Evidence-based Comparisons of Antibiotics in Common Clinical Dilemmas While Treating Acute Dental Pain and/or Intraoral Swelling

Selection of a proper antibiotic for individual clinical situations is critical to ensure adequate treatment of existing infections. While approximately 10% of the population self-reports a penicillin allergy, it is estimated that less than 1% of the population demonstrates a true penicillin allergy.^39,40 However, in patients with a true penicillin allergy (e.g., history of anaphylaxis, angioedema, or hives), it is suggested that oral azithromycin be prescribed in cases where antibiotics are warranted and cephalosporin drugs should be avoided due to cross-reactivity.⁷ Recent reports have removed oral clindamycin as a recommendation for penicillin-allergic patients due to the incidence of post-operative adverse reactions, including Clostridioides difficile infection (CDI). ^41-43 It is also recommended that if initial therapy with first-line antibiotics is not effective, clinicians should consider adding complementary treatment with metronidazole or discontinuing first-line antibiotic therapy and prescribing oral amoxicillin with clavulanate to enhance the efficacy against gram negative anaerobic bacteria.⁷

Duration of antibiotic course should also be carefully considered and personalized to patient symptoms and response. There is little to no evidence suggesting that in the case of symptomatic oral infections, a shortened course of antibiotics contributes to antimicrobial resistance.^42,43 As such, it is suggested that dental healthcare providers reevaluate patients who present with pulpal and periapical-related dental pain and/or intraoral swelling and who receive antibiotic therapy after three days to assess the current level of systemic signs and symptoms. If symptoms have begun to resolve, the ADA expert panel suggests that patients are instructed to discontinue antibiotics 24 hours after complete resolution of symptoms.⁷

Figure 3. Common Antibiotic Agents and their Targets.⁹⁷

Figure 3. Common Antibiotic Agents and their Targets.⁹⁷