What is the treatment for an infected tooth?

Treatment for an Infected Tooth

The primary treatment for an infected tooth requires both mechanical intervention (drainage or extraction) and appropriate antibiotic therapy, as treating with antibiotics alone will not resolve the infection and may lead to progressive worsening with risk of systemic complications. 1

Diagnostic Evaluation

• Perform intraoral periapical X-ray as the first-line diagnostic investigation
• Look for signs of infection: fluctuant masses, erythema, warmth, and assess for systemic infection
• Consider laboratory studies (CBC with differential, blood cultures) if systemic symptoms are present
• Advanced imaging (CBCT, CT with IV contrast) for unclear cases or suspected deep space infections

Treatment Algorithm

1. Mechanical Intervention (Primary Treatment)

• Drainage or extraction is the cornerstone of treatment
  • Immediate extraction has shown faster resolution of infection, decreased pain, and earlier return of function 2
  • For abscesses, incision and drainage is essential 3
  • The risk of spreading infection by immediate extraction is low 2

2. Antibiotic Therapy (Adjunctive Treatment)

• Indications for antibiotics:

  • Presence of systemic symptoms (fever, malaise)
  • Extensive cellulitis
  • Immunocompromised patients
  • Spreading infection beyond the confines of the jaws

• First-line antibiotic regimen:

  • Amoxicillin-clavulanic acid (covers both aerobic and anaerobic organisms) 3

• For penicillin-allergic patients:

  • Clindamycin (300-450 mg PO TID) - good coverage for oral pathogens with excellent bone penetration
  • Alternative options: Doxycycline or Trimethoprim-sulfamethoxazole 3

• Duration of therapy:

  • 5-7 days for most dental infections
  • Reassess after 48-72 hours for clinical improvement 3

3. Management Based on Severity

• Small abscesses with systemic symptoms:

  • Intravenous antibiotics after drainage 3

• Large abscesses (>3 cm):

  • Percutaneous drainage plus intravenous antibiotics 3

• Severe infections with risk of airway compromise:

  • Immediate referral to tertiary hospital
  • Surgical intervention if percutaneous drainage fails or sepsis persists 3

Important Considerations and Pitfalls

• Antibiotics alone will not resolve a dental abscess - mechanical intervention is essential 1
• Avoid unnecessary antibiotic use - studies show that antibiotics are unnecessarily prescribed in up to 74% of dental cases 4
• Monitor for complications - infections that spread beyond the jaws increase risk of airway obstruction and septicemia 1
• Reassess non-responsive cases - if no improvement after 2-3 days, consider:
  • Reevaluation of diagnosis
  • Culture and sensitivity testing
  • Alternative antibiotic regimen 3

Special Populations

• Immunocompromised patients:

  • Require more aggressive treatment and monitoring
  • May need longer courses of antibiotics
  • Consider consultation with patient's medical specialist 5

• Patients with endocarditis risk:

  • Consider antibiotic prophylaxis only for patients at highest risk for endocarditis undergoing at-risk dental procedures 6
  • Not recommended for routine dental procedures in most patients

By addressing both the mechanical removal of the source of infection and providing appropriate antibiotic coverage when indicated, infected teeth can be effectively managed while minimizing complications and reducing unnecessary antibiotic use.