Treatment of Tooth Abscess
Surgical intervention through root canal therapy, extraction, or incision and drainage is the primary treatment for tooth abscess, with antibiotics reserved only for patients with systemic symptoms (fever, malaise), spreading infection, or immunocompromised status. 1, 2, 3
Primary Treatment Algorithm
Step 1: Immediate Surgical Management
The cornerstone of treatment is removing the source of infection through one of three approaches 1, 2, 3:
- Root canal therapy for teeth that are structurally salvageable and periodontally sound 1, 2
- Extraction for non-restorable teeth with extensive caries, severe crown destruction, or failed previous endodontic treatment 1, 2
- Incision and drainage for accessible dentoalveolar abscesses to establish drainage 1, 2, 3
Critical point: Do not delay surgical intervention—drainage removes the inflammatory source and is essential for resolution 2, 3
Step 2: Assess Need for Antibiotics
Antibiotics should be added to surgical treatment only when specific criteria are met 1, 2, 3:
Indications for Antibiotic Therapy:
- Systemic involvement present (fever, malaise, lymphadenopathy) 1, 2, 3
- Spreading infection with cellulitis or diffuse swelling that cannot be adequately drained 1, 2
- Medically compromised or immunosuppressed patients 1, 2, 3
- Infections extending into cervicofacial tissues or facial spaces 1, 2
- Failure to respond to surgical treatment alone 1
Evidence Against Routine Antibiotic Use:
Multiple systematic reviews demonstrate no statistically significant differences in pain or swelling outcomes when antibiotics are added to proper surgical management 2, 3. The 2018 Cope study found no significant differences in participant-reported pain or swelling at any time point comparing penicillin versus placebo when both groups received surgical intervention 2.
Antibiotic Selection (When Indicated)
First-Line Therapy:
- Phenoxymethylpenicillin or amoxicillin for 5 days 2, 3
- Adult dosing: 500 mg every 12 hours or 250 mg every 8 hours for mild/moderate infections; 875 mg every 12 hours or 500 mg every 8 hours for severe infections 4
- Take at the start of a meal to minimize gastrointestinal intolerance 4
Second-Line Options:
- Clindamycin 300-450 mg orally three times daily for penicillin-allergic patients 2, 3
- Amoxicillin-clavulanate 875/125 mg twice daily for treatment failures or broader spectrum coverage 2
- Adding metronidazole to amoxicillin for treatment failures 2, 3
Duration:
- Maximum 7 days for immunocompromised or critically ill patients with adequate source control 2
- Continue treatment 48-72 hours beyond symptom resolution 4
Common Pitfalls to Avoid
Never prescribe antibiotics without surgical intervention—this is ineffective, does not eliminate the infection source, and contributes to antibiotic resistance 1, 3. Studies show that 74.4% of antibiotic prescriptions for dental problems are unnecessary 5, and only 7.7% of acute apical abscess cases receive appropriate drainage as first-line therapy 5.
Do not extract a restorable tooth solely due to patient anxiety—root canal therapy generates lower anxiety levels than extraction among patients who have experienced both procedures 1. Light sedation is appropriate for managing anxiety during either procedure 1.
Avoid inadequate drainage—mechanical treatment must be the first step before considering antibiotics 5. The infection will not resolve with antibiotics alone when the source remains 1, 3.
Special Considerations
Renal Impairment:
- GFR 10-30 mL/min: 500 mg or 250 mg every 12 hours 4
- GFR <10 mL/min: 500 mg or 250 mg every 24 hours 4
- Hemodialysis: Additional dose during and at end of dialysis 4
- Do not use 875 mg dose in patients with GFR <30 mL/min 4