What is the best treatment for a tooth infection?

Best Treatment for Tooth Infection

Surgical intervention through root canal therapy, extraction, or incision and drainage is the primary treatment for tooth infections and should not be delayed, with antibiotics reserved only for cases with systemic symptoms (fever, malaise), spreading infection (cellulitis, diffuse swelling), or immunocompromised patients. 1, 2

Primary Treatment Algorithm

Step 1: Assess Infection Severity and Systemic Involvement

Localized infection without systemic symptoms:

• Proceed directly to surgical management without antibiotics 1, 2
• Multiple systematic reviews demonstrate no statistically significant differences in pain or swelling outcomes when antibiotics are added to surgical treatment 1, 3

Systemic involvement present (any of the following):

• Fever or malaise 1, 2
• Cellulitis or diffuse swelling that cannot be drained effectively 1, 2
• Lymph node involvement 2
• Patient is immunocompromised or medically compromised 1, 2
• Infection extending into facial spaces or cervicofacial tissues 2

Step 2: Perform Appropriate Surgical Intervention

For salvageable teeth:

• Root canal therapy (chemo-mechanical debridement and filling) is the treatment of choice 1, 2
• Indicated when tooth is restorable, periodontally sound, and adequate crown structure remains 2

For non-restorable teeth:

• Extraction is required 1, 2
• Indicated for extensive caries, severe crown destruction, structural compromise, severe periodontal disease, or failed previous endodontic treatment 2

For accessible abscesses:

• Incision and drainage to establish drainage and remove source of infection 1, 2

Step 3: Add Antibiotics Only When Indicated

First-line antibiotic choice:

• Phenoxymethylpenicillin (Penicillin VK) or amoxicillin for 5 days 1
• Amoxicillin dosing for adults: 500 mg every 12 hours or 250 mg every 8 hours for mild/moderate infections; 875 mg every 12 hours or 500 mg every 8 hours for severe infections 4
• Take at the start of a meal to minimize gastrointestinal intolerance 4

For penicillin-allergic patients:

• Clindamycin is the effective alternative 1
• Adult dosing: 150-300 mg every 6 hours for serious infections; 300-450 mg every 6 hours for more severe infections 5
• Must be taken with a full glass of water to avoid esophageal irritation 5

For treatment failures:

• Consider adding metronidazole to amoxicillin 1

Critical Evidence Supporting This Approach

The 2018 Cope study found no significant differences in participant-reported pain or swelling at any time point when comparing penicillin versus placebo (both groups received surgical intervention) 1. The median pain values were identical or nearly identical across groups at 24,48, and 72 hours 3.

A 2024 Cochrane systematic review confirmed that preoperative clindamycin resulted in little to no difference in pain or swelling when provided with endodontic debridement, and postoperative phenoxymethylpenicillin showed very uncertain effects 3.

Common Pitfalls to Avoid

Do not prescribe antibiotics without surgical intervention:

• Antibiotics alone do not eliminate the source of infection and are ineffective 2, 6
• This practice contributes to antibiotic resistance 3
• Only 12% of dentists adequately and correctly prescribe antibiotics 6

Do not delay surgical treatment:

• Surgical drainage is the key to resolving infection by removing the source of inflammation 1
• Antibiotics cannot substitute for proper surgical management 2

Do not extract restorable teeth solely due to patient anxiety:

• Root canal therapy generates lower anxiety levels than extraction among patients who have experienced both procedures 2
• Light sedation is appropriate for managing anxiety during either procedure 2

Special Considerations

For infections extending into cervicofacial tissues:

• Require more aggressive management including tooth extraction and treatment as necrotizing fasciitis 1

Treatment duration:

• Continue treatment for minimum 48-72 hours beyond symptom resolution or evidence of bacterial eradication 4
• For Streptococcus pyogenes infections, treat for at least 10 days to prevent acute rheumatic fever 4, 5

Renal impairment:

• Patients with glomerular filtration rate less than 30 mL/min should NOT receive the 875 mg amoxicillin dose 4
• Adjust dosing based on severity of renal impairment 4