Antibiotics for Dental Pain and Swelling

* Immunocompetent is defined as the ability of the body to mount an appropriate immune response to an infection. Immunocompromised patients do not meet the criteria for this recommendation, and they can include, but are not limited to, patients with HIV with an AIDS-defining opportunistic illness, cancer, organ or stem cell transplants, and autoimmune conditions on immunosuppressive drugs.
^† Symptomatic irreversible pulpitis is characterized by spontaneous pain that may linger with thermal changes due to vital inflamed pulp that is incapable of healing.
^‡ Symptomatic apical periodontitis is characterized by pain with mastication, percussion, or palpation, with or without evidence of radiographic periapical pathosis, and without swelling.
^§ Clinicians including dentists, dental hygienists, and other members of the oral health care team may refer patients to an endodontist, oral and maxillofacial surgeon, or general dentist who is trained to perform definitive, conservative dental treatment (DCDT).
^¶ DCDT: Definitive, conservative dental treatment.
^# Patients should be instructed to call if their condition deteriorates (progression of disease to a more severe state) or if the referral to receive DCDT within 1-2 d is not possible. Evidence suggests that nonsteroidal anti-inflammatory drugs and acetaminophen (specifically, 400-600 milligrams ibuprofen plus 1,000 mg acetaminophen) may be effective in managing dental pain.
** Localized acute apical abscess is characterized by spontaneous pain with or without mastication, percussion, or palpation, with formation of purulent material, localized swelling, and without evidence of fascial space or local lymph node involvement, fever, or malaise (fatigue, reduced energy).
^†† Dentists should communicate to the patient that if their symptoms worsen and they experience swelling or pus formation, the delayed prescription should be filled. Delayed prescribing is defined by the Centers for Disease Control and Prevention as a prescription that is “used for patients with conditions that usually resolve without treatment but who can benefit from antibiotics if the conditions do not improve. [Dentists] can apply delayed prescribing practices by giving the patient a postdated prescription and providing instructions to fill the prescription after a predetermined period or by instructing the patient to call or return to collect a prescription if symptoms worsen or do not improve.”
^‡‡ Although the expert panel recommends both amoxicillin and penicillin as first-line treatments, amoxicillin is preferred over penicillin because it is more effective against various gram-negative anaerobes and its lower incidence of gastrointestinal side effects.
^§§ As an alternative for patients with a history of a penicillin allergy, but without a history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin, the panel suggests dentists prescribe oral cephalexin (500 mg, 4 times per d, 3- 7d). Of note, the anaerobic activity of cephalexin is not well described for some oral pathogens. Clinicians should have a low threshold to add metronidazole to cephalexin therapy in patients with a delayed response to antibiotics. As an alternative for patients with a history of a penicillin allergy and with a history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin, the panel suggests dentists prescribe oral azithromycin (loading dose of 500 mg on day 1, followed by 250 mg for an additional 4 d) or oral clindamycin (300 mg, 4 times per d, 3-7 d). Bacterial resistance rates for azithromycin are higher than for other antibiotics, and clindamycin substantially increases the risk of developing Clostridioides difficile infection even after a single dose. Owing to concerns about antibiotic resistance, patients who receive azithromycin should be instructed to closely monitor their symptoms and call a dentist or primary care provider if their infection worsens while receiving therapy. Similarly, clindamycin has a US Food and Drug Administration black box warning for C. difficile infection, which can be fatal. Patients should be instructed to call their primary care provider if they develop fever, abdominal cramping, or 3 loose bowel movements per day.
An antibiotic with a similar spectrum of activity to those recommended above can be continued if the antibiotic was initiated before the patient sought treatment. As with any antibiotic use, the patient should be informed about symptoms that may indicate lack of antibiotic efficacy and adverse drug events.
^¶¶ Clinicians should reevaluate patient within 3 d (for example, in-person visit or phone call). Dentists should instruct patient to discontinue antibiotics 24 h after patient’s symptoms resolve, irrespective of reevaluation after 3 d.
^## In cases in which patients without a penicillin allergy fail to respond to first-line treatment (that is, patient shows no improvement in symptoms or the condition progresses to a more severe state) with oral amoxicillin or oral penicillin V potassium, the panel suggests that dentists should broaden antibiotic therapy to either complement first-line treatment with oral metronidazole (500 mg, 3 times per d, 7d) or discontinue first-line treatment and prescribe oral amoxicillin and clavulanate (500/125 mg, 3 times per d, 7 d). Clinicians should reevaluate patient within 3 d (for example, in-person visit or phone call). Dentists should instruct patient to discontinue antibiotics 24 h after patient’s symptoms resolve, irrespective of reevaluation after 3 d.
*** In cases in which patients with a history of a penicillin allergy and with or without a history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin fail to respond to firstline treatment (that is, patient shows no improvement in symptoms or the condition progresses to a more severe state) with oral cephalexin, oral azithromycin, or oral clindamycin, the panel suggests that dentists should broaden antibiotic therapy to complement first-line treatment with oral metronidazole (500 mg, 3 times per d, 7d). Clinicians should reevaluate patient within 3 d (for example, in-person visit or phone call). Dentists should instruct patient to discontinue antibiotics 24 h after patient’s symptoms resolve, irrespective of reevaluation after 3 d.
^††† Acute apical abscess with systemic involvement is characterized by necrotic pulp with spontaneous pain, with or without mastication, percussion, or palpation, with formation of purulent material, swelling, evidence of fascial space or local lymph node involvement, fever, or malaise.
^‡‡‡ Urgent evaluation will most likely be conducted in an urgent care setting or an emergency department.
^§§§ DCDT refers to nonsurgical root canal treatment or incision for drainage of abscess. Extractions are not within the scope of this guideline. Only clinicians who are authorized or trained to perform the specified treatments should do so.
^¶¶¶ DCDT refers to pulpotomy, pulpectomy, or nonsurgical root canal treatment. Extractions are not within the scope of this guideline. Only clinicians who are authorized or trained to perform the specified treatments should do so.