ADULT
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ORAL/DENTAL INFECTIONS
1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS
1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS
1.1 Infections of the Teeth and Supporting Structures
1.1.1 Reversible/ Irreversible Pulpitis
Symptomatic treatment. Antibiotic use is not recommended.
1.1.2 Localised Dentoalveolar Abscess / Apical / Periapical / Periodontal abscess
Preferred
Superficial:
Systemic antibiotic use not recommended (immunocompetent).
Deep Infection / Immunocompromised patient:
Amoxicillin 500mg PO q8h
MAY ADD
Metronidazole 400mg PO q8h
Alternative
Deep Infection / Immunocompromised patient:
Amoxicillin/clavulanate 625mg PO q8h
Antibiotic allergy:
Clindamycin 300mg PO q6h for 7 days
Comments
The definitive treatment involves aggressive surgical intervention for source control, which includes drainage of the abscess with or without tooth extraction. If the procedure is successful, a minimum duration of 3 days of antibiotic therapy should be administered.
Duration: 3 – 7 days
Refer to Appendix 3 for antibiotic allergy.
1.1.3 Dry Socket
Systemic antibiotic use is not recommended. Local treatment with saline irrigation and antiseptic/ analgesic dressings and symptomatic relief of pain.
1.1.4 Localised Pericoronitis
Preferred
Systemic antibiotic use is not recommended in the absence of regional or systemic signs and symptoms.
Once systemic spread of infection is suspected:
Amoxicillin 500mg PO q8h
MAY ADD
Metronidazole 400mg PO q8h
Alternative
--
Comments
Local treatment with antiseptic irrigation and mouthwash and symptomatic relief of pain.
Duration: 5 days
1.1.5 Chronic Gingivitis
Systemic antibiotic use is not recommended.
First line treatment:
Mechanical and chemical plaque control.
0.2% Aqueous Chlorhexidine Gluconate is not used alone but as an adjunct to mechanical debridement.
Second line treatment:
Antimicrobial mouth rinse
1.1.6 Chronic Periodontitis
Antibiotic use can be considered in cases of:
1. Unresponsive to conventional mechanical therapy.
2. Acute infection associated with systemic manifestation.
3. Immunocompromised.
4. Generalized periodontitis stage III in young adults.
Preferred
Systemic antibiotic use is generally not recommended.
Amoxicillin 500mg PO q8h
PLUS
Metronidazole 400mg PO q8h
OR
Amoxicillin/clavulanate 625mg PO q8h
Alternative
Antibiotic allergy:
Clindamycin 300mg PO q6h
Comments
First line treatment:
Mechanical plaque control
Duration: 3-7 days
Refer to Appendix 3 for antibiotic allergy.
1.1.7 Aggressive Periodontitis
Common organisms:
Aggregatibacter actinomycetemcomitans
Porphyromonas gingivalis
Tannerella forsythia
Prevotella intermedia
Treponema denticola
Preferred
Amoxicillin 500mg PO q8h
PLUS
Metronidazole 400mg PO q8h
Alternative
Antibiotic allergy:
Clindamycin 300mg PO q6h
OR
Azithromycin 500mg PO q24h for 3 days
Comments
Duration: 7 days
Antibiotics are used as an adjunct to scaling and root debridement.
Refer to Appendix 3 for antibiotic allergy.
1.2 Infections of the Jaws
1.2.1 Osteomyelitis of the jaws of dental origin
Different organisms may be involved
Preferred
For acute cases, start with:
Amoxicillin 500mg PO q8h
PLUS
Metronidazole 400mg PO q8h
OR
Amoxicillin/clavulanate 625mg PO q8h
Alternative
Antibiotic allergy:
Clindamycin 300-450mg PO q6h or 600-900mg IV q8h
Comments
Culture and sensitivity are necessary to guide the antibiotic.
For chronic cases, start with surgical treatment first. Start antibiotics only when causative organisms are identified.
Duration of antibiotic therapy:
4-6 weeks depending on patient response / microbiological clearance of the pathogen.
Refer to Appendix 3 for antibiotic allergy.
1.3 Spreading Infections and Infections of Fascial Spaces (with/without Systemic Signs)
1.3.1 Cellulitis ± Abscess of Dental Origin
Common organisms (polymicrobial including):
Prevotella
Peptostreptococcus
Fusobacterium nucleatum
Viridans Streptococci
Streptococcus anginosus group
Clostridium sp
Surgical site infection:
Infection is usually by endogenous organisms rather than exogenous
Common organisms:
Viridans Streptococci
Staphylococci
Prevotella intermedia
Peptostreptococcus
Eubacterium
Fusobacterium nucleatum
Preferred
Benzylpenicillin 2-4MU IV q4-6h
PLUS
Metronidazole 500mg IV q8h
OR
Amoxicillin/Clavulanate 1.2g IV q8h
OR
Cefuroxime 1.5g IV q8h
PLUS
Metronidazole 500mg IV q8h
Alternative
Antibiotic allergy:
Clindamycin 300-450mg PO q6h or 600-900mg IV q8h
Comments
Incision and drainage are advised and change antibiotics in accordance with the result of culture and sensitivity.
Continue IV therapy for 1 to 2 days following successful abscess drainage, then switch to oral therapy.
Refer to Appendix 6 for IV to PO switch.
Refer to Appendix 3 for antibiotic allergy.
1.3.2 Traumatic Wound Infection
Infection is usually by endogenous organisms rather than exogenous
Refer to section Trauma-related Infections – Dental Infections.
1.4 Post Implant Infections (Peri Implantitis)
Heterogeneous mixed infection:
Actinomyces sp.
Eubacterium sp.
Propionibacterium sp.
Lactobacillus sp.
Veillonella sp.
Porphyromonas gingivalis
Prevotella intermedia
Fusobacterium nucleatum
Preferred
Systemic antibiotics are generally not recommended unless in severe cases.
Severe cases (e.g. deep pockets ≥7 mm, extensive suppuration):
Amoxicillin/clavulanate 625mg PO q8h
OR
Amoxicillin 500mg PO q8h
PLUS
Metronidazole 400mg PO q8h
Alternative
Antibiotic allergy:
Doxycycline 100mg PO q12h
OR
Clindamycin 300mg PO q6h
Comments
Refer to Appendix 3 for antibiotic allergy.
2. ANTIMICROBIAL USE FOR FUNGAL INFECTIONS
2. ANTIMICROBIAL USE FOR FUNGAL INFECTIONS
2.1 ORAL CANDIDIASIS
Refer to section Infections in Immunocompromised Patients - Opportunistic Infections (OI) in Patients with HIV.
3. ANTIMICROBIAL USE FOR VIRAL INFECTIONS
3. ANTIMICROBIAL USE FOR VIRAL INFECTIONS
Common oral viral infections:
Herpes simplex virus type 1 (HSV-1)
Primary herpetic gingivostomatitis
Herpes labialis
Herpes simplex virus type 2 (HSV-2)
Symptomatic treatment in most cases.
Refer to section Sexually Transmitted Infections - Genital Herpes.
References:
Lockhart, P. B., et al (2019). Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. Journal of the American Dental Association (1939), 150(11), 906–921.e12. https://doi.org/10.1016/j.adaj.2019.08.020
Schmidt, J., Kunderova, M., Pilbauerova, N., & Kapitan, M. (2021). A Review of Evidence-Based Recommendations for Pericoronitis Management and a Systematic Review of Antibiotic Prescribing for Pericoronitis among Dentists: Inappropriate Pericoronitis Treatment Is a Critical Factor of Antibiotic Overuse in Dentistry. International journal of environmental research and public health, 18(13), 6796. https://doi.org/10.3390/ijerph18136796
Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Beglundh, T., Sculean, A., Tonetti, M. S., & EFP Workshop Participants and Methodological Consultants (2020). Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. Journal of clinical periodontology, 47 Suppl 22(Suppl 22), 4–60. https://doi.org/10.1111/jcpe.13290
Teughels, W., Feres, M., Oud, V., Martín, C., Matesanz, P., & Herrera, D. (2020). Adjunctive effect of systemic antimicrobials in periodontitis therapy: A systematic review and meta-analysis. Journal of clinical periodontology, 47 Suppl 22, 257–281. https://doi.org/10.1111/jcpe.13264
Teughels, W., Dhondt, R., Dekeyser, C., & Quirynen, M. (2014). Treatment of aggressive periodontitis. Periodontology 2000, 65(1), 107–133. https://doi.org/10.1111/prd.12020
Bridwell, R., Gottlieb, M., Koyfman, A., & Long, B. (2021). Diagnosis and management of Ludwig's angina: An evidence-based review. The American journal of emergency medicine, 41, 1–5. https://doi.org/10.1016/j.ajem.2020.12.030
Shweta, & Prakash, S. K. (2013). Dental abscess: A microbiological review. Dental research journal, 10(5), 585–591.
Herrera, D., Berglundh, T., Schwarz, F., Chapple, I., Jepsen, S., Sculean, A., Kebschull, M., Papapanou, P. N., Tonetti, M. S., Sanz, M., & EFP workshop participants and methodological consultant (2023). Prevention and treatment of peri-implant diseases-The EFP S3 level clinical practice guideline. Journal of clinical periodontology, 50 Suppl 26, 4–76. https://doi.org/10.1111/jcpe.13823
Lafaurie, G. I., Sabogal, M. A., Castillo, D. M., Rincón, M. V., Gómez, L. A., Lesmes, Y. A., & Chambrone, L. (2017). Microbiome and Microbial Biofilm Profiles of Peri-Implantitis: A Systematic Review. Journal of Periodontology, 88(10), 1066–1089. https://doi.org/10.1902/jop.2017.170123
Herrera, D. Jan Van Winkelhoff, A. , Matesanz, P. , Lauwens, K. , Teughels, W. Europe;s contribution to the evaluation of the use of systemic antimicrobials in the treatment of periodontitis. Periodontology 2000. 2023; 00:1-28. https://doi: 10.1111/prd.12492
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