Treatment of Dental Abscess
The primary treatment for dental abscess is surgical intervention (root canal therapy or extraction of the tooth), with antibiotics reserved only for specific circumstances such as systemic involvement or medically compromised patients. 1
Types of Dental Abscesses and Primary Treatment
- Acute dental abscess: Treatment is exclusively surgical - root canal therapy or extraction of the tooth 1
- Acute dentoalveolar abscess: Incision and drainage is the primary treatment, followed by amoxicillin for 5 days only if necessary 1
- Infections extending to underlying soft tissues: Tooth extraction and treatment as necrotizing fasciitis 1
Evidence-Based Treatment Algorithm
Step 1: Surgical Management (First-Line)
- Perform surgical drainage through root canal therapy, extraction, or incision and drainage 1
- Multiple studies show no statistically significant differences in pain or swelling outcomes when antibiotics are added to surgical treatment 1
- If treated with antibiotics alone, the infection will not resolve and will become progressively worse 2
Step 2: Consider Antibiotics Only If:
- Patient has systemic complications (fever, lymphadenopathy, cellulitis) 1
- Patient is medically compromised 1
- Patient has diffuse swelling 1
- Infection is extending into cervicofacial tissues 1
Step 3: Antibiotic Selection (When Indicated)
- First choice: Phenoxymethylpenicillin (for patients with systemic involvement or who are medically compromised) 1
- Alternative: Amoxicillin for 5 days (for dentoalveolar abscesses requiring antibiotics) 1
- No specific antibiotic has been shown to be superior over another 1
Microbiology and Pathophysiology
- Dental abscesses are polymicrobial infections, comprising both strict anaerobes (Prevotella, Fusobacterium) and facultative anaerobes (viridans group streptococci) 3, 4
- The multispecies bacterial community is dominated by anaerobic bacteria 3
- Species richness and interactions among community members may affect pathogenicity and contribute to acute infection development 3
Important Considerations and Pitfalls
- Common pitfall: Treating with antibiotics alone without surgical intervention - this approach will not resolve the infection 2
- Avoid unnecessary antibiotic use: Studies show 74.4% of antibiotics prescribed for dental problems may be unnecessary 5
- For acute apical abscess, mechanical treatment (drainage) should always be the first step 5
- Dental abscesses can potentially lead to severe complications including airway obstruction and septicemia if infection spreads beyond the confines of the jaws 2
- Prompt assessment and referral to a specialist is required for cases at risk of airway compromise 2
Special Situations
- Chronic periodontitis: Do not use antimicrobials for chronic periodontitis or peri-implantitis 1
- Irreversible pulpitis: Do not use antibiotics for treatment 1
- Dental implant-associated abscess: May require specific management during maintenance phase 6
By following this evidence-based approach, clinicians can effectively manage dental abscesses while minimizing unnecessary antibiotic use and preventing complications.