What is the recommended treatment for a tooth infection?

Treatment for Tooth Infection

Surgical intervention—including root canal therapy for salvageable teeth, extraction for non-restorable teeth, or incision and drainage for accessible abscesses—is the mandatory first-line treatment for tooth infections, with antibiotics reserved only for cases with systemic involvement (fever, malaise, lymphadenopathy), immunocompromised patients, or diffuse swelling extending into facial spaces. 1, 2

Primary Treatment: Surgical Management

The cornerstone of treating any tooth infection is removing the source of infection through surgical means 1, 2:

• Root canal therapy is indicated when the tooth is restorable, periodontally sound, has adequate crown structure remaining, and this is the first endodontic intervention 1
• Extraction is appropriate when the tooth is non-restorable due to extensive caries, severe crown destruction, structural compromise, severe periodontal disease, or failed previous endodontic treatment 1
• Incision and drainage should be performed for accessible abscesses to establish drainage 1
• Acute dental abscesses require immediate surgical intervention 1

Critical point: Adding antibiotics to proper surgical management has not shown statistically significant differences in pain or swelling outcomes 1. Antibiotics alone are ineffective because they do not eliminate the source of infection 1, 2, 3.

When Antibiotics Are Indicated

Antibiotics should be added to surgical treatment only in specific circumstances 1, 2, 3:

Systemic Involvement

• Fever, malaise, or constitutional symptoms 1, 3
• Lymphadenopathy 1, 3

Anatomic Spread

• Infections extending into facial spaces or cervicofacial tissues 1, 2
• Diffuse swelling that cannot be drained effectively 1, 2
• Cellulitis 3

Patient Factors

• Immunocompromised patients 2, 3
• Medically compromised patients 1
• Failure to respond to surgical treatment alone 1

Severe Cases Requiring Hospitalization

• Airway compromise 3
• Inability to maintain oral intake 3
• Signs of deep space infection 3

Antibiotic Selection and Dosing

First-Line Antibiotic: Amoxicillin

Amoxicillin 500 mg orally three times daily for 5 days is the preferred first-line agent for odontogenic infections with systemic involvement 2, 3, 4:

• Safe, highly effective, and inexpensive 5
• Should be taken at the start of a meal to minimize gastrointestinal intolerance 4
• Treatment should continue for a minimum of 48 to 72 hours beyond when the patient becomes asymptomatic 4

Second-Line Option: Amoxicillin-Clavulanic Acid

• Use when there is inadequate response to amoxicillin alone 2
• Provides broader coverage including penicillinase-producing organisms 6

Penicillin Allergy: Clindamycin

Clindamycin is the recommended alternative for patients with penicillin allergy 2, 3:

• Adults: 150 to 300 mg every 6 hours for serious infections; 300 to 450 mg every 6 hours for more severe infections 7
• Very effective against all odontogenic pathogens 5
• Should be taken with a full glass of water to avoid esophageal irritation 7
• Warning: If significant diarrhea occurs during therapy, discontinue immediately due to risk of antibiotic-associated colitis 7

Agents to Avoid

• Erythromycin has high incidence of gastrointestinal disturbances and is less effective than clindamycin for penicillin-allergic patients 5
• Fluoroquinolones and vancomycin should be avoided for routine dental infections due to unclear efficacy and resistance concerns 3
• Metronidazole alone should not be used as monotherapy because it is only moderately effective against facultative and anaerobic gram-positive cocci 5

Common Pitfalls to Avoid

The Most Critical Error

Never prescribe antibiotics without surgical intervention 1, 2, 3:

• This approach is ineffective and contributes to antibiotic resistance 1
• Antibiotics cannot substitute for proper surgical management 1, 3
• The source of infection must be removed through drainage or definitive dental treatment 3

Other Important Considerations

• Do not extract a restorable tooth solely because the patient has anxiety—root canal therapy generates lower anxiety levels than extraction among patients who have experienced both procedures 1
• Ensure adequate source control through incision and drainage or extraction of the offending tooth before or concurrent with antibiotic therapy 3
• For β-hemolytic streptococcal infections, treatment should continue for at least 10 days to prevent acute rheumatic fever 4, 7

Renal Impairment Dosing

For patients with severe renal impairment receiving amoxicillin 4:

• GFR 10 to 30 mL/min: 500 mg or 250 mg every 12 hours
• GFR less than 10 mL/min: 500 mg or 250 mg every 24 hours
• Hemodialysis: 500 mg or 250 mg every 24 hours, with an additional dose during and at the end of dialysis