What is the appropriate first‑line treatment for dental pain associated with a swollen cheek?

Treatment of Dental Pain with Swollen Cheek

Immediate surgical drainage (incision and drainage, root canal therapy, or tooth extraction) is the essential first-line treatment for dental pain with a swollen cheek; antibiotics are adjuncts reserved only for patients with systemic signs (fever, tachycardia, malaise) or spreading infection (cellulitis, diffuse facial swelling). 1

Primary Treatment Algorithm

Step 1: Assess for Surgical Intervention (Required in All Cases)

• Perform definitive surgical source control immediately—this is the cornerstone of treatment and must not be delayed 1
• Options include:
  • Incision and drainage for accessible abscesses 1
  • Root canal therapy for salvageable teeth 1
  • Extraction for non-restorable teeth 1

Step 2: Determine Need for Antibiotics

Antibiotics should be added ONLY when:

• Systemic signs are present: fever, tachycardia, tachypnea, elevated white blood cell count, or malaise 1
• Evidence of spreading infection: cellulitis, diffuse facial swelling, or rapidly progressing infection 1
• Patient is immunocompromised or medically compromised (diabetes, chronic cardiac/hepatic/renal disease, age >65 years) 1
• Infection extends into cervicofacial soft tissues 1

Do NOT prescribe antibiotics when:

• The abscess is localized without systemic symptoms—surgical drainage alone is sufficient 1
• Multiple systematic reviews demonstrate no statistically significant benefit in pain or swelling outcomes when antibiotics are added to adequate surgical treatment in localized infections 1

Antibiotic Selection (When Indicated)

First-Line Oral Regimen

• Amoxicillin 500 mg orally three times daily for 5 days (or 875 mg twice daily) 1
• Alternative: Phenoxymethylpenicillin (Penicillin V) 500 mg four times daily for 5 days 1, 2

For Penicillin-Allergic Patients

• Clindamycin 300–450 mg orally three times daily for 5–7 days 1, 2
• Clindamycin provides excellent coverage of oral anaerobes but carries higher risk of Clostridioides difficile infection 1

Second-Line Options (Specific Indications Only)

Amoxicillin-clavulanate (875 mg/125 mg twice daily) should be reserved for:

• Recent antibiotic use within the past month 1
• Prior treatment failure with amoxicillin 1
• Moderate to severe infection with systemic toxicity 1
• Age >65 years 1
• Rapidly spreading cellulitis 1

Severe Infections Requiring Hospitalization

• Ampicillin-sulbactam 1.5–3.0 g IV every 6 hours is the preferred single-agent regimen for severe odontogenic infections with systemic involvement 1
• Alternative: Ceftriaxone 1 g IV every 24 hours plus metronidazole 500 mg IV every 8 hours 1

Pain Management

Analgesic Therapy

• Ibuprofen 400–600 mg orally every 6–8 hours for pain control 3
• Ibuprofen provides both analgesic and anti-inflammatory effects through prostaglandin synthetase inhibition 3
• Consider acetaminophen (paracetamol) as maintenance therapy in combination with ibuprofen 4

Topical Measures

• Benzydamine hydrochloride oral rinse every 3 hours, particularly before eating, for localized pain relief 4
• Viscous lidocaine 2% (15 mL per application) may be used as a topical anesthetic alternative 4

Common Pitfalls to Avoid

Antibiotic Overuse

• The 2018 Cope randomized trial demonstrated no significant difference in pain or swelling between penicillin versus placebo when both groups received surgical intervention 1
• Prescribing antibiotics for localized abscesses without systemic signs provides no clinical benefit and increases resistance risk 1

Inadequate Surgical Management

• Antibiotics cannot substitute for definitive surgical source control 1, 5
• If no clinical improvement occurs within 48–72 hours, reassess for inadequate drainage rather than simply changing antibiotics 1

Inappropriate Antibiotic Selection

• Avoid fluoroquinolones—they lack adequate activity against typical odontogenic pathogens 1
• Never use metronidazole alone—it does not cover facultative and aerobic gram-positive cocci; it may only be added to amoxicillin for documented treatment failures 1, 2
• Macrolides (erythromycin, azithromycin) have high resistance rates (>40%) and should not be used routinely 1

Treatment Duration

• 5–7 days of antibiotic therapy is sufficient when adequate surgical source control is achieved 1
• Extending therapy beyond this duration does not improve outcomes and increases adverse event risk 1

Follow-Up Criteria

• Clinical improvement (reduction of pain, swelling, systemic signs) should be evident within 48–72 hours after surgical drainage with or without antibiotics 1
• If the abscess has not reduced in size within 4 weeks after initial drainage, repeat surgical intervention is almost always required 1