG, Harte JA, Malvitz DM, Collins AS, Clevland JL, Eklund KJ, et al. Guidelines for infection control in dental health care settings—2003. J Am Dent Assoc. 2004; 135(1): 33-47.

8. D A Van Eldik, P S Zilm, A H Rogers, P D Marin. Microbiological evaluation of endodontic files after cleaning and steam sterilization procedures. Aust Dent J. 2004; 49(3): 122-127.

9. Simarpreetkaur, Rekharao, Sanjunanda. Amoxicillin: a broad spectrum antibiotic International Journal of Pharmacy and Pharmaceutical Sciences. 2011; 3(3).

10. Weber DJ, Tolkoff-Rubin NE, Rubin RH. Amoxicillin and potassium clavulanate: an antibiotic combination. Mechanism of action, pharmacokinetics, antimicrobial spectrum, clinical efficacy and adverse effects. Pharmacotherapy. 1984; 4(3): 122-36.

11. Tripathi, K.D. (2008a). Essentials of Pharmacology 6thed. New Delhi: Jaypee.

12. Ramulu SSRS, Neelakantan P. Pharmacotherapy inRoot canal treatment. Res J Pharma Bio Chem Scie. 2014; 5(3): 43-51.

13. Mohan M, Gupta A, Shenoy V, Parolia A: Pharmacological Agents in Dentistry: A Review: British Journal of Pharmaceutical Research. 2011; 1(3): 66-87.

14. Endodontics and infective endocarditis – is antimicrobial chemoprophylaxis required? M. Brincat, L. Savarrio and W. Saunders.

15. Antibiotic Prophylaxis In Dentistry: A Review And Practice Recommendations Darryl C. Tong; Bruce R. Rothwell JADA. 2000; 131: 366-374.

16. L.P. Longman, A.J. Preston, M.V. Martin, N.H.F. Wilson: Endodontics in the adult patient: the role of Antibiotics. Journal of Dentistry. 2000; 28: 539–548.

17. Paul D. Eleazer ; Pharmacology for Endodontics.

18. Building effective strategies for the management of endodontic pain: Karl Keiser and Kenneth M. Hargreaves: Endodontic Topics. 2002; 3: 93-105.

19. Mickel AK, Wright AP, Chogle S, Jones JJ, Kantorovich I, Curd F. An analysis of current analgesic preferences for endodontic pain management. J Endod. 2006; 32(12): 1146-54.

20. Afrand M, Mian A, Pannu H et al :Review of Literature to determine the effectiveness of analgesic medications on post‐operative management of endodontically treated teeth.

21. Holstein A, Hargreaves K, Niederman R:Evaluation of NSAIDs for treating post‐endodontic pain: Endodontic Topics. 2003; 3(1): 3 -13.

Received on 13.03.2024 Revised on 08.07.2024

Accepted on 21.09.2024 Published on 27.03.2025

Available online from March 27, 2025

Research J. Pharmacy and Technology. 2025;18(3):1405-1409.

DOI: 10.52711/0974-360X.2025.00202

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.