What is the treatment for dental infection (periodontal infection)?

From the Guidelines

Dental infections should be treated promptly with a combination of dental procedures and antibiotics when necessary, with amoxicillin 500mg three times daily for 7-10 days being the first-line antibiotic treatment, as recommended by recent guidelines 1. For most dental infections, the primary treatment involves addressing the source through dental procedures such as drainage of abscesses, root canal therapy, or tooth extraction.

• The use of antibiotics is generally recommended for acute dental and dentoalveolar abscesses, infections extending into cervicofacial tissues, and in specific patient groups such as medically compromised patients, patients with systemic involvement, and patients with progressive infections 1.
• Amoxicillin is typically the first-line antibiotic treatment, with clindamycin 300mg four times daily for 7-10 days being an alternative for patients allergic to penicillin, and amoxicillin with clavulanic acid (Augmentin) 875/125mg twice daily being prescribed for more severe infections.
• While taking antibiotics, patients should complete the entire course even if symptoms improve, maintain good oral hygiene, use warm salt water rinses (1/2 teaspoon salt in 8 ounces of warm water) 3-4 times daily, take over-the-counter pain relievers like ibuprofen or acetaminophen as needed, and stay hydrated.
• A recent study found that systemic antibiotics significantly improved pocket depth reduction and clinical attachment level gain, with metronidazole/amoxicillin being the most potent combination 2.
• However, it's essential to note that antibiotics only address the infection temporarily if the underlying dental problem remains untreated, and professional dental care is essential alongside antibiotic therapy.
• The American Dental Association recommends the use of systemic sub-antimicrobial dose doxycycline (20 mg twice daily for 3-9 months) as an adjunct to scaling and root planning for chronic periodontitis 1.

From the Research

Dental Infection Treatment

• Dental infections can be caused by various factors such as dental caries, pulpal necrosis, trauma, and periodontal diseases, and can have severe consequences on both soft and hard tissues of the oral cavity 3.
• The treatment of dental infections typically involves surgical and endodontic treatments, followed by antibiotic therapy 3.
• Antibiotics are generally used in dental procedures to treat odontogenic infections, nonodontogenic infections, local infection, focal infection, and prophylaxis 3.

Antibiotic Therapy

• Penicillin V (phenoxymethyl penicillin) remains the antimicrobial of choice for the initial empirical treatment of odontogenic infections, as it is safe, highly effective, and inexpensive 4.
• Amoxicillin has little indication for the routine treatment of odontogenic infections, but is the agent of choice for endocarditis prophylaxis, as it produces higher serum levels than penicillin V 4.
• Erythromycin may be used for mild, acute odontogenic infections in penicillin-allergic patients, while tetracycline may be considered as an alternative therapy for penicillin-allergic patients over the age of 13 who cannot tolerate erythromycin 4.
• Clindamycin is very effective against all odontogenic pathogens, but its potential gastrointestinal toxicity relegates it to third- or even fourth-line therapy in general dentistry 4, 5, 6.
• Metronidazole displays excellent activity against anaerobic gram-negative bacilli, but is only moderately effective against facultative and anaerobic gram-positive cocci, and should not be used alone in the treatment of acute odontogenic infections 4, 5, 6.

Duration of Antibiotic Treatment

• The optimum length of treatment with systemic antibiotics in adults with dental infections is not well established, with guidelines varying across different countries 7.
• A systematic review found that only one small randomized controlled trial (RCT) compared the effectiveness of short-duration (3-5 days) courses of systemic antibiotics with longer-duration courses (≥7 days) for the treatment of dental infections in adults in outpatient settings 7.
• The trial found no significant difference between groups in terms of participant-reported pain or clinical assessment of wound healing, but the results are limited by the small sample size and the fact that all participants commenced amoxicillin two days before tooth extraction, which is not common clinical practice 7.