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 Committee
- 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
- Antibiotics are only required in the case of spreading infection (cellulitis, lymph node involvement, swelling) or systemic involvement (fever, malaise) 5,6.
- 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.
- Erythromycin is no longer recommended due to it’sstrong association with development of resistance. Clarithromycin achieves higher tissue concentrations and activity.
- The duration of treatment depends on the severity of the infection and the clinical response but drugs are usually given for 5 days1.
- Do not prolong courses of treatment unduly because this can encourage the development of resistance 1.
- 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.
- 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.
- Where there is significant trismus, floor of mouth swelling or difficulty breathing transfer patients to hospital as an emergency.
- 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
