What antibiotics should you give for dental caries, cavities, or abscesses?

First, a quick view of the landscape:

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As a doctor, there are several kinds of dental infections you should be aware of:

  • Caries (cavities): we’ve all had them. They usually look like a brown/black spot on the tooth surface.
  • Pulpitis: someone may describe a severe toothache that can be elicited by temperature changes, especially cold drinks, and the tooth may be sensitive to touch. As the infection gets worse, so does the pain.
  • Gingivitis: infection of the gums. The appearance includes swelling, bluish purple discoloration of the gums, and bleeding after eating or brushing. The only kind of gingivitis that can’t be treated with a little chlorhexidine swish-and-spit is acute necrotizing ulcerative gingivitis which is pretty scary.
  • Periodontal abscess: a red, fluid-filled swollen area around the gingiva, VERY tender so be gentle! Usually you can see pus coming out.

If it looks like caries or pulpitis, you can get a Panorex to see if the teeth are restorable (can get fillings) or need to come out.

Beware infections that can extend into fascial spaces and cause infections in the head and neck or osteomyelitis, of the jaw. Be concerned if a patient has trismus: clamping the mouth shut, difficulty opening the mouth. This indicates pressure on or infection of the masseter or pterygoids, or the motor branch of the trigeminal nerve (CN V3). You need to start thinking about things like purulent meningitis, subdural empyema, or mediastinitis.

How could these infections be treated? 

The first thing to ask yourself is, is there visible pus and possible abscess? Does the patient have fever, swollen lymph nodes, or possible involvement of soft tissue or bone? If the answer is yes, antibiotics are helpful–if these features are not present, you could consider using antibiotics but they’ll be less helpful.

Which antibiotics? Depends on what you’re trying to cover. The mouth is a zoo of oral flora including Strep species, Actinomyces, fusiform bacteria and more. In patients with mild infections, a course of Augmentin may be sufficient. Regimens like Unasyn or penicillin + IV flagyl are being recommended for more serious infections, and patients should be transitioned to a PO regimen for 1-2 weeks afterwards.