The effect of antibiotic use on endodontic post-operative pain and flare-up rate: a systematic review with meta-analysis.

Aim Antibiotics are widely used to prevent flare-ups after endodontic treatment of non-vital teeth. This systematic review assessed the effect of antibiotic administration on post-endodontic treatment pain and flare-up rate.Methods Five major databases including Web of Science, Cochrane Library, PubMed, Scopus and Embase were searched to identify randomised clinical trials (RCTs) published until September 2020. Retrieved papers were critically appraised using the revised Cochrane risk of bias tool (RoB 2). To reduce the clinical heterogeneity, the included studies were divided into two groups: studies on symptomatic non-vital teeth and studies on asymptomatic non-vital teeth. The primary outcomes were 'post-operative pain' and 'flare-up rate'. The data of included studies were statistically combined through meta-analysis using random-effect model. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of evidence.Results Six RCTs involving two RCTs (N = 61) on symptomatic teeth and four RCTs (N = 310) on asymptomatic teeth were included. In two RCTs on asymptomatic teeth, prophylactic antibiotic had been used, while in the remaining two RCTs, antibiotics had been administered after treatment. Quantitative synthesis of the RCTs showed that antibiotic administration following endodontic treatment of symptomatic non-vital teeth has no effect on pain severity at 24 hours following treatment (weighted mean difference [WMD] = -0.03; 95% confidence interval [CI]: -0.53 to 0.47), and the use of antibiotics before endodontic treatment of asymptomatic non-vital teeth has no effect on flare-up rate (relative risk [RR] = 0.58; 95% CI: 0.22-1.54). The GRADE approach revealed that the overall quality of evidence on the topic is low.Conclusions The antibiotic administration following endodontic treatment of symptomatic non-vital teeth has no effect on pain severity at 24 hours following treatment. Also, prophylactic antibiotics are ineffective in reducing the flare-up rate following treatment of asymptomatic non-vital teeth. However, to evaluate the effect of post-treatment antibiotics on flare-up rate in asymptomatic non-vital teeth, more high-quality RCTs are needed.