Treatment of Mouth Abscess in Adults
For an adult with a mouth abscess, immediate surgical drainage combined with broad-spectrum intravenous antibiotics is the definitive treatment, with airway assessment as the critical first priority. 1, 2
Immediate Airway Assessment
- Evaluate airway patency first in all mouth abscesses, particularly tongue or floor-of-mouth locations, as these can rapidly compromise breathing. 1
- Be prepared for difficult intubation if airway intervention is needed; consider fiberoptic intubation or surgical airway for significant tongue swelling. 1
- Never delay intervention if airway compromise is suspected—this significantly worsens outcomes and increases risk of airway loss. 1
Surgical Drainage: The Cornerstone of Treatment
- Surgical drainage is mandatory and should be performed immediately—antibiotics alone are insufficient and will fail without source control. 1, 2
- The specific drainage technique depends on abscess location (tongue, mandibular, periodontal, peritonsillar). 2, 3
- Complete evacuation of all purulent material and loculations is essential, as incomplete drainage leads to recurrence rates as high as 41%. 4
- Send aspirated pus for aerobic and anaerobic cultures to guide targeted antibiotic therapy. 1
- Obtain blood cultures in all patients, as bacteremia occurs in up to 28% of deep space oral infections. 1
Antibiotic Therapy
First-Line Regimens
- Ampicillin-sulbactam or cefoxitin IV are the agents of choice, providing coverage of gram-positive, gram-negative, and anaerobic bacteria from oral mucosa. 1, 2
- Alternative regimens include clindamycin (covers anaerobes and most oral flora) or combination therapy with a beta-lactam plus metronidazole. 1
MRSA Coverage
- Add vancomycin IV if MRSA is suspected based on risk factors (prior MRSA infection, healthcare exposure, injection drug use, or recurrent abscesses). 1, 2
Duration
- Patients typically require 5-6 days of IV antibiotics postoperatively and can be discharged 1 day after cessation of IV therapy. 2
- Total antibiotic duration is generally 5-10 days, adjusted based on clinical response. 4
Location-Specific Considerations
Periodontal Abscess
- Establish drainage via pocket lumen with subgingival scaling, root planing, and curettage of inflamed tissue. 5
- Compress pocket wall to underlying tooth and maintain tissue contact. 5
- Consider systemic antibiotics as preventive measure if systemic symptoms are present. 5
Tongue Abscess
- This is a rare but potentially life-threatening condition requiring immediate surgical intervention under general anesthesia. 1, 6
- Irrigate the pocket with normal saline and 2% hydrogen peroxide after drainage. 6
Mandibular/Submandibular Abscess
- Refer to ENT specialist and maxillofacial surgeon if dental or gum infection is suspected as the source. 2
- These polymicrobial infections contain normal regional skin flora combined with organisms from adjacent oral mucosa. 2
Critical Pitfalls to Avoid
- Never rely on antibiotics alone—source control through drainage is mandatory. 1, 2
- Never delay surgical drainage—delayed intervention significantly worsens outcomes. 1, 2
- Do not attempt needle aspiration alone, as success rates are only 25% and even lower with MRSA infections. 2
- Avoid routinely packing the wound, as this adds pain and cost without proven benefit for healing or recurrence rates. 4
Follow-Up and Monitoring
- Re-evaluate at 48-72 hours to ensure adequate drainage and clinical improvement. 1, 2, 4
- Persistent fever, bacteremia, or failure to improve indicates inadequate source control, requiring reimaging and potential reoperation. 2
- Adjust antibiotic therapy based on culture results and clinical response. 1