What antibiotic is recommended for a patient with a severe toothache and facial swelling?

Antibiotic Treatment for Severe Toothache with Facial Swelling

For a patient with severe toothache and facial swelling, amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 5-7 days is the recommended antibiotic, but only as adjunctive therapy following urgent surgical intervention (drainage/extraction). 1, 2

Critical First Step: Surgical Intervention Required

• Antibiotics alone are insufficient and should never be prescribed without addressing the source of infection surgically 1, 2
• The presence of facial swelling indicates spread beyond the tooth apex and mandates immediate dental referral for incision and drainage or extraction 1, 3
• Progressive facial swelling requires aggressive management and may necessitate hospital referral for definitive treatment 3

Antibiotic Selection Algorithm

First-Line Choice (No Penicillin Allergy):

• Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days is preferred for severe infections with facial swelling 1, 2, 4
• The clavulanate component provides coverage against beta-lactamase producing organisms commonly found in established dental abscesses 5
• Take at the start of meals to enhance absorption and minimize gastrointestinal side effects 4

Alternative if Mild-Moderate Infection (No Swelling):

• Plain amoxicillin 500 mg three times daily for 5 days would suffice for less severe cases, but your patient has facial swelling indicating more severe disease 1, 2

For Penicillin-Allergic Patients:

• Clindamycin 300-400 mg three times daily is the preferred alternative 2, 6
• Clindamycin provides excellent coverage against all odontogenic pathogens including anaerobes 7
• However, warn patients about the risk of antibiotic-associated colitis (C. difficile) 6, 8

When Antibiotics Are Specifically Indicated

Your patient meets multiple criteria for antibiotic therapy:

• Facial swelling (diffuse swelling extending into cervicofacial tissues) 1, 2
• Likely systemic involvement given severity 1, 2
• Progressive infection requiring immediate intervention 1, 2

Treatment Duration and Monitoring

• 5 days is typically sufficient; avoid prolonged courses unless clinically indicated 1, 2
• Reassess at 2-3 days for resolution of fever, marked reduction in swelling, and improved function 1
• Failure to improve by 3-5 days suggests inadequate source control (abscess not drained), resistant organisms, or alternative diagnosis—do not simply extend antibiotics 1

Common Pitfalls to Avoid

• Never prescribe antibiotics without arranging urgent surgical intervention—this is the most critical error 1, 2
• Do not use plain amoxicillin for established abscesses with facial swelling; the infection likely involves beta-lactamase producers requiring amoxicillin-clavulanate 1, 5
• Avoid metronidazole monotherapy as it lacks coverage against facultative streptococci that are key pathogens 7
• Do not substitute two 250/125 mg tablets for one 500/125 mg tablet—they contain different amounts of clavulanate and are not interchangeable 4

Microbiology Context

• Odontogenic infections are typically polymicrobial, involving Streptococcus, Peptostreptococcus, Fusobacterium, Bacteroides, and Actinomyces species 7
• The mixed aerobic-anaerobic nature of these infections explains why broad-spectrum coverage with amoxicillin-clavulanate is superior to narrow-spectrum agents 5