What is the recommended management for a patient with a tooth infection, and are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) an appropriate treatment option?

Management of Tooth Infections in Adults

Surgical intervention—not antibiotics—is the primary treatment for tooth infections, with antibiotics reserved only for specific high-risk situations. 1, 2

Primary Treatment Algorithm

Surgical management must be performed first and includes the following options based on tooth restorability 1, 2:

• Root canal therapy for salvageable teeth with adequate crown structure and periodontal health 2
• Tooth extraction for non-restorable teeth with extensive caries, severe crown destruction, or failed previous endodontic treatment 2
• Incision and drainage for accessible abscesses, particularly acute dentoalveolar abscesses 1

The evidence is clear: antibiotics added to proper surgical management show no statistically significant differences in pain or swelling outcomes compared to surgical treatment alone 1. This finding comes from systematic reviews showing that penicillin versus placebo (both with surgical intervention) produced no differences in participant-reported pain or swelling at any time point 1.

When Antibiotics Are Indicated

Antibiotics should only be added to surgical management in these specific situations 1, 2, 3:

• Systemic involvement: fever, malaise, lymphadenopathy, or cellulitis 1, 2, 3
• Medically compromised patients: immunosuppression, uncontrolled diabetes, or other significant comorbidities 1
• Progressive infections: diffuse swelling that cannot be adequately drained 1, 3
• Deep space involvement: trismus, floor of mouth elevation, dysphagia, or respiratory compromise indicating cervicofacial extension 3
• Infections extending into facial spaces or cervicofacial tissues requiring treatment as necrotizing fasciitis 1

Antibiotic Selection When Indicated

First-line antibiotic: Amoxicillin 500 mg three times daily for 5 days, in combination with surgical management 3

Second-line options 3:

• Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days for treatment failure or enhanced anaerobic coverage
• Clindamycin 300-450 mg three times daily for penicillin allergy

First-choice for severe cases requiring parenteral therapy: Phenoxymethylpenicillin 1

The European Society of Endodontology specifically states that antibiotics should not be used for acute apical periodontitis, acute apical abscesses, or irreversible pulpitis without the systemic features listed above 1.

NSAIDs for Pain Management

Yes, NSAIDs are appropriate and should be the primary analgesic for dental infections. 1, 4, 5

Pain management should be addressed regardless of antibiotic use, especially during the first 24 hours 1. NSAIDs provide effective analgesia for dental pain without the risks of opioid overprescribing 5.

NSAID Options and Considerations

Topical NSAIDs may be superior to oral NSAIDs for initial symptom relief 4:

• Topical benzydamine showed significantly greater improvement in oral health-related quality of life compared to oral diclofenac and oral flurbiprofen during the first four days of treatment for pericoronitis 4
• Significant initial improvement occurred on day 1 for benzydamine versus day 2-3 for oral NSAIDs 4

Important NSAID safety considerations 6:

• NSAIDs can cause serious gastrointestinal adverse events including ulceration, bleeding, and perforation at any time, which can be fatal 6
• Risk increases with longer duration of use, concomitant corticosteroids or anticoagulants, smoking, alcohol use, older age, and poor general health 6
• Use the lowest effective dose for the shortest possible duration 6
• Avoid in late pregnancy due to risk of premature ductus arteriosus closure 6
• May increase risk of cardiovascular events with longer use, especially in patients with heart disease 6

Critical Pitfalls to Avoid

Never prescribe antibiotics without surgical intervention—this is ineffective and contributes to antibiotic resistance 2, 7. The systematic review evidence demonstrates that once drainage is performed and/or the cause of infection is removed, the choice of antibiotic matters far less than the local intervention procedure itself 7.

Do not use antibiotics as monotherapy for 1:

• Chronic periodontitis (unless as adjunct to scaling and root planing with specific low-dose doxycycline regimen) 1
• Peri-implantitis 1
• Irreversible pulpitis 1

Limit antibiotic duration to 5-7 days maximum with adequate source control 3, 7. Studies show that antibiotics should be used for the shortest time possible until clinical cure is achieved 7.

Follow-up Requirements

Re-evaluate within 48-72 hours to ensure resolution of swelling and pain 3. If no improvement occurs despite appropriate surgical and antibiotic management, consider 3:

• CT imaging to evaluate for deep space abscess, osteonecrosis, or other complications
• Referral to oral surgeon or emergency department for spreading infection or systemic illness