Dental abscess - Management of Infection Guidance for Primary Care

Publication: 31/05/2011  --
Last review: 05/09/2018  
Next review: 05/09/2021  
Clinical Guideline
CURRENT 
ID: 2564 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Dental abscess in Primary Care

Antibiotics are secondary to surgical/dental drainage of abscess.

Surgical/dental drainage of abscess should be sought immediately.

Regular analgesia should be the first optionA+ until a dentist can be seen for urgent drainage;A+  repeated courses of antibiotics for abscesses are not appropriate.A+

Antibiotic should ONLY be given to patients:

  • with features of systemic infection (eg. fever, lymphadenopathy, cellulitis, diffuse swelling);
  • who are high risk to reduce the risk of complications (e.g. people who are immunocompromised or diabetic or have heart valve disease).

Patients with complicated infection:

  • refer to secondary care eg. compromised airway, “base of mouth” swelling, dysphagia, spreading facial cellulitis, neurological signs.
  • assess for referral or seeking specialist advice if signs/symptoms of systemic infection, immunocompromised., very young or elderly, severe pain despite analgesia prescribed in primary care.

 Preferred Option

Alternative Option

Notes

AnalgesiaA+ and referral to dentist/surgeon.   For emergency dental treatment contact Local Care Direct on 111

If antibiotic indicated (must be prescribed by dentist or surgeon after their assessment):
Amoxicillin B+
500mg TDS PO 5 days, review at 3 days.*

 

Penicillin allergy:
ClarithromycinD
500mg BD PO 5 days, review at 3 days*.

If spreading infection (lymph node involvement or systemic signs, i.e. fever or malaise)A+

ADD

MetronidazoleB+
400mg TDS PO
5 days, review at 3 days*

*Note: the duration of antibiotic therapy in most patients with acute dentoalveolar infections can safely be 2-3 days, provided that drainage has been established. It is not, therefore, necessary for the majority of patients to complete a 5-day course of antibiotics.

PHE
CKS

General Principles for Treating Infections

This guidance is based on the best available evidence but its application must be modified by professional judgement.

  1. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  2. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  3. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  5. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1,A+
  6. Limit prescribing over the telephone to exceptional cases.
  7. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  8. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  9. In pregnancy, take specimens to inform treatment, use this guidance alternative or seek expert advice. Penicillins, cephalosporins and erythromycin are not associated with increased risks. If possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin, clarithromycin, high dose metronidazole (2g stat) unless the benefits outweigh the risks. Short-term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist.
  10. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic medicines are similar cost. Use erythromycin in pregnancy.
  11. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)  

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

Provenance

Record: 2564
Objective:
Clinical condition:

Dental abscess

Target patient group:
Target professional group(s): Pharmacists
Primary Care Doctors
Adapted from:

Management of Infection guidance for primary care for consultation and local adaptation


Evidence base

Evidence base
Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.

Study design

Recommendation grade

Good recent systematic review and meta-analysis of studies

A+

One or more rigorous studies; randomised controlled trials

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Non-analytic studies, eg case reports or case series

C

Formal combination of expert opinion

D

  1. Matthews DC, Sutherland S, Basrani B. Emergency management of acute apical abscesses in the permanent dentition: a systematic review of the literature. J Can Dent Assoc. 2003 Nov; 69(10):660. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14611715.
  2. Dahlen G. Microbiology and treatment of dental abscesses and periodontal-endodontic lesions. Periodontol 2000. 2002 Jan; 28(1):206-239. Available from: http://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2002.280109.x/abstract.
  3. Robertson D, Smith AJ. The microbiology of the acute dental abscess. J Med Microbiol. 2009 Feb; 58(2):155-162. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19141730.
  4. Ellison SJ. The role of phenoxymethylpenicillin, amoxicillin, metronidazole and clindamycin in the management of acute dentoalveolar abscesses – a review. Br Dent J. 2009 Apr; 206(7):357-362. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19357666.
  5. Kuriyama T, Absi EG, Williams DW, Lewis MA. An outcome audit of the treatment of acute dentoalveolar infection: impact of penicillin resistance. Br Dent J. 2005 Jun; 198(12):759-763. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15980845.
  6. Scottish Dental Clinical Effectiveness Programme (SDCEP). Management of acute dental problems: guidance for healthcare professionals. 2013 Mar. Available from: http://www.sdcep.org.uk/wp-content/uploads/2013/03/SDCEP+MADP+Guidance+March+2013.pdf.
  7. Eick S, Pfister W, Straube E. Antimicrobial susceptibility of anaerobic and capnophilic bacteria isolated from odontogenic abscesses and rapidly progressive periodontitis. Int J Antimicrob Agents. 1999 Jun; 12(1):41-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10389646.
  8. Kuriyama T, Absi EG, Williams DW, Lewis MA. An outcome audit of the treatment of acute dentoalveolar infection: impact of penicillin resistance. Br Dent J. 2005 Jun; 198(12):759-763. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15980845.
  9. Ellison SJ. An outcome audit of three-day antimicrobial prescribing for the acute dentoalveolar abscess. Br Dent J. 2011 Dec; 211(12):591-594. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22193484.
  10. Martin MV, Longman LP, Hill JB, Hardy P. Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy. Br Dent J. 1997 Aug; 183(4):135-137. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9293130.
  11. Kulik EM, Lenkeit K, Chenaux S, Meyer J. Antimicrobial susceptibility of periodontopathogenic bacteria. J Antimicrob Chemother. 2008 May; 61(5):1087-1091. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18326855.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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