Treatment of Dental Infections
The primary treatment for dental infections is surgical intervention (drainage, debridement, or extraction) followed by antibiotic therapy only when specific clinical criteria are met—antibiotics alone without source control are ineffective and contribute to resistance. 1, 2
Immediate Assessment and Source Control
Surgical management is the cornerstone of treatment and must be performed before or concurrent with antibiotic therapy. 1, 2
- For accessible dental abscesses, perform incision and drainage immediately 2
- For infected deciduous teeth, extract if there is extensive infection, high recurrence risk, or the tooth is near normal exfoliation 1
- For infected permanent teeth, endodontic treatment (root canal) is preferred over extraction when feasible 1
- Antibiotics added to proper surgical management show no statistically significant difference in pain or swelling outcomes compared to surgery alone 2
Critical pitfall: Never prescribe antibiotics as sole therapy without surgical source control—this is ineffective and promotes antimicrobial resistance. 1, 2
Antibiotic Therapy Indications
Prescribe systemic antibiotics ONLY when any of the following are present:
- Fever, malaise, or lymphadenopathy 2
- Systemic involvement or diffuse swelling 1
- Immunocompromised state (including HIV patients with CD4+ count <200/μL) 1
- Spreading cellulitis beyond the immediate dental area 3, 4
First-Line Antibiotic Regimen
For patients meeting criteria for antibiotics:
- Amoxicillin 500 mg orally three times daily for 5 days 1, 2, 5
- For inadequate response or more severe infections, consider amoxicillin-clavulanic acid 1
- For penicillin allergy: Clindamycin 300-450 mg orally three times daily 1, 2, 6
The amoxicillin regimen should be taken at the start of meals to minimize gastrointestinal intolerance 5. Clindamycin capsules should be taken with a full glass of water to avoid esophageal irritation 6.
Severe or Life-Threatening Infections
Refer immediately to oral surgeon or emergency department if:
- Spreading infection to facial spaces or neck 2, 3
- Airway compromise or trismus 3
- Signs of mediastinitis or cavernous sinus involvement 3
- Inability to swallow or maintain oral intake 2
For severe cases requiring hospitalization:
- Ampicillin-sulbactam 3 grams IV every 6 hours (preferred for excellent oral flora coverage) 2
- Clindamycin 600-900 mg IV every 6-8 hours (alternative, especially for penicillin allergy or MRSA concern) 2
- Limit IV antibiotics to 1-2 weeks maximum, transitioning to oral therapy once clinically stable 2
Supportive Care and Prevention
Daily oral hygiene protocol during active infection:
- Brush teeth at least twice daily with soft toothbrush 2
- Rinse mouth with alcohol-free mouthwash or sterile water/normal saline 4-6 times daily for 1 minute 2
- Avoid smoking, alcohol, and irritating foods (citrus, hot/spicy foods) 2
Important context: Poor oral hygiene and periodontal disease—not dental procedures—are responsible for the vast majority of oral infections 2, 7. Prevention through regular dental care is essential 8.
Special Populations
HIV-positive patients:
- Do not require routine antibiotic prophylaxis based solely on HIV status 9
- Prescribe antibiotics using the same criteria as immunocompetent patients, but maintain lower threshold when CD4+ count <200/μL 1
- Consult with HIV care provider for patients with advanced AIDS 1
- Universal precautions should be applied to all dental patients regardless of known HIV status 9
Duration and Follow-Up
- Continue treatment for minimum 48-72 hours beyond resolution of symptoms 5
- For streptococcal infections, treat for at least 10 days to prevent acute rheumatic fever 5
- Clinical and bacteriological follow-up may be necessary for several months after cessation of therapy 5
Avoid fluoroquinolones for dental infections due to unclear efficacy against oral flora and promotion of antimicrobial resistance 2.