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 day4.
- 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 resistance1.
- 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.
- 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:
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 sugar free:
- 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 Susp QDS |
12.5mg/kg per dose to be given 4 times daily |
1 yr (9kg)
5 yrs (18kg)
|
6-12 years |
250mg Susp QDS
333mg tablets
|
12.5 mg/kg per dose to be given 4 times daily Up to a Max of 500mg Susp QDS
Up to a Max tablets 666mg QDS
|
6 yrs (21kg)
11 yrs (35kg)
|
12-18 years
|
500mg Susp QDS or 666mg tablets QDS
|
|
|
Adult |
666mg QDS
|
|
|
* 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 |
50mg Susp TDS |
|
3 - 7 years |
100mg Susp BD |
|
7-10 years |
100mg Susp TDS |
|
10-18 years |
200-250mg TDS |
|
Adult |
400mg TDS |
|
**Advise patients to avoid alcohol. The anticoagulant effect of Warfarin might be enhanced by Metronidazole3.
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Second line Antibiotics not recommended for routine treatments
Clarithromycin*** if penicillin allergic consider as a second line antimicrobial. 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
|
250mg twice daily (increase to 500mg twice daily if necessary)
|
Adults
|
|
500mg 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 |
|
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 |
50mg Susp TDS |
|
3-7 years |
100mg Susp BD |
|
7-10 years |
100mg Susp TDS |
|
10-18 years |
200-250mg TDS |
|
Adult |
400mg 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 |
50mg Susp TDS |
|
3-7 years |
100mg Susp BD |
|
7-10 years |
100mg Susp TDS |
|
10-18 years |
200-250mg TDS |
|
Adult |
400mg TDS |
|
**Advise patients to avoid alcohol. The anticoagulant effect of Warfarin might be enhanced by Metronidazole3.
Clarithromycin*** if penicillin allergic consider as a second line antimicrobial. 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
|
40kg and greater
|
250mg twice daily (increase to 500 mg twice daily if necessary)
|
Adults
|
500mg 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 Dec 2019
