Currently insufficient evidence to decide if antibiotics are effective in treating irreversible pulpitis


Irreversible pulpitis often presents as an acute and intense pain and is a frequent reason for emergency dental visits.  Treatment involves accessing the root canal of the tooth to remove the inflamed pulp (nerve) and cleaning the root canal. The aim of this review was to assess the effects of systemic antibiotics for irreversible pulpitis.

The usual Cochrane approaches were taken with Searches being conducted in the Cochrane Oral Health Group’s Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Medline; Embase and the US National Institutes of Health Trials Register  with no language restrictions.  Randomised controlled trials (RCTs) that compared pain relief with systemic antibiotics and analgesics, against placebo and analgesics in the acute preoperative phase of irreversible pulpitis were included.

  • Only one trial involving 40 patients and assessed as at low risk of bias was included.
  • 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 in the penicillin group versus the placebo group;
  • This applied equally for the mean total number of Tylenol tablets
  • Reporting of adverse events was not addressed in this study.

The authors concluded

This systematic review, which was based on one low powered small sample trial assessed as a 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.


In Scotland dental prescribing accounts for around 10% of all prescribing and while not all of this relates to antibiotics increasing concerns over antibiotic resistance highlight the need for dentists prescribe responsibly. Recent guidance from the Scottish Dental Clinical Effectiveness Programme (SDCEP) on the Management of Acute Dental Problems recommended optimal analgesia and endodontic treatment rather than antibiotics based in part on the earlier version of this review.


Fedorowicz Z, van Zuuren EJ, Farman AG, Agnihotry A, Al-Langawi JH. Antibiotic use for irreversible pulpitis. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD004969. DOI: 10.1002/14651858.CD004969.pub3.

SDCEP  – Management of Acute Dental Problems


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