In October 2020, the Scottish Antimicrobial Prescribing Group (SAPG) and its Dental sub-group published a statement on the management of acute dento-alveolar infections.  The SAPG statement reiterates that antibiotic therapy is only appropriate if immediate drainage is not achieved via local measures or where there is evidence of spreading infection or systemic involvement. When an antibiotic is unavoidable, phenoxymethylpenicillin is now recommended as the preferred first line antibiotic. This is due to its narrower spectrum of activity, which is less likely to drive antimicrobial resistance.

SDCEP guidance was updated with this information in June 2021.

  • Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscess are not appropriate. Repeated antibiotics alone, without drainage are ineffective in preventing the spread of infection.
  • Antibiotics are only recommended if there are signs of severe infection, systemic symptoms or high risk of complications.
  • Severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway obstruction, Ludwigs angina should be referred urgently for admission to protect airway, achieve surgical drainage and IV antibiotics.
  • The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage for most dental patients and should only be used if no response to first line drugs when referral is the preferred option.
  • There are a number of significant drug interactions with clarithromycin eg warfarin, theophylline, tacrolimus; see the BNF for a comprehensive list. Clarithromycin can prolong the QT interval and should be avoided in patients with other risk factors, for example, heart disease, electrolyte disturbances and concomitant QT prolonging medications. Clarithromycin is contra-indicated in patients taking simvastatin. If treatment with clarithromycin is necessary simvastatin should be temporarily discontinued and replaces by atorvastatin, up to a maximum of 20mg daily, for the duration of the clarithromycin therapy.

If severe infection: refer to hospital.

Drug details

If pus is present, refer for drainage by tooth extraction or via root canal. Send pus for microbiology.

Phenoxymethylpenicillin 500mg to 1 gram four times daily (doses to be taken 30 minutes before food to maximise absorption)

Up to 5 days with review at 3 days

If concerns about compliance

Amoxicillin 500mg to 1 gram three times daily

Up to 5 days with review at 3 days

In penicillin allergy

Clarithromycin 500mg twice daily

Up to 5 days review at 3 days

If spreading infection (lymph node involvement or systemic signs - fever, malaise)

ADD Metronidazole 400mg three times daily

Up to 5 days with review at 3 days

True penicillin allergy and spreading infection OR unresponsive to first line antibiotics

Clindamycin 300mg four times daily

Up to 5 days with review at 3 days

Last reviewed: 08/11/2021

Next review date: 08/11/2024

Author(s): Antimicrobial Management Team.

Approved By: TAM subgroup of ADTC

Reviewer name(s): Alison Macdonald, Area Antimicrobial Pharmacist.

Document Id: AMT110