What is the best treatment approach for a resistant dental abscess?

From the Guidelines

The best treatment approach for a resistant dental abscess is incision and drainage, followed by antibiotic therapy with clindamycin (300-450 mg PO TID) or TMP-SMX (1-2 DS tab PO BID), as recommended by the Infectious Diseases Society of America guidelines 1.

Treatment Approach

The primary intervention for a resistant dental abscess should be incision and drainage, which allows for immediate pressure relief and removal of purulent material. This procedure is crucial in reducing the bacterial load and promoting healing.

• Incision and drainage is likely adequate for most simple abscesses, with high cure rates (85%–90%) whether or not an active antibiotic is used 1.
• Antibiotic therapy is recommended for abscesses associated with conditions such as severe or extensive disease, systemic toxicity, or rapid progression despite receipt of appropriate oral antibiotics.

Antibiotic Therapy

The choice of antibiotic therapy should be guided by the severity of the infection and the presence of any underlying medical conditions.

• Clindamycin (300-450 mg PO TID) is a recommended option for the treatment of resistant dental abscesses, as it provides coverage for both b-hemolytic streptococci and CA-MRSA 1.
• TMP-SMX (1-2 DS tab PO BID) is another option, although its activity against b-hemolytic streptococci is not well-defined 1.
• Other antibiotics, such as doxycycline (100 mg PO BID) and minocycline (200 mg 3 1, then 100 mg PO BID), may also be effective, but their use should be guided by local epidemiology and the type of SSTI.

Additional Considerations

• Pain management with acetaminophen or ibuprofen is important during recovery.
• Patients should maintain good oral hygiene and use warm salt water rinses (1/2 teaspoon salt in 8 ounces of warm water) 4-6 times daily to promote healing.
• If symptoms worsen or don't improve within 48-72 hours of treatment, the patient should seek immediate follow-up care as this may indicate spreading infection or the need for culture-guided antibiotic adjustment.

From the FDA Drug Label

Metronidazole has been shown to have in vitro and clinical activity against the following organisms: Anaerobic gram negative bacilli, including: Bacteroides species, including the Bacteroides fragilis group A bacterial isolate may be considered susceptible if the MIC value for metronidazole is not more than 16 mcg/mL. An organism is considered resistant if the MIC is greater than 16 mcg/mL Clindamycin hydrochloride should be prescribed with caution in individuals with a history of gastrointestinal disease, particularly colitis. Clindamycin dosage modification is not necessary in patients with renal disease In patients with moderate to severe liver disease, prolongation of clindamycin half-life has been found.

The best treatment approach for a resistant dental abscess is to use clindamycin as it is effective against a wide range of anaerobic bacteria, which are often the cause of dental abscesses.

• Key considerations:
  • Dose adjustment: may not be necessary in patients with renal disease, but caution should be exercised in patients with liver disease.
  • Monitoring: periodic liver and kidney function tests and blood counts should be performed during prolonged therapy.
  • Potential interactions: clindamycin may interact with other medications, such as neuromuscular blocking agents, and its metabolism may be affected by CYP3A4 inhibitors or inducers 2. It is essential to note that metronidazole may not be effective against all strains of bacteria that cause dental abscesses, particularly if the MIC value is greater than 16 mcg/mL 3.

From the Research

Treatment Approaches for Resistant Dental Abscess

• The treatment of resistant dental abscess typically involves a combination of surgical drainage and adjunctive antibiotics 4.
• A study comparing amoxicillin/clavulanic acid to clindamycin for the treatment of odontogenic infections found that amoxicillin/clavulanic acid was comparable to clindamycin in achieving clinical success 4.
• However, another study suggested that systemic antibiotics may only be recommended for situations where there is evidence of spreading infection or systemic involvement, and that their use in the absence of these signs could contribute to the development of antibiotic-resistant bacteria 5.

Antibiotic Options

• Amoxicillin/clavulanic acid is a broad-spectrum antibacterial that has been used for over 20 years in the treatment of community-acquired respiratory tract infections, and may be effective in the treatment of resistant dental abscess 6.
• Clindamycin is another antibiotic that has been used in the treatment of odontogenic infections, and may be effective in cases where amoxicillin/clavulanic acid is not suitable 4.
• Phenoxymethylpenicillin (penicillin VK) has also been used in the treatment of acute apical abscess or symptomatic necrotic tooth, but its effectiveness is uncertain 5.

Clinical Guidelines

• The American Dental Association has published clinical practice guidelines on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling, which recommend against using antibiotics in most clinical scenarios, except in cases of systemic involvement or high risk of progression to systemic involvement 7.
• A review of the literature on the management of acute dentoalveolar abscesses suggested that antibiotics should only be prescribed when necessary, and that the choice of antibiotic should be based on evidence-based guidelines 8.