What is the management of a dental abscess in the Emergency Room (ER) setting?

From the Guidelines

The management of a dental abscess in the ER setting should focus on surgical intervention, such as incision and drainage, rather than antibiotic therapy as the primary treatment. This approach is supported by recent guidelines, including those from the European Society of Endodontology (2018) 1, which recommend surgical drainage as the key treatment for acute apical abscesses, with adjunctive antibiotics only considered in specific patient groups, such as those with systemic involvement or medically compromised patients.

In the ER setting, the initial approach to a dental abscess should include:

• Administration of appropriate analgesics, such as ibuprofen 400-600mg every 6 hours or acetaminophen 500-1000mg every 6 hours, for pain relief
• Surgical intervention, such as incision and drainage, to relieve pressure and remove purulent material
• Consideration of adjunctive antibiotic therapy, such as amoxicillin, only in cases with systemic symptoms, diffuse swelling, or in patients with medical indications, as recommended by the Canadian Collaboration on Clinical Practice Guidelines in Dentistry (2004) 1

It is essential to note that antibiotics should not be used as the primary treatment for dental abscesses, as stated by the Medecins sans frontieres guidelines (2019) 1, which recommend surgical treatment, such as root canal therapy or extraction of the tooth, as the primary approach. Patients should be instructed to maintain good oral hygiene, rinse with warm salt water several times daily, and elevate their head while sleeping to reduce swelling. Most importantly, all patients require prompt dental follow-up within 24-48 hours for definitive treatment, as surgical intervention and antibiotics are temporary measures, and the underlying cause must be addressed by a dentist to prevent recurrence and complications.

From the Research

Management of Dental Abscess in the ER Setting

• Dental abscesses are commonly evaluated and managed in the emergency department, with recent research evaluating the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics 2
• The management of dental abscesses in the ER setting typically involves clinical examination alone, but ultrasound may be a useful adjunct 2
• Incision and drainage (I&D) is a common procedure for managing dental abscesses, but the use of antibiotics is only recommended in certain situations, such as evidence of spreading infection or systemic involvement 3, 4

Use of Antibiotics in Dental Abscess Management

• The use of systemic antibiotics for symptomatic apical periodontitis and acute apical abscess is only recommended when there is evidence of spreading infection or systemic involvement 3, 4
• The American Dental Association recommends against using antibiotics in most clinical scenarios, irrespective of the availability of definitive, conservative dental treatment (DCDT) 4
• A systematic review found that narrow-spectrum antibiotics appear to be as effective as broad-spectrum antibiotics in the management of acute dentoalveolar infections 5

ER Setting Management Strategies

• Emergency physicians should be comfortable treating most dental and related infections, and should prioritize immediate DCDT in all cases 6
• The management of dental abscesses in the ER setting should involve a thorough clinical examination, and the use of ultrasound and I&D as needed 2
• Antibiotics should only be used in certain situations, such as evidence of spreading infection or systemic involvement, and narrow-spectrum antibiotics may be preferred over broad-spectrum antibiotics 3, 4, 5