What is the treatment for a tooth abscess?

Treatment of Tooth Abscess

Primary Treatment: Surgery First, Not Antibiotics

Surgical intervention through root canal therapy, extraction, or incision and drainage is the definitive treatment for dental abscess, and antibiotics should only be added in specific circumstances such as systemic involvement, spreading infection, or immunocompromised status. 1, 2, 3

The evidence is clear that surgical management alone is sufficient for most dental abscesses, with multiple systematic reviews showing no statistically significant differences in pain or swelling outcomes when antibiotics are added to proper surgical treatment. 1, 2

Treatment Algorithm

Step 1: Assess Severity and Determine Need for Antibiotics

Antibiotics are NOT needed if:

• Localized abscess without fever, tachycardia, or elevated white blood cell count 2, 3
• No evidence of spreading cellulitis or diffuse swelling 2
• Patient is immunocompetent 1, 2
• Surgical drainage can be completed adequately 1

Antibiotics ARE indicated if:

• Systemic symptoms present (fever >38°C, tachycardia, malaise, elevated WBC) 2, 3
• Evidence of spreading infection with cellulitis or diffuse swelling beyond the localized abscess 2, 3
• Patient is immunocompromised or medically compromised 1, 2
• Infection extends into cervicofacial tissues (requires aggressive management as necrotizing fasciitis) 1, 2
• Incomplete source control after surgical drainage 1

Step 2: Perform Appropriate Surgical Intervention

Choose based on tooth salvageability:

• Root canal therapy for salvageable teeth 1, 3
• Extraction for non-restorable teeth 1, 3
• Incision and drainage for accessible abscesses 1, 2, 3

Surgical drainage removes the source of inflammation and is the cornerstone that should not be delayed. 2, 3

Step 3: Select Antibiotic Regimen (Only if Indicated)

First-line oral antibiotics:

• Amoxicillin 500mg three times daily for 5 days (adults) 1, 2
• Pediatric dosing: 25-50 mg/kg/day divided into 3-4 doses 2
• Alternative: Phenoxymethylpenicillin 1, 2

For penicillin-allergic patients:

• Clindamycin 300-450mg orally three times daily (adults) 1, 2
• Pediatric dosing: 10-20 mg/kg/day in 3 divided doses 2

For treatment failures or severe infections:

• Add metronidazole to amoxicillin 2
• Or switch to amoxicillin-clavulanate 875/125mg twice daily (adults) 2
• Pediatric dosing: 90 mg/kg/day divided twice daily 2

For severe infections requiring IV therapy:

• Clindamycin 600-900mg IV every 6-8 hours (preferred for penicillin allergy) 2
• Piperacillin-tazobactam 3.375g IV every 6 hours or 4.5g every 8 hours (for broader coverage with systemic toxicity) 2
• Ceftriaxone 1g IV every 24 hours plus metronidazole 500mg IV every 8 hours 2

Duration: Maximum 5-7 days with adequate source control 1, 2

Critical Pitfalls to Avoid

Do not use fluoroquinolones - they are inadequate for typical dental abscess pathogens which are predominantly anaerobic. 2

Do not routinely cover for MRSA - current evidence does not support routine MRSA coverage in initial empiric therapy of dental abscesses. 2

Do not delay surgical intervention - antibiotics alone will not resolve a dental abscess as the necrotic root canal harbors a mixed anaerobic biofilm that requires physical removal. 4, 5

Do not miss spreading infections - look specifically for facial swelling extending beyond the tooth, trismus, difficulty swallowing, or neck involvement which indicate deep space infection requiring urgent surgical consultation. 1, 2

Special Populations

Pediatric patients: Be vigilant for occult dental abscesses presenting as sepsis without obvious dental symptoms, as bacteremia from dental infections can cause systemic illness even when dental pain is minimal or absent. 6, 7

Immunocompromised patients: Lower threshold for antibiotic therapy and broader coverage, with consideration for hospitalization and IV antibiotics. 8, 2

Monitoring and Follow-up

Patients should show clinical improvement within 2-3 days of appropriate treatment. 2 If no improvement occurs, consider second-line antibiotic regimens, inadequate source control requiring repeat drainage, or alternative diagnoses. 2