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Toothache and Antibiotics

Posted on 9th July 2020 by Ridyumna Garain

Evidence Reviews

In this post, Ridyumna provides his own summary of a Cochrane systematic review on the effect of antibiotics on the toothache.


Toothache is a widespread problem arising due to injury or death of the nerve inside a tooth (known as the pulp). This is frequently caused by extensive tooth decay or injury. If left untreated, bacteria from the dead or damaged tooth may spread beyond the root leading to the formation of a dental abscess, swelling, pain, and at times fever. This can occasionally progress to life-threatening infections of the head and neck. (1)


The recommended treatment in these situations is removing the bacteria and the pulp from the tooth to reduce infection. Depending on the status of the tooth, a root canal treatment (which involves removal of the pulp, cleaning the inside of the tooth followed by filling) may be carried out, or it may be extracted.

Antibiotics are recommended only if the infection is severe, has spread to the neighbouring tissues, and systemic symptoms (fever, malaise) are noticed. However, some dentists may prescribe antibiotics to patients with acute conditions who have no signs of spreading infection, at times without dental treatment, to remove the infected material. (2,3)

Unrestricted use of antibiotics can lead to the development of antibiotic resistance. This practice of prescribing antibiotics for common medical problems may increase patient expectations for antibiotics, leading to a vicious cycle of increased prescribing to meet expectations. (4,5)

In 2018, a Cochrane systematic review was carried out to assess the effect of antibiotics on the tooth pain. (6)

Antibiotics and Toothache

The systematic review included parallel-group randomized controlled trials (RCTs) with participants having toothache due to pulpal injury or death. The intervention in consideration was any systemic antibiotic or matched placebo, with or without dental treatment or painkillers.

The review included two trials (7,8), with 62 participants. These trials used oral penicillin V potassium (penicillin VK) and a matched placebo, in conjunction with dental intervention and analgesics. Neither study examined the effect of antibiotics by themselves, without dental treatment. The patients included had no signs of spreading infection or systemic symptoms.

The primary outcome of the studies was participant‐reported pain and swelling. Both studies found no statistically significant differences in the pain or swelling reported by participants after the different interventions. One of the studies had a high risk of bias overall (7), whilst the other had an unclear risk of bias (8), thereby downgrading the quality of evidence

Clinical Implication

There is “currently insufficient evidence to be able to determine the effects of antibiotics in these conditions” (6). Given the very low quality evidence, clinical translation of the results is difficult.


  1. Abbott P V. Classification, diagnosis and clinical manifestations of apical periodontitis. Endod Top [Internet]. 2004 Jul 1 [cited 2020 Jun 12];8(1):36–54. Available from: http://doi.wiley.com/10.1111/j.1601-1546.2004.00098.x
  2. Cope AL, Francis NA, Wood F, Chestnutt IG. Antibiotic prescribing in UK general dental practice: a cross-sectional study. Community Dent Oral Epidemiol [Internet]. 2016 Apr 1 [cited 2020 Jun 12];44(2):145–53. Available from: http://doi.wiley.com/10.1111/cdoe.12199
  3. Dailey YM, Martin M V. Are antibiotics being used appropriately for emergency dental treatment? Br Dent J. 2001 Oct 13;191(7):391–3.
  4. Coenen S, Michiels B, Renard D, Denekens J, Van Royen P. Antibiotic prescribing for acute cough: The effect of perceived patient demand. Br J Gen Pract. 2006 Mar 1;56(524):183–90.
  5. Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: The medicalising effect of prescribing antibiotics. Br Med J. 1997 Aug 9;315(7104):350–2.
  6. Cope AL, Francis N, Wood F, Chestnutt IG. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database Syst Rev. 2018;2018(9).
  7. Fouad AF, Rivera EM, Walton RE. Penicillin as a supplement in resolving the localized acute apical abscess. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 May 1;81(5):590–5.
  8. Henry M, Reader AI, Beck M. Effect of penicillin on postoperative endodontic pain and swelling in symptomatic necrotic teeth. J Endod. 2001 Feb 1;27(2):117–23.


Ridyumna Garain

I am currently pursuing my Post Graduation in the field of Conservative Dentistry and Endodontics in Bangalore, India. I am interested in patient-centric research to better understand their problems and how solve them. View more posts from Ridyumna

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