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Oral health

Dental abscess

Last revised in May 2023

A dental abscess is a localized collection of pus in the teeth, supporting structures of the teeth, or gums.

Dental abscess: Summary

  • A dental abscess is a localized collection of pus in the teeth, supporting structures of the teeth, or gums. The two main types of dental abscess are:
    • Periapical abscess (dentoalveolar abscess) — originates in the dental pulp (centre of the tooth), and is the most frequently occurring type, in both adults and children.
    • Periodontal abscess — originates in the supporting structures of the teeth (such as the periodontal ligament) between the tooth and the gum.
  • Dental abscess occurs as a result of bacterial infection affecting the structures around a tooth and the tooth itself.
    • Periapical abscess formation is usually secondary to dental decay (caries).
    • Periodontal abscess formation is associated with chronic periodontitis.
  • The lifetime prevalence of dental abscess is between 5% and 46%.
  • Symptoms of dental abscess include:
    • Pain (usually of sudden onset, worsening over a few hours to a few days).
    • Unpleasant taste in the mouth.
    • Fever and malaise.
    • Trismus (inability to open the mouth) or dysphagia.
  • Signs of dental abscess include:
    • Facial swelling.
    • Regional lymphadenopathy.
    • An elevated or decayed tooth, with increased mobility and tenderness.
    • Gum swelling, with tenderness, warmth, and a purulent exudate.
  • Differential diagnoses include: infections (such as mumps, sinusitis, acute otitis media, or facial cellulitis); salivary gland problems; neoplasm; and unerupted teeth.
  • Definitive treatment for a dental abscess should be provided by a dentist. 
  • Interim treatment (whilst waiting to see a dentist) consists of:
    • Self-care advice to reduce the pressure and pain of the dental abscess.
    • Analgesia (ibuprofen or paracetamol) to relieve symptoms.
  • Antibiotics are generally not indicated for otherwise healthy people at low risk of complications when there are no signs of spreading infection. Antibiotics should be prescribed for:
    • People who are systemically unwell or with signs of severe infection (such as fever, lymphadenopathy, cellulitis, diffuse swelling).
    • People with a high risk of complications (for example people who are immunocompromised or have diabetes).
  • A person should be admitted to hospital as an emergency if they have a dental abscess and:
    • Signs of airway compromise.
    • Are unwell with a high temperature and cardio-respiratory compromise.
    • Significant mandibular, submandibular, or infraorbital swelling (or difficulty opening the eye).
    • 'Floor of mouth' swelling. 
    • A spreading facial infection or orbital cellulitis.
    • Neurological signs (for example decreased level of consciousness, headache, eye signs).
    • Dehydration.
  • Clinical judgement should be used regarding admission to hospital or seeking specialist advice for people who: 
    • Have signs and symptoms of systemic infection (for example nausea, malaise, pyrexia, or rigors).
    • Are immunocompromised.
    • Are very young or elderly.
    • Experience severe pain despite analgesia prescribed in primary care.

Have I got the right topic?

From age 12 months onwards.

This CKS topic covers the management of dental abscess in primary care, including out-of-hours care.

This CKS topic does not cover the definitive management of dental abscess by a dentist.

There are separate CKS topics on Aphthous ulcer, Gingivitis and periodontitis, and Herpes simplex - oral.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

May 2024 — minor update. Information added stating that concomitant treatment with clarithromycin and ivabradine is now contra-indicated and caution is now advised when co-administering clarithromycin with edoxaban, as per the manufacturer's updated SPC.

Previous changes

July 2023 — minor update. The manufacturer's SPC for metronidazole has been updated to note that QT prolongation has been reported (unknown frequency), particularly when metronidazole was administered with drugs with the potential for prolonging the QT interval.

December 2022 — minor update. The choice of antibiotic for dental abscess has been updated in line with the Faculty of Dental General Practice guideline Antimicrobial Prescribing in Dentistry. 

July 2022 — reviewed. A literature search was conducted in June 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. The topic has been updated. There have been no major changes to recommendations. 

January 2022 — minor update. The dose of amoxicillin has been updated in line with the Public Health England document Summary of antimicrobial prescribing guidance – managing common infections. 

October 2018 — minor update. Adverse effects updated within prescribing information - metronidazole. 

February 2017 — reviewed. A literature search was conducted in January 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. The management section has been restructured. Other changes include removal of: detailed information on analgesia as this is now covered in the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues; Clindamycin as a first-line option for antibiotic treatment in primary care; detailed information on dental service provision and dental treatments.

July 2015 — minor update. The information on the concurrent use of clarithromycin with statins has been clarified.

April 2015 — minor update. The prescribing information on the use of analgesics in pregnancy and breastfeeding has been removed and replaced with a link to the CKS topic on Analgesia - mild-to-moderate pain.

July 2014 — minor update. Update to prescribing information to reflect the fact that there are reports of raised INRs and increased bleeding with the concomitant use of clindamycin and vitamin K antagonists.

June 2014 — minor update. Update to the text to reflect the fact that tramadol has been reclassified to a Schedule 3 controlled drug.

January 2014 — minor update. The text regarding the use of codeine during breastfeeding has been updated to reflect new guidance from the Medicines and Healthcare products Regulatory Agency (MHRA). Codeine is no longer recommended for breastfeeding mothers, and tramadol or dihydrocodeine are preferred alternatives.

July 2013 — minor update. Update to the text to reflect recent advice from the MHRA regarding diclofenac.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

January 2013 — minor update. Change to the text to reflect updated advice from the Health Protection Agency and British Infection Association regarding the choice of antibiotic for treating a dental abscess.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

February 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

July 2010 — minor update. In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line NSAIDs. 

October 2007 to January 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

October 2006 — minor update. Analgesia prescriptions updated because new doses of ibuprofen for children are recommend by the British National Formulary.

November 2005 — minor technical update. 

June 2004 — written. Validated in September 2004 and issued in November 2004.

Update

New evidence

Evidence-based guidelines

No new guidelines published since 1 June 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2022.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 June 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2022.

New policies

No new national policies or guidelines since 1 June 2022.

New safety alerts

No new safety alerts since 1 June 2022.

Changes in product availability

No changes in product availability since 1 June 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of dental abscess.
  • Reduce pain from dental abscess.
  • Treat with antibiotics, only when appropriate.
  • Ensure that the person is aware that they should be seen by a dentist for definitive treatment.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • A dental abscess is a localized collection of pus in the teeth, supporting structures of the teeth (periodontal ligament, alveolar bone), or gums [BMJ Best Practice, 2021]. The two main types of dental abscess are [Stephens, 2018; Sanders, 2022]:
    • Periapical abscess (also known as acute apical abscess, dentoalveolar abscess, or periradicular abscess) — caused by infection of the root canal of the tooth.
    • Periodontal abscess — originates in deep periodontal pockets between the tooth and the gum and occurs when there is occlusion of drainage of the periodontal pocket. 
  • These two forms of abscess are distinct, both anatomically and in terms of dental management. However, as this CKS topic is written for primary care, and the management therein is the same for both, they will be considered as the single entity of dental abscess throughout.

What causes it?

  • Dental abscesses occur as a result of bacterial infection affecting the structures around a tooth and the tooth itself (tooth decay can enable bacteria to invade the dental pulp inside the tooth) [BMJ Best Practice, 2021; Sanders, 2022].
    • Bacteria associated with dental infection include oral streptococci and anaerobes, including Fusobacterium species (73%), Prevotella (65%), and Porphyromonas gingivalis (46%) [George et al, 2016; Irshad, 2020].
  • Periapical abscess formation is usually secondary to dental caries (tooth decay), but can also occur as a result of trauma. Compromise of the enamel (outer coating of the tooth) enables bacteria to pass from the oral cavity into the pulp of the tooth. Inflammation and death of pulp tissue can occur and infection can spread to the periapical area around the tip of the tooth's root, the surrounding dentoalveolar bone, and soft tissues [BMJ Best Practice, 2021].
  • Periodontal abscess formation is associated with chronic periodontitis. If a periodontal pocket occurs due to loss of supporting bone and periodontal ligament compromise and is not able to drain, an abscess can develop  [BMJ Best Practice, 2021].

How common is it?

Conditions that are secondary to dental caries and primary periodontal disease are both prevalent worldwide.

  • It is estimated that 25% of all adults over 65 years have lost all of their teeth because of these two factors [BMJ Best Practice, 2021].
  • There is a higher incidence in developing countries and among those in lower socio-economic groups, but no age or sex differences are found [Kim, 2019].
  • There is evidence that emergency department visits in high income countries are increasing [Bassey, 2020].
  • The lifetime prevalence of dental abscess has been reported as 5–46% [Matthews et al, 2003]. 

What are the risk factors?

  • Risk factors for dental abscess include:
    • Poor oral hygiene.
    • Dental caries.
    • Periodontal disease.
    • Dental trauma.
    • Partially erupted or impacted tooth.
    • Alcohol or drug misuse.
    • Malnutrition.
    • Immunocompromise (may also be seen at extremes of age).
    • History of radiotherapy.
    • Medications causing dry mouth (for example antihistamines, anticholinergics, antidepressants).

[BMJ Best Practice, 2021]

What are the complications?

  • Complications of dental abscess include:
    • Loss of the affected tooth.
    • A fistula or sinus tract may develop that can discharge intraorally or into the overlying skin.
    • Spread of infection (more common in immunocompromised and elderly people), for example:
      • Maxillary sinusitis.
      • Cellulitis/periorbital cellulitis.
      • Osteomyelitis.
      • Retropharyngeal abscess.
      • Cavernous sinus thrombosis. 
      • Encephalitis and meningitis.
      • Brain abscess.
      • Descending neck infection leading to mediastinitis.
      • Ludwig's angina — a serious, potentially life-threatening infection of the tissues of the floor of the mouth. Symptoms include swelling, pain on raising of the tongue, swelling of the neck and the tissues of the submandibular and sublingual spaces. Malaise, fever, dysphagia (difficulty swallowing), trismus and, in severe cases, stridor or difficulty breathing can occur.
    • Sepsis — rarely, sepsis can develop from odontogenic infections.
    • Airway obstruction — caused by spread of infection into the fascial spaces around the oropharynx.

[Beech et al, 2014; Herrera et al, 2014; Alotaibi et al, 2015; Bali et al, 2015; Robertson et al, 2015; BMJ Best Practice, 2021].

Diagnosis

When should I suspect a dental abscess?

  • Ask about symptoms, including:
    • Pain — this is usually of sudden onset, and worsens over a few hours to a few days.
      • It may be intense and throbbing, and may cause waking from sleep during the night.
      • The tooth may be tender to touch, temperature (hot or cold sensitivity), or to pressure from biting.
    • Unpleasant taste in the mouth.
    • Fever and malaise.
    • Trismus (inability to open the mouth) or dysphagia may be present in severe cases.
    • Listlessness, lethargy, and loss of appetite (particularly in children younger than 16 years of age).
  • Examine the oral cavity (both externally and internally) for signs of abscess.
    • Observation may reveal:
      • Facial swelling, with or without cellulitis.
      • Regional lymphadenopathy.
      • Altered tooth appearance: the affected tooth may be elevated, broken, or show signs of decay.
      • Gum swelling.
      • Purulent drainage: may be intra- or extra-oral.
    • Palpation may reveal:
      • Tooth: increased mobility and tenderness.
      • Gum: tenderness, warmth, and a purulent exudate.
  • Check for features of severe infection or impending airway compromise. For more information, see the section on Referral and seeking specialist advice.
  • Assess the likelihood of existing caries and periodontal disease. Ask about:
    • Dental hygiene — such as frequency of brushing and flossing.
    • Diet — ask about intake of sugar-containing foods and drinks.
    • Previous dental procedures — for example fillings, root canal treatment, and extractions.
    • Any coexisting factors that might increase the risk of dental disease progressing — for example diabetes, compromised immune system, smoking, and drugs causing dry mouth or gum enlargement.

Basis for recommendation

Symptoms and signs of dental abscess

Checking for features of severe infection or impending airway compromise

Assessing the likelihood of existing caries and periodontal disease

  • This recommendation is pragmatic and is extrapolated from information in Public Health England's guideline Delivering better oral health: an evidence-based toolkit for prevention [PHE, 2021a] and based on what CKS considers to be good clinical practice.

What else might it be?

  • Infections:
  • Salivary gland problem due to stone, infection (parotitis), or dehydration/dry mouth.
  • Neoplasm:
    • Intraoral.
    • Salivary gland.
  • Unerupted teeth.
  • Trigeminal neuralgia or atypical facial pain — for more information, see the CKS topic on Trigeminal neuralgia.
  • Acute coronary syndrome.
  • Temporomandibular disorders — for more information, see the CKS topic on Temporomandibular disorders (TMDs).
  • Giant cell arteritis — for more information, see the CKS topic on Giant cell arteritis.

Basis for recommendation

This information is based on expert opinion in review articles [Beech et al, 2014; Herrera et al, 2014; Keine et al, 2015; Robertson et al, 2015; Koh, 2019; BMJ Best Practice, 2021].

Management

Scenario: Management

From age 12 months onwards.

When should I refer or seek specialist advice?

  • Admit a person to hospital as an emergency if they have a dental abscess and:
    • Signs of airway compromise (for example difficulty breathing or speaking, unable to swallow their own saliva, drooling, uvular deviation, trismus, or unable to push their tongue forward out of their mouth).
    • Are unwell with a high temperature and cardio-respiratory compromise (rapid pulse rate or low blood pressure, high respiratory rate).
    • A rapidly progressing infection.
    • Significant mandibular, submandibular, or infraorbital swelling (or difficulty opening the eye).
    • 'Floor of mouth' swelling. 
    • A spreading facial infection or orbital cellulitis.
    • Neurological signs (for example decreased level of consciousness, headache, eye signs [such as diplopia, papilloedema, pupil dilation, proptosis]).
    • Dehydration.
    • Social factors that may compromise outpatient treatment.
  • Use clinical judgement regarding admission to hospital or seeking specialist advice for people who: 
    • Have signs and symptoms of systemic infection (for example nausea, malaise, pyrexia, or rigors).
    • Are immunocompromised.
    • Are very young or elderly.
    • Experience severe pain despite analgesia prescribed in primary care.

Basis for recommendation

Admission to hospital
Using clinical judgement to assess the need for hospital admission or seeking specialist advice
  • This recommendation is based on expert opinion in review articles and is pragmatic, based on what CKS considers to be good clinical practice.
    • Expert opinion in a review article suggests considering hospital referral for people in whom systemic infection is suspected [MacAuley et al, 2013]. Another review article recommends hospital admission for people at extremes of age and acknowledges that spread of infection may be faster in people who are immunocompromised and therefore this group may require more urgent treatment [BMJ Best Practice, 2021]. 

How should I manage someone with a dental abscess?

  • Ensure that the person does not have features of serious illness or complications requiring immediate hospital treatment. For more information, see the section on When should I refer or seek specialist advice?.
  • Emphasize the need to seek treatment from a dentist as soon as possible. Advise that:
    • Definitive treatment can only be given by a dentist and medication will not eliminate the source of infection.
    • Serious complications may occur if the abscess is not treated correctly by a dentist.
  • In the absence of immediate assessment and treatment by a dentist:
    • Provide appropriate self-care advice to reduce the pressure and pain of the dental abscess:
      • Use a soft toothbrush to reduce discomfort. Avoid flossing the tooth with the abscess.
      • Consume soft foods and try eating on the other side of the mouth to reduce discomfort and irritation to the abscess.
      • Avoid food or drink that may be too hot or cold.
    • Advise the use of an analgesic to relieve symptoms.
      • Ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is recommended first-line. For more information, see the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.
      • Advise the safe use of analgesics:
        • Warn not to exceed the recommended or prescribed dose.
        • Remind the person that analgesics should not be used to delay appropriate dental treatment.
        • Inform the individual that many over-the-counter preparations contain similar analgesics. The person should avoid taking combinations of analgesic products at the same time without first checking with a healthcare professional or the packaging. 
    • Antibiotics are generally not indicated for otherwise healthy people at low risk of complications when there are no signs of spreading infection. In the absence of immediate attention by a dentist, only prescribe an antibiotic:
      • For people who are systemically unwell or if there are signs of severe infection (for example fever, lymphadenopathy, cellulitis, diffuse swelling).
      • For high-risk individuals to reduce the risk of complications (for example people who are immunocompromised or have diabetes).
    • If an oral antibiotic is indicated:
      • Prescribe either phenoxymethylpenicillin or amoxicillin. If the person has a true penicillin allergy, prescribe metronidazole or a macrolide such as clarithromycin.
      • Consider concomitant treatment with metronidazole if the infection is severe or spreading (lymph node involvement, or systemic signs such as fever or malaise). 
      • For more information on the duration of treatment and recommended doses, see the section on the relevant antibiotic in Prescribing information.
    • When prescribing an antibiotic:
      • Do not routinely provide repeat prescriptions or switch antibiotics in people who fail to respond to first-line treatment.
      • Always consider an alternative diagnosis or the development of a complication in people with a suspected dental abscess who do not respond, or become systemically unwell after first-line antibiotic treatment.
      • Advise the person to seek urgent dental intervention rather than switching antibiotics or, if this is not available, seek advice from an oral and maxillofacial specialist. 

Basis for recommendation

Ensuring hospital admission, referral, or specialist advice is not required
Referral to a dentist
Self-care advice
  • These recommendations are pragmatic advice and are extrapolated from expert opinion in review articles that dental pain can be exacerbated by temperature (pulpal pain) and by biting (periapical periodontal pain) [Roberts et al, 2000; MacAuley et al, 2013].
  • CKS found no evidence that specifically looked at self care in the treatment of dental abscess.
Analgesia
  • Public Health England's Summary of antimicrobial prescribing guidance - managing common infections [PHE, 2021b] recommends the use of analgesia as first-line management of the symptoms of dental abscess while the person is awaiting treatment from a dentist. Expert opinion in the British National Formulary is consistent with this, advising the use of analgesics as a temporary measure (for up to a week) until the underlying cause of pain is treated [BNF, 2022].
  • The recommendation to offer ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is based on the Scottish Dental Clinical Effectiveness Programme guideline on Drug prescribing for dentistry [Scottish Dental Clinical Effectiveness Programme, 2021] and the British National Formulary [BNF, 2022]. This choice of analgesic drugs for dental abscess is also supported by expert opinion in the BMJ Best Practice review article [BMJ Best Practice, 2021].
    • The British National Formulary states that most odontogenic pain can be effectively relieved by a nonsteroidal anti-inflammatory drug and notes that paracetamol is also an effective analgesic, although it does not have the same anti-inflammatory effect [BNF, 2022]. This is supported by expert opinion in review articles [Moore, 2018; Koh, 2019; Pergolizzi, 2020].
    • Although suggested as an option by some experts [Pergolizzi, 2020; BMJ Best Practice, 2021] opioid drugs such as codeine have a number of adverse effects including nausea, constipation, and the potential for dependence [Scottish Dental Clinical Effectiveness Programme, 2021]. Despite their established use for treating moderate to severe pain, opioid drugs are relatively ineffective for dental pain and are rarely required in this situation [BNF, 2022].
    • CKS found no trials that specifically looked at oral analgesics in the treatment of dental abscess by general medical practitioners.
  • The recommendation on advising safe use of analgesics is based on the Scottish Dental Clinical Effectiveness Programme guideline on Drug prescribing for dentistry [Scottish Dental Clinical Effectiveness Programme, 2021] which reports that acute dental pain may lead to unintentional overdose, for example if a person unknowingly takes more than one paracetamol-containing preparation to try to relieve their pain.
Prescribing an antibiotic
  • The recommendation on groups of people with dental abscess for whom antibiotic treatment is indicated in primary care is based on expert opinion in Public Health England's Summary of antimicrobial prescribing guidance - managing common infections [PHE, 2021b] which states that, for people being managed in primary care pending treatment by a dentist or dental specialist, 'Antibiotics are only recommended if there are signs of severe infection, systemic symptoms or high risk of complications'. This is also consistent with guidance from the Scottish Dental Clinical Effectiveness Programme on Management of acute dental problems [Scottish Dental Clinical Effectiveness Programme, 2013], Faculty of General Dental Practice Antimicrobial Prescribing in Dentistry [FGDP, Antimicrobial Prescribing in Dentistry, Good Practice Guidelines, 3rd Edition, 2020] and Drug prescribing for dentistry [Scottish Dental Clinical Effectiveness Programme, 2021] and expert opinion in review articles [Tampi, 2019; BMJ Best Practice, 2021] and the British National Formulary [BNF, 2022].
  • CKS found no evidence that specifically looked at antibiotics in the treatment of dental abscess by general medical practitioners. A Cochrane systematic review (search date October 2018) found two trials (n = 62) comparing penicillin VK with placebo for adults with acute apical abscess or symptomatic necrotic tooth, but concluded that this was insufficient evidence on which to draw conclusions on the effects of systemic antibiotics in this group [Cope, 2018]. 
Choice of antibiotic
Not providing repeat prescriptions or switching antibiotics
  • The recommendations not to provide a repeat prescription or switch antibiotic, and to seek advice if a person is not responding to treatment (in addition to advising them to seek treatment from a dentist) is based on a Scottish Dental Clinical Effectiveness Programme guideline on Drug prescribing for dentistry [Scottish Dental Clinical Effectiveness Programme, 2021], which advises checking the diagnosis and considering specialist referral if the person does not show improvement on the initial antibiotic.

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Analgesics

Amoxicillin

What dose of amoxicillin should I prescribe?

  • For dental abscess, prescribe a course of amoxicillin for up to 5 days (review after 3 days): 
    • Adults: 500 mg to 1000 mg three times a day. 
    • Child 12–18 years of age: 500 mg three times a day. 
    • Child 5–12 years of age: 500 mg three times a day. 
    • Child 1–5 years of age: 250 mg three times a day. 

[PHE, 2021b; BNF, 2022; BNF for children, 2022]

What are the cautions and contraindications?

  • Do not prescribe amoxicillin to people with a true penicillin hypersensitivity.
  • Prescribe amoxicillin with caution in people with:
    • Hypersensitivity to cephalosporins.
    • Renal impairment — reduce the dose of amoxicillin in severe renal impairment.

[ABPI, 2021a; BNF, 2022]

What are the adverse effects of amoxicillin?

  • The most common adverse effects are gastrointestinal and include nausea, vomiting, and diarrhoea. 
  • Skin rashes have also been reported.

[ABPI, 2021a; BNF, 2022]

What drug interactions are important with amoxicillin?

Possible drug interactions with amoxicillin include:

  • Probenecid — concurrent use with amoxicillin is not recommended as it may cause increased and prolonged blood levels of amoxicillin.
  • Allopurinol — be aware of the increased risk of rash when allopurinol is given with amoxicillin. 
  • Warfarin — monitor the international normalized ratio (INR) closely during concomitant use. Adjust the warfarin dose as necessary according to the INR.
  • Methotrexate — amoxicillin may reduce methotrexate excretion, causing an increased risk of toxicity.
  • Tetracyclines — the effects of amoxicillin may be antagonised.
  • Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of amoxicillin [CoSRH, 2020a].

[ABPI, 2021a; BNF, 2022]

Clarithromycin

What dose of clarithromycin should I prescribe?

  • For dental abscess, prescribe a 5 day course of clarithromycin (review after 3 days): 
    • Adult: 500 mg twice a day. 
    • For a child aged 1 month to 12 years:
      • Bodyweight less than 8 kg 7.5 mg/kg twice daily. 
      • Bodyweight 8–11 kg 62.5 mg twice daily. 
      • Bodyweight 12–19 kg 125 mg twice daily. 
      • Bodyweight 20–29 kg 187.5 mg twice daily. 
      • Bodyweight 30–40 kg 250 mg twice daily. 
    • Child 12–18 years of age: 250 mg twice daily. 
    • Note that clarithromycin tablets are not licensed for use in children under 12 years. 

[PHE, 2021b; BNF, 2022; BNF for children, 2022]  

What cautions and contraindications are associated with clarithromycin?

  • Do not prescribe clarithromycin to people with:
    • Known hypersensitivity to clarithromycin or other macrolide antibiotics.
    • A history of QT prolongation or ventricular arrhythmia, including Torsade de Pointes.
    • Hypokalaemia.
    • Severe hepatic failure.
  • Prescribe clarithromycin with caution in people with:
    • Coronary artery disease, severe cardiac insufficiency, or bradycardia (less than 50 beats per minute) — increased risk of QT prolongation.
    • Impaired hepatic function (or people concomitantly receiving potentially hepatotoxic drugs) — clarithromycin is principally excreted by the liver. 
    • Moderate to severe renal impairment.
    • Use half the normal dose in severe renal impairment (eGFR less than 30mL/min) for a maximum duration of 14 days. Avoid Klaricid XL® (clarithromycin prolonged release once daily tablets) in people with eGFR less than 30 mL/min.
    • Conditions that predispose to QT interval prolongation, such as electrolyte disturbances and people taking drugs that prolong the QT interval  — macrolides can also prolong the QT interval, increasing the risk of Torsades de Pointes arrhythmia. 
    • Myasthenia gravis — macrolide antibiotics may aggravate weakness symptoms of people with myasthenia gravis.

[ABPI, 2022; BNF, 2022]

What are the adverse effects of clarithromycin?

  • The most common adverse effects are gastrointestinal — such as nausea, vomiting, dyspepsia, and diarrhoea.
    • Consider pseudomembranous colitis if a person develops severe diarrhoea during or after treatment with clarithromycin.
    • Pseudomembranous colitis is an acute, exudative colitis caused by Clostridium difficile, a Gram-positive toxin-releasing bacillus. It often follows antibiotic treatment. For more information, see the CKS topic on Diarrhoea - antibiotic associated.
  • Less common adverse effects include rash and hepatoxicity.
  • Very rarely, QT prolongation, ventricular tachycardia, and Torsade de Pointes arrhythmia have been reported.

[ABPI, 2022; BNF, 2022]

What drug interactions are important with clarithromycin?

  • Drug interactions with clarithromycin include:
    • Pimozide — do not prescribe with clarithromycin as concurrent use may result in QT prolongation, cardiac arrhythmias including ventricular tachycardia, ventricular fibrillation, and Torsade de Pointes.
    • Ergotamine and dihydroergotamine — do not prescribe with clarithromycin as concurrent use may result in acute ergot toxicity. 
    • Colchicine — avoid concomitant administration as it may increase the risk of colchicine toxicity.
    • Carbamazepine — monitor carbamazepine levels within 3–5 days of starting clarithromycin, and adjust dose accordingly. Clarithromycin can increase carbamazepine levels, causing carbamazepine toxicity (may present as nausea and vomiting, ataxia, and drowsiness).
    • Edoxaban — manufacturer advises caution with concurrent treatment with edoxaban, particularly in those with a high risk of bleeding.
    • Ivabradine — concomitant treatment is contra-indicated, owing to CYP3A4 inhibition by clarithromycin which can cause elevated levels of ivabradine.
    • Other drugs that prolong the QT interval — if possible, avoid giving clarithromycin to a person who is already taking a drug that can potentially prolong the QT interval.
    • Statins — there is an increased risk of myopathy.
      • For simvastatin — do not prescribe clarithromycin to a person taking simvastatin. 
      • For atorvastatin — avoid concurrent use with clarithromycin if possible. 
      • For pravastatin — prescribe clarithromycin with caution and advise the person to seek medical advice if they experience symptoms of myopathy (for example muscle pain, tenderness, or weakness).
      • Other statins — clinically significant interaction with clarithromycin is not expected for rosuvastatin and fluvastatin. Nevertheless, advise the person to report any muscle pain, tenderness, or weakness. 
    • Warfarin — increase frequency of monitoring of the international normalized ratio (INR) when both drugs are used (particularly in elderly people), and adjust the warfarin dose accordingly. Clarithromycin may enhance the effect of warfarin. 
    • Oral hypoglycaemic drugs and insulin — the concurrent use of clarithromycin and antidiabetic drugs (such as sulphonylureas and/or insulin) can result in significant hypoglycaemia.
    • Calcium channel blockers (CCBs) — due to an increased risk of hypotension, caution is advised with the concurrent use of clarithromycin and CCBs metabolised by CYP3A4 (such as verapamil, amlodipine, and diltiazem).
    • Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of clarithromycin.
      • However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the CKS topic on Contraception - assessment.

[BNF, 2022; Preston, 2023; EMC, 2024]

Metronidazole 

What dose of metronidazole should I prescribe?

  • For dental abscess, prescribe a 5 day course of metronidazole (review after 3 days):
    • Adults: 400 mg three times a day. 
    • Child 10–18 years of age: 200–250 mg every 8 hours. 
    • Child 7–10 years of age: 100 mg every 8 hours. 
    • Child 3–7 years of age: 100 mg every 12 hours. 
    • Child 1–3 years of age: 50 mg every 8 hours.

[PHE, 2021b; BNF, 2022; BNF for children, 2022]  

What cautions and contraindications are associated with metronidazole?

  • Do not prescribe metronidazole to a person with:
    • Known metronidazole or nitroimidazole hypersensitivity.
    • Cockayne syndrome. Cases of severe hepatotoxicity/acute hepatic failure, including cases with a fatal outcome with very rapid onset after treatment initiation in patients with Cockayne syndrome have been reported with products containing metronidazole for systemic use (oral and suppositories). For people with Cockayne syndrome specialist advice should therefore be sought before prescribing metronidazole.
  • Prescribe metronidazole with caution in:
    • People with active or chronic severe peripheral and central nervous system disease as there is a risk of neurological aggravation.
    • People with severe liver disease and hepatic encephalopathy due to substantial impairment of metronidazole clearance in the presence of advanced hepatic insufficiency, which may contribute to the symptoms of encephalopathy. One third of the daily dosage may be given once daily.

[BNF, 2022; ABPI, 2021b]

What are the adverse effects of metronidazole?

  • Adverse effects of metronidazole include [BNF, 2022]:  
    • Gastro-intestinal disturbances including nausea and vomiting, anorexia, very rarely hepatitis, jaundice, pancreatitis.
    • Taste disturbances, furred tongue, oral mucositis.
    • Headache, ataxia.
    • Thrombocytopenia, pancytopenia. 
    • Myalgia, arthralgia.
    • Darkening of urine.
    • Rash, pruritus, and erythema multiforme.
  • Warn people taking metronidazole about the potential for drowsiness, dizziness, confusion, hallucinations, convulsions or transient visual disorders. Advise them not to drive or operate machinery if these symptoms occur [ABPI, 2021b]. 
  • Severe bullous skin reactions such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) or acute generalised exanthematous pustulosis (AGEP) have been reported. If symptoms/signs are present, treatment must be immediately discontinued.

What are the important drug interactions with metronidazole?

  • Important drug interactions associated with metronidazole include: 
    • Alcohol — some people taking oral metronidazole experience a disulfiram-like reaction with alcohol [BNF, 2022].
    • Warn the person that they might experience this reaction if they drink alcohol whilst on metronidazole and for at least 48 hours afterwards.  
    • Anticoagulants — the anticoagulant effects of warfarin can be markedly increased by metronidazole [Preston, 2023]. 
      • Monitor the international normalized ratio (INR) if metronidazole is given with warfarin and adjust the warfarin dose accordingly. 
    • Ciclosporin — when co-administration of metronidazole and ciclosporin is necessary, serum ciclosporin levels and serum creatinine should be closely monitored.
    • Lithium — seek specialist advice regarding the use of metronidazole with lithium, as lithium dose reduction may be required due to the risk of renal damage with concurrent use. Plasma concentrations of lithium, creatinine, and electrolytes should be monitored if metronidazole and lithium are used simultaneously .
    • The manufacturers SPC also notes that QT prolongation has been reported (unknown frequency), particularly when metronidazole was administered with drugs with the potential for prolonging the QT interval [EMC, 2023].
  • Additional contraceptive precautions are not required during or after courses of metronidazole [CoSRH, 2020b]. However, advise women on the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on vomiting or diarrhoea in the CKS topics on Contraception - combined hormonal methods and Contraception - progestogen-only methods.

Phenoxymethylpenicillin

What dose of phenoxymethypenicillin should I prescribe?

  • For dental abscess, prescribe a 5 day course of phenoxymethylpenicillin (review after 3 days):
    • Adults: 500 mg to 1 gram four times a day. 
    • Child 12–18 years: 500 mg four times daily.
    • Child 6–12 years: 250 mg four times daily. 
    • Child 1–6 years: 125 mg four times daily. 

[PHE, 2021b; BNF, 2022; BNF for children, 2022]  

What are the cautions and contraindications associated with phenoxymethylpenicillin?

  • Do not prescribe phenoxymethylpenicillin (penicillin V) to people with a true penicillin hypersensitivity. Gastrointestinal adverse effects alone (such as nausea, vomiting, or diarrhoea) do not constitute an allergy to penicillin. 
  • Prescribe penicillin V with caution in people with:
    • Hypersensitivity to cephalosporins — there is some evidence of partial cross-allergenicity. 
    • Renal impairment — reduce dose. 

[BNF, 2022]

What are the adverse effects of phenoxymethylpenicillin?

  • Adverse effects of phenoxymethylpenicillin (penicillin V) include:
    • Hypersensitivity reactions including urticaria, fever, joint pains, rashes, angio-oedema, anaphylaxis, and serum sickness-like reaction.
    • Interstitial nephritis. 
    • Haemolytic anaemia, leucopenia, thrombocytopenia, and coagulation disorders.
    • Diarrhoea, nausea and vomiting.
      • Severe diarrhoea during or after treatment with antibiotics may be a sign of pseudomembranous colitis. For more information, see the CKS topic on Diarrhoea - antibiotic associated.
    • Rarely central nervous system toxicity including convulsions (especially with high doses or in severe renal impairment).

[ABPI, 2017; BNF, 2022]

What drug interactions are important with phenoxymethylpenicillin?

  • Possible drug interactions with phenoxymethylpenicillin (penicillin V) include:
    • Anticoagulants — an interaction between broad-spectrum penicillins and coumarins or phenidone has not been demonstrated in studies, but common experience is that the International Normalised Ratio (INR) can be altered.
      • Increase monitoring of coagulation status — check INR within 3 days of starting phenoxymethylpenicillin [Preston, 2016].
    • Methotrexate — penicillins reduce excretion of methotrexate (increased risk of toxicity). 
      • Monitor levels of methotrexate more closely. One recommendation is to carry out twice weekly platelet and white cell counts for 2 weeks initially, with the measurement of methotrexate levels if toxicity is suspected [Preston, 2016].
  • Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of penicillins. However, advise women on the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on vomiting or diarrhoea in the CKS topics on Contraception - combined hormonal methods and Contraception - progestogen-only methods.

[BNF, 2022; Preston, 2023]  

Supporting evidence

This CKS topic is largely based on guidelines from the Scottish Dental Clinical Effectiveness Programme: Management of acute dental problems [Scottish Dental Clinical Effectiveness Programme, 2013] the British Medical Association: Patients presenting with dental problems [BMA, 2020]and guidelines from Faculty of General Dental Practice, Antimicrobial Prescribing in Dentistry [FGDP, Antimicrobial Prescribing in Dentistry, Good Practice Guidelines, 3rd Edition, 2020]Public Health England: Management of infection guidance for primary care for consultation and local adaptation  [PHE, 2021b]; the Scottish Dental Clinical Effectiveness Programme: Drug prescribing for dentistry [Scottish Dental Clinical Effectiveness Programme, 2021] in addition to expert opinion in review articles [MacAuley et al, 2013; Beech et al, 2014; Robertson et al, 2015]. Additional information came from systematic reviews [Moore, 2018],[Cope, 2018; Tampi, 2019; Pergolizzi, 2020]. The rationale for the assessment, referral, and primary care management of people with dental abscess is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of dental abscess.

Search dates

January 2017 - June 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Periapical Abscess/, exp Periodontal Abscess/, ((dental or dentalveolar or odontogenic or periapical or pericoronal) and (abscess$ or infection$ or pain)).tw., (dental ADJ abscess).tw., (periapical ADJ abscess).tw., (periodontal ADJ abscess).tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

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