Dental Infection and Abscess: Management

Following diagnosis and the administering of appropriate analgesia, the question arises whether to prescribe a course of antibiotics.

Considerable variation exists in practice as demonstrated by one study [7], which found that antibiotic prescribing for dental problems varied greatly; 68% of patients attending a medical practitioner received antibiotics whereas antibiotics were only given to less than a third of patients attending a dentist.

The type of antibiotic prescribed also varies greatly; 90% of prescriptions in one study [8] were for either amoxicillin, metronidazole or penicillin V. Another study [9] showed that combinations of antibiotics were used in nearly 6% of cases despite guidance [10] that combination antibiotics should be avoided if at all possible in dental infection.

A number of questions arise:

Are antibiotics indicated in my patient?

National antibiotic prescribing guidance for dental problems [11,12] states that antimicrobials should be only given to patients with:

• Symptoms or signs of systemic illness
• Spreading infection e.g. cellulitis, lymph node involvement
• High risk patients where complications are likely e.g. immunocompromised patients, diabetics

Antibiotics are generally not indicated for otherwise healthy individuals or when there are no signs of spreading infection. They do not form the mainstay of treatment of local infection and early management of the source must be a priority.

Learning bite

Antibiotics should only be prescribed for dental abscess where there are signs of systemic infection or in patients who are at a high risk of complications.

Which antibiotic should be prescribed?

If prescribing an antibiotic, first-line treatment is amoxicillin or metronidazole for a total of 5 days.

If, after 48 hours, there is no improvement in systemic symptoms, consider changing to second-line therapy; either adding metronidazole 400 mg twice daily or changing to co-amoxiclav 625 mg. For those patients who are penicillin allergic, erythromycin is no longer recommended due to high levels of resistance, instead clarithromycin is first line for five days duration [16].

Learning bite

First line antibiotic treatment of dental abscess consists of either amoxicillin or metronidazole.

Does this patient need admission?

Very few patients presenting with dental infection require referral and admission to hospital but it is important to recognise those that do. The presence of any of the following should prompt urgent referral to a maxillofacial specialist for consideration of admission:

• Evidence of significant systemic disturbance
• Failure to control infection with antibiotics
• Rapid spread of infection
• Dysphagia
• Dysphonia
• Immunocompromised patients
• General anaesthetic needed to drain an abscess