Little evidence for antibiotic use in irreversible pulpitis

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Irreversible pulpitis typically presents with acute and intense pain. Commonly this occurs in vital teeth beneath deep caries, the tooth normally having an extensive restoration, or caries or both. Immediate pulpectomy is considered to be the treatment of choice although antibiotics continue to be prescribed.

The aim of this Cochrane review update is to assess the effects systemic antibiotics for irreversible pulpitis.


Searches were conducted in the Cochrane Oral Health Group’s Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, and the WHO International Clinical Trials Registry Platform with no language restrictions.Randomised controlled trials (RCTs) which compared pain relief with systemic antibiotics and analgesics, against placebo and analgesics in the acute preoperative phase of irreversible pulpitis were considered. The main outcome was patient-reported pain (intensity/duration) and pain relief measured on a categorical scale in the preoperative phase of irreversible pulpitis. With type, dose and frequency of medication required and adverse effects as secondary outcomes. Two reviewers independently selected studies abstracted data and assessed risk of bias. Pooling of data was not possible so a descriptive summary was presented.


  • Only one trial assessed at low risk of bias and involving 40 patients was included
  •  The quality of the body of evidence was rated low for the different outcomes.
  • There was a close parallel distribution of the pain ratings in both the intervention and placebo groups over the seven-day study period.
  • There was insufficient evidence to claim or refute a benefit for penicillin for pain intensity.
  • There was no significant difference in the mean total number of ibuprofen tablets over the study period: 9.2 (standard deviation (SD) 6.02) in the penicillin group versus 9.6 (SD 6.34) in the placebo group; mean difference -0.40 (95% confidence interval (CI) -4.23 to 3.43; P value = 0.84).
  • This applied equally for the mean total number of Tylenol tablets: 6.9 (SD 6.87) used in the penicillin group versus 4.45 (SD 4.82) in the placebo group; mean difference 2.45 (95% CI -1.23 to 6.13; P value = 0.19).
  • Adverse events were not reported.


The authors concluded

This systematic review which was based on one low powered small sample trial assessed as at low risk of bias, illustrates that there is insufficient evidence to determine whether antibiotics reduce pain or not compared to not having antibiotics. The results of this review confirm the necessity for further larger sample and methodologically sound trials that can provide additional evidence as to whether antibiotics, prescribed in the preoperative phase, can affect treatment outcomes for irreversible pulpitis.


No new trials have been published since this Cochrane review was last updated in 2013 so the reviews conclusions are unchanged. The authors also highlight one new systematic review published by Aminoshariae & Kulild in 2015. That review which was registered on the PROPSERO database had broader inclusions criteria that the Cochrane review and concluded: –

The best available clinical evidence signals no indications for prescribing antibiotics preoperatively or postoperatively to prevent endodontic infection or pain unless the spread of infection is systemic, the patient is febrile, or both. Generally, an accurate diagnosis coupled with effective endodontic treatment will decrease microbial flora enough for healing to occur.


Primary paper

Agnihotry A, Fedorowicz Z, van Zuuren EJ, Farman AG, Al-Langawi JH. Antibiotic use for irreversible pulpitis. Cochrane Database of Systematic Reviews 2016, Issue 2. Art. No.: CD004969. DOI: 10.1002/14651858.CD004969.pub4.

Other references

Cochrane Oral Health Group – antibiotics for severe toothache.

Dental Elf – 20th Jan 2014 – Currently insufficient evidence to decide if antibiotics are effective in treating irreversible pulpitis

Aminoshariae A, Kulild JC. Evidence-based recommendations for antibiotic usage to treat endodontic infections and pain: A systematic review of randomized controlled trials. J Am Dent Assoc. 2015 Dec 24. pii: S0002-8177(15)01097-1. doi: 10.1016/j.adaj.2015.11.002. [Epub ahead of print] Review. PubMed PMID: 26724957.

Aminoshariae review protocol

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