What is the treatment for a tooth abscess?

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

Primary Treatment Algorithm

Step 1: Immediate Surgical Management

• Perform surgical drainage without delay as this removes the source of infection and is the cornerstone of treatment 2, 3
• Choose the appropriate surgical intervention based on tooth restorability:
  • Root canal therapy for salvageable teeth with adequate crown structure and sound periodontal status 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 2, 3

Step 2: Assess Need for Antibiotics

Do NOT prescribe antibiotics routinely - multiple systematic reviews demonstrate no statistically significant differences in pain or swelling outcomes when antibiotics are added to proper surgical treatment 2, 3

Only add antibiotics if ANY of the following are present:

• Systemic involvement: fever, malaise, or lymphadenopathy 1, 2
• Evidence of spreading infection: cellulitis or diffuse swelling that cannot be drained effectively 1, 2
• Medically compromised or immunosuppressed patients 1, 2
• Infection extending into facial spaces or cervicofacial tissues 1, 3
• Failure to respond to surgical treatment alone 1

Antibiotic Selection (When Indicated)

First-Line Therapy

• Phenoxymethylpenicillin or amoxicillin for 5 days 2, 3

For Penicillin-Allergic Patients

• Clindamycin 300-450 mg orally three times daily for adults 2
• Pediatric dosing: 10-20 mg/kg/day in 3 divided doses 2

For Treatment Failures

• Add metronidazole to amoxicillin for enhanced anaerobic coverage 2
• Alternative: Amoxicillin-clavulanate 875/125 mg twice daily for broader spectrum including beta-lactamase producing organisms 2

Duration of Antibiotic Therapy

• Maximum 7 days for immunocompromised or critically ill patients with adequate source control 2

Critical Pitfalls to Avoid

Never prescribe antibiotics without surgical intervention - this is ineffective, does not eliminate the source of infection, and contributes to antibiotic resistance 1, 3

Do not delay surgical drainage - antibiotics cannot substitute for mechanical removal of the infection source 2, 3

Avoid extracting restorable teeth solely due to patient anxiety - root canal therapy generates lower anxiety levels than extraction among patients who have experienced both procedures 1

Evidence Strength

The recommendation prioritizing surgical management over routine antibiotics is supported by high-quality evidence from the American Dental Association, Centers for Disease Control and Prevention, and American College of Physicians 1, 2. The 2018 Cope study specifically demonstrated no significant differences in pain or swelling when comparing penicillin versus placebo (both groups received surgical intervention) 2. This represents the most recent and robust evidence contradicting the widespread practice of routine antibiotic prescription for dental abscesses.