The recommended treatment for apical periodontitis or acute apical abscess is removal of the source of inflammation or infection by local, operative measures ie tooth extraction or pulp extirpation possibly in combination with the incision and drainage of any swelling present. Antibiotics are only recommended where there is evidence of spreading infection or systemic symptoms. The aim of this Cochrane review was 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 following databases without restrictions on language or date:- Cochrane Oral Health Group’s Trials Register Cochrane Central Register of Controlled Trials Medline, Embase, CINAHL , World Health Organization (WHO) International Trials Registry Platform and the US National Institutes of Health Trials Registry (ClinicalTrials.gov), OpenGrey and ZETOC Conference Proceedings. Randomised controlled trials of systemic antibiotics in adults with a clinical diagnosis of symptomatic apical periodontitis or acute apical abscess, with or without surgical intervention (considered in this situation to be extraction, incision and drainage or endodontic treatment) and with or without analgesics were considered. Primary outcomes were patient reported pain and swelling and clinician reported measures of infection,( temperature, swelling , trismus, cellulitis). Standard Cochrane approaches were taken for data collection and analysis.
- Only 2 trials (62 patients) were included, 1 was at high risk and 1 at uncertain risk of bias.
- Both trials were conducted in a university setting and compared oral penicillin V potassium (penicillin VK) versus a matched placebo given in conjunction with a surgical intervention (total or partial pulpectomy) and analgesics to adults with acute apical abscess or symptomatic necrotic tooth (no signs of spreading infection or systemic involvement (fever, malaise)).
- For systemic antibiotics versus placebo with surgical intervention and analgesic.
- There were no statistically significant differences in participant-reported measures of pain or swelling at any of the time points assessed within the review.
- For systemic antibiotics without surgical intervention
- No studies that compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.
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.
In their introduction the authors highlight that one UK study found that, ‘69% of individuals attending a British out-of-hours dental clinic with symptomatic apical periodontitis received a prescription for systemic antibiotics, many in the absence of a surgical intervention’ As apical periodontitis and acute apical abscess are common problems it is perhaps surprising that little or no high quality studies have been conducted in this area. As the authors report around 10% of antibiotics in developed countries is prescribed by dentists and with rising concern over the increase in antibiotic resistance it is important that the relevance of dental prescribing is not overlooked and that prescribing is limited to situations where it is shown to be effective. Recent guidance on the management of acute dental problems including apical periodontitis and acute apical abscess is available from Scottish Dental Clinical Effectiveness Programme (SDCEP).
Cope A, Francis N, Wood F, Mann MK, Chestnutt IG. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD010136. DOI: 10.1002/14651858.CD010136.pub2.