eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Dental Abscess: Treatment & Medication
Updated: Jul 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- In patients with dental abscess, assess the airway upon respiratory distress, oropharyngeal tissue swelling, or inability to handle secretions; then, secure the airway via endotracheal intubation or tracheostomy.
- Properly collect specimen for Gram stain and culture.
- Administer empiric antibiotic therapy.
- Administer analgesia.
- Hydrate the patient.
Surgical Care
- The primary therapeutic modality is surgical drainage of any pus collection. Incision and drainage or spontaneous rupture of the abscess quickly accelerates resolution of the infection.
- Emergent surgery is indicated in the operating room if the airway is threatened or if the patient's condition is rapidly deteriorating.
- Third molar removal is a common surgical procedure.4
Consultations
- Consult a dentist if the patient has an uncomplicated abscess.
- Consult a maxillofacial oral surgeon if the patient has a complicated abscess.
Diet
- Diet is as tolerated. However, a soft bland diet is usually preferred.
Activity
- Activity is as tolerated.
Medication
When drainage cannot be achieved or the patient shows signs of systemic involvement, antibiotic therapy is indicated; in addition, an increasing number of immunocompromised patients require antibiotic therapy.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Penicillin (Pfizerpen, Pen-Vee K, Beepen-VK)
DOC; effective against most aerobes and anaerobes. Penicillin has traditionally been considered the DOC for odontogenic infections. The efficacy of penicillin is a concern because of the emergence of beta-lactamase – producing organisms, which confer resistance to penicillins. Penicillin still remains the antibiotic of choice for mild-to-moderate infections.
Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Penicillin V (phenoxymethyl penicillin) is administered PO, whereas aqueous penicillin G is administered IV or IM.
Adult
Penicillin V: 250-500 mg PO q6-8h
Penicillin G: 2-24 million U/d IV/IM divided q4-6h
Pediatric
Penicillin V: 15-62.5 mg/kg/d (25,000-100,000 U/kg/d) PO divided q4-8h
Penicillin G: 100,000-400,000 U/kg/d divided q4-6h; not to exceed 24 million U/d
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. Concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Treats mild-to-moderate microbial infections.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg/d PO
Alternatively, 1 g PO once
Pediatric
<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg/d PO; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in patients who are hospitalized, geriatric, or debilitated
Metronidazole (Flagyl)
Effective against only obligate anaerobes. Alternative for patients who are allergic to penicillin. Consider the combination of penicillin with metronidazole because metronidazole compensates for limited activity of penicillin against beta-lactamase – producing stains of anaerobes. Compliance must be considered with a 2-drug regimen.
Adult
Loading dose: 15 mg/kg or 1 g for a 70-kg adult IV over 1 h
Maintenance dose: 6 h following loading dose, administer 7.5 mg/kg or 500 mg for a 70-kg adult IV over 1 h q6-8h; not to exceed 4 g/d
Pediatric
30 mg/kg/d PO/IV divided q6h; not to exceed 4 g/d
Cimetidine may increase toxicity of metronidazole; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with PO ingested ethanol
Documented hypersensitivity; first trimester of pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Clindamycin (Cleocin)
Considered by many as first-line therapy because of emergent penicillin resistance. Excellent activity against PO aerobes and anaerobes; penetrates bone and abscess cavities, but its use is limited because of the danger of inducing pseudomembranous colitis; no more effective than penicillin against anaerobes. Use in patients who are allergic to penicillin.
Adult
150-450 mg PO q6-8h; not to exceed 1.8 g/d
600-1200 mg/d IV/IM divided q6-8h
Pediatric
20-30 mg/kg/d PO divided q6h; not to exceed 1.8 g/d
25-40 mg/kg/d IV/IM divided q6-8h
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Amoxicillin and clavulanate (Augmentin)
Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase – producing bacteria. Good alternative antibiotic for patients allergic or intolerant to the macrolide class. Is usually well tolerated and provides good coverage to most infectious agents. Not effective against Mycoplasma and Legionella species. The half-life of PO dosage form is 1-1.3 h. Has good tissue penetration but does not enter cerebrospinal fluid.
For children aged 3 mo or older, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Adult
500 mg PO tid for 7-10 d
Pediatric
<3 months: 125 mg/5mL PO susp; 30 mg/kg/d (based on amoxicillin component) PO divided bid for 7-10 d
>3 months: if using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO q12h; if using 125 mg/5 mL or 250 mg/5 mL susp, 40 mg/kg/d PO q8h for 7-10 d
>40 kg: Administer as in adults
Coadministration with warfarin or heparin increases risk of bleeding; may act synergistically against selected microorganisms when coadministered with aminoglycosides; coadministration with allopurinol may increase incidence of amoxicillin rash; may decrease efficacy of PO contraceptives when administered concomitantly
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; diarrhea may occur; cross-allergy may occur with other beta-lactams and cephalosporins
Cefoxitin (Mefoxin)
Second-generation cephalosporin with activity against some gram-positive cocci, gram-negative rod infections, and anaerobic bacteria. Inhibits bacterial cell wall synthesis by binding to 1 or more of the penicillin-binding proteins; inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death.
Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.
Adult
2 g IV q6h and 100 mg IV doxycycline q12h; continue at least 4 d and at least 48 h after improvement; then, 100 mg PO doxycycline bid 10-14 d
Pediatric
80-160 mg/kg/d IV/IM divided q4-8h; not to exceed 12 g/d
Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Moxifloxacin (Avelox)
Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription.
Adult
400 mg/d PO/IV
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, cimetidine increase serum levels; NSAIDs enhance CNS-stimulating effect; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ferrous sulfate decreases bioavailability (administer moxifloxacin 4 h prior to or 8 h following ferrous sulfate); coadministration with drugs that prolong QTc interval (quinidine, procainamide, amiodarone, sotalol, erythromycin, tricyclic antidepressants) increase risk of life-threatening arrhythmia
Documented hypersensitivity; known Q-T prolongation, concurrent administration of drugs that cause Q-T prolongation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, periodically evaluate organ-system functions (eg, renal, hepatic, hematopoietic); superinfections may occur with prolonged or repeated antibiotic therapy; fluoroquinolones have induced seizures in patients with CNS disorders and have caused tendinitis or tendon rupture
More on Dental Abscess |
| Overview: Dental Abscess |
| Differential Diagnoses & Workup: Dental Abscess |
 Treatment & Medication: Dental Abscess |
| Follow-up: Dental Abscess |
| Multimedia: Dental Abscess |
| References |
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References
[Guideline] Krebs KA, Clem DS 3rd. Guidelines for the management of patients with periodontal diseases. J Periodontol. Sep 2006;77(9):1607-11. [Medline].
Stefanopoulos PK, Kolokotronis AE. The clinical significance of anaerobic bacteria in acute orofacial odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Oct 2004;98(4):398-408. [Medline].
Jain S, Nagpure PS, Singh R, Garg D. Minor trauma triggering cervicofacial necrotizing fasciitis from odontogenic abscess. J Emerg Trauma Shock. Jul 2008;1(2):114-8. [Medline].
Brauer HU. Unusual complications associated with third molar surgery: A systematic review. Quintessence Int. Jul-Aug 2009;40(7):565-72. [Medline].
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Gill Y, Scully C. The microbiology and management of acute dentoalveolar abscess: views of British oral and maxillofacial surgeons. Br J Oral Maxillofac Surg. Dec 1988;26(6):452-7. [Medline].
Hall V, Collins MD, Hutson RA, et al. Actinomyces oricola sp. nov., from a human dental abscess. Int J Syst Evol Microbiol. Sep 2003;53(Pt 5):1515-8. [Medline]. [Full Text].
LeJeune HB, Amedee RG. A review of odontogenic infections. J La State Med Soc. Jun 1994;146(6):239-41. [Medline].
Lewis MA, MacFarlane TW, McGowan DA. A microbiological and clinical review of the acute dentoalveolar abscess. Br J Oral Maxillofac Surg. Dec 1990;28(6):359-66. [Medline].
Lewis MA, MacFarlane TW, McGowan DA. Antibiotic susceptibilities of bacteria isolated from acute dentoalveolar abscesses. J Antimicrob Chemother. Jan 1989;23(1):69-77. [Medline].
Pynn BR, Sands T, Pharoah MJ. Odontogenic infections: Part one. Anatomy and radiology. Oral Health. May 1995;85(5):7-10, 13-4, 17-8 passim. [Medline].
Sands T, Pynn BR, Katsikeris N. Odontogenic infections: Part two. Microbiology, antibiotics and management. Oral Health. Jun 1995;85(6):11-4, 17-21, 23 passim. [Medline].
Further Reading
Keywords
dental abscess, odontogenic abscess, tooth abscess, dentoalveolar abscess, periapical abscess, periodontal abscess, pericoronitis, tooth infection, infected tooth, dental caries, pulpitis, baby-bottle tooth decay, BBTD, Ludwig angina, Ludwig's angina, simple dentoalveolar abscess, odontogenic infection, pulpitides, early-childhood caries, caries, gingivitis, plaque, teeth problem, tooth problem, diagnosis, treatment
