Red Flags
- Spreading facial infection with trismus, dysphagia, drooling, dyspnoea, or systemic features (Ludwig's angina, parapharyngeal/retropharyngeal abscess) — admit for IV antibiotic and surgical drainage; airway monitoring[1]
- Immunocompromised patient with dental pain or swelling — lower threshold for antibiotic and same-day OMFS review[1]
- Pregnancy with dental infection — definitive dental treatment and pregnancy-safe antibiotic when systemic involvement present[1]
- Diabetes with poor control and dental abscess — risk of cellulitis and sepsis; coordinate dental and medical management[1]
First-line treatment
Interventions
- Pulpitis or symptomatic apical periodontitis WITHOUT systemic involvement[1]DO NOT prescribe antibiotic; provide pulpectomy/pulpotomy or root canal therapy; analgesia (NSAID + paracetamol); definitive dental treatment within 24–48 h
- Localised intraoral swelling (periapical abscess) WITHOUT systemic involvement[1]DO NOT prescribe antibiotic routinely; perform incision and drainage with definitive dental treatment; analgesia
- Systemic involvement (fever ≥38°C, malaise, lymphadenopathy, trismus, lethargy, cellulitis) or immunocompromise[1]Add oral antibiotic (amoxicillin first-line) AS ADJUNCT to definitive dental management; review at 24–72 h with stop date 3 days after symptoms resolve
- Severe spreading infection with airway risk[1]Admit; IV antibiotic; surgical drainage by oral and maxillofacial surgery; airway support if compromised; consider Ludwig's angina, parapharyngeal/retropharyngeal abscess
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Paracetamol + ibuprofen (analgesia)[1] | Non-opioid analgesia | Paracetamol 1 g PO QDS + ibuprofen 400 mg PO TDS (with food and PPI cover for risk groups) | — | First-line for pulpal pain — superior to opioid for dental pain; do not use opioid first-line for acute dental pain |
| Amoxicillin (when antibiotic indicated)[1] | Aminopenicillin | 500 mg PO TDS × 3–7 days (stop 3 days after symptom resolution) | 25 mg/kg/dose TDS | First-line oral antibiotic when systemic involvement; review at 48–72 h; review with definitive dental treatment |
| Phenoxymethylpenicillin (penicillin V — alternative)[1] | Beta-lactam antibiotic | 500 mg PO QDS × 3–7 days | 12.5 mg/kg/dose QDS | Narrow-spectrum alternative; equivalent efficacy to amoxicillin in odontogenic infections; widely available |
| Metronidazole (combination for severe / anaerobic)[1] | Nitroimidazole | 400 mg PO TDS × 5 days | 7.5 mg/kg/dose TDS | Combine with amoxicillin for severe odontogenic infections (anaerobic cover); avoid alcohol (disulfiram-like reaction) |
| Clarithromycin or azithromycin (penicillin allergy)[1] | Macrolide | Clarithromycin 500 mg PO BD × 5 days; azithromycin 500 mg PO daily × 3 days | Clarithromycin 7.5 mg/kg BD; azithromycin 10 mg/kg daily | Penicillin allergy alternative; QTc caution with concurrent QT-prolonging agents |
| Co-amoxiclav (severe / failure of first-line)[1] | Aminopenicillin + beta-lactamase inhibitor | 625 mg PO TDS × 5–7 days | 30 mg/kg/dose TDS amoxicillin component | Severe odontogenic infection with cellulitis or failure of amoxicillin; broader gram-negative and anaerobic cover |
Paracetamol + ibuprofen (analgesia)[1]
Non-opioid analgesia
- Adult
- Paracetamol 1 g PO QDS + ibuprofen 400 mg PO TDS (with food and PPI cover for risk groups)
- Paediatric
- —
First-line for pulpal pain — superior to opioid for dental pain; do not use opioid first-line for acute dental pain
Amoxicillin (when antibiotic indicated)[1]
Aminopenicillin
- Adult
- 500 mg PO TDS × 3–7 days (stop 3 days after symptom resolution)
- Paediatric
- 25 mg/kg/dose TDS
First-line oral antibiotic when systemic involvement; review at 48–72 h; review with definitive dental treatment
Phenoxymethylpenicillin (penicillin V — alternative)[1]
Beta-lactam antibiotic
- Adult
- 500 mg PO QDS × 3–7 days
- Paediatric
- 12.5 mg/kg/dose QDS
Narrow-spectrum alternative; equivalent efficacy to amoxicillin in odontogenic infections; widely available
Metronidazole (combination for severe / anaerobic)[1]
Nitroimidazole
- Adult
- 400 mg PO TDS × 5 days
- Paediatric
- 7.5 mg/kg/dose TDS
Combine with amoxicillin for severe odontogenic infections (anaerobic cover); avoid alcohol (disulfiram-like reaction)
Clarithromycin or azithromycin (penicillin allergy)[1]
Macrolide
- Adult
- Clarithromycin 500 mg PO BD × 5 days; azithromycin 500 mg PO daily × 3 days
- Paediatric
- Clarithromycin 7.5 mg/kg BD; azithromycin 10 mg/kg daily
Penicillin allergy alternative; QTc caution with concurrent QT-prolonging agents
Co-amoxiclav (severe / failure of first-line)[1]
Aminopenicillin + beta-lactamase inhibitor
- Adult
- 625 mg PO TDS × 5–7 days
- Paediatric
- 30 mg/kg/dose TDS amoxicillin component
Severe odontogenic infection with cellulitis or failure of amoxicillin; broader gram-negative and anaerobic cover
Safety-net
- Antibiotic alone does not cure dental infection — definitive dental treatment (root canal or extraction) within 24–48 h is essential; antibiotics are adjunct only when systemic involvement[1]
- Spreading facial swelling, trismus, dysphagia, drooling, breathlessness, fever, or feeling unwell — same-day OMFS / emergency department review[1]
- Take analgesia regularly (paracetamol + NSAID) for pain control rather than as needed; superior pain relief than opioid for dental pain[1]
Referral criteria
- Severe spreading infection (Ludwig's angina, parapharyngeal abscess), airway risk, systemic sepsisEmergency department; oral and maxillofacial surgery[1]
- Failure to improve at 24–48 h on oral antibiotic with definitive dental treatmentOMFS for incision and drainage, IV antibiotic, imaging[1]
- Immunocompromised, diabetic with poor control, pregnant patient with significant infectionOMFS and relevant medical team[1]
- No access to dental practitioner for definitive treatmentEmergency dental services / hospital dental clinic[1]
Clinical summary
Antibiotic stewardship and definitive dental management for adults with pulpal- and periapical-related dental pain and localised intraoral swelling.