Antibiotics and toothache

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Recommended first line treatments for teeth with symptomatic apical periodontitis or an acute apical abscess are the removal of the source of inflammation or infection by local, operative measures. This would include tooth extraction or removal of the pulp and possibly incision and drainage or any swelling. Antibiotic use is only recommended where there is evidence of spreading infection or systemic symptoms (fever/malaise).  However, there is evidence to show that dentists prescribe antibiotics to patients with symptomatic apical periodontitis or acute apical abscess in the absence of these signs.

This is an update of a Cochrane review to evaluate the effects of systemic antibiotics provided with or without surgical intervention (such as extraction, incision and drainage of a swelling or endodontic treatment), with or without analgesics, for symptomatic apical periodontitis or acute apical abscess in adults.


Searches were conducted in the Cochrane Oral Health’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, OpenGrey, ZETOC Conference Proceedings, the US National Institutes of Health ongoing Trials Register ( and the World Health Organization International Clinical Trials Registry Platform with no restrictions on the language or date of publication when searching the electronic databases. Randomised controlled trials (RCTs) of systemic antibiotics in adults with a clinical diagnosis of symptomatic apical periodontitis or acute apical abscess, with or without surgical intervention and with or without analgesics were considered.

Two reviewers independently selected studies, extracted data and assessed risk of bias.  The primary outcomes were patient-reported pain and swelling and clinician-reported measures of infection.  Mean differences (MD) or standardised mean differences (SMD) and 95% confidence intervals (CIs) were calculated and fixed-effect meta-analysis conducted.


  • 2 trials involving 62 patients were included.
  • 1 trial was considered to be at high risk of bias the other at unclear risk.
  •  2 studies compared systemic antibiotics (penicillin VK) and placebo for adults with acute apical abscess or a symptomatic necrotic tooth in conjunction with a surgical intervention.
  • There were no statistically significant differences in participant-reported measures of pain or swelling at any of the time points assessed. The body of evidence was assessed as at very low quality.
Pain*  MD (95%CI) Swelling  SMD (95%CI)
24 hrs -0.03 (-0.53 to 0.47) 0.27 (-0.23 to 0.78)
48 hrs  0.32 (-0.22 to 0.86 0.04 (-0.47 to 0.55)
72 hrs  0.08 (-0.38 to 0.54) 0.02 (-0.49 to 0.52)

*(short ordinal numerical scale 0 to 3)

  • No studies compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention.


The authors concluded: –

There is very low-quality evidence that is insufficient to determine the effects of systemic antibiotics on adults with symptomatic apical periodontitis or acute apical abscess.


The review is an update of the earlier version of this Cochrane review published in 2014 (Dental Elf 1st Jul 2014). Unfortunately no new studies have been conducted since the earlier version so there remains very limited quality of the evidence in relation to antibiotic use for adults with symptomatic apical periodontitis or acute apical abscess.  While existing guidelines do not recommend use of antibiotics for these conditions, with the exception of patients with spreading infection or systemic symptoms evidence shows that antibiotics are still being used for these conditions. With increasing concern about antimicrobial resistance, the need for well-designed large scale- adequately powered RCTs to provide better evidence on their use is sorely needed.


Primary Paper

Cope AL, Francis N, Wood F, Chestnutt IG.
Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database of Systematic Reviews 2018, Issue 9. Art. No.: CD010136. DOI: 10.1002/14651858.CD010136.pub3.

Other references

Cochrane Oral Health Group Blog : Toothache caused by inflammation or infection at the root of the tooth: do antibiotics help?




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Derek Richards

Derek Richards is a specialist in dental public health, Director of the Centre for Evidence-Based Dentistry and Specialist Advisor to the Scottish Dental Clinical Effectiveness Programme (SDCEP) Development Team. He is a former editor of the Evidence-Based Dentistry Journal, the chief blogger for the Dental Elf website and a past president of the British Association for the Study of Community Dentistry. He has been involved with a wide range of evidence-based initiatives both nationally and internationally since 1994. Retired from the NHS he is currently a part-time senior lecturer at Dundee Dental School.

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