Dental antibiotics – When to use what

Dental antibiotics – When to use what

Dental antibiotics vary from procedure to procedure and from dentist to dentist.

Cephalosporins don’t offer any advantage over penicillin V unless the patient is in the hospital. Cephalosporins are effective against S aureus, an organism responsible for many secondary infections that patients acquire in hospitals. For penicillin-allergic patients, the antibiotic of choice is clindamycin. If allergic to both then see below.  Macrolides, such as erythromycin and azithromycin, have no place in the treatment of odontogenic infections and have the potential to cause significant harm. Tetracyclines, although effective for the treatment of some periodontal infections, are not indicated in the treatment of patients with infections of odontogenic origin.

If the source of the infection has been removed and the patient fails to respond favorably after two to three days of penicillin V or clindamycin therapy, it is necessary to add metronidazole. Metronidazole is highly effective against anaerobic bacteria but inactive against obligate aerobes, thus it is a good antibiotic for sinus graft infections. Therefore, it is not appropriate as a first line of defense or replacement antibiotic for infections of odontogenic origin, but is very effective in combination with the primary antibiotic of choice.

The recommended dosage for dental antibiotics are as follows:

  • Penicillin V: 1000mg loading and then 500mg QID 3-7 days. This is our first line of defense.
  • Amoxicillin: 1000mg loading and then 500mg TID for 3-7 days.
  • Clindamycin: 600mg loading dose and then 300mg TID or QID for 3-7 days. This is no longer the first line if allergic to pen VK.
  • Cefuroxine: 250-500mg BID for 7-10 days. This is go to for bone grafting if patient has Pen allergy according to Misch. 1 gram loading dose pre-op for penicillin allergy. There is debate on the amount of cross antibiotic reactions that exist.
  • Cephalexin: 1000mg loading and then 250-500mg QID 3-7 days.
  • Metronidazole: 1000mg loading dose and then 500mg TID for 5-7 days. This is adjunct to pen VK or clindamycin if no improvement after 2-3 days, both will be taken then.

What to do when a patient is allergic to both penicillin and clindamycin? As of 2021 clindamycin is no longer number 1 for penicillin allergy.

When patient is allergic to both penicillin and clindamycin then probably best to have them ask MD.  Dentaltown thread on this.  Great study on allergy to antibiotics.

  • Azithromycin Z-Pack 3 or 5 day pack (This is now number 2 after amoxicillin for endodontic infection according to AAE guideline below). Loading dose for surgery or pre-med is 500-1000mg.
  • Clarithromycin 500mg loading dose and then 250mg q 12hr 7-14 day
  • Erythromycin 500 mg (2 tabs for premed) 250-500mg q6-12hr 7 day. AAE states this should be thought of as historical antibiotic and is not useful for odontogenic infections. Fall 2019 update.

Penicillin allergy chart = very useful!

Should patients take the full does of antibiotics?

The dosage and time lines are arbitrary and best guesses more than anything that comes from solid research. Add in the fact that every infection and individual is different and that the bacteria is mutating means IMHO the guidelines are not terribly useful. The AAE put out a very nice dental antibiotics myths. I especially like the following two myths,

  • Myth #7: Antibiotic dosages, dosing intervals and duration of therapy are established for most infections.
  • Myth #8: Bacterial infections require a “complete course” of antibiotic therapy.

Another article from Discover Oct 2014 issue that lists plenty of research showing that it is likely NOT the best advice to take all antibiotics.

When should a patient take an antibiotic for a root canal?

Patients should not be given antibiotics for a root canal treatment unless there are signs of systemic infection, which are fever, malaise, cellulitis and/or lymphadenopathy. Pen VK and amoxicillin are fist line defense for endodontics, although amoxicillin is preferable. Dosage for amoxicillin is same as above for just 2-3 days. If this does not improve symptoms after the root canal then go to Augmentin (125mg clavulanic acid per dose). If penicillin allergy then clindamycin.

What if a patient is already taking an antibiotic and requires a prophylactic antibiotic?

“Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the recommendations for infective endocarditis recommend that the dentist select an antibiotic from a different class than the one the patient is already taking. For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin or clarithromycin for prophylaxis.”   From this post on antibiotic prophylaxis recommendations.

Issues with dental antibiotic resistance and overuse

We need to ensure we are not over-prescribing antibiotics. There are at least 2 million antibiotic resistant infections in the US a year and 23,000 deaths. JOE Spet 2017 AAE Guidance

C. difficile

Without question we are causing some of these Clostridium difficile infections from the overuse of antibiotics. The antibiotic most commonly to get blamed for this is Clindamycin, but amoxicillin and cephalosporins are responsible as well. Nearly 500,000 C. difficile infections occur a year n the US and 29,000 people die from it. Anyone taking Clindamycin needs to stop if they have diarrhea with fever, abdominal pain, or mucus or blood in the stool.

Antibiotic use for bacteremia and antibiotic use for dental implants.

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28 Responses to “Dental antibiotics – When to use what”

  1. October 1, 2017 at 1:16 am #

    What is a patient is allergic to both Amoxicillin and Clindamycin?

    • October 2, 2017 at 4:29 am #

      Amoxicillin and penicillin are equal in terms of allergy so you can refer to the paragraph that starts>

      What to do when a patient is allergic to both penicillin and clindamycin

  2. January 17, 2018 at 11:03 pm #

    What to do if the pt is fnishing a 5 day course of Metronidazol 400mg/there times a day on the day of the xla? Is he still need Amoxicillin 1 h prior to the xla? TIA

    • January 18, 2018 at 8:28 am #

      Yes. Patients are supposed to mix up their antibiotics for treatment. “Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the recommendations for infective endocarditis recommend that the dentist select an antibiotic from a different class than the one the patient is already taking. For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin or clarithromycin for prophylaxis.”

  3. January 25, 2018 at 12:29 am #

    I am a healthy 44 yr old female. I had #3 extracted after failed retreated root canal. It had a visible abscess with no pain on Jan 3rd. Before the extraction I was in 7 days of Amoxicillian. Tooth extracted, bone graft and membrane placed. He put me on ibuprofen 800mg. had awful taste and bleeding, it abscessesed within a few days. On Jan 10th, they removed bone graft, cleaned and scraped the area extensively. He replaced bone graft and membrane and put me on Clindamycin for 10 days. Within 2 days the membrane fell out and bad taste and bleeding continued. On Jan 15th they put me on Levafloxcian for 7 days. By Jan 19th I sought help from an Oral Surgeon that took CT and found a hole in the sinus area. He did surgery to repair the next day. He mentioned the hole was very obvious and that my home was very white(more than he had ever seeen), the smell and taste are gone. No more bleeding. Within 3 days on Levafloxcin I started having tingling, burning skin, very sore muscles and joints. I can hardly move around. The oral surgeon told me to stop the Leva and called in Amoxocillian for 5 days. Told me to go to my PCP for the reaction. She has me seeing an Orthopedic doctor to check for damage from the Leva. I went for post-op 5 days later said the surgical site was looking good but was concerned about area in roof of my mouth. Wants to look at in one week and possibly send me to infectious specialist! I’m very scared now!

    • January 27, 2018 at 4:47 am #

      Sounds like you had a bad infection but are over the worst of it now. Follow up with PCP like they said.

  4. February 1, 2018 at 4:45 pm #

    I had 2 root canals done and had a tremendous flare up that caused a canine space soft tissue infection. The lacrimal duct between my eye and nose also swelled up/ the exudate was just clear and gooey. I could barely see out of my eye! After a week on clindamycin, I went off and it swelled up again within 24 hours. I was given another course of same clindamycin and worry that when I take last pill tonight the infection will return. What is the best protocol for a stubborn canine space infection related to flare-ups?

    • February 1, 2018 at 9:19 pm #

      Are you on any medications that inhibit your immune system? Things for autoimmune diseases all do so RA and Sjogrens are two examples. Those make it nearly impossible to get rid of infection. If so you want a drug holiday if MD says ok. For meds you need to follow up with your dentist or MD as what to use next. Too many variables.

  5. February 21, 2018 at 11:12 am #

    Hi, I was prescribed Clindamycin cause i’m allergic to Penicllin to treat a wisdom tooth infection before extraction. the antibiotic made me very sick since i have ibs and possibly celiac disease. it took away the tooth infection but i think i may have another one again on the lower left wisdom tooth and have appointment today for surgery to have the two pulled out. not sure if i do have an infection again, could be soreness from brushing and flossing. but since i had to stop the clindamycin when i had massive chronic diarreha to the point of sending me to the ER cause of dehydration, is why i suspect i got it back. i will NEVER trust an antibiotic ever again!!! if in case they see the infection came back, they may prescribe another antibiotic, the truth is i cant stand to be on any of them!!! it will trigger dehydration that will send me to the hospital again. please help me in advising what can i take as an alternative to heal a bacterial infection? even if i am fine, and they can proceed with surgery, i would like to know for the near future what can be taken in place of antibiotics in case i get a bacterial infection in the near future. i can NOT ever be like this again. My life is too precious to let these doctors destroy my life with these antibiotics. i was tested for C. difficile and came out negative, but it felt like it was a serious and still is somewhat a type of colitis i have never dealt with before. I am also looking for other alternatives for a colonoscopy since the bowel prep is very much like the dehydration cycle i just went through, which was HELL! i’ve looked online for days to try and find an alternative, but all i see is to take another antibiotic! what the f***!

    • February 22, 2018 at 6:23 am #

      Most infected teeth don’t need an antibiotic they just need to be removed. Antibiotics probably help in most cases and are needed some times but getting the tooth out is the number one goal. Get the tooth out.

  6. Cindy KappsMarch 2, 2018 at 11:49 am #

    I became ill after amoxicillin for a “possible abcess”….developed c diff….recovered well with metronazidole… my tooth is flaring again…..what are dentists best options….so I don’t go thru this again.

    • March 2, 2018 at 8:47 pm #

      Treat the source of the infection. Root canal or extraction. I try not to give people antibiotics unless really necessary for the exact reason that you stated, c diff is no joke.

  7. June 1, 2018 at 9:40 pm #

    Hello. Looking for some advice got my wisdom tooth out on the left hand side. Wasn’t a straight forward extraction. This was two weeks ago now still in a lot of pain. Went for an emergency appointment at the dentist as the pain was keeping me awake. Turns out I’ve got an infection in it. Anyway I was given amoxacillin the first week. Didn’t do anything. Then put on metronidazole which hasn’t helped. Had to go back to today as the pain is doing my head in. Got erythromycin this time.. Any other ideas would be great to deal with the pain. Thanks for reading

    • June 4, 2018 at 8:30 pm #

      Probably not infection but dry socket. Did you have a dentist look at it? Start there not the ER room.

  8. July 8, 2018 at 6:51 pm #

    Hello. Had bad tooth infection that started on a Saturday. Went in to the dentist on a Monday and had a root canal done and left with amoxicillin 500mg 3x a day. Well by Thursday morning swelling in my jaw and face was worse and extremely painful and I was barely able to control the pain. They switched me to clindamycin 300mg 3xday for 10 days. this past Thursday and the swelling began to go down around the 24 hour mark on Friday. However each dose I take I break out in hives. It keeps increasing as I take another pill. I took two doses yesterday and just one today. There is still minor swelling in my jaw and gum area under the tooth but not nearly to the extent it was. Should I switch back to the amoxicillin or try a different antibiotic? I don’t want the infection to come back but don’t want this reaction of hives to continue.

    • July 14, 2018 at 4:46 pm #

      Follow up with dentist. They may need to see you.

  9. August 28, 2018 at 5:51 pm #

    Which is better for a abscess tooth cephalexin or clindamycin

    • August 28, 2018 at 6:01 pm #

      An extraction or root canal is needed and antibiotics should only be used if patient has swelling. A draining abscess antibiotics will do nothing for. Pen Vk or clinda is what I would use

  10. September 12, 2018 at 1:53 am #

    I had to have #30 retreated after 1st root canal was done 13 years ago. Endo prescribed Amoxicillin. I had a reaction within 30 minutes of taking 1 pill, 500mg. He is now prescribing Clindamycin which I am reluctant to start. I haven’t had a need to take antibiotics in 30 years.

    He said while the infection was treated thru the 2nd root canal (2nd and final visit next week) that the bone is infected and antibiotics will help heal the bone.

    I feel like I need to get a 2nd opinion on this advice. What questions should I be asking about the bone infection. I feel like if the infection was removed then the surrounding bone should heal over time.

    • September 14, 2018 at 3:13 pm #

      There is no guarantee that an infection will ever heal. The antibiotic pushes the odds in your favor.

  11. December 6, 2018 at 4:09 pm #

    On 11/21 My back molar which had a root canal 2 years ago started throbbing. Dentist put me on Amox 500 4xday for 5 days. It eased it but didn’t go away. On 11/27 oral surgeon extracted it but did not continue Amox. On 11/30 the swelling increased. I called my dentist she prescribed the Amox again for 3 days. It did nothing. I saw the oral surgeon on 12/3 he prescribed clindamycin 300 3x day. It is now day 3 and there is no change. I called he said to just continue taking it. Do you think it will actually work if it hasn’t yet? I’m very nervous any help will be appreciated.

    • December 10, 2018 at 5:15 pm #

      Antibiotics don’t work that fast. My guess is you are fine now.

      • December 10, 2018 at 6:23 pm #

        As of today I still have some swelling, redness and slight pain. I just finished the clindamycin. I have a follow up with the oral surgeon this afternoon. I’m still very concerned since it hasn’t healed yet. I’m not sure what he will do. I feel like the clindamycin wasn’t strong enough to get rid of it. Could there be anything left in there causing this? I know you haven’t seen it but do you have any ideas? Thanks

        • December 11, 2018 at 2:37 pm #

          Sounds like pretty classic dry socket. If that is the case then the clida really did nothing. Time is what you need and if it’s getting better day to day then you’re fine.

  12. December 13, 2018 at 7:32 am #

    Hello, I’m allergic to Amox and have an impacted and infected wisdom tooth. I was prescribed clindamycin but am now having a reaction to that. What do you suggest I take now?

    • December 13, 2018 at 8:31 pm #

      I would get the wisdom tooth out asap then. Some infections need surgical intervention and the sooner the better off for all involved. The 3 choices listed above are the next choices but asking your MD would be good idea and you may want to know if you are allergic to the antibiotics or are just having a side effect.

  13. December 14, 2018 at 11:33 pm #

    I need some advice. Twenty years or so ago, I had a root canal in #3 so I have a crown there. Recently the crown became loose and, after x-rays, was told the tooth was cracked underneath and must be removed [there seems to be a bit of drainage also when the crown is pushed]. I’m scheduled next week for oral surgery to remove #3 [I’ve decided on an implant] . I was told to begin taking amoxicillin the day before surgery [for a total of 7 days]. Thirty years ago I had pneumonia and took penicillin and it was fine, but it’s been 20+ years since I’ve taken antibiotics and I’m very afraid of stomach [or other] negative reactions. I’m 63 and was recently found to have hematuria [unbeknownst to me] in a urine test. Also, for post-oral surgery pain they say to take acetaminophin/tylenol extra strength. I don’t know if the Tylenol will exacerbate the hematuria [I won’t be followed up for that until early January – CT and another test], AND VERY afraid of what I’ve read about amoxicillin causing or worsening hematuria. Can I take erythromicin instead? I hate to take prescriptions, but need to have this tooth removed. Another worry is the sinus cavity is low around #3 and I don’t want a hole remaining – why isn’t a sinus lift done right after the extraction? I was told it wouldn’t be done until the time when the implant is put in place. So many questions, so much apprehension.

    • December 19, 2018 at 11:51 pm #

      Need to bring your concerns up with your doctor.

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