Acute Dento-Alveolar Infection

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 or there is evidence of spreading infection or systemic involvement. Where there is a significant swelling, trismus or difficulty breathing refer patient to hospital as an emergency.

Broad spectrum antibiotics are rarely indicated due to adverse effects and build-up of resistance and are associated with Clostridioides difficile infection. Prolonged courses of antibiotics can encourage the development of drug resistance and therefore the prescribing of antibiotics must be kept to a minimum.

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

1. Dental abscesses are usually infected with viridians-type streptococcus or anaerobic organisms. Treat dental abscesses in the first instance using local measures to achieve drainage with removal of the cause where possible
2. Antibiotics are only required in the case of spreading infection (cellulitis, lymph node involvement, swelling) or systemic involvement (fever, malaise).
3. 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).
4. Taking medication on an empty stomach means taking it 1 hour before or 2 hours after food. For children in particular, this can be challenging and may result in a reduced daily dose. This should be considered when choosing a drug to prescribe
5. The duration of treatment depends on the severity of the infection and the clinical response but drugs are usually given for 5 days
6. Do not prolong courses of treatment unduly because this can encourage the development of resistance
7. For severe infections consideration should be given to using both phenoxymethylpenicillin and metronidazole in combination. 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 offer no advantage over a penicillin, metronidazole or a macrolide and is not recommended for the routine management of dento-alveolar infections.
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.
11. 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.

Treatment

If antibiotics deemed clinically indicated:

Severe Infections

Full PDF of Dento-Alveolar Infection treatment table

Patient Information

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

Safe Prescribing (visit the safe prescribing page)

• 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
• 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).