Summarize the latest clinical guidelines for prescribing systemic antibiotics in acute dental abscesses.

3. Discussion

This is a clinical situation in which antibiotics are not indicated in systemically healthy patients [6,79], yet the percentage of endodontists who prescribed them (48%) was the same as that of general practitioners. What characterizes acute apical abscesses is swelling, and it seems that this is what alarms the clinicians and leads them to prescribe antibiotics, even in the absence of moderate/severe symptoms. But localized swelling with no/mild symptoms in non-medically compromised patients is a clinical situation in which antibiotics are not indicated [6]. Clinical evidence only supports antibiotics prescription in the management of apical periodontitis when the infection spreads systemically; the patient is febrile, or both [7,79]. When the patient has no swelling and moderate/severe symptoms, antibiotic use is not indicated. In these cases, the appropriate treatment should be limited to root canal treatment, with pulp extirpation, which eliminates the source of infection, followed by drainage of abscess, debridement of the root canal space and analgesics [5].

Antibiotic Over-Prescription by Dentists in the Treatment of Apical Periodontitis: A Systematic Review and Meta-Analysis. © 2024 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Survey of European guidelines

Two specific clinical conditions were further explored: odontogenic abscess in a primary tooth and replantation of an avulsed permanent tooth. In case of the odontogenic abscess, respondents agreed unanimously that antibiotic therapy is only indicated when systemic signs of infection are present. In addition, when there is evidence of local spread of the infection, antibiotics are recommended if the child is immunocompromised or there is lack of cooperation for immediate intervention. Penicillin V was the antibiotic of first choice most frequently recommended (10 out of 18 respondents, 55.6%), with the dosage and duration showing great variation. Second choice products were mentioned in only a few guidelines (5 out of 18, 27.8%), with amoxicillin being advised in 60.0% of the cases (3 out of 5). In case of insufficient therapeutic response, combination therapy with metronidazole was also mentioned for 6 countries (33.3%). Dosage calculation varied in different guidelines, with some recommending a body weight-based method whilst others propose age-standardised doses. Regarding duration of antibiotic therapy, variation was large, ranging between 3 to 10 days, with 5 days being most frequently recommended (33.3%).

Best clinical practise guidance for the use of antibiotics in children: an EAPD policy document. © Crown 2025. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

4. Discussion

A comprehensive evaluation of oral antibiotic regimens as adjunctive measures for the management of acute dentoalveolar infections and their corresponding clinical outcomes was undertaken. There was a range of antibiotics trialled, with varying spectrums and regimens used, and all produced similar clinical success. Interestingly, one study employed a broad-spectrum combination of amoxicillin with clavulanic acid in addition to metronidazole in one patient cohort versus no antibiotic in another group, and both arms of this study produced the same clinical outcomes [32]. Given the anaerobic coverage of amoxicillin with clavulanic acid, the additional benefit of metronidazole is unclear, but this review highlights the effectiveness of dental treatment to address the source of infection as being the primary factor in the successful management of dentoalveolar abscesses. It is unclear which antibiotic or regimen is the most effective to manage odontogenic infections in clinical practice, but the evidence here suggests that broad-spectrum antibiotics as first-line empirical therapy for infections with non-severe features, such as single-space extraoral swelling, are unnecessary since the narrow-spectrum antibiotic phenoxymethylpenicillin was also effective [4,28,29].

Oral Antibiotic for Empirical Management of Acute Dentoalveolar Infections—A Systematic Review. © 2021 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

4. Discussion

Antibiotic selection in dental practice is largely informed by antimicrobial-susceptibility data, typically derived from pus samples and aligned with established prescribing guidelines [29]. Australian dental therapeutic recommendations, for instance, are influenced by susceptibility profiles from European countries, including Russia [30], Romania [31], and broader European datasets [32]. Kuriyama et al. [27] reported significant penicillin resistance in OI cases treated with phenoxymethylpenicillin or amoxicillin. Despite this, CI was observed within 2–3 days, and no major differences in outcomes were found between patients with penicillin-resistant and penicillin-sensitive infections. This led the authors to question the need for antibiotics when adequate drainage is achievable [27]. However, in cases such as diffuse cellulitis or deep-space infections, where drainage is delayed or not feasible, antibiotics play a more critical role. In hospitalized patients with severe infections, resistance was linked to worse clinical outcomes [33]. For moderate extraoral swelling, particularly when drainage is possible and systemic health is uncompromised, the benefit of broad-spectrum antibiotics should be reevaluated [34].

Optimal Duration of Antibiotic Therapy for Space Infections in the Maxillofacial Region: A Systematic Review. © 2025 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

1. Introduction

The contribution of dental antibiotic prescriptions towards the global public health problem of the development of antimicrobial resistance is an ongoing concern, with dentists being more recently included in antibiotic stewardship initiatives [12,13]. Dental antibiotic prescription accounts for approximately 10% of all antibiotic prescriptions worldwide [14], and it is known from surveys, retrospective studies and prospective audits that overprescribing of dental antibiotics occurs at rates between 55 and 80% [15,16,17,18]. Dental antibiotic prescribing is associated with increased bacterial resistance, especially with regard to the use of metronidazole [19,20], and serious antibiotic-associated adverse events including Clostridioides (formerly Clostridium) difficile infections [21]. Penicillin-resistant odontogenic infections are also associated with increased hospital stays and poorer clinical outcomes [22]. Inappropriately managed dental infections can progress to severe submandibular space infections with associated serious complications, such as sepsis and airway obstruction [23]. Appropriate use and choice of antibiotics in dentistry plays an important role in antibiotic stewardship.

Oral Antibiotic for Empirical Management of Acute Dentoalveolar Infections—A Systematic Review. © 2021 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Abstract

Concerns regarding increasing antibiotic resistance raise the question of the most appropriate oral antibiotic for empirical therapy in dentistry. The aim of this systematic review was to investigate the antibiotic choices and regimens used to manage acute dentoalveolar infections and their clinical outcomes. A systematic review was undertaken across three databases. Two authors independently screened and quality-assessed the included studies and extracted the antibiotic regimens used and the clinical outcomes. Searches identified 2994 studies, and after screening and quality assessment, 8 studies were included. In addition to incision and drainage, the antibiotics used to manage dentoalveolar infections included amoxicillin, amoxicillin/clavulanic acid, cefalexin, clindamycin, erythromycin, metronidazole, moxifloxacin, ornidazole and phenoxymethylpenicillin. Regimens varied in dose, frequency and duration. The vast majority of regimens showed clinical success. One study showed that patients who did not receive any antibiotics had the same clinical outcomes as patients who received broad-spectrum antibiotics. The ideal choice, regimen and spectrum of empirical oral antibiotics as adjunctive management of acute dentoalveolar infections are unclear. Given that all regimens showed clinical success, broad-spectrum antibiotics as first-line empirical therapy are unnecessary. Narrow-spectrum agents appear to be as effective in an otherwise healthy individual. This review highlights the effectiveness of dental treatment to address the source of infection as being the primary factor in the successful management of dentoalveolar abscesses. Furthermore, the role of antibiotics is questioned in primary space odontogenic infections, if drainage can be established.

Oral Antibiotic for Empirical Management of Acute Dentoalveolar Infections—A Systematic Review. © 2021 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

3. Discussion

In these cases, the appropriate treatment should be limited to root canal treatment, with pulp extirpation, which eliminates the source of infection, followed by drainage of abscess, debridement of the root canal space and analgesics [5]. Given evidence of systemic involvement and manifest, rapid and diffuse spread of the infection, antibiotics should be prescribed [6]. However, the indication for antibiotics for the treatment of apical periodontitis changes radically when the patient is immunosuppressed or medically compromised. In these cases, antibiotics are indicated from the first phase of the acute apical abscess [6,79]. The search carried out for this systematic review provided a large number of studies, indicating the great interest of the scientific community in the topic. The design of all studies was cross-sectional surveys carried out among dentists, rated as having a low degree of certainty. Although the inconsistency was serious due to the high heterogeneity of the studies, the evaluation of a moderate risk of bias leads to not modifying the consideration of the quality of the overall evidence, using the GRADE methodology, as low certainty.

Antibiotic Over-Prescription by Dentists in the Treatment of Apical Periodontitis: A Systematic Review and Meta-Analysis. © 2024 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Antibiotic regimens

Penicillins continue to be the antibiotic group of choice for the majority of odontogenic infections. Evidence showed that duration of treatment should be for up to 5 days, with recommended review after 2–3 days and discontinuation of therapy following the elimination of the source of infection and resolution of systemic signs/symptoms (Palmer et al. 2020). Antibiotic regimens should take in consideration the child’s age, weight and maximum daily dosage and allergy status. Country-specific antibiotic prescribing guidelines should be followed. In the absence of local guidelines, antibiotic regimen suggestions are presented in Appendix 1.

Best clinical practise guidance for the use of antibiotics in children: an EAPD policy document. © Crown 2025. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Abstract

BACKGROUND: An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated clinical recommendations for the urgent management of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis and symptomatic apical periodontitis, or pulp necrosis and localized acute apical abscess using antibiotics, either alone or as adjuncts to definitive, conservative dental treatment (DCDT) in immunocompetent adults. TYPES OF STUDIES REVIEWED: The authors conducted a search of the literature in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature to retrieve evidence on benefits and harms associated with antibiotic use. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and the Evidence-to-Decision framework. RESULTS: The panel formulated 5 clinical recommendations and 2 good practice statements, each specific to the target conditions, for settings in which DCDT is and is not immediately available. With likely negligible benefits and potentially large harms, the panel recommended against using antibiotics in most clinical scenarios, irrespective of DCDT availability. They recommended antibiotics in patients with systemic involvement (for example, malaise or fever) due to the dental conditions or when the risk of experiencing progression to systemic involvement is high. CONCLUSION AND PRACTICAL IMPLICATIONS: Evidence suggests that antibiotics for the target conditions may provide negligible benefits and probably contribute to large harms. The expert panel suggests that antibiotics for target conditions be used only when systemic involvement is present and that immediate DCDT should be prioritized in all cases.