What is the treatment for an abscessed tooth?

Treatment of an Abscessed Tooth

Surgical intervention—either root canal therapy for salvageable teeth or extraction for non-restorable teeth—is the definitive first-line treatment for a dental abscess, with antibiotics reserved only for patients with systemic involvement (fever, malaise, lymphadenopathy) or those who are medically compromised. 1, 2

Primary Treatment Algorithm

Immediate surgical management is mandatory and includes:

• Root canal therapy for teeth that are restorable, periodontally sound, with adequate crown structure remaining for post-endodontic restoration 1
• Extraction for non-restorable teeth due to extensive caries, severe crown destruction, structural compromise, severe periodontal disease, or failed previous endodontic treatment 1, 2
• Incision and drainage for accessible abscesses with fluctuant swelling 1, 2

Critical point: Adding antibiotics to proper surgical management shows no statistically significant differences in pain or swelling outcomes—surgery alone is sufficient for most cases 1, 2

When Antibiotics Are Indicated

Antibiotics should be added to surgical treatment only when:

• Systemic involvement is present: fever, malaise, or lymphadenopathy 1, 2
• Patient is medically compromised or immunocompromised 1, 2
• Infection extends into facial spaces or cervicofacial tissues 1, 2
• Diffuse swelling that cannot be effectively drained 1
• Failure to respond to surgical treatment alone after 48-72 hours 3

Antibiotic Selection (When Indicated)

First-line regimen:

• Amoxicillin 500 mg three times daily for 5 days in combination with surgical management 3, 2
• Alternative: Phenoxymethylpenicillin for patients with systemic involvement 2

Second-line regimen (for treatment failure or enhanced anaerobic coverage):

• Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 3

For penicillin allergy:

• Clindamycin 300-450 mg three times daily 3
• Doxycycline can be considered as an alternative in adults 2

Common 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, 2, 4

Do not delay surgical treatment in favor of antibiotic therapy alone, as the infection will not resolve and will become progressively worse, potentially leading to airway obstruction and septicemia 4

Antibiotics should not be used for irreversible pulpitis, chronic periodontitis, or peri-implantitis 2

When to Escalate Care

Immediate referral to oral surgeon or emergency department is required for:

• Signs of deep space involvement: trismus, floor of mouth elevation, dysphagia, or respiratory compromise 3
• Spreading infection or systemic illness despite appropriate initial management 3
• Persistent symptoms after 48-72 hours of proper surgical and antibiotic treatment 3

For severe cases requiring hospitalization:

• IV antibiotics: Clindamycin 600-900 mg IV every 6-8 hours or piperacillin-tazobactam 3.375g IV every 6 hours 3
• Consider CT imaging to evaluate for deep space abscess or complications 3

Follow-Up Requirements

• Re-evaluate within 48-72 hours to ensure resolution of swelling and pain 3
• Limit antibiotic duration to 5-7 days maximum with adequate source control 3, 2
• If no improvement occurs despite appropriate management, consider imaging and reassess for complications 3