Treatment of Dental Infections
Surgical intervention (drainage, debridement) is the cornerstone of treatment for dental infections, with antibiotics serving only as adjunctive therapy when systemic involvement is present. 1, 2
Primary Treatment Approach
Definitive surgical management must be performed first – antibiotics alone are ineffective and contribute to antimicrobial resistance. 1, 2 The surgical approach depends on the source:
- For dental abscesses: Incision and drainage is mandatory 2
- For deciduous teeth: Extract if infection is extensive, recurrent, or tooth is near natural exfoliation 2
- For permanent teeth: Endodontic treatment or re-treatment is preferred 2
- For impacted teeth with pericoronitis: Remove trapped food debris and improve oral hygiene 3
Antibiotic Therapy Indications
Antibiotics should ONLY be prescribed when specific criteria are met – never as monotherapy. 1, 2 The indications are:
Systemic Involvement (High-Quality Evidence)
- Fever, malaise, or lymphadenopathy 1, 2
- Cellulitis or diffuse swelling that cannot be adequately drained 1
- Progressive infection extending into cervicofacial tissues or facial spaces 1
Patient-Specific Factors
- Immunocompromised patients (HIV, chemotherapy, transplant recipients) 1, 2
- Medically compromised patients (poorly controlled diabetes, cardiac conditions) 1
- Failure to respond to surgical treatment alone 1
Antibiotic Selection and Dosing
First-Line Therapy
Amoxicillin 500 mg orally three times daily for 5 days is the standard regimen following surgical drainage. 1, 2, 4 This should be taken at the start of meals to minimize gastrointestinal intolerance. 4
Second-Line Therapy
Amoxicillin-clavulanic acid should be used when there is inadequate response to amoxicillin alone, particularly for severe infections. 2 This provides coverage against beta-lactamase producing organisms including Bacteroides fragilis, which is present in 29.5% of dental infections and may be penicillin-resistant. 5
Penicillin Allergy
Clindamycin is the preferred alternative for penicillin-allergic patients. 2, 6 Dosing:
- Adults: 300-450 mg orally every 6 hours for severe infections 6
- Pediatric patients: 16-20 mg/kg/day divided into 3-4 doses for severe infections 6
- Must be taken with a full glass of water to avoid esophageal irritation 6
Clindamycin provides excellent coverage against B. fragilis (susceptible at <2 mcg/mL) and has demonstrated 100% cure rates in dental infections involving this organism. 5
Critical Pitfalls to Avoid
Never prescribe antibiotics without surgical intervention – this is the most common error and leads to treatment failure and antimicrobial resistance. 1, 2 Five patients with mandibular fractures infected with B. fragilis failed conventional penicillin therapy because surgical management was inadequate. 5
Never prescribe antibiotics for irreversible pulpitis alone – definitive dental treatment (endodontics or extraction) is required. 1 The tooth is dying and antibiotics cannot penetrate the necrotic pulp chamber. 7, 3
Do not use antibiotics for simple gingivitis – mechanical debridement and improved oral hygiene are sufficient. 3
Special Populations
Post-Radiation Patients (≥50 Gy)
Enhanced protocols are required: 8
- Amoxicillin 500 mg three times daily starting 1 hour to 1 day pre-extraction
- Continue 5-7 days post-extraction
- Add chlorhexidine gluconate 0.12% or 0.2% mouth rinse twice daily until healing
Renal Impairment
Dose adjustments are necessary: 4
- GFR 10-30 mL/min: 500 mg or 250 mg every 12 hours
- GFR <10 mL/min: 500 mg or 250 mg every 24 hours
- Hemodialysis: Additional dose during and at end of dialysis
Treatment Duration
Continue antibiotics for 2-3 days after resolution of symptoms, typically totaling 5-7 days. 8 For Streptococcus pyogenes infections, treat for at least 10 days to prevent acute rheumatic fever. 4
Monitoring and Follow-Up
Patients should be evaluated 48-72 hours after initiating treatment to ensure clinical improvement. 4 If no improvement occurs, consider: