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Clinical Guidelines: Are antibiotics appropriate for pulpal- and periapical-related dental pain and associated intraoral swelling?

This summary of the guidelines is based on the article:
Plain language summary for “Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: systematic review and metaanalysisda report of the American Dental Association" which appeared in the Journal of the American Dental Association, December 2019 Edition.


This information is important for dentists who prescribe antibiotics for these conditions, as well as for patients who seek care in settings in which definitive conservative dental treatment (DCDT), such as pulpectomy, pulpotomy, nonsurgical root canal therapy, and incision and drainage of abscess may not always be available (for example, hospital emergency departments). However, this information is also important for practitioners and patients in settings in which DCDT, with or without the additional use of antibiotics, can be delivered.

It is important for clinicians to prescribe antibiotics in clinical scenarios in which they are absolutely needed because their use, whether appropriate or inappropriate, can contribute to a future in which antibiotics are not effective at fighting bacterial infections.

  1. Evidence suggests that antibiotics, prescribed alone or as adjuncts to DCDT, can sometimes reduce, but can also not reduce, dental pain and associated intraoral swelling.
  2. The evidence also suggests that antibiotic use can contribute to serious potential harms, such as antibiotic-resistant infections and even death due to opportunistic infections.
  3. Clinical decision making is not limited to considering the benefits and harms of a treatment and should include additional factors, such as patients’ values and preferences, acceptability of a treatment by key stakeholders, and the feasibility of providing the treatment in a given setting.

Randomized Controlled Trials data was used to determine the magnitude of the potential benefits of antibiotics for dental pain and associated intraoral swelling when DCDT is and is not available. According to these data, antibiotics with or without DCDT may provide an increase or decrease in the relief of pain or intraoral swelling after 24 hours through 7 days follow-up (very low to low certainty).

Data from the same 3 Randomized Control Trials (RCTs) and the 8 observational studies was used to determine the harms associated with antibiotic use.

Data from the 8 observational studies suggested that the use of antibiotics may cause harm, like Clostridioides difficile infections (overgrowth of a life-threatening bacteria after antibiotic use) and antibiotic-resistant infections (in which antibiotics become less
effective at killing bacteria), while data from the RCTs suggested that the use of antibiotics may cause side effects like diarrhea and malaise.

The available evidence suggests that antibiotic use probably contributes to both small to moderate individual-level harms (very low to low certainty) and potentially large population-level harms (very low to moderate certainty).


  1. Dr. Jim Roxborough December 5, 2019

    Who writes this type of advice? Are we lawyers or dentists? I have been practicing dentistry for over 43 years and I can state without equivocation that I have prescribed antibiotics thousands of times for the condition described without fear of death to the patient and indeed no patients have died or been hospitalized as a result. This pendulum (like the sterilization one) has swung way past the point of reason.

  2. Sheryl Lipton December 6, 2019

    With all due respect to Dr. Jim Roxborough, I have been practicing dentistry for 37 years–so I would say that we are the same vintage. However, I have written very few prescriptions in my career. The pendulum has swung–and research has unequivocally shown that antibiotic use is creating superbugs which cannot be treated with our traditional antibiotics. Hence antibiotics must be used judiciously. Without fever, trismus, lymphadenopathy, or swelling, I do not prescribe antibiotics and try to treat the problem locally. We are not trying to be lawyers. He are trying to do no harm.

    1. John December 8, 2019

      Dr. Jim just because you did something for 43 years doesn’t mean it is correct. In fact likely if you are doing the same thing for 43 years it would suggest One of two things. 1) it is correct 2) you have never taken any continuing education or have been keeping up with the times.

      Dr. Sheryl is right evidence clearly shows prescribing antibiotics is warranted in a few cases but most certainly not all.

      I suggest you educate yourself prior to writing comments.

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