What is the treatment for a dental abscess?

Treatment of Dental Abscess

The primary treatment for dental abscess is surgical intervention through root canal therapy, extraction, or incision and drainage, with antibiotics reserved only for specific circumstances such as systemic involvement or medically compromised patients. 1, 2

Primary Surgical Management

• Surgical drainage is the cornerstone of treatment and should not be delayed as it removes the source of inflammation 2
• Treatment options include:
  • Root canal therapy for salvageable teeth 2
  • Extraction for non-restorable teeth 2
  • Incision and drainage for accessible abscesses 1, 2
• For dentoalveolar abscesses, incision and drainage is the first step in management 2
• If treated with antibiotics alone without surgical intervention, the infection will not resolve and will become progressively worse 3

Indications for Antibiotic Therapy

Antibiotics should only be used as an adjunct to surgical treatment in specific situations:

• Presence of systemic symptoms (fever, malaise) 1, 2
• Evidence of spreading infection (cellulitis, diffuse swelling) 1, 2
• Medically compromised or immunosuppressed patients 2
• Infections extending into cervicofacial tissues 1, 2
• Progressive infections requiring referral to oral surgeons 2

Antibiotic Selection (When Indicated)

• First-line options:
  • Phenoxymethylpenicillin or amoxicillin for 5 days 1, 2
• For penicillin-allergic patients:
  • Clindamycin is an effective alternative 2
• For treatment failures:
  • Consider adding metronidazole to amoxicillin 2
• For more severe infections with systemic involvement, parenteral antibiotics may be necessary 1

Evidence Against Routine Antibiotic Use

• Multiple systematic reviews show no statistically significant differences in pain or swelling outcomes when antibiotics are added to proper surgical treatment 1, 2
• Inappropriate antibiotic use is widespread in dentistry and contributes to antibiotic resistance 4
• The 2018 Cochrane review found no significant differences in participant-reported measures of pain or swelling when comparing penicillin versus placebo (both with surgical intervention) 5

Treatment Algorithm

1. Assess severity of infection:

   • Localized abscess without systemic symptoms → Surgical drainage only 2
   • Presence of systemic symptoms or spreading infection → Surgical drainage plus antibiotics 2

2. Perform appropriate surgical intervention based on abscess type:

   • For acute dental abscesses: root canal therapy or extraction 1
   • For dentoalveolar abscesses: incision and drainage followed by definitive treatment 1, 2
   • For complex abscesses (perianal, perirectal): incision and drainage with adjuvant antibiotic therapy 6

3. Consider antibiotics only if:

   • Systemic involvement is present 1, 2
   • Patient is immunocompromised 2
   • Infection is spreading beyond localized area 2
   • Surgical drainage is incomplete or difficult 2

Special Considerations

• For complex skin and subcutaneous abscesses, empiric broad-spectrum antibiotic therapy with coverage of Gram-positive, Gram-negative, and anaerobic bacteria may be necessary if systemic signs of infection are present 6
• Dexamethasone as an adjunct to conventional medical management has shown significant reduction in pain at 12 hours post-treatment compared to placebo 7
• Dental abscesses can potentially cause serious complications including airway obstruction and septicemia if not properly treated 3
• In cases of periodontal abscess, management includes establishing drainage via pocket lumen, subgingival scaling and root planing 8