Antibiotic use for severe toothache (irreversible pulpitis)

Review question
Are oral antibiotics effective and safe for treating pain in irreversible pulpitis (inflammation of the nerve inside the tooth/nerve damage)?

Irreversible pulpitis occurs where the dental pulp (tissue inside the tooth which contains the nerve) has been damaged beyond repair. It is characterised by intense pain (toothache), sufficient to wake someone up at night and is considered to be one of the most frequent reasons that patients attend for emergency dental care. Any tooth may be affected, it is not restricted to particular age groups, and it usually occurs as a direct result of dental decay, a cracked tooth, or trauma.

The 'standard of care' for irreversible pulpitis - immediate removal of the pulp from the affected tooth - is now widely accepted and yet in certain parts of the world antibiotics continue to be prescribed.

Study characteristics
The evidence on which this review is based was current as of 18 February 2019. One study involving 40 people with irreversible pulpitis (nerve damage) was included. There were two groups of 20 people, one group was treated with penicillin 500 mg, the other with placebo (no active ingredient) every six hours over a seven-day period. In addition, all of the participants received painkillers (ibuprofen and paracetamol (acetaminophen) combined with codeine).

Key results
Antibiotics do not appear to significantly reduce toothache caused by irreversible pulpitis. Furthermore, there was no difference in the total number of ibuprofen or Tylenol tablets used over the study period between both groups. The administration of penicillin does not significantly reduce the pain perception, the percussion (tapping on the tooth) perception, or the quantity of pain medication required by people with irreversible pulpitis. There was no reporting on adverse events or reactions.

Certainty of the evidence
This was a study with a small number of participants and the certainty of the evidence for the different outcomes was rated as low. There is currently insufficient evidence to be able to decide if antibiotics help for this condition. This review highlights the need for more and better quality studies on the use of antibiotics for irreversible pulpitis.

Authors' conclusions: 

This Cochrane Review which was based on one low-powered small sample trial assessed as at low risk of bias, illustrates that there is insufficient evidence to determine whether antibiotics reduce pain or not compared to not having antibiotics. The results of this review confirm the necessity for further larger sample and methodologically sound trials that can provide additional evidence as to whether antibiotics, prescribed in the preoperative phase, can affect treatment outcomes for irreversible pulpitis.

Read the full abstract...

Irreversible pulpitis, which is characterised by acute and intense pain, is one of the most frequent reasons that patients attend for emergency dental care. Apart from removal of the tooth, the customary way of relieving the pain of irreversible pulpitis is by drilling into the tooth, removing the inflamed pulp (nerve) and cleaning the root canal. However, a significant number of dentists continue to prescribe antibiotics to stop the pain of irreversible pulpitis.This review updates the previous version published in 2016.


To assess the effects of systemic antibiotics for irreversible pulpitis.

Search strategy: 

We searched Cochrane Oral Health's Trials Register (to 18 February 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 18 February 2019); MEDLINE Ovid (1946 to 18 February 2019); Embase Ovid (1980 to 18 February 2019); US National Institutes of Health Ongoing Trials Register (searched 18 February 2019); and the World Health Organization International Clinical Trials Registry Platform (searched 18 February 2019). There were no language restrictions in the searches of the electronic databases.

Selection criteria: 

Randomised controlled trials which compared pain relief with systemic antibiotics and analgesics, against placebo and analgesics in the acute preoperative phase of irreversible pulpitis.

Data collection and analysis: 

Three review authors screened studies and extracted data independently. We assessed the certainty of the evidence of included studies using GRADE. Pooling of data was not possible and a descriptive summary is presented.

Main results: 

No additional trials could be included in this update. One trial at low risk of bias evaluating oral penicillin in combination with analgesics versus placebo with analgesics, involving 40 participants was included in a former update of the review. The certainty of the evidence was rated low for the different outcomes. Our primary outcome was patient-reported pain (intensity/duration) and pain relief. There was a close parallel distribution of the pain ratings in both the intervention (median 6.0, interquartile range (IQR) 10.5), and for placebo (median 6.0, IQR 9.5) over the seven-day study period. There was insufficient evidence to claim or refute a benefit for penicillin for pain intensity. There was no significant difference in the mean total number of ibuprofen tablets over the study period: 9.20 (standard deviation (SD) 6.02) in the penicillin group versus 9.60 (SD 6.34) in the placebo group; mean difference -0.40 (95% confidence interval (CI) -4.23 to 3.43; P = 0.84). This applied equally for the mean total number of Tylenol tablets: 6.90 (SD 6.87) used in the penicillin group versus 4.45 (SD 4.82) in the placebo group; mean difference 2.45 (95% CI -1.23 to 6.13; P = 0.19). Our secondary outcome on reporting of adverse events was not addressed in this study.