Acute Dento-Alveolar Infection (Dental abscess)

Summary

Most localised uncomplicated dental infections can be successfully treated without antibiotics using local measures.

Always consider local measures in the first instance. Antibiotics should only be used as an adjunct where local measures are ineffective or there is evidence of spreading infection or systemic involvement.

Where there is a significant swelling, trismus, eye closing or difficulty breathing refer patient to hospital as an emergency.

Inappropriate antibiotic use can encourage the development of drug resistance and therefore the prescribing of antibiotics must be kept to a minimum.

Broad spectrum antibiotics are rarely indicated and increase the risk of adverse effects, antibiotic resistance and Clostridioides difficile infection.

Local Measures

• If pus is present in a dental abscess drain by extraction of the tooth or through root canals.
• If pus is present in the soft tissue attempt incision.

Comments from Expert Advisory Group

• Treat dental abscesses in the first instance using local measures to achieve drainage with removal of the cause where possible.
• Antibiotics are only required in the case of spreading infection (cellulitis, lymph node involvement, swelling), systemic involvement (fever, malaise) or when local measures are ineffective or not possible.
• Dental abscesses are usually infected with viridians-type streptococcus or anaerobic organisms.
• Phenoxymethylpenicillin (penicillin V) has a narrower spectrum of antimicrobial activity than amoxicillin, but has equivalent efficacy for treatment of acute dento-alveolar infections. Amoxicillin should be reserved for patients where adherence is likely to be more challenging (for example in children).
• It is recommended to take phenoxymethylpenicillin 30 minutes before a meal or 2 hours after food. If the clinician and/or patient/carer feels this is not feasible, amoxicillin should be considered as the next option.
• The duration of treatment depends on the severity of the infection and the clinical response but antibiotic treatment is usually given for 5 days.
• Do not prolong courses of treatment unduly because this can encourage the development of resistance.
• For a severe dental abscess, consideration should be given to using both a penicillin and metronidazole in combination. Severe infections include those cases where there is extra-oral swelling, trismus or eye closing, but is a matter of clinical judgement. Use clinical judgement regarding referral to hospital or seeking specialist advice. All cases with suspicion of orbital cellulitis should be referred to hospital urgently.
• For children with a severe infection or at extremes of body weight for their age, the antibiotic dose should be calculated using the weight-based dose (mg/kg) recommended in the treatment table below. The child’s weight should be recorded on the prescription. 
• The prescribing of clindamycin, cephalosporins or co-amoxiclav offer no advantage over a penicillin, metronidazole or a macrolide and is not recommended for the routine management of dento-alveolar infections.
• If the patient does not respond to the prescribed antibiotic check the diagnosis and consider referral to a specialist. Patients with severe infections who are allergic to penicillin may need to be referred earlier.
• Patients should be informed of any potential side effects of chosen antibiotic and given clear information on dose, frequency, duration of course and how best to take antibiotics. The reason for the prescription, antibiotic, dose and duration should be recorded in patient’s notes.
• Further information on prescribing in children is available.

Treatment

ACUTE DENTO-ALVEOLAR INFECTION TREATMENT TABLE
Drug	Dose	Duration	Notes
1st choice options
Phenoxymethylpenicillin	1-5years:  125mg every 6 hours 6-11 years: 250mg (Kopen® tablet or liquid) or 333mg (Calvepen® tablet) every 6 hours For children with severe infection (or at extremes of body weight for their age) consider 12.5mg/kg (max. 1g) every 6 hours Adults and children ≥ 12 years:  666mg (Calvepen® tablet) or 500mg (Kopen® tablet or liquid) every 6 hours (increased in severe infection to a max. of 1g every 6 hours)	5 days	Recommend to take 30 minutes before a meal or 2 hours after food. Avoid in penicillin allergy. Liquid preparations: 125mg/5ml 250mg/5ml Tablet preparations: Calvepen® 333mg or 666mg Kopen® 250mg
Or (if 6 hourly dosing and/or fasting requirement above is likely to lead to poor adherence)
Amoxicillin	1-11 months: 125mg every 8 hours 1-4 years: 250mg every 8 hours 5-11 years: 500mg every 8 hours For children with severe infection (or at extremes of body weight for their age) consider 30mg/kg (max. 1g) every 8 hours Adults and children ≥ 12 years: 500mg every 8 hours (max. 1g every 8 hours for severe infection)	5 days	Avoid in penicillin allergy. Liquid preparations available (sugar-free): 125mg/5ml 250mg/5ml
2nd choice options / Penicillin Allergy
Metronidazole (1st choice for penicillin allergy, or if recent penicillin course)	1-2 years: 50mg every 8 hours 3-6 years: 100mg every 12 hours 7-9 years: 100mg every 8 hours 10-17 years: 200mg every 8 hours For children with severe infection (or at extremes of body weight for their age) consider 7.5mg/kg (max. 400mg) every 8 hours Adults: 400mg every 8 hours	5 days	Advise patients to avoid alcohol. Anticoagulant effect of warfarin may be enhanced by metronidazole. Liquid preparations available: 200mg/5ml
OR
Clarithromycin (2nd choice for penicillin allergy)	1-2 years: 62.5mg every 12 hours 3-6 years: 125mg every 12 hours 7-9 years: 187.5mg every 12 hours 10-11 years: 250mg every 12 hours 12-17 years: 250mg every 12 hours (max. 500mg every 12 hours) For children with severe infection (or at extremes of body weight for their age) consider 7.5mg/kg (max. 500mg) every 12 hours Adults: 500mg every 12 hours	5 days	See Macrolide warning and check drug interactions before prescribing Patients on warfarin will require close INR monitoring during and after treatment with clarithromycin. Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy. Prolonged release tablets not recommended in children. Liquid Preparations available: 125mg/5ml 250mg/5ml
Severe Infection: For severe infection, maximum dose of a single agent (as above) should be considered in the first instance for a duration of 5 days. Use of dual therapy regimens can also be considered as outlined below. If the patient does not respond to the prescribed antibiotic therapy, check the diagnosis and consider referral to a specialist.
Phenoxymethylpenicillin Plus Metronidazole	Adults: 1g every 6 hours Plus 400mg every 8 hours Children: Use max weight-based dose (mg/kg) of each agent as indicated in tables above.	5 days	Phenoxymethylpenicillin: Recommend to take 30 minutes before a meal or 2 hours after food. Avoid in penicillin allergy. Phenoxymethylpenicillin tablet preparations: Kopen® 250mg Liquid preparations: 125mg/5ml 250mg/5ml Metronidazole: Anticoagulant effect of warfarin may be enhanced by metronidazole. Advise patients to avoid alcohol.
OR (if 6 hourly dosing and/or fasting requirement above is likely to lead to poor adherence)
Amoxicillin Plus Metronidazole	Adults: 1g every 8 hours Plus 400mg every 8 hours Children: Use max weight-based dose (mg/kg) of each agent as indicated in tables above.	5 days	Amoxicillin: Avoid in penicillin allergy. Metronidazole: Advise patients to avoid alcohol. Anticoagulant effect of warfarin may be enhanced by metronidazole.
OR (Penicillin allergy)
Metronidazole Plus Clarithromycin	Adults: 400mg every 8 hours Plus 500mg every 12 hours Children: Use maximum weight-based dose (mg/kg) of each agent as indicated in tables above.	5 days	Metronidazole: Advise patients to avoid alcohol. Anticoagulant effect of warfarin may be enhanced by metronidazole and clarithromycin.  Clarithromycin: See Macrolide warning and check drug interactions before prescribing. Patients on warfarin will require close INR monitoring during and after treatment with clarithromycin.  Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy. Prolonged release tablets not recommended in children. Liquid Preparations available: 125mg/5ml 250mg/5ml

Weight Based Dosing Tables for Analgesics in Children

• Paracetamol
• Ibuprofen

Patient Information

Safe Prescribing (visit the safe prescribing page)

• Doses are oral and for adults unless otherwise stated
• Dosing in children quick reference dosage/weight guide
• Clarithromycin and other macrolides warning
• Penicillin allergy – tips on prescribing in penicillin allergy
• Renal impairment dosing table
• Safety in Pregnancy and Lactation
• Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
• Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed November 2023