Bacterial infections

Antibiotic treatment can encourage the development of drug resistance and therefore antibiotics must only be prescribed when there is a clear need, when there is no other treatment option and when there is evidence that they may be beneficial for the patient.⁶

The emergence and spread of antibiotic resistance is a global concern and is a major threat to public health.⁷ The indiscriminate use of antimicrobials in primary care, including dentistry, has been identified as one of the drivers of antibiotic resistance. Prior to 2020, antimicrobial prescribing in primary care dental practice in Scotland showed a downward trend. During the Covid-19 pandemic, dental antibiotic prescribing increased by over 20% and has not yet returned to pre-pandemic levels.^8,9 In 2024 dental prescriptions accounted for 7.7% of all oral antibacterials dispensed in NHS primary care in Scotland.⁹ Prudent, appropriate use of antibacterials will slow the emergence of bacterial resistance and will preserve the usefulness of existing drugs for future generations.*

The use of broad-spectrum antibiotics has also been associated with the rise in Clostridioides difficile- associated disease observed in both primary and secondary care. Care should therefore be taken when prescribing these antibiotics to vulnerable groups, such as the elderly and those with underlying comorbidities, frailty or immunosuppression. In addition, prescribe with caution in patients with a history of prolonged or repeated courses of antibiotics, those with a history of a C. difficile infection and those taking acid-suppressing drugs such as proton pump inhibitors.³  Refer to the BNF (available at www.medicinescomplete.com) for more information on the management of these patients.

As a first step in the treatment of bacterial infections, use local measures. For example, drain pus if present in dental abscesses by extraction of the tooth or through the root canals, and attempt to drain any soft-tissue pus by incision or aspiration. However, do not attempt to drain a cellulitis-type swelling. Evidence suggests that prescribing antibiotics in addition to local measures makes very little or no difference to outcomes in most patients presenting with acute dental conditions.⁶

Antibiotics are only appropriate for oral infections where there is evidence of spreading infection (cellulitis, lymph node involvement, swelling), systemic involvement (fever, malaise) or where the patient has a high risk of complications (e.g. immunocompromised states, uncontrolled diabetes). In addition, other indications for antibiotics are cases of necrotising gingivitis, necrotising periodontitis or pericoronitis where there is systemic involvement or persistent swelling despite local treatment. Use antibiotics in conjunction with, and not as an alternative to, local measures.

If antibiotics are prescribed, record the diagnosis and the reasons for prescribing in the clinical notes. Advise the patient to contact the practice if their symptoms worsen rapidly or significantly, do not improve, or new symptoms appear (safety netting advice). Ensure that the patient is reviewed at 3 days (see Bacterial infections 3-day review tool). The review can take place in person or by phone, with the choice based on clinical judgement but ideally should take place in person for cases of severe infection. At the review appointment, re-assess local measures (to review the outcome and to determine whether additional local measures are required), confirm the diagnosis, review pain management and provide further safety netting advice. If at review, there is resolution of systemic signs and symptoms, advise the patient to stop taking the antibiotic.²

For any patient with red flag signs and symptoms of severe or rapidly progressing spreading infection, such as significant trismus, floor-of-mouth swelling, difficulty breathing, difficulty swallowing, rapidly spreading cellulitis or involvement of deep or high risk fascial spaces, transfer them to hospital as an emergency. For any patient with airway compromise, for example in cases of Ludwig’s angina or sepsis (see Sepsis), call 999 for an ambulance and provide any necessary medical emergency care.^10,11 Ensure that the diagnosis and any appropriate assessments (e.g. temperature, pulse, blood pressure) carried out prior to hospital transfer are recorded in patient’s clinical record.

Immunocompromised patients are at higher risk of complications from infections including sepsis, and there is a lower threshold for prescribing antibiotics, discussion with secondary care and transfer to hospital for these patients.

Antibiotics should not be prescribed to manage pain arising from inflammatory conditions (e.g. irreversible pulpitis, dry socket after dental extractions).^2,5  Dental pain arising from these conditions is due primarily to an inflammatory response which should be managed by the appropriate use of analgesics and local measures. In addition, antibiotics should not be used as prophylactic prescriptions to prevent infections after a routine dental surgical procedure (e.g. peri-radicular surgery, minor surgical removal of soft tissue lesions, extraction of impacted wisdom teeth, surgical extractions of teeth or retained roots).

Before prescribing antibiotics, refer to the BNF and BNFC for drug interactions (available at www.medicinescomplete.com). Advise patients to space out doses as much as possible throughout the day. 

*The UK 5-year action plan for antimicrobial resistance 2024 to 2029 recognises the need to reduce antimicrobial prescribing to contain antimicrobial resistance and preserve antibiotics. The recent update on indicators for antibiotic use includes two dental targets: 

• By 2029, total antibiotic use in dental prescribing will be 5% lower than the 2019 baseline.
• By 2029, penicillin will be prescribed more frequently than amoxicillin in general dental practice and will account for at least 60% of total antibiotic prescribing.