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Acta Odontológica Latinoamericana

versão impressa ISSN 0326-4815versão On-line ISSN 1852-4834

Acta odontol. latinoam. vol.35 no.3 Buenos Aires dez. 2022  Epub 31-Dez-2022 


Antibiotic indication in endodontics by Colombian dentists with different levels of training: a survey

Indicação dos antibióticos em Endodontia por dentistas colombianos com diferentes níveis de formação: uma pesquisa por questionário

1Universidade Estácio de Sá, Departamento de Pós-Graduação em Odontologia, Rio de Janeiro, Brasil

2Universidad Santo Tomás - Bucaramanga, Facultad de Odontología, Bucaramanga, Colombia

3Universidade Iguaçu, Departamento de Endodontia, Nova Iguaçu, Brasil


Aim: This study investigated how Colombian dentists with different academic levels indicate antibiotics with therapeutic purposes in endodontics. Materials and method: A cross-sectional survey was conducted among 559 dentists in the form of an online questionnaire. Results: Three hundred and twenty questionnaires were answered (57.2%). There were significant differences among respondents. For irreversible pulpitis, 140 dentists (43.7%) said they prescribe antibiotics (57.5% of general practitioners, 20.1% of specialists and 38.9% of those with Master’s and/or PhD degrees), while for symptomatic apical periodontitis, 183 (57.2%) did so (74.1% of general practitioners, 28.4% of specialists and 50.0% of those with Master’s and/or PhD degrees) (p < 0.05). Amoxicillin was the most frequently prescribed antibiotic, and its association with clavulanic acid was the most often cited for acute periradicular abscess with systemic involvement. Conclusions: The greatest misunderstandings in prescribing antibiotics occurred among general practitioners. Considering all clinical conditions that do not require antibiotics, 60% of general practitioners and 34% of specialists, on average, indicated antibiotics.

Keywords: antimicrobial stewardship; dental pulp disease; bacteria; dental infection control; antibacterial drug resistance


Objetivo: Este estudo investigou como dentistas colombianos com diferentes níveis acadêmicos indicaram antibióticos com fins terapêuticos em Endodontia. Materiais e método: Realizou-se um levantamento transversal com 559 dentistas. Foi enviado um questionário online. Resultados: Foram respondidos 320 questionários (57,2%). Houve diferenças significativas entre os profissionais com diferentes níveis de formação. Para pulpite irreversível, 140 (43,7%) dentistas afirmaram indicar antibióticos (57,5% clínicos gerais, 20,1% especialistas e 38,9% com mestrado e/ou doutorado), enquanto para periodontite apical sintomática, 183 (57,2%) prescrevem estes medicamentos (74,1% clínicos, 28,4% especialistas e 50,0% com mestrado e doutorado) (p < 0,05). A amoxicilina foi a mais indicada entre os profissionais, e sua associação com ácido clavulânico foi a mais referida para abscesso perirradicular agudo com acometimento sistêmico. Conclusões: Os maiores equívocos na prescrição de antibióticos ocorreram com os clínicos gerais. Considerando todas as condições clínicas que não requerem antibióticos, 60% dos clínicos gerais e 34% dos especialistas, em média, indicaram estes medicamentos.

Palavras-chave: administração de antimicrobianos; doença da polpa dentária; bactérias; controle de infecção dentária; resistência a medicamentos antibacterianos


The discovery and large-scale use of antibiotics since the middle of last century has enormous impact on the treatment of infections, leading to the survival of thousands of people who would otherwise have died, mainly during the second world war 1 . Due to advances in molecular methods in microbiology, especially at the beginning of the current century, “new pathogens” have been detected in different types of infections that affect humans. However, the development, approval, and launch of new antibiotics have not kept pace with this evolution, and several “new microorganisms” already have multiple resistance to traditional antimicrobials 2 . The emergence and spread of antibiotic-resistant pathogens have become important public health problems, requiring global action from the different health areas 3 . It is estimated that infectious diseases will be the main cause of human mortality in the coming decades, mainly due to the growing number of microorganisms that are multi-resistant to antimicrobials 4 .

A broad range of bacterial resistance genes has been detected through molecular methods in samples obtained directly from infected root canals 5 . Although the presence of a resistance gene in a sample does not necessarily imply phenotypic resistance, proteomics studies have detected the expression of resistance factors such as TetR and Beta-lactamase in endodontic infections 6, 7 . As the unnecessary use of antibiotics can contribute to selecting these resistant microorganisms, antibiotics should be prescribed with great caution.

The American Association of Endodontics (AAE) and the European Society of Endodontology (ESE) frequently revise the guidelines for endodontists regarding proper antibiotic prescription. There is general consensus that in most clinical endodontic situations, it suffices to provide local treatment with removal or reduction of the infection source, without using systemic antibiotics 8-10 .

Different studies around the world have shown that dentists still prescribe antibiotics unnecessarily in endodontics 11-14 . There is a clear discrepancy between the recommended protocols for prescribing antimicrobials for patients who really need them and current practices among dentists in different parts of the world 15 . For most Latin American countries, including Colombia, there are few studies on whether antibiotics are prescribed correctly for endodontic purposes.

Thus, the aim of this study was to investigate, through an online questionnaire, how professionals with different levels of academic education, who provide endodontic treatment in Colombia, prescribed antibiotics.


This study was approved by the institutional ethics committee at Universidad Santo Tomas under number 1-18-30082018. A questionnaire ( Table 1 ) was created through Google forms and e-mailed to 559 dentists registered in the Federation of Colombian Dentistry database. The answers were received from February 21 to November 13, 2018. The questionnaire enquired about gender, age, length of professional experience, workplace, region of the country, weekly mean number of patients, monthly mean number of antibiotic prescriptions, clinical situations in which antibiotics are prescribed, duration of antibiotic prescriptions, prescription of loading dose, conduct for patients allergic to penicillins, and management in case of failure of the first-choice antibiotic. The antibiotics listed in the different clinical situations were amoxicillin, amoxicillin with clavulanic acid, azithromycin, cephalexin, clindamycin, erythromycin, penicillin v, and metronidazole.

Table 1 Questionnaire about the prescription of antibiotics in endodontics by Colombian dentists 

Sample calculation and statistical analysis

The following parameters were established to estimate the sample size: effect size (w) 0.30 (Cohen’s Test scale), power 90%, a error 5%, and degree of freedom equal to 30. Calculation software was G * Power (Universitat Kiel, Germany), indicating a total number of 233 individuals. The Kolmogorov-Smirnov and Shapiro-Wilk tests were used to test data normality. The chi-square test or Fisher’s exact test were used for the comparison among dentists. The level of statistical significance was established as 5% (p < 0.05).


A total 320 (57.2%) questionnaires were answered, 193 (60.3%) by general practitioners, 109 (34.1%) by specialists, and 18 (5,6%) by professionals with Master’s or PhD degrees. Most dentists who answered the questionnaire were > 25 years old (n = 269; 84.1%), women (61.6%), and had more than 10 years of professional experience in dentistry (48.4%) ( Table 2 ).

Table 2 Demographics, academic education levels, and profile of the service provided 

Regarding the prescription of antibiotics, 257 professionals (80.3%) prescribe antibiotics for 7 days, and only 6 (1.9%) suspend the prescription after the symptoms disappear. Comparison among the groups for prescription time showed no statistical difference (p > 0.05), suggesting that the level of training does not influence this decisión ( Table 3 ). More than half of the respondents prescribe antibiotics in up to 3 cases per month, and only 7% do not prescribe them. Regardless ofthe clinical situation and the professional training, amoxicillin is the most frequently prescribed antibiotic. Only in acute periradicular abscess with systemic involvement, the association of amoxicillin with clavulanic acid was the most frequently reported prescription. Also, 243 professionals (75.9%) responded that they do not prescribe an attack dose. Clindamycin was the most frequently recommended antibiotic in case of allergy to penicillin (n = 120; 37.5%), followed by erythromycin (n = 97; 30.3%) and azithromycin (n = 76; 23.8%).

Table 3 Comparison among the three levels of academic education for general clinical conduct in antibiotic prescription 

Comparing the three groups of professionals, only the variable “2nd choice in case of allergy to penicillin” showed a significant difference (p < 0.01), with specialists in endodontics presenting the highest frequency of clindamycin prescription (54.1%). In the other groups, Master’s or PhD and clinicians, azithromycin (44.4%) and erythromycin (37.8%) were the most frequently prescribed alternatives. When the antibiotic does not have the desired effect, 52.5% of the professionals choose to change the antibiotic, without significant differences among groups.

There were significant differences in antibiotic prescription among groups for irreversible pulpitis with symptomatic apical periodontitis and symptomatic acute apical periodontitis (p < 0.01). For irreversible pulpitis with symptomatic apical periodontitis, 140 dentists (43.7%) said they prescribe antibiotics (57.5% general practitioners, 20.1% specialists, and 38.9% with Master’s or PhD degrees), while for symptomatic acute apical periodontitis, 183 (57.2%) prescribe antibiotics (74.1% clinical, 28.4% specialists and 50.0% with Master and PhD). In cases of abscesses, clinicians prescribe significantly more antibiotics than specialists and professionals with Master’s or PhD degrees, not only for chronic cases (78.2%, 45.9%, and 50%, respectively, p < 0.001), but also for acute cases with localized intraoral edema/pain (94.3%, 87.2%, and 66.7%, respectively, p < 0.05). In cases of root perforation, 61.1% of clinicians prescribe some antibiotic, against 26.6% of specialists and 50% of professionals with Master’s or PhD degrees (p < 0.01).


Healthcare professionals often use systemic antimicrobials to treat or prevent infections. However, there is still a global threat to the effectiveness of these agents related to their indiscriminate use, resulting in the emergence of resistant microorganisms 16 . This concern also applies to endodontics, since antibiotic resistance by bacteria isolated from infected root canals has been frequently reported 17 . Moreover, the number of deaths related to endodontic infections refractory to antibiotic treatment is significant 18 .

Endodontic infections are polymicrobial, which means that multiple species and virulence factors are involved 7 . Sometimes, the immune system cannot suppress this type of infection, and antibiotics are required 18 . However, the prescription of antibiotics in endodontics should be limited to certain clinical conditions, with the aim of preventing the spread of infection and the development of secondary infections in medically compromised patients. As verified in the present study, many professionals lack knowledge about the proper use of antibiotics in endodontics. In this context, the main contribution of this study was to recognize and point out the magnitude of this problem among Colombian dentists.

The present study was based on a questionnaire about antibiotic prescription in different clinical situations, which was answered by 320 dentists with different levels of training. Studies using similar questionnaires have been conducted in different countries 11,12,14,19, 20 . However, this was the first study to investígate antibiotic prescription habits among dentists in Colombia. The response rate was acceptable (54.7%), compared to similar studies in Spain (31.1%) 11 , Norway (27.2%) 19 , United States (22.9%) 20 , and Brazil (4.4%) 14 .

In this type of study, it is important to record the level of professional training and geographic location in order to design continuing education strategies, if necessary. The current study compared different regions of Colombia, but found no significant difference among them regarding prescription or level of professional training.

The greatest misunderstandings in prescribing antibiotics occurred among general practitioners. Considering all clinical conditions that do not require antibiotics, 60% of general practitioners, on average, prescribed them, while only 34% of endodontics specialists did so. The mean for professionals with Master’s or PhD degrees was 45%, which contradicts expectations, considering their higher level of education. Another alarming finding was for avulsion conditions, which do require antibiotic therapy, but for which 44% of general practitioners reported they did not prescribe antibiotics. The same occurred with 25% of specialists and 39% of professionals with Master’s and PhD degrees. Specific training in endodontics is the most likely explanation for the fact that specialists prescribe more accurately and better than other professionals. In the present study, professionals with different levels of education prescribe antibiotics for irreversible pulpitis (21.2%) and irreversible pulpitis with symptomatic apical periodontitis (43.7%), which is a matter of concern. Dentists prescribe antibiotics to reduce the patient’s pain, though there is no evidence in the literature justifying it 21 . In irreversible pulpitis with acute apical periodontitis, the pulp remains vital, with no infection or signs and symptoms of systemic involvement. In these cases, there is only an inflammatory process in the pulp, and therefore, antibiotics are not indicated 21 . The level of professional training showed a statistical difference in this case ( Table 4 ). A low percentage was found for this situation in studies in other countries such as Lithuania (19.4%) 12 and Brazil (6.2%) 14 , while the percentage was higher in a study in India 22 . The significant difference between the results of the present study and those observed in Lithuania 12 and Brazil 14 may be related to the fact that the present study included general practitioners who perform endodontic treatment, while the other studies included only specialists in endodontics. Due to the short half-life of antibiotics, a minimum serum inhibitory concentration is essential for the success of antibiotic therapy. Therefore, a higher initial dose (attack dose) is usually recommended to ensure antibiotic penetration into bone tissue in a concentration high enough to eliminate the microorganisms in the infection site. The present findings showed that more than 70% of all interviewed professionals do not prescribe attack doses. Different results were found in other countries 14, 20 , where most professionals do prescribe the attack dose.

Regarding the second-choice antibiotic in cases of penicillin allergy, most professionals choose clindamycin (37.5%), regardless of training level. A similar rate was found in Brazil (33%) 14 . However, differences were found in intragroup analysis in which professionals with Master’s or PhD degrees prescribe more azithromycin; specialists prescribe more clindamycin; and clinicians prescribe more erythromycin. Current recommendations suggest azithromycin instead of clindamycin in these cases 23 . The problem with clindamycin is the risk of infection by Clostridioides difficile, and the consequent development of pseudomembranous colitis. It is important to emphasize that not only clindamycin, but also many other broad-spectrum antibiotics have been associated with this type of adverse reaction, and the risk increases with longer treatment periods and greater number of antibiotics administered 24 .

Systemic antibiotics are unnecessary in most cases in endodontics, including acute abscesses located without systemic involvement 18, 25 . However, antibiotic therapy is a crucial coadjuvant to treat cases of cellulite with signs of systemic effects, such as lymphadenopathy, limited mouth opening (trismus), fever, loss of appetite, and general malaise. These symptoms suggest that the patient’s immune system is not controlling the infection, and the microorganisms may spread to other anatomical spaces 23 . In the present study, most respondents prescribe antibiotics for acute periradicular abscesses with systemic involvement, although the prescription frequency was lowest among the professionals with higher qualifications ( Table 4 ). In these most critical situations, respondents’ antibiotic of choice was amoxicillin associated with clavulanic acid, as has been recommended 23 . The association of these two drugs provides a greater spectrum of action, including penicillin-resistant strains.

Table 4 Frequency of antibiotic prescription in clinical conditions according to different academic education levels 

It is clear that clinicians should keep in mind that antibiotics should be indicated as a therapeutic adjunct to local treatment to help prevent the spread of infection in severe cases 9 . Continuing medical and dental education should be encouraged in order to improve the indication of systemic antimicrobials and prevent erroneous prescriptions, reducing the probability of development of bacterial resistance 15 . There is a clear need to improve antibiotic recommendations as well as knowledge of pulpal and periradicular diseases, which are a problem not only locally, but also globally.

A limitation of the present study is that the professionals were not asked about why they did or did not prescribe antibiotics, as was done in a previous study 20 . Such answers could help identify the degree of information or misinformation about the prescription of antibiotics. However, the longer the questionnaire, the less accurate the information provided 26 .


The greatest misunderstandings in prescribing antibiotics occurred among general practitioners. Considering all clinical conditions that do not require antibiotics, 60% of general practitioners, on average, indicated antibiotics, while only 34% of specialists in endodontics did so. This information reinforces the need to create continuing education programs for Colombian dentists, in order to avoid unnecessary prescriptions, thereby reducing the development of microbial resistance to antibiotics.


Mohr KI. History of Antibiotics Research. Curr Top Microbiol Immunol. 2016;398:237-272. [ Links ]

Bumann D. Pathogen proteomes during infection: A basis for infection research and novel control strategies. J Proteomics. 2010;73(11):2267-2276. [ Links ]

Gajdács M. The Concept of an Ideal Antibiotic: Implications for Drug Design. Molecules. 2019 Mar 3;24(5):892. [ Links ]

Weiner LM, Webb AK, Limbago B, Dudeck MA et al. Antimicrobial-Resistant Pathogens Associated With Healthcare-Associated Infections: Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2011-2014. Infect Control Hosp Epidemiol. 2016;37(11): 1288-1301. [ Links ]

Rocas IN, Siqueira JF Jr. Antibiotic resistance genes in anaerobic bacteria isolated from primary dental root canal infections. Anaerobe. 2012; 18(6): 576-580. [ Links ]

Nandakumar R, Madayiputhiya N, Fouad AF. Proteomic analysis of endodontic infections by liquid chromatography-tandem mass spectrometry. Oral Microbiol Immunol 2009;24(4):347-352. [ Links ]

Provenzano JC, Siqueira JF, Jr., Rocas IN, Domingues RR et al. Metaproteome analysis of endodontic infections in association with different clinical conditions. PLoS One. 2013;8(10):e76108. [ Links ]

AAE position statement: AAE guidance on the use of systemic antibiotics in endodontics. J Endod. 2017;43(9):1409-1413. [ Links ]

Segura-Egea JJ, Gould K, Sen BH, Jonasson P et al.European Society of Endodontology position statement: the use of antibiotics in endodontics. Int Endod J. 2018;51(1):20-25. [ Links ]

Abraham SB, Abdulla N, Himratul-Aznita WH, Awad M et al. Antibiotic prescribing practices of dentists for endodontic infections; a cross-sectional study. PLoS One. 2020;15(12):e0244585. [ Links ]

Rodriguez-Nunez A, Cisneros-Cabello R, Velasco-Ortega E, Llamas-Carreras JM et al. Antibiotic use by members of the Spanish Endodontic Society. J Endod. 2009;35(9):1198-1203. [ Links ]

Skucaite N, Peciuliene V, Maneliene R, Maciulskiene V. Antibiotic prescription for the treatment of endodontic pathology: a survey among Lithuanian dentists. Medicina (Kaunas). 2010;46(12):806-813 [ Links ]

Alattas HA, Alyami SH. Prescription of antibiotics for pulpal and periapical pathology among dentists in southern Saudi Arabia. J Glob Antimicrob Resist. 2017;9:82-84. [ Links ]

Bolfoni MR, Pappen FG, Pereira-Cenci T, Jacinto RC. Antibiotic prescription for endodontic infections: a survey of Brazilian Endodontists. Int Endod J. 2018;51(2): 148-156. [ Links ]

Shemesh A, Batashvili G, Shuster A, Slutzky H et al.International questionnaire study on systemic antibiotics in endodontics. Part 1. Prescribing practices for endodontic diagnoses and clinical scenarios. Clin Oral Investig. 2022;26(3):2921-2926. [ Links ]

Kandasamy G, Sivanandy P, Almaghaslah D, Khobrani M et al. Knowledge, attitude, perception and practice of antibiotics usage among the pharmacy students. Int J Clin Pract 2020:e13599. [ Links ]

Jungermann GB, Burns K, Nandakumar R, Tolba M et al.Antibiotic resistance in primary and persistent endodontic infections. J Endod. 2011;37(10):1337-1344. [ Links ]

Siqueira JF, Jr., Rocas IN. Microbiology and treatment of acute apical abscesses. Clin Microbiol Rev. 2013;26(2):255-273. [ Links ]

Preus HR, Fredriksen KW, Vogsland AE, Sandvik L et al.Antibiotic-prescribing habits among Norwegian dentists: a survey over 25 years (1990-2015). Eur J Oral Sci. 2017;125(4):280-287. [ Links ]

Germack M, Sedgley CM, Sabbah W, Whitten B. Antibiotic Use in 2016 by Members of the American Association of Endodontists: Report of a National Survey. J Endod. 2017;43(10):1615-1622. [ Links ]

Agnihotry A, Thompson W, Fedorowicz Z, van Zuuren EJ et al. Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev. 2019;5:CD004969. [ Links ]

Garg AK, Agrawal N, Tewari RK, Kumar A et al. Antibiotic prescription pattern among Indian oral healthcare providers: a cross-sectional survey. J Antimicrob Chemother. 2014;69(2):526-528. [ Links ]

Lockhart PB, Tampi MP, Abt E, Aminoshariae A et al.Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc. 2019;150(11):906-921.e12. [ Links ]

Guh AY, Kutty PK. Clostridioides difficile Infection. Ann Intern Med. 2018;169(7):ITC49-ITC64. [ Links ]

Fouad AF, Rivera EM, Walton RE. Penicillin as a supplement in resolving the localized acute apical abscess. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(5):590-595. [ Links ]

Kost RG, de Rosa JC. Impact of survey length and compensation on validity, reliability, and sample characteristics for Ultrashort-, Short-, and Long-Research Participant Perception Surveys. J Clin Transl Sci. 2018;2(1):31-37. [ Links ]


This study was supported by grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), and Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Brazilian Governmental Institutions.

Received: August 01, 2022; Accepted: November 01, 2022

CORRESPONDENCE José Claudio Provenzano

DECLARATION OF CONFLICTING INTERESTS The authors declare no potential conflicts of interest regarding the research, authorship, and/or publication of this article.

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