Clinical Topic A-Z Clinical Speciality

Dental abscess

Dental abscess
D000038Abscess
Oral health
2012-09-01Last revised in September 2012

Dental abscess - Summary

A dental abscess is a localized collection of pus in the teeth, supporting structures of the teeth, or gums. There are two types of dental abscess:

Periapical abscess (dentoalveolar abscess) — originates in the dental pulp (centre of the tooth), and is the most frequently occurring type (both in 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 when bacteria invade and multiply in normally sterile dental tissues.

Periodontal abscess formation is associated with chronic periodontitis.

Periapical abscess formation is usually secondary to dental decay (caries).

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).

Bad 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 discoloured 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); localized lymphadenopathy; salivary gland problems; neoplasm; and unerupted teeth.

Definitive treatment for a dental abscess should be provided by a dental practitioner. This includes a combination of mechanical treatment, systemic antibiotics, and possibly surgery.

Interim treatment (whilst waiting to see a dental practitioner) 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 healthy people with 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 or valvular heart disease).

Specialist advice or hospital admission should be considered if a dental abscess is associated with:

Signs of systemic infection (such as high temperature) and cardio-respiratory compromise (rapid pulse rate, low blood pressure, high respiratory rate).

Early signs of dysphagia or a significant 'floor of mouth' swelling.

Severe pain despite analgesia.

Spreading facial infection.

A history of being immunocompromised.

Have I got the right topic?

12months3060monthsBoth

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 dental practitioner.

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

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

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in September 2012

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) [MHRA, 2013b]. 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 regarding diclofenac [MHRA, 2013a].

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

January 2013 — minor update. change to the text to reflect updated advise regarding the choice of antibiotic for treating a dental abscess [HPA and British Infection Association, 2012].

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

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.

Previous changes

May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.

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

June 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. Issued in July 2010.

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. Issued in October 2006.

October 2005 — minor technical update. Issued in November 2005.

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

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 September 2012.

HTAs (Health Technology Assessments)

No new HTAs since 1 September 2012.

Economic appraisals

No new economic appraisals relevant to England since 1 September 2012.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 September 2012.

Primary evidence

No new randomized controlled trials published in the major journals since 1 September 2012.

New policies

No new national policies or guidelines since 1 September 2012.

New safety alerts

No new safety alerts since 1 September 2012.

Changes in product availability

No changes in product availability since 1 September 2012.

Goals and outcome measures

Goals

To reduce pain

To treat with antibiotics, only when appropriate

To ensure that the person is aware that they should be seen by a dental practitioner within the next few days

QIPP - options for local implementation

QIPP - options for local implementation

Non-steroidal anti-inflammatory drugs (NSAIDs)

Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).

If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA advice and the NICE clinical guideline on osteoarthritis [CSM, 2005; NICE, 2008].

Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008; NICE, 2009a; NICE, 2009b].

Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.

Antibiotic prescribing — especially quinolones and cephalosporins

Review and, where appropriate, revise current prescribing practice and use implementation techniques to ensure prescribing is in line with Health Protection Agency (HPA) guidance.

Review the total volume of antibiotic prescribing against local and national data.

Review the use of quinolones and cephalosporin prescribing against local and national data.

[NICE, 2013]

Background information

Definition

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. There are two types of dental abscess:

Periapical abscess (also known as dentoalveolar abscess) — this originates in the dental pulp (centre of the tooth), and is the most frequently occurring type (both in adults and children).

Periodontal abscess — this originates in the supporting structures of the teeth (such as the periodontal ligament) between the tooth and the gum [Herrera et al, 2000; Gould, 2012].

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.

Cause

What causes it?

Dental abscesses result when bacteria invade and multiply in normally sterile dental tissues, due to general or local predisposing factors, such as dental decay.

Microbiological studies have shown that most dental abscesses are due to polymicrobial anaerobic bacterial infections [Dahlen, 2002]. Usually three or more causative organisms can be isolated from a dental abscess. These are predominantly Gram-negative anaerobic bacilli [Herrera et al, 2000; Dahlen, 2002; Wilson and Kornman, 2003].

Periodontal abscess formation is associated with chronic periodontitis [Jaramillo et al, 2005].

Periodontitis can cause separation of the periodontal ligament from the base of the tooth (due to chronic inflammation), resulting in the formation of a periodontal pocket. Periodontal pockets can be difficult to clean, allowing bacteria to invade and multiply. By-products of bacteria cause more inflammation, which allows further bacteria to invade, eventually causing an abscess.

Other causes have been proposed, including periodontal treatment (occlusion of the gingival margin after mechanical intervention), antibiotic use in untreated periodontitis, and periodontal trauma in people without periodontitis [Jaramillo et al, 2005].

Periapical abscess formation is usually secondary to dental caries (dental decay):

Dental decay (caries) erodes the protective layers of the tooth (enamel, dentine) and allow bacteria to invade the pulp (pulpitis). Pulpitis can progress to necrosis, with bacterial invasion of the alveolar bone, causing an abscess.

Prevalence

How common is it?

The lifetime prevalence of dental abscess has been reported as 5–46% [Matthews et al, 2003].

Complications and prognosis

Complications

A sinus may develop that can discharge intraorally or into the overlying skin.

A dental cyst may develop around the apex of the tooth.

Maxillary sinusitis.

Rarer complications include:

Osteomyelitis.

Cavernous sinus thrombosis: it is estimated that 10% of cases have a dental origin.

Ludwig's angina is 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) and, in severe cases, stridor or difficulty breathing can occur.

[Gould, 2012]

Prognosis

The abscess will remain as long as the tooth is left untreated. The spread of infection may lead to bone destruction, but the prognosis is good with appropriate dental care. If the tooth is severely broken down, or if there is advanced periodontal disease, extraction of the tooth is necessary.

[Herrera et al, 2000; Gould, 2012]

Diagnosis

Diagnosis of dental abscess

Diagnosis

How do I know my patient has it?

Take a history including possible risk factors and current symptoms.

Assess the likelihood of existing caries and periodontal disease. Ask about:

Dental hygiene: frequency of brushing and flossing.

Diet: ask about intake of sugar containing foods and sugared carbonated/fizzy drinks (non-sugared drinks are less of a risk).

Previous dental procedures: fillings, root canal treatment, and extractions.

Any coexisting factors that might increase the risk of dental disease progressing: the presence of diabetes, compromised immune system (either acquired or drug induced), smoking, and drug-induced gum conditions (e.g. phenytoin-induced gum hypertrophy).

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, worse when lying down and may cause waking from sleep during the night.

The tooth may be tender to touch, or to pressure from biting.

Pain may radiate to the ear, lower jaw, and neck on the same side as the dental abscess.

Bad taste in the mouth.

Fever and malaise if associated with systemic involvement.

Trismus (inability to open the mouth) or dysphagia may be present in severe cases.

Examine the oral cavity (both externally and internally) for signs of abscess.

Observation may reveal:

Facial swelling, with or without cellulitis: most commonly in the submandibular, sublingual, or buccal areas.

Regional lymphadenopathy.

Altered tooth appearance: the affected tooth may be elevated or discoloured.

Gum swelling: this is smooth, shiny, and erythematous. It may involve one or several teeth. It may develop into a fluctuant mass.

Palpation may reveal:

Tooth: increased mobility and tenderness.

Gum: tenderness, warmth, and a purulent exudate.

Investigations are not routinely carried out in medical primary care settings.

A dental practitioner may consider radiography to help with the diagnosis.

Basis for recommendation

Basis for recommendation

Recommendations on the diagnosis of dental abscess are expert opinion from American guidelines [American Academy of Periodontology, 2000; Krebs et al, 2006], review articles [Herrera et al, 2000; Gould, 2012], and a text book [Wilson and Kornman, 2003].

Differential diagnosis

What else might it be?

Infections:

Mumps.

Sinusitis.

Acute otitis media.

Facial cellulitis.

Localized lymphadenopathy due to other infection or a neoplasm.

Salivary gland problem due to stone, infection (parotitis), or dehydration/dry mouth.

Neoplasm:

Intraoral.

Salivary gland.

Unerupted teeth.

Management

Management

Scenario: Management : covers the management of dental abscess in primary care whilst awaiting specialist management.

Scenario: Management

Scenario: Management of dental abscess

12months3060monthsBoth

Overview of management

How should I manage dental abscess in primary care?

Emphasize the need to seek dental treatment as soon as possible.

Advise the person when and where to seek urgent medical or dental intervention.

In the absence of immediate dental attention by a dental practitioner:

Provide appropriate self-care advice.

Advise the use of an analgesic to relieve symptoms.

Ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is recommended first-line. See the CKS topic on NSAIDs - prescribing issues.

Paracetamol and ibuprofen can be taken together if pain relief with either alone is insufficient.

For adults, if taking paracetamol and ibuprofen together does not provide enough pain relief, consider adding codeine phosphate or switching to an alternative nonsteroidal anti-inflammatory drug (NSAID).

For women who are pregnant or breastfeeding, paracetamol is preferred. A short course of codeine may be added if paracetamol alone is insufficient.

Antibiotics are generally not indicated for otherwise healthy individuals when there no signs of spreading infection.

Only prescribe an antibiotic:

For people who are systemically unwell or if there are signs of severe infection (e.g. fever, lymphadenopathy, cellulitis, diffuse swelling).

For high risk individuals to reduce the risk of complications (e.g. people who are immunocompromised or diabetic or have valvular heart disease).

Do not routinely provide repeat prescriptions or switch antibiotics in people who fail to respond to first-line treatment. Instead advise the person to see a dental practitioner urgently.

Basis for recommendation

Basis for recommendation

The basis for each recommendation is discussed in the specific management section.

Who should treat dental abscess

Who should treat a dental abscess?

All people with a dental abscess should have definitive treatment provided by a dental practitioner.

Advise the person to access services (for emergency treatment) via:

Their registered Dental Practice, or

The Accident and Emergency department of a dental hospital (if available), or

The local Dental Access Centre (if available), or

The Accident and Emergency department of a district general hospital, if the airway is compromised or only if no other avenues are available.

Interim treatment by the medical practitioner may be needed while the person is waiting to see a dental practitioner.

Emergency access to a dental practitioner may not be immediately available and the person may seek help from medical services.

Treatment may be provided by the person's GP, medical out-of-hours service, or local Accident and Emergency department.

Interim treatment while waiting to see a dental practitioner may consist of advice about self-care and analgesia, with or without an antibiotic prescription.

Basis for recommendation

Basis for recommendation

These recommendations are based on current medical literature looking at the provision of dental services in the UK [Anderson and Thomas, 2000].

Self-care advice

What self-care advice should I recommend for dental abscess?

Provide advice regarding food and drink to reduce the pressure and pain of the dental abscess:

Avoid food or drink that may be too hot or cold.

Consume cool, soft foods.

Advise the safe use of analgesics:

Encourage regular use of analgesics and warn the individual not to exceed the recommended or prescribed dose.

For choice of analgesics, see Recommended analgesia.

Remind the individual 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.

If a person is refusing to go to a dental practitioner, consider the following self-care advice:

Brushing — use a soft tooth brush to reduce discomfort. Avoid flossing the tooth with the abscess.

Eating — try eating on the other side of the mouth to reduce discomfort and irritation to the abscess.

People should be advised that serious complications may happen if the abscess is not treated correctly by a dental practitioner.

Basis for recommendation

Basis for recommendation

CKS considers these recommendations to be pragmatic advice. CKS found no evidence that specifically looked at self care in the treatment of dental abscess.

Food and drink:

Dental pain can be exacerbated by temperature (pulpal pain) and by biting (periapical periodontal pain) [Roberts et al, 2000].

Safe use of analgesics:

People with acute dental pain are known to consume excessive quantities of analgesics, and there have been case reports of overdose requiring hospital treatment [Sivaloganathan et al, 1993; Preshaw et al, 1994; Dodd and Graham, 2002; Milner et al, 2006; Thomas et al, 2007].

Recommended analgesia

What analgesia is recommend for dental abscess?

Ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is recommended first-line.

Over-the-counter (OTC) analgesics containing paracetamol, aspirin, or ibuprofen are available with or without codeine.

By the time of presentation, the person may already have tried OTC medications, including a combination of these analgesics.

Paracetamol and ibuprofen can be taken together if pain relief with either alone is insufficient.

For adults, if taking paracetamol and ibuprofen together does not provide enough pain relief, consider adding codeine phosphate or switching to an alternative nonsteroidal anti-inflammatory drug (NSAID) such as naproxen or diclofenac.

In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are preferred to diclofenac.

Diclofenac is now contraindicated in people with ischaemic heart disease, cerebrovascular disease, peripheral arterial disease, mild, moderate, or severe heart failure.

For women who are pregnant or breastfeeding, paracetamol is preferred. A short course of codeine may be added if paracetamol alone is insufficient.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion and standard clinical practice. CKS found no trials that specifically looked at oral analgesics in the treatment of dental abscess by medical practitioners.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally regarded as the analgesic of choice, given the inflammatory aetiology of most dental pain (being caused by factors such as infection and trauma) [Dionne and Berthold, 2001; Canadian Collaboration on Clinical Practice Guidelines in Dentistry, 2004; Hargreaves and Abbott, 2005; Mickel et al, 2006; BNF 64, 2012].

Ibuprofen is the preferred NSAID as it is associated with a lower risk of gastrointestinal adverse effects compared with other NSAIDs [Dionne and Berthold, 2001; CSM, 2002; CSM, 2003; Hargreaves and Abbott, 2005; BNF 64, 2012]. Ibuprofen is widely available over the counter and, unlike aspirin, can be given to those less than 16 years of age.

Differences in anti-inflammatory activity between different NSAIDs are small, but there is considerable variation in individual tolerance and response to them.

The MHRA now recommend that like coxibs, diclofenac is contraindicated for people with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, and, congestive heart failure (New York Heart Association [NYHA] classification II–IV) [MHRA, 2013a]. The MHRA based this recommendation on a recently published meta-analysis which found evidence that the arterial thrombotic risk with oral diclofenac is similar to that for the selective COX-2 inhibitors.

For those unresponsive to ibuprofen, a different NSAID should be chosen on the basis of incidence of gastrointestinal and other adverse effects [BNF 64, 2012]. For further information see the CKS topic on NSAIDs - prescribing issues.

Paracetamol is an alternative if NSAIDs are unsuitable. Its analgesic effect for mild-to-moderate dental pain is probably lower than aspirin. However, paracetamol has the advantage that it does not affect bleeding time or interact significantly with warfarin, and is less irritating to the stomach [BNF 64, 2012].

Codeine and other opioids on their own are thought to be relatively ineffective for dental pain, and their adverse effects can be unpleasant. Opioids should only be considered as adjunctive analgesics and not as primary analgesics [Dionne and Berthold, 2001; Hargreaves and Abbott, 2005; BNF 64, 2012].

Over-the-counter analgesics containing low dose codeine are available (e.g. co-codamol 8/500 tablets), but the efficacy of these preparations is uncertain [Hargreaves and Abbott, 2005].

Combined use of analgesics in severe dental pain:

CKS found no trials supporting the combined use of analgesics (NSAID, paracetamol, and codeine) for severe dental pain. However, this recommendation is pragmatic advice as a combination of drugs are commonly used in clinical practice for pain management.

Prescribing an antibiotic

Should I prescribe an antibiotic for a dental abscess?

In the absence of immediate attention by a dental practitioner, prescribe an antibiotic if the person has:

Signs of severe infection (e.g. fever, lymphadenopathy, cellulitis, diffuse swelling).

Systemic symptoms (e.g. fever or malaise).

A high risk of complications (e.g. people who are immunocompromised or diabetic or have valvular heart disease).

If an oral antibiotic is indicated prescribe a 5-day course of either amoxicillin (500 mg three times a day), or phenoxymethylpenicillin (500-1000 mg four times day).

If the person has a true penicillin allergy prescribe clarithromycin (500 mg twice a day) for 5 days.

Consider concomitant treatment with metronidazole (400 mg three times as day for 5 days) if the infection is severe or spreading (lymph node involvement, or systemic signs ie fever or malaise).

If an adult is allergic to, or cannot tolerate metronidazole, clindamycin (300 mg four times a day for 5 days) may be considered as an alternative to metronidazole.

When prescribing an antibiotic, explain to the person that:

Antibiotic therapy is prescribed to reduce the spread of infection. It is not a substitute for dental treatment.

Regular analgesia should be taken to relieve the symptoms.

Do not routinely provide repeat prescriptions or switch antibiotics in people who fail to respond to first-line treatment. Instead advise the person to see a dental practitioner urgently.

Explain that definitive treatment by a trained professional is the only long-term solution, and repeated antibiotics may be masking underlying complications (for example sinus or dental cyst).

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.

Basis for recommendation

Basis for recommendation

Prescribing antibiotics

These recommendations are based on guidance issued by the Faculty of General Dental Practitioners [Faculty of General Dental Practice, 2000], the British Society of Antimicrobial Chemotherapy [BSAC, 2007], the Canadian Collaboration on Clinical Practice Guidelines in Dentistry [Canadian Collaboration on Clinical Practice Guidelines in Dentistry, 2004], the American Academy of Periodontology [American Academy of Periodontology, 2004], and published expert opinion from the Health Protection Agency: Management of infection guidance for primary care for consultation and local adaptation [HPA and British Infection Association, 2012].

CKS found no evidence that specifically looked at antibiotics in the treatment of dental abscess by general medical practitioners.

The Faculty of General Dental Practitioners does not recommended changing antibiotics because the failure of the antibiotic is not usually due to microbial resistance [Faculty of General Dental Practice, 2000].

Choice of antibiotic

Recommendations on antibiotic choice and duration of treatment are based on those issued by the Health Protection Agency and the Association of Medical Microbiologists [HPA and British Infection Association, 2012].

CKS found no evidence that specifically looked at antibiotics in the treatment of dental abscess by general medical practitioners. Antibiotics are often prescribed empirically, due to the difficulty in evaluating microbiology and the delay in obtaining sensitivity results [Dahlen, 2002; Kuriyama et al, 2007].

Although clindamycin is licensed for use in children, CKS have not included it for the treatment of a dental abscess in primary care for pragmatic reasons. Clindamycin liquid a 'special' and as such needs to be ordered by the pharmacy; this may take a few days.

Specialist advice/hospital admission

When should I seek specialist advice or arrange hospital admission?

Seek further advice or admit a person to hospital if they have a dental abscess and:

Are unwell with a high temperature and cardio-respiratory compromise (rapid pulse rate or low blood pressure, high respiratory rate).

Early signs of dysphagia or a significant 'floor of mouth' swelling.

Are in severe pain despite analgesia (maximum tolerated dosage) prescribed in primary care.

Have a spreading facial infection.

Have a history of being immunocompromised.

For more information, see When to seek advice.

When to seek advice

When to seek advice

Consider (if available) speaking to the oral and maxillofacial doctor on call in the local hospital for advice before a referral is made.

Referral to secondary care or admission to hospital may be required if the person is showing signs of worsening systemic upset or is known to be at risk of complications.

The cause and duration of immunodeficiency affects the degree of risk of infection. Consider further advice in people with:

Haematological malignancies.

AIDS with low CD4+ counts.

Bone marrow or other organ transplants.

Splenectomy.

Genetic disorders, such as severe combined immunodeficiency.

Basis for recommendation

Basis for recommendation

These admission criteria are based on pragmatic advice and include criteria from the British Society for Antimicrobial Chemotherapy [BSAC, 2007].

Specialist treatments

What treatments are available from a dental practitioner?

The treatment of dental abscesses includes a combination of mechanical treatment, systemic antibiotics, and possibly surgery.

Mechanical treatment and surgery:

The most important and immediate step in treating a dental abscess is to mechanically incise the abscess and create drainage to reduce the load of infectious bacteria.

Periapical abscesses are normally managed by root canal treatment. The dentist will drill into the dead tooth and allow pus to escape through the tooth, and then remove necrotic pulpal tissue. A root filling is then placed into the tooth to prevent further infection. If the infection persists despite root canal treatment the dentist may have to extract the tooth, or consider referring to an oral surgeon who may surgically remove diseased tissue.

Periodontal abscesses are normally managed by drainage of the abscess and thorough cleaning of the periodontal pocket. Following this procedure the dentist will usually smooth out the root surfaces (subgingival scaling and root planing) of the tooth to promote healing and prevent the infection reoccurring. A repeat radiograph will normally be carried out at 3–6 months. Sometimes a referral to an oral surgeon may be needed (for repeated infections) to allow reshaping of the gum tissue. Reshaping of the gum will help the individual keep the area clean, reducing the risk of further infection.

Systemic antibiotics:

Systemic antibiotic treatment is of secondary importance to surgical incision and drainage of abscesses. Its role is aimed at preventing bacterial spread and serious complications.

Basis for recommendation

Basis for recommendation

Information on specialist treatments for dental abscess is based on review articles [Dahlen, 2002; American Academy of Periodontology, 2004; Jaramillo et al, 2005].

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) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

Antibiotics

Issues prescribing amoxicillin

What are the general issues when prescribing amoxicillin?

Amoxicillin is a broad spectrum antibiotic and is usually well tolerated, but nausea, vomiting, or diarrhoea can sometimes occur.

It should not be taken by people who have true penicillin allergy. However, gastrointestinal adverse effects alone (i.e. nausea, vomiting, or diarrhoea) do not constitute an allergy to penicillin.

Drug interactions:

Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of amoxicillin [FSRH, 2011].

However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Anticoagulants — documented reports of oral anticoagulant/penicillin (including amoxicillin) interaction are relatively rare [Baxter, 2010]. However, the British National Formulary advises that common experience in anticoagulant clinics is that the International Normalization Ratio (INR) can be altered by a course of broad spectrum penicillin [BNF 64, 2012].

Warn the individual of the possible risk of increased bruising and bleeding. Advise when to seek medical help.

Issues prescribing metronidazole

What are the general issues when prescribing metronidazole?

Common adverse effects include a metallic taste and gastrointestinal irritation (in particular nausea and vomiting). These are more common at higher doses.

Advise that metronidazole should be taken with or after food.

Drug interactions:

Alcohol — some people taking oral metronidazole experience disulfiram-like reactions to alcohol (flushing, increased respiratory rate, increased pulse rate). Although there is no conclusive evidence to support an interaction between metronidazole and alcohol, people taking metronidazole should be advised of the possible consequences of drinking alcohol [Baxter, 2010].

Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of metronidazole [FSRH, 2011].

However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Anticoagulants — the anticoagulant effects of warfarin can be markedly increased by metronidazole [Baxter, 2010; ABPI Medicines Compendium, 2011a; ABPI Medicines Compendium, 2012a].

If concurrent use cannot be avoided, consider reducing the warfarin dosage appropriately (by between one-third to one-half) [Baxter, 2010].

Warn the individual of the possible risk of increased bruising and bleeding. Advise when to seek medical help.

Issues prescribing clarithromycin

Issues prescribing clarithromycin

Clarithromycin, may cause gastrointestinal adverse effects (e.g. nausea, vomiting, diarrhoea), however it is thought to cause less gastrointestinal effects than other macrolides [BNF 64, 2012].

Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of erythromycin or clarithromycin [FSRH, 2011].

However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Interactions

Possible enhanced effect of aminophylline or theophylline, and carbamazepine (due to cytochrome P450 enzyme inhibition). Check levels if toxicity is suspected (e.g. palpitations, nausea, headache), or 48 hours after starting concurrent treatment with clarithromycin [Baxter, 2010].

Possible enhanced effect of warfarin. Reduce warfarin dose by 50% (especially in people over 60 years of age, who clear warfarin slowly) and monitor weekly for up to 3 weeks after stopping.

Possible QT-interval prolongation. Avoid concomitant use with drugs that can potentially prolong the QT interval (e.g. anti-arrhythmics, antipsychotics, tricyclic antidepressants) [Baxter, 2010].

Increased risk of myopathy in people taking a statin such as atorvastatin or simvastatin (due to cytochrome P450 enzyme CYP3A4 inhibition) [CSM, 2004]. When treatment with clarithromycin is indicated in patients receiving statin treatment, therapy with statins should be suspended during the course of treatment [ABPI Medicines Compendium, 2011b].

Issues prescribing clindamycin

Issues prescribing clindamycin

Oral clindamycin has been associated with pseudomembranous colitis, which may be fatal. Although this can occur with most antibiotics, it appears to be more common with clindamycin [BNF 64, 2012].

Advise the person to stop treatment with clindamycin if they develop diarrhoea.

Other common adverse effects include abdominal discomfort, oesophagitis, oesophageal ulcers, taste disturbances, nausea, vomiting, andantibiotic-associated colitis [BNF 64, 2012].

Rarely, clindamycin has been reported to cause blood dyscrasias, hepatotoxicity, and adverse skin reactions such as maculopapular rash, urticaria and very rarely erythema multiforme [ABPI Medicines Compendium, 2012b].

Analgesics

In pregnancy or breastfeeding

Which analgesic is suitable for use during pregnancy or breastfeeding?

Paracetamol

Paracetamol is preferred because it can be given at all stages of pregnancy and during breastfeeding [Schaefer et al, 2007].

Weak opioids

For pregnant women — codeine may be used as an analgesic for pregnant women if paracetamol is not sufficiently effective. However, there is a potential to cause neonatal respiratory depression when used near to term [Schaefer et al, 2007].

For breastfeeding mothers — either tramadol or dihydrocodeine is preferred. Both should be prescribed at the lowest effective dose for the shortest duration of time.

If significant opioid adverse effects occur in the breastfeeding mother this may suggest that she is an 'ultra rapid metaboliser', and that the risk of opioid adverse effects in the infant may be increased.

All breastfeeding mothers who are taking weak opioids should be advised to stop breastfeeding if they have opioid adverse effects and seek medical advice.

Until recently codeine was the preferred weak opioid for breastfeeding women, however the Medicines and Healthcare products Regulatory Agency (MHRA) have now advised against the use of codeine during breastfeeding [MHRA, 2013b]. This advice was based on a report of a fatal case of morphine toxicity in a breastfed infant following maternal use of codeine.

Subsequent to the publication of this advice the UK Drugs in Lactation Advisory Service now recommend dihydrocodeine or tramadol for use during breastfeeding. This recommendation is based on an evidence based review published by the UK Medicines Information service [UKMi, 2013]. This review found that although there is no published evidence for the safety of dihydrocodeine use by a breastfeeding mother, extensive anecdotal experience supports its safe use. Tramadol use is considered acceptable based on the low levels in breast milk when prescribed at the lowest effective dose for the shortest duration.

The nonsteroidal anti-inflammatory drug (NSAID), ibuprofen, can be considered for use during pregnancy (up to 27 weeks of gestation) and breastfeeding [Schaefer et al, 2007].

Pregnancy

Ibuprofen should not be used beyond 27 weeks of gestation because this can lead to heart problems in the neonate (increased risk of constriction of the ductus arteriosus and possibly persistent pulmonary hypertension of the newborn) [Schaefer et al, 2007; BNF 64, 2012].

Breastfeeding

Ibuprofen was not detected in breast milk following administration of 800–1600 mg daily in two small studies. No adverse effects on breastfed children were reported in both studies and also in a prospective study covering 21 mother-child pairs [Schaefer et al, 2007].

Evidence

Evidence

Search strategy

Scope of search

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

Search dates

October 2007 - September 2012

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.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

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

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

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

Bandolier

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

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.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

ABPI Medicines Compendium (2011a) Summary of product characteristics for Flagyl 400mg tablets. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2011b) Summary of product characteristics for Klaricid 500mg tablets. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2012a) Summary of product characteristics for Flagyl 200mg tablets. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2012b) Summary of product characteristics for Dalacin C Capsules 75mg and 150mg. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

American Academy of Periodontology (2000) Parameter on comprehensive periodontal examination. Journal of Periodontology 71(5 Suppl), 847-883. [Abstract] [Free Full-text]

American Academy of Periodontology (2004) Position paper: systemic antibiotics in periodontics. Journal of Periodontology 75(11), 1553-1565. [Abstract]

Anderson, R. and Thomas, D.W. (2000) Out-of-hours dental services: a survey of current provision in the United Kingdom. British Dental Journal 188(5), 269-274. [Abstract]

Baxter, K. (Ed.) (2010) Stockley's drug interactions: a source book of interactions, their mechanisms, clinical importance and management. 9th edn. London: Pharmaceutical Press.

BNF 64 (2012) British National Formulary. 64th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.

BSAC (2007) Dental abscess. Treatment of Hospital InfectionsBritish Society for Antimicrobial Chemotherapy. www.bsac.org.uk

Canadian Collaboration on Clinical Practice Guidelines in Dentistry (2004) Clinical practice guideline on treatment of acute apical abscess (AAA) in adults. Evidence-based Dentistry 5(1), 8.

CSM (2002) Non-steroidal anti-inflammatory drugs (NSAIDs) and gastrointestinal (GI) safety. Current Problems in Pharmacovigilance 28(Apr), 5. [Free Full-text]

CSM (2003) Reminder: gastrointestinal toxicity and NSAIDs. Current Problems in Pharmacovigilance 29(Sep), 8-9. [Free Full-text]

CSM (2004) Statins and cytochrome P450 interactions. Current Problems in Pharmacovigilance 30(Oct), 1-2. [Free Full-text]

CSM (2005) Updated advice on the safety of selective COX-2 inhibitors. Committee on Safety of Medicines. www.mhra.gov.uk [Free Full-text]

Dahlen, G. (2002) Microbiology and treatment of dental abscesses and periodontal-endodontic lesions. Periodontology 2000 28(1), 206-239.

Dionne, R.A. and Berthold, C.W. (2001) Therapeutic uses of non-steroidal anti-inflammatory drugs in dentistry. Critical Reviews in Oral Biology & Medicine 12(4), 315-330. [Abstract] [Free Full-text]

Dodd, M.D. and Graham, C.A. (2002) Unintentional overdose of analgesia secondary to acute dental pain. British Dental Journal 193(4), 211-212. [Abstract]

Faculty of General Dental Practice (2000) Adult antimicrobial prescribing in primary dental care for general dental practitioners. London: Royal College of Surgeons of England.

FSRH (2011) Drug interactions with hormonal contraception. Faculty of Sexual and Reproductive Healthcare. www.fsrh.org [Free Full-text]

Gould, J.M. (2012) Dental abscess. eMedicineWebMD. www.emedicine.com [Free Full-text]

Hargreaves, K. and Abbott, P.V. (2005) Drugs for pain management in dentistry. Australian Dental Journal 50(4 Suppl 2), S14-S22. [Abstract] [Free Full-text]

Herrera, D., Roldan, S. and Sanz, M. (2000) The periodontal abscess: a review. Journal of Clinical Periodontology 27(6), 377-386. [Abstract]

HPA and British Infection Association (2012) Management of infection guidance for primary care for consultation and local adaptation. Health Protection Agency. www.hpa.org.uk [Free Full-text]

Jaramillo, A., Arce, R.M., Herrera, D. et al. (2005) Clinical and microbiological characterization of periodontal abscesses. Journal of Clinical Periodontology 32(12), 1213-1218. [Abstract]

Krebs, K.A., Clem, D.S. and American Academy of Periodontology (2006) Guidelines for the management of periodontal diseases. Journal of Periodontology 77(9), 1607-1611.

Kuriyama, T., Williams, D.W., Yanagisawa, M. et al. (2007) Antimicrobial susceptibility of 800 anaerobic isolates from patients with dentoalveolar infection to 13 antibiotics. Oral Microbiology & Immunology 22(4), 285-288. [Abstract]

Matthews, D.C., Sutherland, S. and Basrani, B. (2003) Emergency management of acute apical abscesses in the permanent dentition: a systematic review of the literature. Journal of the Canadian Dental Association 69(10), 660. [Abstract] [Free Full-text]

MHRA (2013a) Diclofenac: new contraindications and warnings after a Europe-wide review of cardiovascular safety. Drug Safety Update 6(11), A2. [Free Full-text]

MHRA (2013b) Codeine: restricted use as analgesic in children and adolescents after European safety review. Drug Safety Update 6(11), S1. [Free Full-text]

Mickel, A.K., Wright, A.P., Chogle, S. et al. (2006) An analysis of current analgesic preferences for endodontic pain management. Journal of Endodontics 32(12), 1146-1154. [Abstract]

Milner, N., Dickenson, A. and Thomas, A. (2006) The use of NSAIDs in dentistry: a case study of gastrointestinal complications. Dental Update 33(8), 487-491. [Abstract]

NICE (2008) Osteoarthritis. The care and management of osteoarthritis in adults (NICE guideline) [Replaced by CG177]. . Clinical guideline 59. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NICE (2009a) Rheumatoid arthritis: the management of rheumatoid arthritis (NICE guideline). . Clinical guideline 79. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NICE (2009b) Low back pain: early management of persistent non-specific low back pain (NICE guideline). . Clinical guideline 88. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NICE (2013) Key therapeutic topics - medicines management options for local implementation. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NPC (2011) Key therapeutic topics 2010/11 - Medicines management options for local implementation. National Prescribing Centre. www.npc.nhs.uk [Free Full-text]

NPC (2012) Key therapeutic topics - medicines management options for local implementation. National Prescribing Centre. www.npc.nhs.uk [Free Full-text]

Preshaw, P.M., Meechan, J.G. and Dodd, M.D. (1994) Self-medication for the control of dental pain: what are our patients taking? Dental Update 21(7), 299-304. [Abstract]

Roberts, G., Scully, C. and Shotts, R (2000) ABC of oral health: dental emergencies. British Medical Journal 321(7260), 559-562. [Free Full-text]

Schaefer, C., Peters, P. and Miller, R.K. (Eds.) (2007) Drugs during pregnancy and lactation: treatment options and risk assessment. 2nd edn. Oxford: Academic Press.

Sivaloganathan, K., Johnson, P.A., Bray, G.P. and Williams, R. (1993) Pericoronitis and accidental paracetamol overdose: a cautionary tale. British Dental Journal 174(2), 69-71. [Abstract]

Thomas, M.B., Moran, N., Smart, K. and Crean, S. (2007) Paracetamol overdose as a result of dental pain requiring medical treatment: two case reports. British Dental Journal 203(1), 25-28. [Abstract]

UKMi (2013) Codeine and breastfeeding: Is it safe and what are the alternatives? UK Medicines Information. www.evidence.nhs.uk

Wilson, T.G. and Kornman, K.S. (Eds.) (2003) Fundamentals of periodontics. 2nd edn. London: Quintessence Publishing Co, Inc.