What antibiotics are recommended for a tooth infection?

Antibiotic Treatment for Tooth Infections

Amoxicillin 500 mg orally three times daily for 5-7 days is the first-line antibiotic for dental infections requiring antimicrobial therapy, but only as adjunctive treatment following surgical intervention (drainage or extraction). 1, 2

Critical First Principle: Surgery Before Antibiotics

• Surgical intervention (drainage, extraction, or debridement) is the primary treatment for dental infections—antibiotics serve only as adjunctive therapy and should never be prescribed alone. 1, 2, 3
• Prescribing antibiotics without ensuring proper surgical source control is the most common error leading to treatment failure. 1, 2
• For acute dental abscesses without systemic involvement, surgical drainage alone without antibiotics is often sufficient. 1

First-Line Antibiotic Regimen

• Amoxicillin 500 mg orally three times daily for 5-7 days is the recommended first-line antibiotic when antimicrobial therapy is indicated. 1, 2, 3, 4
• Phenoxymethylpenicillin (penicillin V) 500 mg orally 2-4 times daily is an acceptable alternative first-line option per European guidelines. 1, 3
• A 5-day course is typically sufficient—unnecessarily prolonged antibiotic courses should be avoided. 1, 2, 3

When to Escalate to Amoxicillin-Clavulanate

• For more severe infections or inadequate response to amoxicillin alone, use amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days. 1, 2, 3
• An alternative dosing regimen is amoxicillin-clavulanate 625 mg three times daily for 5-7 days. 3
• This combination is particularly useful when beta-lactamase producing organisms are suspected or for more complex infections. 1

Management of Penicillin-Allergic Patients

• Clindamycin 300-400 mg orally three times daily is the preferred alternative for penicillin-allergic patients. 1, 2, 3
• For non-type I (non-anaphylactic) penicillin hypersensitivity, combination therapy with clindamycin plus a third-generation oral cephalosporin (cefixime or cefpodoxime) can be considered. 1, 2
• Doxycycline or respiratory fluoroquinolones (levofloxacin or moxifloxacin) are additional alternatives, though less commonly recommended for dental infections. 1, 2

Clear Indications for Antibiotic Therapy

Antibiotics are strongly indicated when any of the following are present:

• Systemic involvement: fever, lymphadenopathy, malaise, or elevated white blood cell count. 1, 2, 3
• Diffuse swelling or rapidly spreading cellulitis that cannot be adequately drained. 1, 2, 3
• Progressive infections extending into cervicofacial soft tissues (Ludwig's angina, submandibular space involvement). 1, 3
• Immunocompromised status or medically compromised patients at higher risk for complications. 1, 2, 3

Reassessment and Treatment Failure

• Reassess patients at 48-72 hours for resolution of fever, marked reduction in swelling, and improved trismus and function. 1, 3
• If no improvement by 3-5 days, investigate for inadequate source control, resistant organisms, or alternative diagnoses rather than simply extending antibiotics. 1, 3
• Failure to improve usually indicates inadequate surgical drainage, not antibiotic failure—verify that proper surgical intervention has been performed. 1, 2, 3

Management of Treatment Failure

• For patients who have failed previous antibiotic therapy with adequate surgical drainage, consider a fluoroquinolone (levofloxacin or moxifloxacin) combined with metronidazole as the next-line regimen. 2
• For hospitalized patients with suspected MRSA or severe infection, vancomycin, linezolid, or daptomycin may be considered. 1, 2
• Consider hospitalization if the patient has systemic toxicity, rapidly spreading cellulitis, extension into cervicofacial soft tissues, or immunocompromised status. 2

Critical Pitfalls to Avoid

• Never prescribe antibiotics without ensuring surgical intervention has been performed or is planned immediately—this is the primary cause of treatment failure. 1, 2, 3
• Do not use metronidazole alone, as it lacks activity against facultative streptococci and aerobic organisms commonly present in dental infections. 1, 2
• Avoid prescribing antibiotics for conditions requiring only surgical management, such as acute apical periodontitis and irreversible pulpitis. 1, 3
• Do not delay necessary surgical intervention while relying solely on antibiotics. 1
• Avoid unnecessarily prolonged antibiotic courses when 5 days is typically sufficient. 1, 2, 3