What is the treatment for a tooth abscess?

Treatment of Tooth Abscess

The cornerstone of tooth abscess management is drainage through incision and drainage or definitive dental treatment (extraction or root canal therapy), with antibiotics indicated only for specific circumstances such as systemic symptoms, extensive cellulitis, or immunocompromised states. 1

Diagnosis and Assessment

• Radiographic evaluation:

  • Intraoral periapical X-ray is the diagnostic investigation of choice for suspected tooth abscess 2
  • If a fistula is present, diagnosis requires intraoral radiograph with a gutta-percha cone inserted inside the fistula 2
  • CBCT scans should be limited to suspect or unclear cases after traditional intraoral examination, not as first-line imaging 2

• Physical examination should assess:

  • Fluctuant masses, erythema, warmth
  • Signs of systemic infection
  • Laboratory studies (CBC, blood cultures) if systemic symptoms are present 1

Treatment Algorithm

1. Primary Dental Intervention

• Drainage is essential:

  • Extraction of the infected tooth, OR
  • Root canal therapy to remove infected pulp tissue 3
  • Incision and drainage of abscess if present 1

• Caution: Incomplete or inadequate canal debridement may increase risk for spread of endodontic infection 4

2. Antibiotic Therapy

• Indications for antibiotics:

  • Systemic symptoms (fever, malaise)
  • Extensive cellulitis
  • Immunocompromised patient
  • Spread of infection to fascial spaces 1

• First-line antibiotic regimen:

  • Amoxicillin-clavulanic acid (covers both aerobic and anaerobic organisms) 1, 3
  • Duration: 5-7 days for most dental infections 1

• For penicillin-allergic patients:

  • Clindamycin 300-450 mg PO TID (excellent activity against oral pathogens) 1
  • Doxycycline 100 mg PO BID (not for children <8 years or pregnant women) 1
  • Trimethoprim-sulfamethoxazole (limited activity against β-hemolytic streptococci) 1

3. Monitoring and Follow-up

• Reassessment after 48-72 hours for clinical improvement 1
• If no improvement after 2-3 days:
  • Consider second-line therapy (e.g., Clindamycin)
  • Reassess diagnosis
  • Consider specialist referral 1

Special Considerations

• Diabetic patients have higher risk for developing osteomyelitis following dental abscesses 5
• Primary tooth extraction during acute infection may be associated with higher risk of osteomyelitis compared to delayed extraction 5
• Unfinished root canal treatment is a major risk factor for hospitalization due to spread of odontogenic infection 4

Common Pathogens

• Predominant organisms in dental abscesses:
  • Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species 3, 6
  • Viridans streptococci are commonly isolated 7

Potential Complications

• Without proper treatment, tooth abscesses can lead to:
  • Spread of infection to adjacent tissues
  • Osteomyelitis of the jaw
  • Life-threatening complications including airway obstruction and septicemia 1

Prevention

• Regular dental check-ups
• Good oral hygiene practices
• Prompt treatment of dental caries and infections 1
• Complete and thorough root canal treatment when indicated 4

Remember that early and definitive treatment of the dental source of infection is crucial to prevent complications and reduce the need for prolonged antibiotic therapy.