Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

high risk

1st line – hospital admission

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ACUTE
|
high risk
1st line – 

hospital admission

Hospital admission is recommended for:

Signs of impending airway compromise (e.g., trismus, dysphonia, dysphagia, drooling, uvular deviation, tongue elevation with inability to protrude tongue, dyspnea, stridor), anticipated airway difficulty, or need for perioperative airway monitoring

Rapidly progressing infection

Involvement of high-risk or multiple fascial spaces

Unrelenting fever or signs of volume depletion

Central nervous system signs (e.g., decreased level of consciousness, headache, or abnormal eye signs such as proptosis, pupillary dilation, diplopia, papilledema and ophthalmoplegia)

Treatment failure with outpatient therapy

Presence of comorbid conditions that require supportive medical care

Social factors that preclude outpatient therapy

Extremes of age (i.e., very young or old).

When there is doubt, it is generally best to err on the side of caution and admit the patient to the hospital.[47]

Plus – airway management

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ACUTE
|
high risk
Plus – 

airway management

Treatment recommended for ALL patients in selected patient group

Planning and execution of successful airway management requires a team approach involving the anesthesiologist, surgeon, and surgical team members.[48]

In some cases, needle decompression of the abscess prior to attempted intubation or tracheotomy may be beneficial.

In cases where there is a concern for potential airway compromise, a contingency plan for an urgent or emergent surgical airway should be in place if intubation attempts are not successful.

Plus – supportive care

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ACUTE
|
high risk
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Fever increases fluid losses and metabolic demands and can lead to volume depletion. In addition, the physiologic stress of an aggressive infection can disturb the balance of other concurrent, otherwise controlled, systemic conditions. Therefore, supportive care includes control of fever with an antipyretic (e.g., acetaminophen), intravenous fluids, and nutritional support.[47]

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Plus – analgesia

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ACUTE
|
high risk
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

Most patients with a dental abscess require pain relief, and all patients should be offered analgesia. The selection of analgesic depends on the patient's history, allergy profile, and the anticipated level of discomfort. Options include a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen and/or an opioid analgesic (e.g., morphine).

Primary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

and/or

morphine sulfate: 10-30 mg orally (regular-release) every 3-4 hours when required; 2.5 to 15 mg intravenously/intramuscularly every 2-6 hours when required

Plus – removal of source of infection

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ACUTE
|
high risk
Plus – 

removal of source of infection

Treatment recommended for ALL patients in selected patient group

The cornerstone of successful management is early removal of the source of the infection.

This should only be delayed when concurrent systemic illness must first be managed to facilitate a safe operation.

Periapical abscess: necrotic pulpal tissue should be removed with root canal treatment or extraction.

Periodontal abscess: periodontal therapy or extraction of a periodontally hopeless tooth is recommended.

Pericoronal abscess: if the incompletely erupted tooth is a partially impacted wisdom tooth with inadequate space for eruption. A tooth in another site may be salvageable; an operculectomy (i.e., surgical removal of the operculum, the flap of tissue over a partially erupted tooth) to improve cleansing in the area as the tooth fully erupts may be adequate. In some cases, orthodontic assistance with eruption may be indicated.

Surgical incision and drainage with tooth extraction is considered the definitive treatment for periodontally hopeless teeth, partially impacted wisdom teeth, or when root canal treatment is not possible.

Plus – surgical incision and drainage

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ACUTE
|
high risk
Plus – 

surgical incision and drainage

Treatment recommended for ALL patients in selected patient group

Usually performed concurrently with the removal of the source of infection (e.g., extraction, root canal treatment).

Some physicians believe that the infection must be at the point of forming a drainable abscess before proceeding with surgical incision and drainage; however, no benefit has been found in delaying drainage until an abscess forms, and often this delay in treatment will only lead to increased potential for complications and morbidity.[49]

Incision can be intraoral or extraoral, depending on the site of infection, and based on the principle of establishing a patent dependent drainage path. A small incision is made in an appropriate site that avoids vital structures and any areas of skin or mucosal breakdown. The incision should be made through the epithelium or mucosa into the underlying connective tissue.

Blunt dissection is used to explore the involved spaces, followed by placement of a Penrose or Jackson-Pratt drain. The drain is usually maintained until drainage ceases (typically 2-5 days), and can be removed gradually or all at once.

Culture of abscess contents should be performed.

Plus – broad-spectrum empiric intravenous antibiotic therapy

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ACUTE
|
high risk
Plus – 

broad-spectrum empiric intravenous antibiotic therapy

Treatment recommended for ALL patients in selected patient group

In more serious infections that warrant hospital admission, intravenous antibiotics should be started.

Intravenous clindamycin or metronidazole are the antibiotics of choice owing to their anaerobic coverage. Penicillin-G is a suitable alternative.[10][41][55][56][57]

Intravenous antibiotics can be switched to appropriate oral antibiotic therapy once the patient shows signs of improvement (e.g., decreasing temperature, edema/erythema, and WBC count) and is ready for discharge. However, patients with osteomyelitis may require long-term intravenous antibiotic therapy on an outpatient basis.

Deciding when to cease antibiotic therapy is a matter of clinical judgment and should be based on the patient’s recovery course.

Primary options

clindamycin: 600-2700 mg/day intravenously given in divided doses every 6-12 hours until improvement then switch to oral therapy

OR

metronidazole: 500 mg intravenously every 6-8 hours until improvement then switch to oral therapy

Secondary options

penicillin G potassium: 2-4 million units intravenously every 4-6 hours until improvement then switch to oral therapy

Plus – further investigation

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ACUTE
|
high risk
|
no response to treatment
Plus – 

further investigation

Treatment recommended for ALL patients in selected patient group

For serious odontogenic infections that warrant hospitalization, the patient needs to be followed closely for response to therapy. Typically, by 2 to 3 days the patient should be showing definite signs of improvement (e.g., resolution of fever, reduced drainage, decreasing edema, decreasing WBC count, and improved fatigue/malaise).

If this is not the case, thorough investigation to assess the cause of treatment failure is necessary.

A CT scan of the head and neck may be helpful to assess whether the initial operation adequately drained the involved spaces, or if there has been progression of the infection into additional fascial spaces with the need for further operative exploration.

Other factors to consider include immunosuppression, the presence of a foreign body, or incorrect antibiotic selection. By this point, the infection site culture and sensitivity results should be available and antibiotics should be adjusted accordingly.[47][59]

ONGOING

low risk

1st line – removal of source of infection as an outpatient

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ONGOING
|
low risk
1st line – 

removal of source of infection as an outpatient

Patients who do not meet criteria for hospital admission can typically be managed on an outpatient basis.

The vast majority of otherwise healthy patients presenting with a dental infection can be managed on an outpatient basis. These patients respond quickly to definitive operative intervention with removal of the source of the infection, along with supportive care and antibiotic therapy as indicated.

The cornerstone of successful management is early removal of the source of the infection. Specific treatment depends on the type of abscess.

Periapical abscess: necrotic pulpal tissue should be removed with root canal treatment or extraction.

Periodontal abscess: periodontal therapy or extraction of a periodontally hopeless tooth is recommended.

Pericoronal abscess: if the incompletely erupted tooth is a partially impacted wisdom tooth with inadequate space for eruption, extraction is indicated. A tooth in another site may be salvageable; an operculectomy (i.e., surgical removal of the operculum, the flap of tissue over a partially erupted tooth) to improve cleansing in the area as the tooth fully erupts may be adequate. In some cases, orthodontic assistance with eruption may be indicated.

Surgical incision and drainage with tooth extraction is considered the definitive treatment for periodontally hopeless teeth, partially impacted wisdom teeth, or when root canal treatment is not possible.

Plus – consider surgical incision and drainage

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ONGOING
|
low risk
Plus – 

consider surgical incision and drainage

Treatment recommended for ALL patients in selected patient group

In most situations, an incision and drainage is performed concurrently with the removal of the source of infection (e.g., extraction, root canal treatment); however, in some cases, removal of the tooth alone establishes adequate drainage without the need for surgical incision and drainage.

If incision and drainage are required, the incision can be intraoral or extraoral, depending on the site of infection, and based on the principle of establishing a patent dependent drainage path. A small incision is made in an appropriate site that avoids vital structures and any areas of skin or mucosal breakdown. The incision should be made through the epithelium or mucosa into the underlying connective tissue.

Blunt dissection is used to explore the involved spaces, followed by placement of a Penrose or Jackson-Pratt drain. The drain is usually maintained until drainage ceases (typically 2-5 days) and can be removed gradually or all at once.

Culture of abscess contents should be performed.

Plus – analgesia

Back
ONGOING
|
low risk
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

Most patients with a dental abscess require pain relief, and all patients should be offered analgesia. The selection of analgesic depends on the patient's history, allergy profile, and the anticipated level of discomfort.

Options include a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or an opioid analgesic (e.g., hydrocodone/acetaminophen, oxycodone).

Primary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

hydrocodone/acetaminophen: 2.5 to 5 mg orally every 4-6 hours when required

More

OR

oxycodone: 5-15 mg orally every 4-6 hours when required

Consider – oral antibiotic therapy

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ONGOING
|
low risk
Consider – 

oral antibiotic therapy

Treatment recommended for SOME patients in selected patient group

In immunocompetent patients with evidence of systemic involvement, if conservative dental treatment is not immediately available, a delayed prescription for oral amoxicillin or oral penicillin V should be provided, in the event that symptoms worsen. Interim monitoring should be provided. These patients should also be urgently referred for conservative dental treatment. Patients should be instructed to call their physician if their condition deteriorates or if the referral to receive definitive conservative dental treatment within 1-2 days is not possible.[54] 

Immediate antibiotic prescribing (oral amoxicillin or oral penicillin V) should be provided for immunocompetent patients with pain and swelling, indicating pulp necrosis and localized acute apical abscess, with or without systemic involvement.[54] 

Options for patients with penicillin allergies include cephalexin (provided there is no history of a serious allergic reaction to penicillin), clindamycin, or azithromycin.

If first-line treatment fails, the first-line treatment can be discontinued and oral amoxicillin/clavulanate prescribed, or metronidazole can be added to the first-line regimen (see below).[54] 

Treatment course: 3 to 7 days (except azithromycin which is a 5-day course, and amoxicillin/clavulanate which is a 7-day course).

Primary options

amoxicillin: 500 mg orally three times daily

OR

penicillin V potassium: 500 mg orally four times daily

Secondary options

cephalexin: 500 mg orally four times daily

OR

clindamycin: 300 mg orally four times daily

OR

azithromycin: 500 mg orally once daily on day 1, followed by 250 mg once daily for 4 days

Tertiary options

amoxicillin/clavulanate: 500 mg orally three times daily

More

Consider – metronidazole

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ONGOING
|
low risk
Consider – 

metronidazole

Treatment recommended for SOME patients in selected patient group

If first-line antibiotic treatment fails, metronidazole can be added to the regimen (unless the patient has been switched to amoxicillin/clavulanate).[54] 

Treatment course: 7 days.

Primary options

metronidazole: 500 mg orally three times daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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