Antimicrobial Prophylaxis in Endodontic surgery Article 2022

Antimicrobial Prophylaxis in Endodontic surgery
Evidence Based Dentistry-Professional Project
Critical Appraisal Assignment
Student Number: BP0204333

Table of Contents
1.Introduction.............................................................................................................................3
1.2 Rationale of the study.......................................................................................................3
1.3 Research Questions..........................................................................................................6
2.Critical Appraisal..................................................................Error! Bookmark not defined.
2.1 Article assessment..........................................................Error! Bookmark not defined.
3. Conclusion..............................................................................................................................7

1. Introduction
Antibiotics are life-saving treatment modality for infections. Antibiotics are often misused,
and its adverse effects have been increasingly reported in the healthcare literature
(Ramachandran, et al., 2019). Multidisciplinary approach among dentists, pharmacists, and
patients is needed to steward antibiotic. Puranik et al. (2018) demonstrated that in recent
times there has been an increased number of reports of antibiotic resistance in dentoalveolar
infections. Antibiotics are mainly used for 3 distinct reasons in dentistry namely: preventing
surgical site infections, that concerns with the infection that arises of the surgically handled
tissues; second for the purpose of prophylaxis against remote infections, that mainly concerns
infection that may arise anywhere within the body after the surgical procedure and finally, as
a therapeutic means after the surgery (Puranik et al., 2018). Many clinicians are questioning
the usefulness of prophylactic use of antibiotics and its capability to prevent the risk of
surgical site infection for those individuals who have undergone endodontic surgery (Puranik
et al., 2018). This paper will comprehensively aim to review the efficacy of antibiotic
prophylaxis in endodontic surgeries and whether it is really necessary or not in preventing
surgical site infection.
1.2 Rationale of the study
The usage of antibiotics in surgical endodontics, whether post-operative or pre-operative is
controversial (Zuolo et al., 2000; Siqueira, 2002). However, an article reviewing the efficacy
of antibiotic prophylaxis provided to patients undergoing endodontic surgery stated that there
is no valid evidence to support its use (Longman et al, 2000). Antibiotic prophylaxis in
endodontic surgery is often used based on clinical experience without strong evidence to
support it. Clinicians used it with the hope to prevent postoperative infection and to maximize
the chance for the procedure to be successful. To measure the efficiency of the usage of
antibiotics in hopes for prevention of infection in endodontic surgery, Lindeboom et al (2005)

conducted an RCT on the effectiveness of antibiotic prophylaxis in endodontic surgery. The
study comprised of 256 patients. The group was given either 600mg tablet of clindamycin or
placebo. From the results, it was observed that two patients in the clindamycin group while
four of the patients in placebo group developed postoperative infection. Lindeboom et al
(2005) found that 2 and 4 patients out of a sample of 256 patients was not statistically
significant to justifythe use of the antibiotic as prophylaxis. The average surgical time was
about 30 minutes in both the groups and the overall number of infections was low in both
groups. The results found that 1.6% of patients administered with clindamycin and 3.2%
patients administered with placebo experienced postoperative infection. The difference of
1.6% is a very small, and hence no statistical or biological significance can be concluded.
PICO framework was used to design the research question of the above mentioned study that
compared patients who received clindamycin prophylaxis and those who did not. The
findings of the study indicated that there was no statistically significant difference between
the outcomes on the two groups. The study was of considerable methodological quality. The
patients were allocated into their study groups randomly, but the randomization strategy is
not mentioned. The patients and surgeons were blinded to the study and drug administration
was supervised by an independent nurse. All participants were followed to assess the wound-
healing. The critical appraisal is demonstrated in table 1.
Table 1: JADAD score for Lindeboom et al. (2005).
Item Score
Randomized? 1
Method used to generate the sequence of
randomization described and appropriate?
-1
Double blind? 1
Method of double blinding described and
appropriate?
1
Description of withdrawals and dropouts? 1

4
Mauceri, Campisi, Matranga, Mauceri, Pizzo, and Melilli (2017) investigated whether
antibiotic prophylaxis reduces bacterial contamination by assessing 34 patients who
underwent dental surgical procedures. The PICO framework was used in the study that
compared patients who underwent antibiotic prophylaxis and those who did not. The findings
indicated that antibiotic treatment reduces the infection risk, but did not eliminate the risk
totally.
The study was of considerable methodological quality. The patients were allocated into their
study groups randomly using computer-generated randomization scheme. There was no
evidence of blinding in the study. There is a mention of the availability of all participants
during the entire follow-up period. The critical appraisal is demonstrated in table 2.
Table 2: JADAD score for (Mauceri et al., 2017)
Item Score
Randomized? 1
Method used to generate the sequence of
randomization described and appropriate?
1
Double blind? 0
Method of double blinding described and
appropriate?
0
Description of withdrawals and dropouts? 1
3
Over the past few years, the use of antibiotic prophylaxis has also been associated with
adverse effects and negative consequences. Segura‐Egea et al. (2017) reviewed 12 survey
articles to explore the usage of antimicrobial prophylaxis in endodontics, it was highlighted
that the use antibiotic prophylaxis for medically compromised patients who are undergoing
endodontic is controversial as it can be linked to many negative consequences and should
only be considered if the benefit has been demonstrated. The findings indicated that
antibiotics should only be used in endodontic surgery when there is evidence of their benefits,

putting into consideration factors such as individual cases, disease control and state, risk of
adverse drug reactions and risk of infection-related complications.
Table 3: CASP Assessment for Segura
‐Egea et al. (2017)
Section A: Are the results of the review valid?
Yes Can’t tell No Comments
1. Did the review address a
clearly focused question?
 The study focused solely on
endodontic infections
Did the authors look for the
right type of papers?
 The authors focused on
surveys in Europe and Turkey
Do you think all the important,
relevant studies were included?
 No details on the search
strategy
Did the review’s authors do
enough to assess quality of the
included studies?
 There are no details
If the results of the review
have been combined, was it
reasonable to do so?
 results of all the included
studies are clearly displayed
and results of different studies
are similar
What are the overall results of
the review?
antibiotics should only be
used in endodontic surgery
when there is evidence of
their benefits, putting into
consideration factors such as
individual cases, disease
control and state, risk of
adverse drug reactions and
risk of infection-related
complications.
How precise are the results?  Confidence intervals are not
provided
Can the results be applied to
the local population?
 The studies populations are
similar to the local
populations
Were all important outcomes
considered?
 All the information required
for the research was available
Are the benefits worth the
harms and costs?
 The review provides
meaningful insights in
endodontic surgery and the
use of antibiotics

The review by Segura‐Egea et al. (2017) had some methodological issues that were unclear
such as the preciseness, the relevance and quality of the included studies. The doubt on the
quality of reviewed articles results in a possible doubt of the overall review results. There is
need for adequate consultation in case of doubt. There is a lack of clear evidence of the
effectiveness of antibiotic prophylaxis in reducing the surgical site infection rate. Therefore,
this research will aim to find the efficacy of antibiotic prophylaxis in endodontic surgeries
and whether it is really necessary or not. The necessity of the procedure is a topic few have
undertaken, therefore, this research will be beneficial for other researchers and could be used
in the future as literature.
1.3 Research Questions
What is the effect of antibiotic prophylaxis on surgical site infection rate for patients
undergoing endodontic surgery?
The intention of the research question proposed is to assess the appropriateness of the use of
antibiotic prophylaxis in endodontic surgery by reviewing the relevant literature. To design
this research question, the following PICO framework is used:
P- Patients undergoing endodontic surgery (Apicoectomy)
I- Antibiotic Prophylaxis
C- No Antibiotic Prophylaxis
O- 1°-Surgical Site Infection rate (Based on clinical signs of infection)
1.4 Analysis
Endodontic infections account for the highest incidences of consultations within outpatient
dental emergency clinics. The concern is of antibiotic resistance is prominent in the use of
antibiotics for the treatment of dental and oral infections (Moreno-Drada & García-Perdomo,

2016). The research focuses on explaining antimicrobial resistance and its prevalence is
increasing even in dento-alveolar infections. A discussion about the difference between
concept of prophylaxis for preventing surgical site infection, prophylaxis for remote
infections and the therapeutic use of antibiotic. The narrative critical appraisal is essential for
assessing literature related to prophylaxis in endodontic surgery. The aim of this research is
to assess the appropriateness of the use of antibiotic prophylaxis in endodontic surgery.
For decades, antibiotics have been used for the treatment of bacterial infections. However, the
overuse of antibiotics coupled with the emergence of the antibiotic-resistant bacterial strains
of infections has become a global concern in the recent years. Dentists are responsible for the
prescription of 10% of the antibiotics treatment in primary acre (Cope et al. 2014). Also,
dentistry has significantly contributed to the development of antibiotic resistance bacteria.
The sensitivity of bacteria in the oral cavity to antibiotics is gradually reducing, and there is
an increased detection of antibiotic resistant bacteria strains such as the orphyromonas spp.
and Prevotella spp. Other strains include alpha haemolytic streptococci, which has been
found to be resistant to clindamycin, macrolides and penicilin (Segura‐Egea et al., 2017). The
increasing antibiotics resistance can be attributed to the the inappropriate use of antibiotics.
The misuse of antibiotics also predisposes people to anaphylactic reactions that can be fatal
and other adverse reactions. Additionally, the increased prescribing of antibiotics to patient’s
raises their expectations; hence leading to further prescribing to satisfy their preferences
(Cope et al. 2014). Further, the prescription for antibiotic medications in dentistry is rather
complex and empirical. In most cases, the dentists are unaware of the actual microorganism
causing infections as the collection and analysis of samples from the periapical region and the
root canal is not often common. Therefore, dentists only suspects the nature of infections and
microorganism responsible and decide on the treatment through presuming. Consequently,
dentists often prescribe broad-spectrum antibiotics (Segura‐Egea et al., 2017).

There is no consensus, and an increasing controversy in the use of prophylactic antibiotics for
the prevention of infections following endodontic surgery. The risk factors associated with
the use of antibiotics include uncontrolled diabetes, severe alcoholism, kidney disease and
immunosuppressive diseases. Further, the antibiotic prescription in dental practice us often
unclear due to increased incidence of inappropriate medications, which results bin bacterial
resistance, and an increased risk of adverse reactiosn (Moreno-Drada & García-Perdomo,
2016). Therefore, there is need for research to ascertain the use of antimicrobial prophylaxis
in endodontic surgery.
Conclusion
The review includes three major articles related to appropriateness of the use of antibiotic
prophylaxis in endodontic surgery. The Jadad scale is appropriate for assessing the validity
and suitability of evidence in addressing the research question. The three major
methodological features used in the assessment of clinical trials include randomization,
masking and accountability of all individuals who participated in the study, including the
withdrawals. The suitability of the Jadad scale lies in its easiness to use and its short length.
The CASP tool is also effective in assessing the methodological quality of reviews, with the
focus on assessing the gaps that the current review can address.

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