Dental Abscess Treatment Guidelines

Introduction to Dental Abscesses

A dental abscess is a localized collection of pus resulting from bacterial infection in the tooth or surrounding tissues, characterized by clinical presentation including pain, swelling, erythema, warmth, possible fluctuant mass, and potential systemic symptoms such as fever and malaise 1

The American Dental Association recommends incision and drainage as the primary treatment for dental abscesses, with antibiotics indicated only for specific circumstances such as systemic symptoms, extensive cellulitis, or immunocompromised state, and the treatment approach is similar for children but dosing must be adjusted based on weight 1, 2
For periapical abscesses, root canal treatment (endodontic therapy) or extraction of the affected tooth if severely damaged is recommended, with a treatment duration of 7-10 days and continuation for 48-72 hours after symptoms resolve 1
The American Academy of Pediatric Dentistry recommends amoxicillin 45 mg/kg/day divided every 12 hours for severe infections in children <40 kg, with dose adjustment required for severe renal impairment (GFR <30 mL/min) and avoidance of 875 mg dose in patients with GFR <30 mL/min 1

First-line antibiotic options include amoxicillin 500 mg every 8 hours or 875 mg every 12 hours for 7-10 days, and penicillin V (Phenoxymethylpenicillin), with clindamycin 300-450 mg three times daily recommended for penicillin-allergic patients 1, 2, 3
Empiric antibiotic regimens should cover MRSA and anaerobes, with options including:
Obtain cultures during the drainage procedure to guide targeted antibiotic therapy 2

Spread to surrounding anatomical structures can cause maxillofacial cellulitis, and inadequate treatment may lead to life-threatening complications including airway obstruction and septicemia, with patients with ongoing signs of infection beyond 7 days warranting diagnostic re-evaluation 1, 2, 6
Regular dental check-ups, good oral hygiene practices, and prompt treatment of dental caries and other dental issues are recommended for prevention, with schedule follow-up within 48-72 hours to assess improvement and consideration of reevaluation of diagnosis, culture and sensitivity testing, and alternative antibiotic regimen if no improvement is seen after 2-3 days 1, 2, 3, 7, 8
Review patient's condition 2-3 days after initial treatment to assess improvement and consider reevaluation of diagnosis, culture and sensitivity testing, or alternative antibiotic regimen if no improvement is seen, as recommended by the IDSA and the Italian Council for Antimicrobial Use 3, 6, 2, 9
For recurrent abscesses, consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items, as recommended by the IDSA 2

Physical examination should look for fluctuant masses, erythema, warmth, and assess for signs of systemic infection, as recommended by the American College of Surgeons 10
Laboratory studies, including complete blood count with differential and blood cultures, should be performed if systemic symptoms are present, according to the Infectious Diseases Society of America 11
Imaging studies, such as ultrasonography, can help distinguish cellulitis from abscess, and CT with IV contrast may be used for deeper or complex infections, as reported by the American Heart Association 10
Inadequate drainage may lead to spread of infection and worsening of symptoms, and the facial location is concerning due to potential for spread to cavernous sinus via facial veins 2