JOURNAL OF ENDODONTICS
Copyright © 2002 by The American Association of Endodontists
Antibiotic Use by Members of the American
Association of Endodontists in the Year 2000:
Report of a National Survey
Nicole M. Yingling, DMD, B. Ellen Byrne, RPh, DDS, PhD, and Gary R. Hartwell, DDS, MS
The purpose of this study was to determine the
prescribing habits of active members of the Amer-
ican Association of Endodontists (AAE) with regard
to antibiotics.
A one-page, double-sided questionnaire was
sent to the active members of the AAE living in the
United States. The 1999 mailing list of 3203 mem-
bers was obtained from the AAE, and the return
rate was 50.1% (1606 surveys). With a sample size
over 1000, the study was able to distinguish differ-
ences to within 0.5% with power ⴝ 80% (at alpha ⴝ
5%). The data were analyzed using descriptive sta-
tistics and chi-square tests of independence. Pen-
icillin VK, 500 mg, 4 times a day, was the first
choice antibiotic prescribed by 61.48% of respon-
dents. Clindamycin (Cleocin®), 150 mg, 4 times a
day, was selected by 29.59%. For those patients
with a penicillin allergy, 57.03% prescribed clinda-
mycin and various erythromycin preparations were
prescribed by 26.65%. A loading dose was used by
85.14%. The average duration of antibiotic therapy
was 7.58 days. Those respondents involved in ac-
ademics, either part-time or full-time, were signif-
icantly more likely to prescribe penicillin VK, 500
mg, 4 times a day at a rate of 85% versus those in
part-time or full-time private practice at a rate of
67%. For cases of irreversible pulpitis, 16.76% of
responding endodontists prescribed antibiotics.
For the scenario of a necrotic pulp, acute apical
periodontitis, and no swelling, 53.93% prescribed
antibiotics. Almost 12% prescribed antibiotics for
necrotic pulps with chronic apical periodontitis
and a sinus tract. For the most part, the majority of
the members of the AAE were selecting the appro-
priate antibiotic for use in orofacial infections, but
there are still many who are prescribing antibiotics
inappropriately. Although there were trends of im-
provement in some areas with regards to prescrib-
ing antibiotics, there were other areas where there
396
Printed in U.S.A.
VOL. 28, NO. 5, MAY 2002
had been no improvement in 25 years. Unless
these trends change, our generation and those to
come may not have effective antibiotics for use in
the management of true orofacial infections.
The deaths of four midwestern children due to methicillin-resistant
Staphylococcus aureus (MRSA) infections in August 1999 brought
attention to the increase in drug-resistant infections seen in the
general population (1). The Center for Disease Control (CDC) has
reported that 50% of S. aureus infections are methicillin-resistant,
up from 2% in 1974 (1). The indiscriminate use of antibiotics has
led to this problem. It has been proposed to develop a general
policy to implement new guidelines for antibiotic use. Since 1994,
the American Society for Microbiology (ASM) Task Force has
recommended that restraint in the indiscriminate prescribing of
antibiotics should be the immediate response by practicing physi-
cians, dentists, and veterinarians (2). Although hospitals, agricul-
ture, day care centers, and long-term health care facilities have all
been strongly accused of being responsible for contributing to the
drug resistance problem today, dentistry’s contributions to the
problem can be substantial because dentists prescribe approxi-
mately 10% of all common antibiotics (3). In 1977, Dorn et al. (4,
5) discussed trends in treatment of endodontic emergencies based
on a questionnaire answered by diplomates of the American Board
of Endodontics. The study was repeated in 1988 by Gatewood et
al. (6). Whitten et al. (7) surveyed diplomates of the American
Board of Endodontics and general dentists in 1996 to determine
treatment and drug prescribing practices in endodontics. These
three surveys all included general questions, with regard to anti-
biotic use, by diplomates of the American Board of Endodontics.
The purpose of this study was to ask more specific questions with
regard to antibiotic prescribing habits of all members of the Amer-
ican Association of Endodontists (AAE) rather than just limiting it
to the American Board of Endodontics.
MATERIALS AND METHODS
A one-page, double-sided questionnaire was sent to the active
members of the AAE living in the United States (Fig. 1). A cover
letter and postage-paid return envelope were also included. The
Vol. 28, No. 5, May 2002 Antibiotic Survey 397

FIG. 1. Antibiotic survey sent to members of the AAE.

1999 mailing list of 3274 members was obtained from the AAE. and endodontic faculty for appropriateness and clarity. The sample
Some questions were based on those asked in the previous surveys size was arrived at by a power calculation. With over 1000 sam-
(4 –7), and the questionnaire was reviewed by dental researchers ples, the study was able to distinguish differences to within 0.5%
398 Yingling et al. Journal of Endodontics
Vol. 28, No. 5, May 2002 Antibiotic Survey 399

TABLE 1. Description of respondents

n Mean SD Range
Year graduated Dental 1595 1979 9.05 1955–1997
Year graduated Endo 1562 1985 8.65 1961–2000
Age (yr) 1577 46.75 8.59 28–68
Gender Male 1416 89.68%
Female 163 10.32%
Region of practice Northeast 269 16.82%
Midatlantic 252 15.76%
Southeast 240 15.01%
Great Lakes 260 16.26%
Midwest 195 12.20%
Western 362 22.64%
Other 21 1.31%
Category of practice Full-time private 1364 86.22%
Part-time 80 5.06%
private
Academics only 42 2.65%
Part-time 96 6.07%
Faculty
Treatments per week (n) 1586 34.88 16.57 0–140

TABLE 2. Antibiotic-related topics

n Mean SD Range
Prescriptions for Antibiotics per week (n) 1531 9.25 9.45 0–80
Days of prescription (n) 1581 7.58 1.74 1–28
Loading dose Yes 1352 85.14%
No 236 14.86%
Change strategy Change antibiotic 1606 58.90%
Add second antibiotic 1606 34.93%
Other 1601 20.67%
Change prescription by day of week Yes 153 9.78%
No 1411 90.22%
Culture Yes 61 3.83%
No 1533 96.17%
Recent changes in regimen Yes 210 13.59%
No 1335 86.41%

TABLE 3. Antibiotic preference with no medical allergies

with power ⫽ 80% (at alpha ⫽ 5%). The data were analyzed using
descriptive statistics and groups were compared by using a chi- First Choice
Antibiotic
square test of independence. n %
Penicillin VK, 500 mg, qid 932 61.48
Amoxicillin, 500 mg, tid 417 27.51
RESULTS
Cephalexin (Keflex姞), 500 mg, qid 43 2.84
Ampicillin, 500 mg, qid 35 2.31
Of the 3274 surveys mailed, 1677 surveys were returned. A total Clindamycin (Cleocin姞), 150 mg, qid 29 1.91
of 71 were returned as undeliverable, and the others (n ⫽ 1606) Other 60 3.96
were found to be usable. The overall response rate was 50.1%. The 1516 100.00
results of the survey are presented in Tables 1– 8. Note that in some
instances the percentages may not add up to 100%, because some
questions allowed multiple responses and the sample size (n) for Table 1, the nation-wide proportion of respondents by region of the
each question may be different due to improperly completed or United States was evenly distributed. The majority of respondents,
partially completed surveys. 86.22%, declared themselves to be in full-time private practice.
Only 2.65% were in a full-time academic environment, 6.07% in
part-time academics, and 5.06% in part-time private practice. The
Demographics average number of patients treated in 1 week was 34.88.

Table 1 describes the demographics of the respondents. The

mean year of graduation from dental school was 1979. The mean Antibiotic-Related Topics
year of graduation from endodontic training was 1985. The mean
age of the respondents was 47 yr of age. Male respondents ac- The respondents of this survey wrote an average of 9.25 pre-
counted for 89.7% and females 10.3% of the total. As shown in scriptions per week for antibiotics, with a range of 0 to 80 (Table
400 Yingling et al. Journal of Endodontics

TABLE 4. Antibiotic preference with no medical allergies TABLE 5. Antibiotic preference with medical allergies

Second Choice First Choice

Antibiotic Antibiotic
n % n %
Clindamycin (Cleocin姞), 150 mg, qid 387 29.59 Clindamycin (Cleocin姞), 150 mg, qid 344 35.54
Clindamycin (Cleocin姞), 300 mg, qid 205 15.67 Clindamycin (Cleocin姞), 300 mg, qid 208 21.49
Amoxicillin, 500 mg, tid 190 14.53 Erythromycin Ethylsuccinate (EES姞), 94 9.71
Cephalexin (Keflex姞), 500 mg, qid 140 10.70 400 mg, qid
Penicillin VK, 500 mg, qid 117 8.94 Erythromycin Base, 500 mg, qid 90 9.30
Other 269 20.57 Erythromycin Base, 250 mg, qid 74 7.64
1308 100.00 Cephalexin (Keflex姞), 500 mg, qid 54 5.58
Azithromycin (Zithromax姞), 250 mg, qid 28 2.89
Clarithromycin (Biaxin姞), 500 mg, bid 20 2.07
Ciprofloxacin (Cipro姞), 500 mg, bid 10 1.03
2). The average duration of antibiotic therapy was 7.58 days. The Metrondiazole (Flagyl姞), 500 mg, qid 10 1.03
small standard deviation in this response indicated that almost all Clarithromycin (Biaxin姞), 250 mg, bid 7 0.72
prescribe for between 5 and 10 days. Cephalosporins and clinda- Other 29 3.00
mycin (Cleocin®) were mostly written for 5 to 7 days, whereas 968 100.00
penicillin and amoxicillin were generally written for 7 to 10 days.
A loading dose of twice the normal dose was reported by
85.14% of those surveyed. If improvement was not seen within 2 TABLE 6. Antibiotic preference with medical allergies
to 3 days of initiation of antibiotic therapy, 58.90% of respondents Second
changed antibiotics, 34.93% added a second antibiotic, and Antibiotic Choice
20.67% used some other strategy. Some examples of other strat-
n %
egies were to wait longer, prescribe steroids, reopen the tooth to
reinstrument and search for missed canals, and/or change the Clindamycin (Cleocin姞), 150 mg, qid 153 13.19
Erythromycin Ethylsuccinate (EES姞), 400 mg, qid 147 12.67
intracanal dressing.
Erythromycin Base, 500 mg, qid 130 11.21
Survey item #14 asked if antibiotics were prescribed differently
Clindamycin (Cleocin姞), 300 mg, qid 126 10.86
depending on the day of the week. Almost all, 90.22% responded Cephalexin (Keflex姞), 500 mg, qid 111 9.57
negatively. Interestingly, 72 responded that they would prescribe Azithromycin (Zithromax姞), 250 mg, qid 86 7.41
antibiotics if a weekend or holiday were upcoming. This survey Clarithromycin (Biaxin姞), 500 mg, bid 85 7.33
reported that only 3.83% of the respondents cultured drainage from Metrondiazole (Flagyl姞), 500 mg, qid 72 6.21
a tooth or from an incision and drainage (I & D) procedure. Some Erythromycin Base, 250 mg, qid 70 6.03
endodontists, 13.59%, reported that they had changed their pre- Metrondiazole (Flagyl姞), 250 mg, qid 47 4.05
scription regimens in the last 12 to 18 months. Comments submit- Ciprofloxacin (Cipro姞), 500 mg, bid 46 3.97
ted indicated two main switches: to either clindamycin or to a new Clarithromycin (Biaxin姞), 250 mg, bid 22 1.90
Other 65 5.60
generation macrolide, such as azithromycin (Zithromax®) and cla-
1160 100.00
rithromycin (Biaxin®).

TABLE 7. Situations in which antibiotics were prescribed

Antibiotic References
Prescribe
Penicillin VK, 500 mg, 4 times a day, was the first-choice Situation Antibiotics
antibiotic for patients with no medical allergies, by 61.48% of n %
respondents (Table 3). The second-choice antibiotic for nonpeni-
Irreversibile pulpitis; mod/severe preop 53 3.47
cillin-allergic patients was clindamycin, 150 or 300 mg, 4 times a symptoms
day, at 45.26% (Table 4). The first and second drug of choice for Irreversibile pulpitis with acute apical 203 13.29
patients with an allergy to penicillin was clindamycin 150 mg, 4 peridontitis; mod/severe preop symptoms
times a day (35.54% and 13.19%, respectively) (Tables 5 and 6). Necrotic pulp with chronic apical periodontitis; 288 18.85
In this study, 26.65% prescribed erythromycin, base or salt. no swelling, no/mild preop symptoms
Necrotic pulp with acute apical periodontitis; no 824 53.93
swelling, mod/severe preop symptoms
Antibiotic Usage Necrotic pulp with chronic apical periodontitis; 182 11.91
sinus tract present, no/mild preop symptoms
Table 7 lists the percentage of respondents who prescribed Necrotic pulp with acute apical periodontitis; 1516 99.21
antibiotics for various pulpal and periapical diagnoses. For cases of swelling present, mod/severe preop
irreversible pulpits with moderate/severe symptoms and irrevers- symptoms
Total number of prescribing dentists: 1528
ible pulpitis with acute apical periodontitis and moderate/severe
symptoms, 3.47% and 13.29% of respondents, respectively, pre-
scribed antibiotics. In cases of a necrotic pulp, chronic apical
periodontitis, no swelling, and no other symptoms, antibiotics were periodontitis, asymptomatic but with a sinus tract, 11.91% pre-
prescribed by 18.85%. In the scenario of necrotic pulp, acute apical scribe antibiotics. In the case of a necrotic pulp, acute apical
periodontitis, moderate/severe symptoms but no swelling, 53.93% periodontitis, swelling, and other moderate/severe symptoms,
prescribed antibiotics. For a case of necrotic pulp, chronic apical 99.21% of respondents prescribed antibiotics.
Vol. 28, No. 5, May 2002
TABLE 8. Situations with routinely prescribed antibiotics
(N ⴝ 1606)
Situation n %
I&D of a diffuse intraoral swelling, extraoral 1444 89.91
swelling present
I&D of a diffuse intraoral swelling, no extraoral 1114 69.36
swelling
Avulsions 986 61.39
I&D of a localized intraoral swelling, no extraoral 720 44.83
swelling
Endodontic surgeries 599 37.30
Retreatments, silver points 434 27.02
Retreatments, gutta-percha 247 15.38
Postop pain after instrumentation and/or 202 12.58
obturation
Perforations (before or after repair) 150 9.34
Table 8 lists other endodontic treatment situations and the
percentage of respondents who prescribe antibiotics routinely for
each situation. Incision and drainage of a diffuse intraoral swelling
with extraoral swelling prompted 89.91% to prescribe antibiotics.
The same scenario without the extraoral swelling resulted in
69.36% prescribing antibiotics. Routine prescription of antibiotics
for avulsions was performed by 61.39%. Antibiotics were pre-
scribed by 44.83% of the respondents for I & D of a localized
intraoral swelling. Thirty-seven percent prescribed antibiotics rou-
tinely for endodontic surgeries. For silver point and gutta-percha
retreatment cases, 27.02% and 15.38% prescribed antibiotics. Post-
operative pain after instrumentation or obturation resulted in
12.58% of respondents prescribing antibiotics. Finally, 9.34% pre-
scribed antibiotics before or after a perforation repair.
One question asked “Is there any one or more particular factor
surveyed that has a significant impact on whether penicillin VK
500 mg, 4 times a day was prescribed for therapeutic reasons or
not?” The answer was yes, but after all of the variables were put
through a multiple logistic regression analysis (i.e. making the
predictor variables compete against one another) only year of
graduation from endodontic residency and the type of practice
(part-time versus full-time, academics or private practice) were
statistically significant with regard to this question. The other
variables were no longer significant. Further analysis showed that
the four practice categories could be collapsed into two: part-time
and full-time academics became “academics” and part-time and
full-time private practice became “private practice.” Figure 2
shows two lines, both indicating an increasing trend toward pre-
scribing penicillin VK the more recently the endodontists had
graduated from their residency programs. The solid line with the
filled squares represents the private-practice endodontists. Their
preference for penicillin VK as first choice is significantly less than
endodontists in academic environments. The dotted line with
empty circles shows the proportion for academic endodontists. At
the bottom of the figure, there is a bar graph indicating the number
of respondents who graduated from endodontic residency pro-
grams in any particular year. The graph (Fig. 2) shows that there
is a good cross-sectional representation from all year groups. This
analysis indicates that if one is involved in academics, there is
about an 85% probability that penicillin VK 500 mg, 4 times a day
would be the first therapeutic choice. If one is in private practice,
there is a 67% chance that the first choice would be penicillin.
Antibiotic Survey 401
FIG. 2. The proportion of endodontists that prescribe penicillin VK by
year of graduation from endodontic residency. The vertical height of
the bars is proportional to the number of graduates in that year.
DISCUSSION
The survey instrument has historically been successful in ob-
taining pertinent information on the practice of endodontics. The
population sampled in this study was very large, 3274 members of
the AAE. A large percentage of this target population was prac-
ticing endodontists, and it should be noted that no attempt was
made to survey practicing endodontists who were not members of
the AAE. The overall response rate of 50.1% is considered to be an
acceptable rate of return for surveys. Questions were designed to
glean a variety of information relative to the types of antibiotics
used and the prescribing habits of endodontists as determined by
years in practice, gender, work status, area of the country, and
differences between practitioners who have been recently trained
versus those with more time in practice. However, part of survey,
item #2, regarding years in practice and item #13, regarding single
or multiple appointments, were eliminated from analysis. In hind-
sight, these questions were found to be poorly worded, and no
conclusions could be drawn from the results obtained by these
questions because of the ambiguity that existed.
Antibiotic-Related Topics
Fifteen respondents submitted comments that patients and re-
ferring general practitioners often “demand” antibiotics be pre-
scribed for every endodontic scenario. These endodontists felt
compelled to prescribe them for “medical-legal” reasons and to
decrease the risk of losing referrals. Some of these fifteen, ⬍0.1%
of the total surveyed, commented that they prescribe to all patients
with instructions not to fill the prescription unless swelling devel-
oped. In reality, an infection must be persistent or systemic to
justify the need for antibiotics: i.e. fever, swelling, lymphadenop-
athy, trismus, or malaise in a healthy patient. Antibiotics are also
more likely to be needed in an immunocompromised patient or a
patient in poor health. The decision to prescribe antibiotics should
not be influenced by patient demand, expectation of referring
dentists, “just in case” situations, or because it is the day before a
weekend or holiday. These reasons constitute inappropriate use of
antibiotics.
Odontogenic infections are polymicrobial involving a combina-
tion of Gram-positive, Gram-negative, facultative anaerobes and
strict anaerobic bacteria. Orofacial infections typically have a rapid
onset and short duration, 2 to 7 days or less, particularly if the
cause is treated or eliminated (8). The average length of antibiotic
402 Yingling et al.
prescriptions in this study was 7.58 days with a range of 5 to 10
days. The proper dose and duration of an antibiotic is enough when
there is sufficient evidence that the patient host defenses have
gained control of the infection. When the infection is resolving or
has resolved, then the drug should be terminated (8). It is pro-
longed use of antibiotics or an ineffective dose that can contribute
to the development of resistant microbial species. If resistant
species are already present, it won’t matter how long the antibiotic
is used; it will still be ineffective. A 5 to 7 day course would
probably be appropriate for most endodontic infections, as long as
the patient was monitored every 24 to 28 h.
An antibiotic loading dose should be used whenever the half-life
of the antibiotic is longer than 3 h or whenever a delay of 12 h or
more is unacceptable to achieve therapeutic blood levels (8). Most
antibiotics useful in orofacial infections have half-lives less than
3 h, but the acute nature of orofacial infections requires therapeutic
blood levels far sooner than 12 h (8). A loading dose of 1 to 2
grams for the penicillins, cephalosporins, and erythromycin en-
sures rapid elevation of antibiotic blood levels. This dose of eryth-
romycin may produce epigastric distress in some patients (9). A
loading dose was appropriately used by 85.14% of endodontists in
this survey.
Only 3.83% of the respondents cultured drainage from a tooth
or from an I & D procedure. This is much less then the 10.6%
reported by Dorn et al. in 1977 (4) and the 28.3% reported by Lane
and Grossman in 1971 (10). Culturing is rarely indicated for
endodontic infections, because there is rarely a single causative
organism, but is indicated if the infection persists or is present in
a medically compromised patient. Comments submitted indicated
that this was the procedure being used by 22 of the respondents.
Antibiotic Preferences
The list of antibiotics included in the survey identifies those
most often prescribed by dentists for the management of orofacial
infections. The list included penicillins, erythromycin, cephalospo-
rins, tetracycline, metronidazole, and the newer, longer-acting,
macrolides (11, 12). Penicillin VK, 500 mg, 4 times a day was the
first-choice antibiotic for patients who were not allergic to peni-
cillin, being used by 61.48% of respondents (Table 3). This num-
ber is in agreement with Whitten et al.’s (7) results of 58.4%. The
second-choice antibiotic for nonpenicillin-allergic patients was
clindamycin, 150 or 300 mg, 4 times a day at 45.26% (Table 4).
Penicillin VK has been found to be effective against most aerobic
and anaerobic organisms present in orofacial infections and since
the 1940s, continues to be the drug of choice in nonallergic,
immunocompetent patients (13). It is a narrow spectrum antibiotic
for infections caused by aerobic Gram-negative cocci and anaer-
obes. It is bactericidal and has a 1% to 10% hypersensitivity rate.
If taken with food, absorption may be delayed (14). It should be
taken every 6 h. It is low in cost and toxicity (15).
Clindamycin is a broader spectrum antibiotic than penicillin but
is still narrow in its specificity toward oral pathogens. It is bacte-
riostatic or bactericidal, depending on drug concentration, infec-
tion site, and microorganism. It is 90% absorbed from the gastro-
intestinal tract in the oral form and has peak serum concentration
within 60 min. The recommended dose for adults is 150 to 450 mg,
4 times a day for orofacial infections (14). There is a 1% rate of
pseudomembranous colitis. Clindamycin is appropriate for peni-
cillin-allergic patients even though, historically, it is believed that
there is a higher risk of pseudomembranous colitis than any other
Journal of Endodontics
antibiotic. The risk of pseudomembranous colitis has now been
shown not to be any higher for clindamycin than for other anti-
microbials. At best, clindamycin would occupy a third place after
ampicillin and cephalosporins as a causative agent for pseudomem-
branous colitis (16). People at risk for pseudomembranous colitis
are the elderly and those who have recently taken one or more
courses of antibiotics. Considering its low but serious risk of
pseudomembranous colitis, broader spectrum, and being 4 to 5
times more costly than penicillin, there does not seem to be a need
to prescribe clindamycin as frequently as the results of this survey
indicated. Penicillin is effective with less risk, less cost, and less
contribution to antimicrobial resistance. If an infection were found
to be resistant to penicillin, with or without the adjunct of metro-
nidazole, one could change to clindamycin. If the patient fails to
respond to this treatment, consultation with an oral surgeon is
recommended. The patient may need to be admitted to the hospital
for administration of closely regulated, “limited use” antibiotics.
Amoxicillin, a penicillin derivative with a broader spectrum, is
a good choice for immunocompromised patients (13). It was pre-
scribed by 27.51% of respondents as first drug of choice for
patients with no medical allergies. It is a good drug for orofacial
infections because it is readily absorbed and can be taken with
food. Due to the longer half-life and more sustained serum levels,
amoxicillin is taken 3 times a day and costs only slightly more than
penicillin. However, its broad spectrum is more than is required for
endodontic needs, and its use in a healthy individual may contrib-
ute to the global antibiotic resistance problem.
The first and second drug of choice for patients with an allergy
to penicillin was clindamycin 150 mg, 4 times a day (35.54% and
13.19%, respectively) (Tables 5 and 6). When both dosage regi-
mens of clindamycin, 150 mg and 300 mg are combined, 57.03%
of respondents prescribe clindamycin, compared with only 21.6%
in Whitten et al.’s study (7). Their top choice for penicillin-allergic
patients was erythromycin, base or salt, at 63.5%. In this study only
26.65% prescribed erythromycin, base or salt. Erythromycin, a
macrolide, has a similar spectrum of activity to that of penicillin for
Gram-positive microorganisms but is not as effective against
anaerobes usually involved in dental infections. It carries a high
incidence (10%) of gastrointestinal upset (11, 14). Erythromycin
inhibits the hepatic metabolism of numerous drugs leading to a
decrease in their clearance and resulting in an increased effect
and/or toxicity. This drug interaction can occur with such drugs as
carbamazepine, digoxin, theophylline, triazolam, and warfarin
(14).
Azithromycin and clarithromycin are semisynthetic derivatives
of erythromycin that have been modified to create a broader
spectrum of antibacterial activity and improved tissue penetration
(17). In addition, they have a longer elimination half-life resulting
in decreased dosing schedules and lower incidence of gastrointes-
tinal distress and abdominal cramping. Of the endodontists sur-
veyed, 13.59% reported they had changed their prescription regi-
mens in the last 12 to 18 months (Table 2). Comments indicate two
main switches: to clindamycin and to new generation macrolides,
such as azithromycin and clarithromycin. This is most likely due to
the patient-friendly once or twice a day dosing schedule and fewer
gastrointestinal side effects with the new macrolides. Five end-
odontists “empirically” found that erythromycin, cephalexin (Ke-
flex®), and penicillin were no longer effective against orofacial
infections and decided to change.
Metronidazole (Flagyl®) is an antibiotic that is very effective
against obligate anaerobes but not against facultative anaerobic
bacteria. If penicillin is not effective after 2 to 3 days of use, then
Vol. 28, No. 5, May 2002
metronidazole has been recommended as a supplemental medica-
tion (13). Proper dosage and duration of this combination is im-
portant for effective treatment without increasing the likelihood of
antibiotic resistance. A loading dose of 1000 mg of penicillin VK
should be followed by 500 mg every 6 h for 5 to 7 days. If there
is no improvement after 2 to 3 days, then a supplemental 500 mg
loading dose of metronidazole should be administered followed by
250 mg every 6 h for 7 to 10 days. Pharmacology reference texts
(14, 18) were used to determine the appropriate prescription reg-
imens for all the antibiotics listed on the survey instrument (Fig. 1).
Antibiotic Usage
Table 7 lists the percentage of respondents who prescribe anti-
biotics for various pulpal and periapical diagnoses. Because a
medical history could not be provided and specific details of the
symptoms could not be included in every question, interpretation
of this data must be considered in light of these limitations. The
first category was for irreversible pulpitis with moderate/severe
symptoms and the second category was for the same with an acute
apical periodontitis component. Combined, 16.76% of the respond-
ing endodontists prescribed antibiotics for these cases. These pulps
are still vital. There is no infection or signs of systemic involve-
ment. Antibiotics are not indicated in either situation. These num-
bers are almost identical to the results of Dorn et al. (4) in 1977 and
Gatewood et al. (6) in 1988. This finding is almost 50% less than
that found by Whitten et al. (7) only 5 yr ago.
The third scenario was necrotic pulp, chronic apical periodon-
titis, no swelling, and no or mild symptoms. Again, in a healthy
patient, there is no indication for antibiotic use, and treatment
should be limited to nonsurgical root canal therapy. In Whitten et
al. (7), 35.7% prescribed antibiotics, but in this survey there was
improvement to 18.85%. Although this was a significant improve-
ment, this is still inappropriate usage of antibiotics. The fourth
category was necrotic pulp, acute apical periodontitis, no swelling,
and moderate/severe symptoms. The proper treatment for this case
is debridement of the root canal space and analgesics. Again,
comparing the Dorn et al. (4), Gatewood et al. (6), and Whitten et
al. (7) studies, which reported 30.0%, 33.1%, and 67.3% prescrip-
tion for antibiotics respectively, this survey’s result was 53.93%,
which fits in the same range as previous studies. This again is
over-usage of antibiotics. Interestingly, 11.91% still prescribed
antibiotics for asymptomatic cases of necrotic pulp, chronic apical
periodontitis, and cases with sinus tracts (the fifth scenario). Al-
though reduced from 29.2% in Whitten et al. (7), indicated treat-
ment should consist of nonsurgical root canal therapy with anal-
gesics if needed for pain but no antibiotics. If the patient were
medically compromised and the sinus tract did not close within a
few weeks or the patient experienced a flare up with systemic
involvement, then antibiotics would be indicated. The last situation
described a case of a necrotic pulp, acute apical periodontitis
(abscess), swelling, and moderate to severe symptoms of an infec-
tion. Those prescribing antibiotics in the previous studies (4, 6, 7)
ranged from 87.6% to 96.6%. The results of the present survey
were comparable at 99.21% and appropriately so. If one interprets
that systemic involvement was present in this case, then antibiotics
are indicated in conjunction with debridement of the root canal
space and an I & D procedure.
The interesting point in this survey is that the prescribing habits
of endodontists with regards to irreversible pulpitis, necrotic pulps
with no systemic involvement, and sinus tracts has not changed in
Antibiotic Survey 403
almost 25 years. If endodontists are over-prescribing, what are the
prescribing habits of general dentists? Why are endodontists pre-
scribing antibiotics for any of the first five scenarios in Table 7? If
it were because the patient was immunocompromised, then maybe
this would be acceptable. If it was because of insufficient training
or fear of litigation, then this is clearly an inappropriate use of
antibiotics.
Nonsurgical root canal therapy without antibiotics is usually
adequate to treat cases of irreversible pulpitis, acute and chronic
apical periodontitis, draining sinus tracts, and localized swellings.
The pulpal circulation is compromised in these cases, and systemic
antibiotics will not reach therapeutic concentrations in the pulp.
Removing the source of the infection by performing nonsurgical
root canal therapy will usually allow healing of any periradicular
lesion or inflammation to occur. Analgesics are indicated for
pulpitis pain and pain from periapical inflammation, not
antibiotics.
Table 8 lists other endodontic treatment situations and the
percentage of respondents who prescribe antibiotics routinely for
each situation. The majority reported using antibiotics for incision
and drainage of a diffuse intraoral swelling with or without ex-
traoral swelling present and for avulsion cases. For most of these
scenarios, prescription of antibiotics is appropriate. For the case of
I & D of a localized intraoral swelling, 44.83% prescribed antibi-
otics. As long as the offending tooth was debrided or extracted, and
the patient was otherwise healthy, antibiotics are not indicated in
this situation. Removing the source of the infection and changing
the local environment during the I & D by increasing the oxygen
tension and irrigating facial space with saline is all that is required
to help the host defenses eliminate the pathogens.
Endodontic surgeries are generally performed on healthy tissues
to address a very localized area of pathosis. With good, sterile
surgical technique in a nonimmunocompromised patient, antibiot-
ics are not indicated, but in this survey 37.30% of respondents
routinely prescribed antibiotics for surgeries. Nonsurgical retreat-
ment of endodontically treated teeth has been associated with a
higher incidence of flare-ups (19). The more conservative ap-
proach in these situations is to inform the patient to report any
postoperative signs of infection, and then an antibiotic can be
prescribed rather than to prescribe antibiotics just in case. Antibi-
otics were prescribed by 27.02% of the respondents for silver point
retreatments and by 15.38% for gutta-percha retreatments.
Postoperative pain after instrumentation or obturation is usually
associated with periradicular inflammation, not periradicular in-
fection. Prescribing antibiotics for pain due to the inflammatory
process is inappropriate and ineffective. Analgesics are indicated
for postop pain. Twelve and a half percent of the surveyed respon-
dents in this survey reported prescribing antibiotics for postoper-
ative pain. Antibiotics were also prescribed by 9.34% before or
after perforation repair procedures. There are many variables that
can affect the outcome of a perforation repair, such as location in
relation to the gingival sulcus or furcation and length of time
elapsed since the perforation occurred. The indications for antibi-
otics in this scenario are not clear-cut, but a favorable prognosis is
likely in the case of an immediate repair of a perforation that is not
communicating with the gingival sulcus. In this situation antibiot-
ics would not be required. Even in these categories of “other”
endodontic treatment procedures there are still tendencies to in-
discriminately prescribe antibiotics when they are not really
indicated.
Antibiotic therapy is an art and a science. There are so many
confounding variables, such as suspected pathogen, ability to es-
404 Yingling et al.
tablish drainage, pharmacokinetic properties of the drug, mecha-
nism of action of the antibiotic, virulence of the infection, the
current health status of the host, and host defense mechanisms, that
it is not possible to make antibiotic therapy into a mechanistic
technological science (9). The most important decision for the
dental practitioner to make is not which antibiotic to use but
whether to use one at all. Most endodontic situations are resolved
by nonsurgical endodontics and accompanying incision and drain-
age procedures when indicated. When the decision is made to use
an antibiotic, it is important to adhere to basic principles of anti-
biotic dosing: (a) use high doses for short durations; (b) use an oral
antibiotic loading dose; (c) achieve blood levels of the antibiotic at
2 to 8 times the minimum inhibitory concentration; (d) use frequent
dosing intervals; and (e) determine duration of therapy by remis-
sion of disease (8). The use of antibiotics for minor infections, or
in some cases in patients without infections, could be a major
contributor to the world problem of antimicrobial resistance.
This research was supported in part by the Alexander Fellowship Fund.
The authors thank Dr. Al Best and Ms. Stacey S. Cofield from the Depart-
ment of Biostatistics at Virginia Commonwealth University for their invaluable
assistance in statistical analysis and Ms. Vivian Hyo Lee of the Virginia
Commonwealth University School of Dentistry for her dedicated research
support.
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