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Dental abscess - Management
Which antibiotic is recommended for the treatment of dental abscess?

  • If an oral antibiotic is thought to be indicated, prescribe amoxicillin or metronidazole for 5 days.
  • A course of amoxicillin 3 g repeated after 8 hours may also be offered for adults.
Clarification / Additional information
  • For information when to prescribe an antibiotic, see Prescribing an antibiotic
  • Amoxicillin and metronidazole are generally considered to be the antibiotics of choice for the management of dental abscesses. Nevertheless, CKS found very little evidence to provide clear advice on which of the two antibiotics should be considered first line. National organizations suggest slightly different approaches:
    • The British National Formulary recommend that amoxicillin or metronidazole can be used to manage periapical or periodontal abscesses [BNF 54, 2007]. In cases of penicillin allergy, metronidazole is regarded as the antibiotic of choice [Dahlen, 2002].
    • The Faculty of General Dental Practitioners recommends phenoxymethylpenicillin or amoxicillin as first choice for acute dental abscess, with metronidazole as second choice [Faculty of General Dental Practice, 2000]:
      • A combination of amoxicillin or penicillin with metronidazole is recommended if a predominately anaerobic infection is suspected or microbiologically proven.
      • Erythromycin is third choice.
  • CKS found very little evidence looking at the duration of antibiotic therapy in the management of dental abscesses. Therefore, a practical approach would be to prescribe a 5-day course of antibiotics (or a two-doses course if a dose of amoxicillin 3 g is prescribed), and advise the person to see their dental practitioner urgently.
Basis for recommendation
  • These recommendations are based on those issued by the Faculty of General Dental Practitioners (UK) [Faculty of General Dental Practice, 2000], the British National Formulary (BNF) [BNF 54, 2007] and expert opinion [Roberts et al, 2000].
  • CKS found no evidence that specifically looked at antibiotics in the treatment of dental abscess by general medical practitioners. Antibiotics are often prescribed empirically, due to the difficulty in evaluating microbiology and the delay in obtaining sensitivity results [Dahlen, 2002; Kuriyama et al, 2007].
  • Amoxicillin
    • Both a 5-day course and a two-dose course of amoxicillin have been recommended for the treatment of dental abscess [Faculty of General Dental Practice, 2000; BNF 54, 2007].
    • CKS found no direct randomized studies comparing these two regimens of amoxicillin. However, two small studies found the two-dose amoxicillin course to be as effective as a 5-day course with phenoxymethylpenicillin for treating dental abscess.
      • Two small Scottish randomized controlled trials (RCTs) (assessors blinded to treatment) found amoxicillin to be as effective as phenoxymethylpenicillin in terms of subjective (e.g. pain scores) and certain objective assessments (e.g. presence of lymphadenopathy) in adults (n = 60) [Lewis et al, 1986] and children (n = 58) [Paterson and Curzon, 1993]. However, a greater reduction in swelling during the first 24 hours was found in the amoxicillin group in both studies.
      • Nausea was experienced by 7% of the amoxicillin group following the second 3g dose (none in the phenoxymethylpenicillin group) in the adult study [Lewis et al, 1986].
      • Both studies gave no information regarding the use of analgesics.

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