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Dental Tribune Middle East & Africa Edition No. 5, 2015

Dental Tribune Middle East & Africa Edition | September-October 2015 7mCME mCME SELF INSTRUCTION PROGRAM CAPPmea together with Dental Tribune provides the opportunity with its mCME - Self Instruction Program a quick and simple way to meet your continuing education needs. mCME offers you the flexibility to work at your own pace through the material from any location at any time. The content is international, drawn from the upper echelon of dental medicine, but also presents a regional outlook in terms of perspective and subject matter. Membership: Yearly membership subscription for mCME: 900 AED One Time article newspaper subscription: 250 AED per issue. After the payment, you will receive your membership number and Allowing you to start the program. Completion of mCME • mCME participants are required to read the continuing medical education (CME) articles published in each issue. • Each article offers 2 CME Credit and are followed by a quiz Questionnaire online, which is available on http://www. cappmea.com/mCME/questionnaires.html. • Each quiz has to be returned to events@cappmea.com or faxed to: +97143686883 in three months from the publication date. • A minimum passing score of 80% must be achieved in order to claim credit. • No more than two answered questions can be submitted at the same time • Validity of the article – 3 months • Validity of the subscription – 1 year • Collection of Credit hours: You will receive the summary report with Certificate, maximum one month after the expiry date of your membership. For single subscription certificates and summary reports will be sent one month after the publication of the article. The answers and critiques published herein have been checked carefully and represent authoritative opinions about the questions concerned. Articles are available on www.cappmea.com after the publication. For more information please contact events@cappmea.com or +971 4 3616174 FOR INTERACTION WITH THE AUTHORS FIND THE CONTACT DETAILS AT THE END OF EACH ARTICLE. < Page 6 Fig. 4. Acute apical abscess with extraoral diffuse facial cellulitis. has been properly managed (complete debridement of the pulp space and proper obtu- ration and sealing of the pulp space from the oral environ- ment). Apical periodontitis lesions of pulpal origin are generated by the immune system and are the result of intraradicular infec- tions (Fig. 1). In most situations, this inflammatory process suc- cessfully eliminates the bacteria emerging from the apical fora- men and prevents their spread to the periapical tissues. This process is primarily facilitated by the polymorphonuclear leu- kocytes that eventually phago- cytize and kill the bacteria.13 Asymptomatic apical periodon- titis of pulpal origin does not routinely require systemic an- tibiotic therapy for satisfactory resolution and healing. Endo- dontic therapy alone is usually sufficient. When the intraradicular infec- tion is able to overwhelm the host’s immune response, vi- able bacteria are able to gain access to the periapical tissues and colonize, forming an active infection. This results in the for- mation of an apical abscess. A chronic apical abscess usually presents with gradual onset, no to mild symptoms and the pres- ence of a sinus tract or parulis (Fig. 2). The majority of chronic apical abscesses of endodontic origin do not require systemic antibiotic therapy for satisfac- tory resolution and healing. An acute apical abscess usually presents with rapid onset, spon- taneous pain and swelling, both localized and intraoral, some- times with exudate present, or with diffuse facial cellulitis. When the abscess is intraoral and localized (Fig. 3), debride- ment of the pulp space and placement of calcium hydrox- ide and surgical incision for drainage is usually sufficient to resolve the problem. Systemic antibiotic therapy is not routine- ly indicated, depending on the patient’s general medical status. However, when the patient pre- sents with diffuse facial swell- ing (cellulitis) resulting from an acute apical abscess or an infection with systemic involve- ment (fever or malaise) (Fig. 4), debridement of the pulp space with placement of calcium hy- droxide, surgical incision for drainage, when possible, and an appropriate regimen of sys- temic antibiotics (oral or IV) are the treatments of choice. Understanding the enemy is an important factor in winning any battle. The rational choice and use of antimicrobial agents be- gins with the knowledge of the microorganisms most likely responsible for common dental infections of pulpal origin. The bacterial flora found in endo- dontic infections is indigenous, mixed (Gram-positive and Gram-negative) and predomi- nately anaerobic. Several spe- cies have been implicated with acute apical abscesses. These species include dark-pigment- ed bacteria (Prevotella and Por- phyromonas), eubacteria, fuso- bacteria and Actinomyces.12 Baumgartner and Xia published a report of the susceptibility of bacteria recovered from acute apical abscesses to five com- monly used antibiotics in den- tistry. Antibiotic susceptibility data from 98 species of bacteria recovered from 12 acute apical abscesses led to the following conclusions: 1. Pen-V-K is the antibiotic of choice for endodontic infec- tions due to its effectiveness in polymicrobial infections, its relative narrow spectrum of activity against bacteria most commonly found in endodontic infections, its low toxicity and low cost. 2. Clindamycin is the antibiotic of choice for patients allergic to penicillins. 3. While amoxicillin and aug- mentin (amoxicillin plus clavu- lanate) demonstrated a higher antibacterial effectiveness than Pen-V-K, due to the broader an- tibacterial spectrum of amoxi- cillin and the increased cost of augmentin, the authors rec- ommended that amoxicillin/ augmentin be reserved for un- resolved infections and patients who are immunocompromised. 4. Metronidazol demonstrated the greatest amount of bacterial resistance and is only effective against anaerobes. Therefore, it should not be used alone for the treatment of endodontic infec- tions.14 Myth No. 4: Antibiotics increase the host’s defense to infection. The increased prevalence in organ and tissue transplants, resulting in patients with com- promised immune systems, has heightened the interest in the potential effects of antimicro- bial drugs on the host’s resist- ance to infection.15 In vivo and in vitro studies are highly vari- able and sometimes contradic- tory. However, the following considerations appear valid: 1) Antibiotics that can penetrate into the mammalian cell (eryth- romycin, tetracycline, clinda- mycin and metronidazole) are more likely to affect the host defenses than those that can- not (beta-lactams); 2) Tetracy- clines may suppress white cell chemotaxis; 3) Most antibiot- ics (except tetracycline) do not depress phagocytosis; and 4) T- and B-lymphocyte transforma- tion may be depressed by tetra- cyclines. The greatest potential harm to the host defenses may result from antibiotics that eas- ily penetrate into the mam- malian cell and the least harm is observed with bactericidal, nonpenetrating agents (penicil- lins and cephalosporins). Myth No. 5: Multiple antibiotics are superior to a single antibi- otic. It is often assumed that a combination of antibiotics is su- perior to a single carefully cho- sen antibacterial agent. When the purported benefits of antibi- otic combinations are weighed against the possible conse- quences to the host as well as to the bacterial environment, this assumption is not always real- ity. The usual sequela to com- > Page 8 Table 2. (Tables/Provided by American Association of Endodontists) 4. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE. Table 2 Medical Conditions for Which Endocarditis Prophylaxis is Recommended: Premedication is recommended ONLY for patients with the following conditions associated with the highest risk of adverse outcomes from endocarditis: 1. Prosthetic cardiac/heart valve. 2. History of IE. 3. Cardiac transplant recipients who develop valve pathology. 4. One of the following congenital heart diseases: • Unrepaired cyanotic CHD, including palliative shunts and conduits. • Completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after placement of the material or device (because endothelialization of prosthetic material occurs within six months after the procedure). • Repaired CHD with residual defects at, or adjacent to, the site of a prosthetic patch or prosthetic device (which inhibits endothelialization). 5. Special situations and circumstances: • Patients already receiving antibiotics—Occasionally, a patient may be taking an antibiotic when coming for a dental appointment. If the patient is taking an antibiotic normally used for endocarditis prophylaxis, it is prudent to select a drug from a different class rather that increase the dose of the current antibiotic. If possible, you should delay the dental procedure until at least 10 days after completion of the antibiotic. This will allow for the usual oral flora to be re-established. If an individual receiving long-term parenteral antibiotic therapy for IE requires dental treatment, the treatment should be timed to occur 30 to 60 minutes after the parenteral antibiotic therapy has been delivered. • Failure to administer pretreatment antibiotic dose—If the dosage of an antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to two hours after the procedure. However, administration of the dosage after the procedure should be considered only when the patient did not receive the preprocedure dose. • Individuals with kidney dialysis shunts—Individuals with permanent kidney dialysis shunts should be placed on prophylactic antibiotics using the same protocol as for IE. Use and Abuse of Antibiotics: Winter 2012 +97143616174

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