What is the recommended antibiotic treatment for a patient with a toothache, cheek pain, and swelling, but no fever?

Antibiotic Treatment for Toothache with Cheek Pain and Swelling

For a patient with toothache, cheek pain, and swelling without fever, amoxicillin-clavulanate (875/125 mg twice daily for 5-7 days) is the recommended first-line antibiotic treatment. 1

Clinical Assessment and Diagnosis

When evaluating a patient with toothache, cheek pain, and swelling:

• The absence of fever suggests a mild to moderate odontogenic infection
• Cheek swelling indicates spread of infection beyond the tooth into facial soft tissues (cellulitis)
• This presentation represents a dental abscess with localized cellulitis requiring prompt treatment

Antibiotic Recommendations

First-line Treatment:

• Amoxicillin-clavulanate (875/125 mg twice daily for 5-7 days) 1, 2
  • Provides coverage against both aerobic and anaerobic oral bacteria
  • The addition of clavulanic acid addresses beta-lactamase producing organisms
  • Studies show significantly better pain and swelling reduction compared to amoxicillin alone 2

Alternative Options (Penicillin Allergy):

• Clindamycin (300-450 mg three times daily for 5-7 days) 1
• Doxycycline (100 mg twice daily for 5-7 days) 1
• Azithromycin (500 mg on day 1, then 250 mg for 4 days) 3

Treatment Duration

• Standard duration: 5-7 days 1, 4
• Reevaluation is necessary if no improvement is seen within 72 hours 3
• One small RCT found that a 3-day course of amoxicillin was clinically non-inferior to 7 days for odontogenic infections requiring tooth extraction 4

Important Clinical Considerations

• Definitive dental treatment is essential - antibiotics alone will not resolve the underlying dental problem
• The patient should be referred for prompt dental evaluation for possible:
  • Incision and drainage if abscess is present
  • Root canal therapy or extraction of the affected tooth

Monitoring and Follow-up

• Patient should be evaluated within 48-72 hours to assess response to treatment 1
• Warning signs requiring immediate reassessment:
  • Development of fever
  • Increased swelling
  • Difficulty swallowing or breathing
  • Spread of swelling to the eye or neck

Common Pitfalls to Avoid

1. Prescribing antibiotics without definitive dental treatment - antibiotics are an adjunct to, not a replacement for, dental intervention
2. Using penicillin alone - studies show amoxicillin-clavulanate provides superior outcomes for odontogenic infections 2
3. Prescribing antibiotics for dental pain without signs of infection - research shows antibiotics provide no benefit for undifferentiated dental pain without overt infection 5
4. Prolonged antibiotic courses - evidence suggests shorter courses (5-7 days) are effective for most dental infections 1, 4

Remember that while antibiotics help control the infection, definitive dental treatment is necessary to address the source of infection and prevent recurrence.