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 a rise in Clostridium difficile. Prolonged courses of antibiotics can encourage the development of drug resistance and therefore the prescribing of antibiotics must be kept to a minimum

Doses are oral and for adults unless otherwise stated. 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). See guidance on dosing in children for quick reference dosage/weight guide. Refer to drug interactions table for detailed drug interactions for all antimicrobials. Note extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.

Note additional warnings for clarithromycin and fluoroquinolones

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 days^1.
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
Phenoxymethylpenicillin
Metronidazole
Clarithromycin
Severe Infection

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.

Phenoxymethylpenicillin*. Recommended duration 5 days

Phenoxymethylpenicillin needs to be taken on an empty stomach four times a day⁴

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

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.

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

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

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

**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

Patient Information

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

Reviewed October 2019