Are antibiotics appropriate to manage a toothache?

Are Antibiotics Appropriate to Manage a Toothache?

Antibiotics are NOT appropriate as primary treatment for toothache—surgical intervention (drainage, root canal, or extraction) is the definitive treatment, and antibiotics should only be added when there is evidence of systemic involvement, spreading infection, or the patient is immunocompromised. 1, 2, 3

Primary Treatment: Surgery First

• Surgical drainage is the cornerstone of treatment and removes the source of inflammation—this should never be delayed for antibiotic therapy. 2, 3
• For acute dental abscesses, treatment is primarily surgical through root canal therapy or extraction of the affected tooth. 1, 2
• For dentoalveolar abscesses, incision and drainage is the first step in management. 2, 3

Evidence Against Routine Antibiotic Use

• Multiple systematic reviews demonstrate no statistically significant differences in pain or swelling outcomes when antibiotics are added to proper surgical treatment. 2, 3, 4
• The 2018 Cochrane review by Cope found no significant differences in participant-reported measures of pain or swelling at 24,48, or 72 hours when comparing penicillin versus placebo (both groups received surgical intervention and analgesics). 1, 4
• The 2003 Matthews review showed no significant difference between antibiotics and placebo for outcomes of "absence of infection" and "absence of pain." 1, 2

When to Add Antibiotics: Specific Indications Only

Add antibiotics ONLY when any of the following are present:

• Systemic symptoms: fever, malaise, or lymphadenopathy 1, 2, 3
• Spreading infection: cellulitis, diffuse swelling extending beyond the localized area 1, 2, 3
• Medically compromised patients: immunosuppressed or immunocompromised individuals 1, 2, 3
• Progressive infections: requiring referral to oral surgeons or infections extending into cervicofacial tissues 1, 2

Antibiotic Selection (When Indicated)

First-line choice:

• Amoxicillin or phenoxymethylpenicillin for 5 days 2, 3

For penicillin allergy:

• Clindamycin is the effective alternative 2, 3

For treatment failures:

• Consider adding metronidazole to amoxicillin 2, 3

Treatment Algorithm

1. Assess for indications requiring antibiotics:

   • Check for fever, malaise, or systemic symptoms 2, 3
   • Examine for cellulitis or diffuse swelling beyond the tooth 2, 3
   • Evaluate immune status of the patient 2, 3

2. Perform definitive surgical treatment:

   • Root canal therapy for salvageable teeth 2, 3
   • Extraction for non-restorable teeth 2, 3
   • Incision and drainage for accessible abscesses 2, 3

3. Add antibiotics only if Step 1 criteria are met 2, 3

Critical Pitfalls to Avoid

• Do not prescribe antibiotics as monotherapy for toothache—this delays definitive treatment and contributes to antibiotic resistance without improving outcomes. 5, 4
• Do not assume antibiotics will cure dental pain—the source of infection must be surgically removed. 5
• Avoid prescribing antibiotics for localized dental abscesses without systemic involvement—the evidence shows no benefit over surgical treatment alone. 1, 4
• Be aware that unnecessary antibiotic prescription can lead to serious complications including Clostridium difficile infection, antibiotic resistance, and adverse drug reactions. 5