Acute Dento-Alveolar Infection

Consider a no or delayed antibiotic strategydental image

Note: Most of uncomplicated dental infections can be successfully treated using local measures. Always consider local measures in the first instance. Antibiotics should only be used as an adjunct where local measures are ineffective. Broad spectrum antibiotics are rarely indicated due to adverse effects and build up of resistance

Note Doses are oral unless otherwise stated. Visit the Health Products Regulatory Authority website for drug SPCs, dosage, contraindications, interactions, or IMF/BNF/BNFC/MIMS. See guidance on dosing in children for quick reference dosage/weight guide. Statins can interact with some antibiotics and increase the risk of rhabdomyolysis. Amiodarone and drugs which prolong the QT interval can interact with many antibiotics. Many antibiotics increase the risk of bleeding with anticoagulants. Please refer to our Drug Interactions Table for further information.


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

1 Dental abscesses are usually infected with viridians-type streptococcus or gram negative organisms. Treat dental abscesses in the first instance using local measures to achieve drainage with removal of the cause where possible3

2 Antibiotics are only required in the case of spreading infection (cellulitis, lymph node involvement, swelling) or systemic involvement (fever, malaise) 5,6.

3 Amoxicillin is as effective at treating dental infections as phenoxymethylpenicillin (Penicillin V) but is better absorbed. Phenoxymethylpenicillin needs to be taken on an empty stomach four times a day 4.

4 Erythromycin is no longer recommended due to it’s strong association with development of resistance. Clarithromycin achieves higher tissue concentrations and activity.

5 The duration of treatment depends on the severity of the infection and the clinical response but drugs are usually given for 5 days1.

6 Do not prolong courses of treatment unduly because this can encourage the development of resistance 1.

7 For severe infections consideration should be give to using both amoxicillin and metronidazole in combination3.  Severe infections include those cases where there is extra-oral swelling, eye closing or trismus, but it’s a matter of clinical judgement.

8 The prescribing of clindamycin, cephalosporins or co-amoxiclav offers no advantage over a penicillin, metronidazole or a macrolide and is not recommended for the routine management of dento-alveolar infections4.

9 Where there is significant trismus, floor of mouth swelling or difficulty breathing transfer patients to hospital as an emergency.

10 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.


Treatment

If antibiotics deemed clinically indicated:

Amoxicillin* preferred antibiotic. Recommended duration 5 days

Amoxicillin is as effective at treating dental infections as phenoxymethylpenicillin (Penicillin V) but is better absorbed.

Age

 Normal Dose

Maximum Dose

Maximum dose check (average weight for age)

1-11 months

125mg TDS

30mg/kg per dose to be given 3 times daily

1 month (4.3kg): 125mg 3 times daily
11 months (8kg): 250mg 3 times daily

1-4 years

250mg TDS

30mg/kg per dose to be given 3 times daily

1 yr (9kg): 250mg 3 times daily
4 yrs (16kg): 500mg 3 times daily

5-11 years

500mg TDS

30mg/kg per dose to be given 3 times daily

5 yrs (18kg) : 500mg 3 times daily
11 yrs (35kg): 1g 3 times daily

12-17 years

500mg TDS

1g 3 times daily

1g 3 times daily

Adult

500mg TDS

1g 3 times daily

1g 3 times daily

Please note: various strengths of Amoxicillin powder for suspension available:

  • 125mg/ 1.25ml
  • 125mg/5ml
  • 250mg /5ml

* Amoxicillin and phenoxymethyl penicillin, like other penicillins can cause hypersensitivity reactions including rashes and anyphalaxis and can cause diarrhoea. Do not prescribe to patients with a history of anaphylaxis, urticaria, rash immediately after penicillin administration as these patients are at risk of immediate hypersensitivity³.

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Phenoxymethylpenicillin*. Recommended duration 5 days

Phenoxymethylpenicillin needs to be taken on an empty stomach four times a day 4

Age Normal Dose Maximum Dose Maximum dose check
(average weight for age)
1-5 years 125mg QDS 12.5mg/kg per dose to be given 4 times daily

1 yr (9kg): max 125mg 4 times daily

5 yrs (18kg): max 225mg 4 times daily

6-12 years

250 mg QDS

12.5 mg/kg per dose to be given 4 times a day

6 yrs (20kg) : max 250mg 4 times daily

12 yrs (39kg): max 500mg 4 times daily

≥12 years
and Adults

500 mg QDS
or
666 mg QDS
(Calvepen tablet)

12.5 mg/kg per dose to be given 4 times a day max 1 g 4 times a day

Products for children: Phenoxymethylpenicillin powder for oral solution: (e.g. Calvepen® and Kopen®) 125mg/5ml, 250mg/5ml.  

Tablets: 250mg, 333mg and 666mg (333mg tablet = 250mg suspension)

* Amoxicillin and phenoxymethyl penicillin, like other penicillins can cause hypersensitivity reactions including rashes and anyphalaxis and can cause diarrhoea. Do not prescribe to patients with a history of anaphylaxis, urticaria, rash immediately after penicillin administration as these patients are at risk of immediate hypersensitivity³.

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Metronidazole**

First line in case of penicillin allergy or recent course of penicillin

Recommended duration 5 days

Normal Dose
Duration
5 Days
1-3 years 50 mg Susp TDS
3 - 7 years 100 mg Susp BD
7-10 years 100 mg Susp TDS
10-18 years 200-250 mg TDS
Adult 400 mg TDS

**Advise patients to avoid alcohol. The anticoagulant effect of Warfarin might be enhanced by Metronidazole3.

Products available: Metronidazole oral suspension 200mg/5ml, 200mg and 400 mg tablets

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Clarithromycin*** if penicillin allergic. Recommended duration 7days

Approximate Age 

 Weight

Dose
(based on 7.5mg/kg per dose twice daily)

1-2 years

8-11kg

62.5mg per dose to be given twice daily

3-6 years

12-19kg

125mg per dose to be given twice daily

7-9 years

20-29kg

187.5mg per dose to be given twice daily

10-12 years

30-40kg

250mg per dose to be given twice daily

12-18 years

40 kg and greater

250 mg twice daily
(increase to 500 mg twice daily if necessary)

Adults

500 mg BD

Preparations available for children: Clarithromycin Granules for Oral Solution: 125mg/5mls and 250mg/5mls, 250mg tablets. Prolonged release tablets not recommended in children.

***Patients on warfarin will require close INR monitoring during and after treatment with clarithromycin. Check for drug interactions before prescribing

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Severe Infections

First line Amoxicillin*. Recommended duration 5 days

Age

Amoxicillin Dose for severe infection

Maximum dose check (average weight for age)

1-4 years

30mg/kg per dose to be given 3 times daily

1 yr (9kg): 250mg 3 times daily
4 yrs (16kg): 500mg 3 times daily

5-11 years

30mg/kg per dose to be given 3 times daily

5 yrs (18kg) : 500mg 3 times daily
11 yrs (35kg): 1g 3 times daily

12-17 years

1g 3 times daily

1g 3 times daily

Adult

1g 3 times daily

1g 3 times daily

*Amoxicillin and phenoxymethyl penicillin, like other penicillins can cause hypersensitivity reactions including rashes and anyphalaxis and can cause diarrhoea. Do not prescribe to patients with a history of anaphylaxis, urticaria, rash immediately after penicillin administration as these patients are at risk of immediate hypersensitivity³.

Severe Infection: Dual Therapy

May also consider duel therapy Amoxicillin* and Metronidazole ** for 5 days

If the patient does not respond to the prescribed antibiotic check the diagnosis and consider referral to a specialist.


Amoxicillin*

Age

Amoxicillin Dose for severe infection

Maximum dose check (average weight for age)

1-4 years

30mg/kg per dose to be given 3 times daily

1 yr (9kg): 250mg 3 times daily
4 yrs (16kg): 500mg 3 times daily

5-11 years

30mg/kg per dose to be given 3 times daily

5 yrs (18kg) : 500mg 3 times daily
11 yrs (35kg): 1g 3 times daily

12-17 years

1g 3 times daily

1g 3 times daily

Adult

1g 3 times daily

1g 3 times daily

* Amoxicillin and phenoxymethyl penicillin, like other penicillins can cause hypersensitivity reactions including rashes and anyphalaxis and can cause diarrhoea. Do not prescribe to patients with a history of anaphylaxis, urticaria, rash immediately after penicillin administration as these patients are at risk of immediate hypersensitivity³.


Metronidazole**

Normal Dose
Duration
5 Days
1-3 years 50 mg Susp TDS
3 - 7 years 100 mg Susp BD
7-10 years 100 mg Susp TDS
10-18 years 200-250 mg TDS
Adult 400 mg TDS

**Advise patients to avoid alcohol. The anticoagulant effect of Warfarin might be enhanced by Metronidazole3.

Severe Infection: Dual Therapy

For severe infections in case of with Penicillin allergy consider Metronidazole ** plus Clarithromycin***Recommended duration 5 days

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.

Metronidazole**

Normal Dose
Duration
5 Days
1-3 years 50 mg Susp TDS
3 - 7 years 100 mg Susp BD
7-10 years 100 mg Susp TDS
10-18 years 200-250 mg TDS
Adult 400 mg TDS

**Advise patients to avoid alcohol. The anticoagulant effect of Warfarin might be enhanced by Metronidazole3.

Clarithromycin***

Approximate Age 

 Weight

Dose
(based on 7.5mg/kg per dose twice daily)

1-2 years

8-11kg

62.5mg per dose to be given twice daily

3-6 years

12-19kg

125mg per dose to be given twice daily

7-9 years

20-29kg

187.5mg per dose to be given twice daily

10-12 years

30-40kg

250mg per dose to be given twice daily

12-18 years

40 kg and greater

250 mg twice daily
(increase to 500 mg twice daily if necessary)

Adults

500 mg BD

Preparations available for children: Clarithromycin Granules for Oral Solution: 125mg/5mls and 250mg/5mls, 250mg tablets. Prolonged release tablets not recommended in children.

***Patients on warfarin will require close INR monitoring during and after treatment with clarithromycin. Check for drug interactions before prescribing

* Amoxicillin and phenoxymethyl penicillin, like other penicillins can cause hypersensitivity reactions including rashes and anyphalaxis and can cause diarrhoea. Do not prescribe to patients with a history of anaphylaxis, urticaria, rash immediately after penicillin administration as these patients are at risk of immediate hypersensitivity³.

**Advise patients to avoid alcohol. The anticoagulant effect of Warfarin might be enhanced by Metronidazole3.

***Patients on warfarin will require close INR monitoring during and after treatment with clarithromycin and  erythromycin. Check for drug interactions before prescribing

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Patient Information

Visit HPSC Information Leaflets pages for the General Public, (MRSA, CRE, etc)


Reviewed June 2016

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