What is the appropriate treatment for a tooth that is experiencing discomfort or infection after a dental procedure?

Treatment of an Eased Tooth

The primary treatment for a tooth experiencing discomfort or infection after a dental procedure is surgical intervention, which may include root canal therapy for salvageable teeth, extraction for non-restorable teeth, or incision and drainage for accessible abscesses, with antibiotics reserved only for specific circumstances such as systemic involvement or medically compromised patients. 1, 2

Diagnosis and Assessment

• Determine the type of dental issue causing discomfort:

  • Exposed pulp (complicated crown fracture) requires immediate pulp therapy to preserve vitality 3
  • Exposed dentin (uncomplicated crown fracture) requires dental referral within a few days 3
  • Dental abscess requires surgical drainage as the cornerstone of treatment 2, 4

• Assess for signs of infection spreading beyond the tooth:

  • Fever, malaise, or lymphadenopathy indicates need for antibiotics 1, 2
  • Diffuse swelling that cannot be drained effectively may require antibiotics 1
  • Infections extending into facial spaces require antibiotic treatment 2

Primary Treatment Approach

For Salvageable Teeth with Pulpal Involvement

• Root canal therapy is the treatment of choice for mature teeth with pulpal exposure 3
• For immature permanent teeth (less than 3 years after eruption), pulp therapy should be performed immediately to preserve pulp vitality 3
• Monitor for signs of continued root development and absence of pulpal necrosis 3

For Non-Restorable Teeth

• Extraction is indicated when the tooth cannot be saved 1, 2
• After extraction, proper healing time should be allowed before any prosthetic replacement 3
• For esthetics and space maintenance, the missing crown can be replaced by an orthodontic retainer with a prosthetic tooth 3

For Dental Abscesses

• Incision and drainage is the first step in management of dentoalveolar abscesses 2, 4
• Surgical drainage removes the source of inflammation and should not be delayed 2
• Treatment should continue for 48-72 hours beyond the time that the patient becomes asymptomatic 5

Role of Antibiotics

• Antibiotics should only be used as an adjunct to surgical treatment in specific situations:

  • Presence of systemic symptoms (fever, malaise) 1, 2
  • Evidence of spreading infection or cellulitis 2, 4
  • Medically compromised or immunosuppressed patients 1, 2
  • Infections extending into cervicofacial tissues 2

• When antibiotics are indicated:

  • First-line options: Amoxicillin 500 mg every 8 hours or 875 mg every 12 hours for 5 days 4, 5
  • For penicillin-allergic patients: Clindamycin is an effective alternative 2, 4
  • For treatment failures: Consider adding metronidazole to amoxicillin 2, 4

Evidence Against Routine Antibiotic Use

• Multiple systematic reviews show no statistically significant differences in pain or swelling outcomes when antibiotics are added to proper surgical treatment 2, 4
• Adding antibiotics to proper surgical management has not shown statistically significant differences in pain or swelling outcomes 1
• Prescribing antibiotics without surgical intervention is ineffective and contributes to antibiotic resistance 1

Special Considerations

• For crown fractures involving only enamel, smoothing the fracture area with a dental handpiece or leaving it untreated if smooth to touch is sufficient 3
• For crown fractures involving enamel and dentin without pulp exposure, the tooth should be restored with tooth-colored dental material 3
• For root fractures, management depends on location - fractures closer to the apex have better prognosis and rarely require treatment 3
• For alveolar fractures (involving bone), immediate referral to a dentist or oral surgeon for repositioning and stabilization is indicated 3

Follow-up and Monitoring

• Monitor for signs of pulpal necrosis, which may include tooth discoloration or formation of a parulis (gingival abscess) 3
• Treatment should continue until evidence of bacterial eradication has been obtained 5
• For infections caused by Streptococcus pyogenes, a minimum of 10 days' treatment is recommended to prevent acute rheumatic fever 5

Common Pitfalls to Avoid

• Delaying surgical intervention while relying solely on antibiotics 1, 2
• Prescribing antibiotics without addressing the source of infection 1
• Failing to recognize when a tooth requires immediate specialist referral 3
• Inadequate follow-up to ensure resolution of infection 5