Cochrane · intervention · CD010136

Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults

Cope, AL, Francis, N, Wood, F, et al. · Cochrane Database of Systematic Reviews · 2024 · Cochrane Library

Oral Health Periodontology4 versionsAMSTAR 2: not assessed

Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.

Questions

current version

GRADE rated

No studies

Included studies

as reported

No studies 3 · 11.5%Ungraded 11 · 42.3%Very low 7 · 26.9%Low 5 · 19.2%Moderate 0 · 0%High 0 · 0%

Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.

Review question

Element	Planned (methods)	Found (results)
Population	Adults (18 years of age or older), male or female, who presented with a single tooth with a clinical diagnosis of either symptomatic apical periodontitis or acute apical abscess	Adults with symptomatic apical periodontitis, or localised acute apical abscess / symptomatic necrotic tooth, no signs of spreading infection or systemic involvement (n=134)
Intervention	Administration of any systemic antibiotic (either oral or intravenous) at any dosage prescribed in the symptomatic phase of apical periodontitis or acute apical abscess, with or without analgesics, and with or without surgical intervention (extraction, incision and drainage or endodontic treatment)	Clindamycin 600 mg single preoperative dose (n=36); Oral penicillin VK 7-day course (n=32)
Comparison	Administration of a matched placebo prescribed in the symptomatic phase of apical periodontitis or acute apical abscess, with or without analgesics, and with or without surgical intervention	Matched placebo (n=66)
Outcomes	Participant-reported pain and swelling (continuous, e.g. visual analogue scale (VAS), or binary/dichotomous); Clinician-reported measures of infection (swelling, temperature, trismus, regional lymphadenopathy or cellulitis); Participant-reported quality of life; Type, dose and frequency of analgesics used; Any adverse effects or harms attributed to antibiotics or analgesics, complications of surgical treatment or hospitalisations	Participant-reported pain (n=133); Participant-reported swelling (n=134); Percussion pain (n=41); Incidence of endodontic flare-up (n=19); Number and type of analgesics required (n=113); Adverse effects (n=92)
Study designs	Randomised controlled trials (RCTs) with parallel group design (cluster RCTs excluded)	Randomised controlled trials, parallel group (n=3)
Timing	24, 48 and 72 hours, and seven days postoperatively	24, 48 and 72 hours, and seven days postoperatively

Search date: 2022-11. Databases: Cochrane Central Register of Controlled Trials; MEDLINE Ovid; Embase Ovid; CINAHL EBSCO; ProQuest Dissertations & Theses Global

Questions and results

Current version only

Postoperative systemic antibiotics (phenoxymethylpenicillin/penicillin VK, 7-day course), partial or total chemo-mechanical debridement and analgesics vs Matched placebo, partial or total chemo-mechanical debridement and analgesics

Population: Adults with a symptomatic necrotic tooth or localised acute apical abscess (no signs of spreading infection or systemic involvement)

CD010136.PUB4 (current) · 16 questions

Outcome	Effect	Evidence	Status / GRADE
Number of ibuprofen tablets required 7 days same question in other reviews	MD 1.58 [-4.55, 7.71]	1 study · 41 participants	Ungraded
Percussion pain at 24 hours 24 hours same question in other reviews	MD -0.32 [-0.85, 0.21]	1 study · 41 participants	Ungraded
Swelling at 48 hours 48 hours same question in other reviews	SMD 0.04 [-0.47, 0.55]	2 studies · 61 participants	Ungraded
Swelling at 24 hours 24 hours same question in other reviews	SMD 0.27 [-0.23, 0.78] 0.59 vs 0.27 SD higher (0.23 lower to 0.78 higher)	2 studies · 62 participants	Very low Downgraded: risk of bias, imprecision, inconsistency, indirectness
Pain at 72 hours 72 hours same question in other reviews	MD 0.08 [-0.38, 0.54] 0.3 to 0.82 vs 0.08 higher (0.38 lower to 0.54 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Adverse effects 3 days same question in other reviews	1 participant reported diarrhoea (placebo group); 1 participant reported fatigue and reduced energy postoperatively (antibiotic group). 61 participants (2 studies). 1 participant reported diarrhoea (placebo) vs 1 participant reported fatigue and reduced energy postoperatively…	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Percussion pain at 7 days 7 days same question in other reviews	MD 0.06 [-0.29, 0.41]	1 study · 41 participants	Ungraded
Pain at 24 hours 24 hours same question in other reviews	MD -0.03 [-0.53, 0.47] 1.0 to 1.68 vs 0.03 lower (0.53 lower to 0.47 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Pain at 48 hours 48 hours same question in other reviews	MD 0.32 [-0.22, 0.86]	2 studies · 61 participants	Ungraded
Percussion pain at 72 hours 72 hours same question in other reviews	MD 0.05 [-0.55, 0.65]	1 study · 41 participants	Ungraded
Swelling at 72 hours 72 hours same question in other reviews	SMD 0.02 [-0.49, 0.52] 0.59 vs 0.02 SD higher (0.49 lower to 0.52 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, inconsistency, indirectness
Pain at 7 days 7 days same question in other reviews	MD -0.05 [-0.41, 0.30] 0.32 vs 0.05 lower (0.41 lower to 0.30 higher)	1 study · 41 participants	Very low Downgraded: imprecision, indirectness
Percussion pain at 48 hours 48 hours same question in other reviews	MD 0.09 [-0.44, 0.62]	1 study · 41 participants	Ungraded
Number of paracetamol (acetaminophen) with codeine tablets required 7 days same question in other reviews	MD -0.31 [-3.94, 3.32]	1 study · 41 participants	Ungraded
Endodontic flare-up 3 days same question in other reviews	RR 0.27 [0.01, 4.90]	1 study · 19 participants	Ungraded
Swelling at 7 days 7 days same question in other reviews	MD 0.02 [-0.28, 0.32] 0.14 vs 0.02 higher (0.28 lower to 0.32 higher)	1 study · 41 participants	Very low Downgraded: imprecision, indirectness

Systemic antibiotics without surgical intervention (with or without analgesics) vs Matched placebo without surgical intervention (with or without analgesics)

Population: Adults with symptomatic apical periodontitis or acute apical abscess

CD010136.PUB4 (current) · 1 question

Outcome	Effect	Evidence	Status / GRADE
Outcome NR same question in other reviews	We found no studies comparing systemic antibiotics versus a matched placebo provided without a surgical intervention.	0 studies	No studies

Single preoperative dose of systemic antibiotics (clindamycin 600 mg), total chemo-mechanical debridement and root filling vs Matched placebo, total chemo-mechanical debridement and root filling

Population: Adults with symptomatic apical periodontitis (no signs of spreading infection or systemic involvement)

CD010136.PUB4 (current) · 9 questions

Outcome	Effect	Evidence	Status / GRADE
Swelling at 24 hours 24 hours same question in other reviews	No data available for this outcome.	0 studies	No studies
Pain at 24 hours 24 hours same question in other reviews	The median pain at 24 hours in the control group was 3 (range 0 to 10); the median pain at 24 hours in the intervention group was the same (median 3, range 0 to 8). P = 0.219 (Mann-Whitney U). Median 3 (range 0 to 10) vs Median 3 (range 0 to 8); same as control	1 study · 72 participants	Low Downgraded: imprecision
Analgesic use 7 days same question in other reviews	RR 0.87 [0.48, 1.55]	1 study · 72 participants	Ungraded
Swelling at 7 days 7 days same question in other reviews	RR 0.50 [0.10, 2.56] 111 per 1000 (4/36; 11.1%) vs 56 per 1000 (2/36; 5.6%)	1 study · 72 participants	Low Downgraded: imprecision
Pain at 48 hours 48 hours same question in other reviews	Median pain at 48 hours 1 (range 0 to 9) in the antibiotic group versus 2 (range 0 to 10) in the control group. P = 0.242 (Mann-Whitney U). Median 2 (range 0 to 10) vs Median 1 (range 0 to 9)	1 study · 72 participants	Ungraded
Pain at 72 hours 72 hours same question in other reviews	The median pain at 72 hours in the control group was 0 (range 0 to 10); the median pain at 72 hours in the intervention group was the same (median 0, range 0 to 7). P = 0.116 (Mann-Whitney U). Median 0 (range 0 to 10) vs Median 0 (range 0 to 7); same as control	1 study · 72 participants	Low Downgraded: imprecision
Swelling at 72 hours 72 hours same question in other reviews	No data available for this outcome.	0 studies	No studies
Adverse effects 7 days same question in other reviews	No adverse effects reported in the placebo group; 1 participant reported dizziness in the intervention group. 72 participants (1 study). No adverse effects reported (placebo) vs 1 participant reported dizziness (antibiotic)	1 study · 72 participants	Low Downgraded: imprecision
Pain at 7 days 7 days same question in other reviews	The median pain at 7 days in the control group was 0 (range 0 to 3); the median pain at 7 days in the intervention group was the same (median 0, range 0 to 1). P = 0.673 (Mann-Whitney U). Median 0 (range 0 to 3) vs Median 0 (range 0 to 1); same as control	1 study · 72 participants	Low Downgraded: imprecision

Systemic antibiotics (oral penicillin VK, 7-day course), partial or total pulpectomy and analgesics vs Matched placebo, partial or total pulpectomy and analgesics

Population: Adults with a symptomatic necrotic tooth or localised acute apical abscess (no signs of spreading infection or systemic involvement)

CD010136.PUB3 · 16 questions

Outcome	Effect	Evidence	Status / GRADE
Swelling at 72 hours 72 hours	SMD 0.02 [-0.49, 0.52] 0.59 vs 0.02 SD higher (0.49 lower to 0.52 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Number of paracetamol (acetaminophen) with codeine tablets required 7 days	MD -0.31 [-3.94, 3.32]	1 study · 41 participants	Ungraded
Endodontic flare-up 3 days	RR 0.27 [0.01, 4.90]	1 study · 20 participants	Ungraded
Swelling at 7 days 7 days	MD 0.02 [-0.28, 0.32]	1 study · 41 participants	Ungraded
Percussion pain at 48 hours 48 hours	MD 0.09 [-0.44, 0.62]	1 study · 41 participants	Ungraded
Percussion pain at 24 hours 24 hours	MD -0.32 [-0.85, 0.21]	1 study · 41 participants	Ungraded
Pain at 72 hours 72 hours	MD 0.08 [-0.38, 0.54] 0.3 to 0.82 vs 0.08 higher (0.38 lower to 0.54 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Adverse effects 3 days	During the 3-day follow-up period in Fouad 1996, 1 participant in the placebo group reported diarrhoea and 1 participant in the antibiotic group reported fatigue and reduced energy postoperatively. 1 participant reported diarrhoea (placebo) vs 1 participant reported fatigue and reduced energy postoperatively…	1 study · 20 participants	Ungraded
Pain at 48 hours 48 hours	MD 0.32 [-0.22, 0.86] 0.8 to 0.95 vs 0.32 higher (0.22 lower to 0.86 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Number of ibuprofen tablets required 7 days	MD 1.58 [-4.55, 7.71]	1 study · 41 participants	Ungraded
Pain at 24 hours 24 hours	MD -0.03 [-0.53, 0.47] 1.0 to 1.68 vs 0.03 lower (0.53 lower to 0.47 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Percussion pain at 72 hours 72 hours	MD 0.05 [-0.55, 0.65]	1 study · 41 participants	Ungraded
Percussion pain at 7 days 7 days	MD 0.06 [-0.29, 0.41]	1 study · 41 participants	Ungraded
Swelling at 48 hours 48 hours	SMD 0.04 [-0.47, 0.55] 0.73 vs 0.04 SD higher (0.47 lower to 0.55 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Swelling at 24 hours 24 hours	SMD 0.27 [-0.23, 0.78] 0.59 vs 0.27 SD higher (0.23 lower to 0.78 higher)	2 studies · 62 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Pain at 7 days 7 days	MD -0.05 [-0.41, 0.30]	1 study · 41 participants	Ungraded

Systemic antibiotics without surgical intervention (with or without analgesics) vs Matched placebo without surgical intervention (with or without analgesics)

Population: Adults with symptomatic apical periodontitis or acute apical abscess

CD010136.PUB3 · 1 question

Outcome	Effect	Evidence	Status / GRADE
Outcome NR	We found no studies comparing systemic antibiotics versus a matched placebo provided without a surgical intervention.	0 studies	No studies

Systemic antibiotics (oral penicillin VK, 7-day course), partial or total pulpectomy and analgesics vs Matched placebo, partial or total pulpectomy and analgesics

Population: Adults with a symptomatic necrotic tooth or localised acute apical abscess (no signs of spreading infection or systemic involvement)

CD010136.PUB2 · 16 questions

Outcome	Effect	Evidence	Status / GRADE
Percussion pain at 48 hours 48 hours	MD 0.09 [-0.44, 0.62]	1 study · 41 participants	Ungraded
Pain at 7 days 7 days	MD -0.05 [-0.41, 0.30]	1 study · 41 participants	Ungraded
Swelling at 48 hours 48 hours	SMD 0.04 [-0.47, 0.55] 0.73 vs 0.04 SD higher (0.47 lower to 0.55 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Adverse effects 3 days	During the 3-day follow-up period in Fouad 1996, 1 participant in the placebo group reported diarrhoea and 1 participant in the antibiotic group reported fatigue and reduced energy postoperatively. 1 participant reported diarrhoea (placebo) vs 1 participant reported fatigue and reduced energy postoperatively…	1 study · 20 participants	Ungraded
Pain at 72 hours 72 hours	MD 0.08 [-0.38, 0.54] 0.3 to 0.82 vs 0.08 higher (0.38 lower to 0.54 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Swelling at 7 days 7 days	MD 0.02 [-0.28, 0.32]	1 study · 41 participants	Ungraded
Percussion pain at 24 hours 24 hours	MD -0.32 [-0.85, 0.21]	1 study · 41 participants	Ungraded
Endodontic flare-up 3 days	RR 0.27 [0.01, 4.90]	1 study · 20 participants	Ungraded
Number of paracetamol (acetaminophen) with codeine tablets required 7 days	MD -0.31 [-3.94, 3.32]	1 study · 41 participants	Ungraded
Pain at 24 hours 24 hours	MD -0.03 [-0.53, 0.47] 1.0 to 1.68 vs 0.03 lower (0.53 lower to 0.47 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Swelling at 72 hours 72 hours	SMD 0.02 [-0.49, 0.52] 0.59 vs 0.02 SD higher (0.49 lower to 0.52 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Percussion pain at 72 hours 72 hours	MD 0.05 [-0.55, 0.65]	1 study · 41 participants	Ungraded
Number of ibuprofen tablets required 7 days	MD 1.58 [-4.55, 7.71]	1 study · 41 participants	Ungraded
Pain at 48 hours 48 hours	MD 0.32 [-0.22, 0.86] 0.8 to 0.95 vs 0.32 higher (0.22 lower to 0.86 higher)	2 studies · 61 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Swelling at 24 hours 24 hours	SMD 0.27 [-0.23, 0.78] 0.59 vs 0.27 SD higher (0.23 lower to 0.78 higher)	2 studies · 62 participants	Very low Downgraded: risk of bias, imprecision, indirectness
Percussion pain at 7 days 7 days	MD 0.06 [-0.29, 0.41]	1 study · 41 participants	Ungraded

Systemic antibiotics without surgical intervention (with or without analgesics) vs Matched placebo without surgical intervention (with or without analgesics)

Population: Adults with symptomatic apical periodontitis or acute apical abscess

CD010136.PUB2 · 1 question

Outcome	Effect	Evidence	Status / GRADE
Outcome NR	We found no studies comparing systemic antibiotics versus a matched placebo provided without a surgical intervention.	0 studies	No studies

Any systemic antibiotic (oral or intravenous) at any dosage in the symptomatic phase, with or without analgesics and with or without surgical intervention (extraction, incision and drainage or endodontic treatment) vs Matched placebo, with or without analgesics and with or without surgical intervention

Population: Adults (over the age of 18), male or female, presenting with a single tooth with a clinical diagnosis of either symptomatic apical periodontitis or acute apical abscess

CD010136 · 1 question

Outcome	Effect	Evidence	Status / GRADE
Outcome NR 24, 48 and 72 hours and 7 days (planned)	Protocol only; no studies assessed. Planned comparison of systemic antibiotics versus matched placebo for symptomatic apical periodontitis and acute apical abscess.	NR	No studies