What to do for a chipped tooth with possible infection?

Management of a Chipped Tooth with Possible Infection

A chipped tooth with signs of possible infection requires immediate dental referral for definitive treatment, which is surgical intervention (drainage, debridement, or extraction) as the primary therapy, with antibiotics reserved only for cases showing systemic involvement, immunocompromise, or diffuse swelling. 1, 2

Immediate Assessment and Triage

Determine the type of tooth and fracture severity:

• For primary (baby) teeth: Assess if the chip involves pulp exposure (visible pink/red tissue or bleeding from the tooth center) 3

  • Uncomplicated crown fracture (no pulp exposure): Smooth sharp edges, obtain dental radiograph to rule out root fracture, and refer to dentist within days 3
  • Complicated crown fracture (pulp exposure): Requires immediate dental referral for pulp treatment or extraction 3

• For permanent teeth: Same assessment applies, but preservation is prioritized 3

  • Uncomplicated fractures: Restore tooth and smooth edges 3
  • Complicated fractures: Require pulp treatment (root canal) and restoration 3

Signs of Infection Requiring Urgent Action

Look for these specific indicators that mandate immediate dental referral:

• Gingival swelling adjacent to the affected tooth 3
• Parulis (gum boil/gingival abscess) near the tooth root 3
• Gray discoloration of the tooth (indicates pulpal necrosis) 3
• Fever, lymphadenopathy, or systemic symptoms 1, 2
• Diffuse facial swelling or extension to cervicofacial tissues 1, 2
• Increased tooth mobility 3

Treatment Algorithm

Primary treatment is always surgical, not antibiotics:

1. Immediate dental referral for surgical source control (drainage, debridement, or extraction) 1, 2
2. Do NOT prescribe antibiotics as sole therapy - this is a critical pitfall 1, 2
3. Reserve antibiotics only for:
   • Systemic involvement (fever, lymphadenopathy) 1, 2
   • Immunocompromised patients 1, 2
   • Diffuse swelling extending beyond the immediate tooth area 1, 2

If antibiotics are indicated after surgical intervention:

• First-line: Amoxicillin 500 mg orally three times daily for 5 days 1, 2
• For inadequate response: Amoxicillin-clavulanic acid 1, 2
• Penicillin allergy: Clindamycin 1, 2

Timing of Extraction

Contrary to traditional teaching, infected teeth should be extracted immediately, not delayed:

• Immediate extraction in the presence of acute infection results in faster resolution, decreased pain, and earlier return of function 4, 5
• The risk of spreading infection to deeper spaces by immediate extraction is low 5
• Delaying extraction while giving antibiotics is not evidence-based and prolongs patient suffering 4, 5

Pre-Dental Referral Management

While awaiting dental care (same-day referral):

• Soft diet for comfort 3
• Analgesics as needed for pain control 6
• Chlorhexidine rinses if available 6
• Do NOT prescribe antibiotics without surgical source control 1, 2

Critical Pitfalls to Avoid

• Never prescribe antibiotics without surgical intervention - this is the most common error 1, 2
• Never delay extraction in the presence of acute infection while waiting for antibiotics to "work" 4, 5
• Never assume a chipped tooth is benign - always assess for pulp exposure and infection 3
• Never replant an avulsed primary tooth (if the tooth fell out completely) - this can damage the developing permanent tooth 3

Special Considerations

For primary teeth near natural exfoliation: Extraction is often preferred over complex treatment if the tooth interferes with function or shows recurrent infection 3, 2

For permanent teeth: Endodontic treatment (root canal) is preferred over extraction when feasible to preserve the tooth 3, 2