Antibiotic Recommendations for Endodontic Infections

Primary treatment objectives to manage an endodontic infection are:

Adequate debridement of the infected root canal
Achieving drainage for the soft and hard tissues with an “Incise and Drain” procedure.

Antibiotics are considered adjunctive therapy to help manage infections and are indicated only under certain circumstances:

When there is systemic or regional involvement indicated by fever, malaise, cellulitis and/or lymphadenopathy.
When the infection is spreading or worsening after the two primary treatment objectives have been achieved.
When the two primary treatment objectives cannot be rendered.

Under what conditions are antibiotics NOT indicated?

To manage symptoms in vital cases, i.e. symptomatic irreversible pulpitis
To manage symptoms in necrotic cases after the two primary treatment objectives have been achieved and there is no systemic involvement.

Non-Penicillin Allergic patient

Penicillin allergic patient

First choice

Amoxicillin, 1000 mg loading dose and then 500 mg TID for 5-7 days

Clindamycin, 600mg loading dose and then 300mg q6h for 5-7 days

If no symptom improvement after

48 hours

Add Metronidazole, 500 mg q6 h for 7 days

Switch to Azithromycin 500 mg/day, 250 mg days 2-5

Important things to remember:

Always review the medical history to check if the patient has any allergy, is immunocompromised, has poorly controlled diabetes, has any metabolic dysfunction or a history of C. difficile that might affect drug choice, dosage, or scheduling
Re-assess a patient’s status and response to antibiotic therapy 48 hours after initiation and consider switching the drug or adding to a regimen if there is 1) no improvement or worsening or 2) significant GI upset
C. difficile infection can evolve into pseudomembranous colitis, a potentially life-threatening condition. Signs and symptoms include diarrhea with fever, abdominal pain, and mucous and blood in stool. Refer patient to primary care physician.
Use a loading dose for the fastest onset and relief
Keep the duration as short as is effective (usually no longer than 7 days)
Prescribing Amoxicillin 500mg TID is more effective than 875 BID
Hypersensitivities or allergies can develop at any time