What is the best course of treatment for a patient with a dental abscess or teeth infection?

Treatment of Dental Abscess/Tooth Infection

Surgical intervention—not antibiotics—is the cornerstone of treating dental abscesses, with incision and drainage, tooth extraction, or root canal therapy as first-line treatment; antibiotics are only adjunctive therapy when systemic signs (fever, malaise, lymphadenopathy) are present. 1, 2, 3

Primary Treatment Algorithm

The treatment approach depends on whether the tooth is salvageable:

For Non-Restorable Teeth

• Extract the tooth immediately if there is extensive caries, severe crown destruction, structural compromise, severe periodontal disease, or failed previous endodontic treatment 2, 3
• Extraction addresses the source of infection definitively 3

For Salvageable Teeth

• Perform root canal therapy if the tooth is periodontally sound, structurally restorable, and this is the first endodontic intervention 2, 3
• Root canal therapy preserves the tooth while eliminating the infected pulp 3

For Accessible Abscesses with Fluctuance

• Perform incision and drainage for all accessible collections regardless of tooth restorability 1, 2, 3
• Drainage establishes immediate decompression and removes purulent material 2

When to Add Antibiotics

Antibiotics are adjunctive only and should be prescribed when:

• Systemic involvement is present: fever, malaise, or lymphadenopathy 1, 2, 3
• Patient is immunocompromised or medically compromised 3, 4
• Infection extends into facial spaces or cervicofacial tissues 3
• Diffuse swelling that cannot be drained effectively 3
• Failure to respond to surgical treatment alone 3

First-Line Antibiotic Regimen

• Amoxicillin 500 mg orally three times daily for 5 days 1, 2, 5
• This provides coverage against oral streptococci and anaerobes 5

For Penicillin Allergy

• Clindamycin 300-450 mg orally three times daily 1
• Provides excellent anaerobic and streptococcal coverage 1

For Severe Cases Requiring Hospitalization

• Ampicillin-sulbactam 3 grams IV every 6 hours (preferred for severe odontogenic infections) 1
• Clindamycin 600-900 mg IV every 6-8 hours (alternative, especially if MRSA suspected) 1
• Piperacillin-tazobactam 3.375g IV every 6 hours (for spreading infection) 1
• Limit IV antibiotics to 1-2 weeks maximum, transitioning to oral as soon as clinically stable 1

Critical Evidence on Antibiotic Efficacy

Adding antibiotics to proper surgical management shows no statistically significant difference in pain or swelling outcomes compared to surgery alone. 1, 2 This underscores that antibiotics cannot substitute for mechanical source control—they do not eliminate the infection source without drainage or tooth removal 2, 3.

Supportive Care and Oral Hygiene

While awaiting definitive treatment or during recovery:

• Rinse mouth with alcohol-free mouthwash 4-6 times daily (15 mL for approximately 1 minute) 1
• Use sterile water, normal saline, or sodium bicarbonate rinses for active gum inflammation 1
• Brush teeth at least twice daily with soft toothbrush using Bass or modified Bass method 1
• Avoid smoking, alcohol, and irritating foods (tomatoes, citrus, hot/spicy foods) during active infection 1

Common Pitfalls to Avoid

Never Prescribe Antibiotics Without Surgical Intervention

• This is ineffective and contributes to antibiotic resistance 1, 2, 3
• Antibiotics cannot penetrate avascular necrotic tissue or drain purulent collections 2
• Only 12% of dentists adequately prescribe antibiotics, highlighting widespread misuse 4

Avoid Fluoroquinolones

• Do not use fluoroquinolones for dental infections due to unclear efficacy against oral flora and promotion of antimicrobial resistance 1

Do Not Extract Restorable Teeth Solely Due to Patient Anxiety

• Light sedation is appropriate for both root canal and extraction 3
• Root canal therapy generates lower anxiety than extraction among patients who have experienced both 3

When to Escalate Care Immediately

Refer to oral surgeon or emergency department if:

• Spreading infection with diffuse facial swelling or cervicofacial extension 2, 3
• Airway compromise: difficulty swallowing, breathing, or trismus 2
• Systemic illness: sepsis, high fever, or altered mental status 2
• Ludwig angina (bilateral submandibular space involvement)—this can be fatal 6

Additional Diagnostic Considerations

• Check serum glucose, HbA1c, and urine ketones in all patients to identify undetected diabetes 2
• Order CBC, creatinine, and inflammatory markers (CRP, procalcitonin, lactate) if systemic infection suspected 2
• Obtain intraoral radiograph with paralleling technique as first-line imaging 2
• Insert gutta-percha cone into fistula tract before radiograph to identify source tooth 2

Prevention and Long-Term Management

• Poor oral hygiene and periodontal disease—not dental procedures—are responsible for the vast majority of oral infections 7
• Daily thorough dental hygiene prevents recurrent infections 1
• Patients with history of infective endocarditis should receive thorough dental evaluation to eliminate oral disease that predisposes to bacteremia 7