What treatment should be given for a patient with an infected tooth?

Treatment of an Infected Tooth

For an infected tooth, surgical intervention (drainage, root canal therapy, or extraction) is the primary treatment and must be performed first; antibiotics should only be added when systemic signs (fever, malaise, lymphadenopathy) are present or in immunocompromised patients. 1, 2, 3

Primary Treatment: Surgical Management

The cornerstone of treating dental infections is mechanical intervention, not antibiotics:

• Perform incision and drainage for accessible abscesses to remove the source of infection and establish drainage 1, 3
• Root canal therapy is preferred for restorable teeth with adequate crown structure and periodontal health 3
• Extract non-restorable teeth with extensive caries, severe crown destruction, or failed previous endodontic treatment 2, 3
• Surgical intervention must precede antibiotic therapy - antibiotics alone cannot eliminate the infection source and are ineffective without mechanical debridement 1, 2, 3

Critical Evidence on Surgery vs. Antibiotics

• Adding antibiotics to proper surgical management shows no statistically significant difference in pain or swelling outcomes compared to surgery alone 1
• Immediate extraction in the setting of acute infection results in faster resolution, decreased pain, and earlier return of function 4

When to Prescribe Antibiotics

Antibiotics should be prescribed systemically (oral tablets/capsules) only in these specific situations:

Indications for Antibiotic Therapy

• Presence of fever, malaise, or lymphadenopathy indicating systemic involvement 1, 2, 3
• Immunocompromised patients or those with metabolic disorders 2, 5
• Diffuse swelling that cannot be drained effectively or extends into facial/cervicofacial spaces 2, 3
• Failure to respond to surgical treatment alone after appropriate intervention 3

Antibiotic Selection and Dosing

First-Line Antibiotic

• Amoxicillin 500 mg three times daily for 5 days is the first-line choice 1, 2, 6
• Amoxicillin provides excellent coverage against the gram-positive anaerobic and facultative bacteria that cause most odontogenic infections 5, 7

For Penicillin Allergy

• Clindamycin 300-450 mg three times daily is the preferred alternative 1, 8
• Clindamycin has excellent anaerobic and streptococcal coverage 1

For Severe or Refractory Infections

• Amoxicillin-clavulanic acid (Augmentin) should be used when inadequate response to amoxicillin alone 2, 9
• Consider IV antibiotics for severe cases with spreading infection: ampicillin-sulbactam 3 grams IV every 6 hours or clindamycin 600-900 mg IV every 6-8 hours 1

Duration of Antibiotic Therapy

• Limit oral antibiotics to 5 days for uncomplicated infections 1, 2
• Continue antibiotics only until clinical stability is achieved, not beyond what is necessary for soft tissue stabilization 1
• For IV antibiotics, limit to 1-2 weeks maximum and transition to oral as soon as the patient shows clinical improvement 1

Supportive Care and Oral Hygiene

While surgical intervention proceeds:

• Rinse mouth with alcohol-free mouthwash, sterile water, or normal saline 4-6 times daily for approximately 1 minute 1
• Brush teeth at least twice daily with a soft toothbrush using proper technique 1
• Avoid smoking, alcohol, and irritating foods (tomatoes, citrus, hot/spicy foods) during active infection 1

Critical Pitfalls to Avoid

Most Common Error

• Never prescribe antibiotics without surgical intervention - this is ineffective and contributes to antibiotic resistance 1, 2, 3
• Antibiotics cannot eliminate the source of infection without mechanical debridement 1

Other Important Considerations

• Do not use fluoroquinolones for dental infections due to unclear efficacy against oral flora and promotion of antimicrobial resistance 1
• Do not delay surgical drainage in favor of antibiotic therapy alone 3
• Do not prescribe antibiotics for localized infections without systemic signs that can be adequately drained 10

When to Escalate Care

Refer immediately to oral surgeon or emergency department if:

• Spreading infection develops beyond the local area 1
• Systemic illness with high fever or sepsis signs appears 1
• Airway compromise is threatened by cervicofacial swelling 2

Evidence Quality Note

The recommendation prioritizing surgical intervention over antibiotics is supported by multiple high-quality guidelines from the American Dental Association, American Association of Oral and Maxillofacial Surgeons, and American College of Surgeons 1, 2, 3. A systematic review of 2,197 dental infection cases showed that once drainage is performed and the cause removed, all antibiotics tested are equally effective, confirming that local intervention is more critical than antibiotic choice 10.