• Emphasize the need to seek dental treatment as soon as possible.
• Advise the person when and where to seek urgent medical or dental intervention.
• In the absence of immediate dental attention by a dental practitioner:
• Provide appropriate self-care advice.
• Advise the use of an analgesic to relieve symptoms.
• Ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is recommended first-line. See the CKS topic on NSAIDs - prescribing issues.
• Paracetamol and ibuprofen can be taken together if pain relief with either alone is insufficient.
• For adults, if taking paracetamol and ibuprofen together does not provide enough pain relief, consider adding codeine phosphate or switching to an alternative nonsteroidal anti-inflammatory drug (NSAID).
• For women who are pregnant or breastfeeding, paracetamol is preferred. A short course of codeine may be added if paracetamol alone is insufficient.
• Antibiotics are generally not indicated for otherwise healthy individuals when there no signs of spreading infection.
• Only prescribe an antibiotic:
• For people who are systemically unwell or if there are signs of severe infection (e.g. fever, lymphadenopathy, cellulitis, diffuse swelling).
• For high risk individuals to reduce the risk of complications (e.g. people who are immunocompromised or diabetic or have valvular heart disease).
• Do not routinely provide repeat prescriptions or switch antibiotics in people who fail to respond to first-line treatment. Instead advise the person to see a dental practitioner urgently.

• Determine the duration of symptoms: ask about treatment using over-the-counter drugs, any previous similar episodes, or dental treatment carried out.
• Assess the severity of pain and swelling: ask about problems associated with eating, talking, and disturbed sleep.
• Assess systemic involvement: ask about sweating, rigours, or malaise, and measure temperature.
• Consider whether admission to hospital is appropriate (e.g. for people with severe systemic upset, a history of an immunocompromised state, or signs of spreading infection).

CKS found no evidence on the assessment of dental abscesses in primary care settings. These recommendations are based on pragmatic advice.

• All people will need to see a dental practitioner for definitive treatment. Assessing the severity of the symptoms, and knowing what treatment has already been tried, will help determine what level of analgesia is now required and whether an antibiotic should be prescribed.

• All people with a dental abscess should have definitive treatment provided by a dental practitioner.
• Advise the person to access services (for emergency treatment) via:
• Their registered Dental Practice, or
• The Accident and Emergency department of a dental hospital (if available), or
• The local Dental Access Centre (if available), or
• The Accident and Emergency department of a district general hospital, if the airway is compromised or only if no other avenues are available.
• Interim treatment by the medical practitioner may be needed while the person is waiting to see a dental practitioner.

• All people with a dental abscess should be seen as soon as possible by a dental practitioner. However, emergency access to a dental practitioner may not be immediately available and the person may seek help from medical services.
• Treatment may be provided by the person's GP, medical out-of-hours service, or local Accident and Emergency department. Nevertheless, the person must be strongly advised to see a dental practitioner as soon as possible for definitive treatment.
• Interim treatment while waiting to see a dental practitioner may consist of advice about self-care and analgesia, with or without an antibiotic prescription.

These recommendations are based on current medical literature looking at the provision of dental services in the UK [Anderson and Thomas, 2000].

• Provide advice regarding food and drink to reduce the pressure and pain of the dental abscess:
• Avoid food or drink that may be too hot or cold.
• Consume cool, soft foods.
• Advise the safe use of analgesics:
• Encourage regular use of analgesics and warn the individual not to exceed the recommended or prescribed dose.
• For choice of analgesics, see Recommended analgesia
• Remind the individual that analgesics should not be used to delay appropriate dental treatment.
• Inform the individual that many over-the-counter preparations contain similar analgesics. The person should avoid taking combinations of analgesic products at the same time without first checking with a healthcare professional or the packaging.
• If a person is refusing to go to a dental practitioner, consider the following self-care advice:
• Brushing — use a soft tooth brush to reduce discomfort. Avoid flossing the tooth with the abscess.
• Eating — try eating on the other side of the mouth to reduce discomfort and irritation to the abscess.

• People should be advised that serious complications may happen if the abscess is not treated correctly by a dental practitioner.

• CKS considers these recommendations to be pragmatic advice. CKS found no evidence that specifically looked at self care in the treatment of dental abscess.
• Food and drink:
• Dental pain can be exacerbated by temperature (pulpal pain) and by biting (periapical periodontal pain) [Roberts et al, 2000].
• Safe use of analgesics:
• People with acute dental pain are known to consume excessive quantities of analgesics, and there have been case reports of overdose requiring hospital treatment [Sivaloganathan et al, 1993; Preshaw et al, 1994; Dodd and Graham, 2002; Milner et al, 2006; Thomas et al, 2007].

• Ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is recommended first-line.
• Paracetamol and ibuprofen can be taken together if pain relief with either alone is insufficient.
• For adults, if taking paracetamol and ibuprofen together does not provide enough pain relief, consider adding codeine phosphate or switching to an alternative nonsteroidal anti-inflammatory drug (NSAID) such as naproxen or diclofenac.
• In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are preferred to diclofenac.
• For women who are pregnant or breastfeeding, paracetamol is preferred. A short course of codeine may be added if paracetamol alone is insufficient.

• Over-the-counter (OTC) analgesics containing paracetamol, aspirin, or ibuprofen are available with or without codeine.
• By the time of presentation, the person may already have tried OTC medications, including a combination of these analgesics.
• For further information on the prescribing of nonsteroidal anti-inflammatory drugs, see the CKS topic on NSAIDs - prescribing issues.
• For advice on safe use of analgesics, see Self-care advice.
• For further information on the use of analgesics during pregnancy and breastfeeding, see In pregnancy or breastfeeding.

• These recommendations are based on expert opinion and standard clinical practice. CKS found no trials that specifically looked at oral analgesics in the treatment of dental abscess by medical practitioners.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally regarded as the analgesic of choice, given the inflammatory aetiology of most dental pain (being caused by factors such as infection and trauma) [Dionne and Berthold, 2001; Canadian Collaboration on Clinical Practice Guidelines in Dentistry, 2004; Hargreaves and Abbott, 2005; Mickel et al, 2006; BNF 54, 2007].
• Ibuprofen is the preferred NSAID as it is associated with a lower risk of gastrointestinal adverse effects compared with other NSAIDs [Dionne and Berthold, 2001; CSM, 2002; CSM, 2003; Hargreaves and Abbott, 2005; BNF 54, 2007]. Ibuprofen is widely available over the counter and, unlike aspirin, can be given to those less than 16 years of age.
• Differences in anti-inflammatory activity between different NSAIDs are small, but there is considerable variation in individual tolerance and response to them.
• Choice of NSAID in people at risk of cardiovascular adverse effects: diclofenac 150 mg daily has a similar level of thrombotic risk to etoricoxib and possibly other coxibs. The available data do not suggest an increase in thrombotic risk with naproxen or with lower doses of ibuprofen (up to 1200 mg daily) [CHM, 2006; MHRA, 2007; MHRA, 2009]. For further information, see the section on Supporting evidence in the CKS topic on NSAIDs - prescribing issues.
• For those unresponsive to ibuprofen, a different NSAID should be chosen on the basis of incidence of gastrointestinal and other adverse effects [BNF 54, 2007]. For further information see the CKS topic on NSAIDs - prescribing issues.
• Paracetamol is an alternative if NSAIDs are unsuitable. Its analgesic effect for mild-to-moderate dental pain is probably lower than aspirin. However, paracetamol has the advantage that it does not affect bleeding time or interact significantly with warfarin, and is less irritating to the stomach [BNF 54, 2007].
• Codeine and other opioids on their own are thought to be relatively ineffective for dental pain, and their adverse effects can be unpleasant. Opioids should only be considered as adjunctive analgesics and not as primary analgesics [Dionne and Berthold, 2001; Hargreaves and Abbott, 2005; BNF 54, 2007].
• Over-the-counter analgesics containing low dose codeine are available (e.g. co-codamol 8/500 tablets), but the efficacy of these preparations is uncertain [Hargreaves and Abbott, 2005].
• Combined use of analgesics in severe dental pain:
• CKS found no trials supporting the combined use of analgesics (NSAID, paracetamol, and codeine) for severe dental pain. However, this recommendation is pragmatic advice as a combination of drugs are commonly used in clinical practice for pain management.

• In the absence of immediate attention by a dental practitioner:
• Antibiotics are generally not indicated for otherwise healthy individuals or when there no signs of spreading infection.
• Only prescribe an antibiotic:
• For people who are systemically unwell or if there are signs of severe infection (e.g. fever, lymphadenopathy, cellulitis, diffuse swelling).
• For high risk individuals to reduce the risk of complications (e.g. people who are immunocompromised or diabetic or have valvular heart disease).
• Do not routinely provide repeat prescriptions or switch antibiotics in people who fail to respond to first-line treatment. Instead advise the person to see a dental practitioner urgently.

• For further information regarding choice of antibiotics and duration of treatment:
• See Recommended antibiotic.
• When prescribing an antibiotic, explain to the person that:
• Antibiotic therapy is prescribed to reduce the spread of infection. It is not a substitute for dental treatment.
• Regular analgesia should be taken to relieve the symptoms.
• Avoid giving repeat prescriptions for people who continually refuse to see a dental practitioner. Explain that definitive treatment by a trained professional is the only long-term solution, and repeated antibiotics may be masking underlying complications (sinus or dental cyst).
• Always consider an alternative diagnosis or the development of a complication in people with a suspected dental abscess who do not respond, or become systemically unwell after first-line antibiotic treatment. Advise the person to seek urgent dental intervention rather than switching antibiotics.
• The Faculty of General Dental Practitioners does not recommended changing antibiotics because the failure of the antibiotic is not usually due to microbial resistance [Faculty of General Dental Practice, 2000].

• Although there is debate regarding whether or when antibiotics should be used for management of dental abscess [Herrera et al, 2000; Matthews et al, 2003; Wilson and Kornman, 2003], these recommendations are based on guidance issued by the Faculty of General Dental Practitioners [Faculty of General Dental Practice, 2000], the British Society of Antimicrobial Chemotherapy [BSAC, 2007], the Canadian Collaboration on Clinical Practice Guidelines in Dentistry [Canadian Collaboration on Clinical Practice Guidelines in Dentistry, 2004], the American Academy of Periodontology [American Academy of Periodontology, 2004], and the British National Formulary [BNF 54, 2007], as well as expert opinion [Roberts et al, 2000; Dahlen, 2002; Mansour and Cox, 2006].
• CKS found no evidence that specifically looked at antibiotics in the treatment of dental abscess by general medical practitioners.

• If an oral antibiotic is thought to be indicated, prescribe amoxicillin or metronidazole for 5 days.
• A course of amoxicillin 3 g repeated after 8 hours may also be offered for adults.

• For information when to prescribe an antibiotic, see Prescribing an antibiotic
• Amoxicillin and metronidazole are generally considered to be the antibiotics of choice for the management of dental abscesses. Nevertheless, CKS found very little evidence to provide clear advice on which of the two antibiotics should be considered first line. National organizations suggest slightly different approaches:
• The British National Formulary recommend that amoxicillin or metronidazole can be used to manage periapical or periodontal abscesses [BNF 54, 2007]. In cases of penicillin allergy, metronidazole is regarded as the antibiotic of choice [Dahlen, 2002].
• The Faculty of General Dental Practitioners recommends phenoxymethylpenicillin or amoxicillin as first choice for acute dental abscess, with metronidazole as second choice [Faculty of General Dental Practice, 2000]:
• A combination of amoxicillin or penicillin with metronidazole is recommended if a predominately anaerobic infection is suspected or microbiologically proven.
• Erythromycin is third choice.
• CKS found very little evidence looking at the duration of antibiotic therapy in the management of dental abscesses. Therefore, a practical approach would be to prescribe a 5-day course of antibiotics (or a two-doses course if a dose of amoxicillin 3 g is prescribed), and advise the person to see their dental practitioner urgently.
• A 5-day course is recommended by the British National Formulary [BNF 54, 2007].
• A shorter course can be considered if a 3 g dose of amoxicillin is prescribed (two doses 8 hours apart) [Faculty of General Dental Practice, 2000; BNF 54, 2007].

• These recommendations are based on those issued by the Faculty of General Dental Practitioners (UK) [Faculty of General Dental Practice, 2000], the British National Formulary (BNF) [BNF 54, 2007] and expert opinion [Roberts et al, 2000].
• CKS found no evidence that specifically looked at antibiotics in the treatment of dental abscess by general medical practitioners. Antibiotics are often prescribed empirically, due to the difficulty in evaluating microbiology and the delay in obtaining sensitivity results [Dahlen, 2002; Kuriyama et al, 2007].
• Amoxicillin
• Both a 5-day course and a two-dose course of amoxicillin have been recommended for the treatment of dental abscess [Faculty of General Dental Practice, 2000; BNF 54, 2007].
• CKS found no direct randomized studies comparing these two regimens of amoxicillin. However, two small studies found the two-dose amoxicillin course to be as effective as a 5-day course with phenoxymethylpenicillin for treating dental abscess.
• Two small Scottish randomized controlled trials (RCTs) (assessors blinded to treatment) found amoxicillin to be as effective as phenoxymethylpenicillin in terms of subjective (e.g. pain scores) and certain objective assessments (e.g. presence of lymphadenopathy) in adults (n = 60) [Lewis et al, 1986] and children (n = 58) [Paterson and Curzon, 1993]. However, a greater reduction in swelling during the first 24 hours was found in the amoxicillin group in both studies.
• Nausea was experienced by 7% of the amoxicillin group following the second 3g dose (none in the phenoxymethylpenicillin group) in the adult study [Lewis et al, 1986].
• Both studies gave no information regarding the use of analgesics.

• Seek further advice or admit a person to hospital if they have a dental abscess and:
• Are unwell with a high temperature and cardio-respiratory compromise (rapid pulse rate or low blood pressure, high respiratory rate).
• Early signs of dysphagia or a significant 'floor of mouth' swelling.
• Are in severe pain despite analgesia (maximum tolerated) prescribed in primary care.
• Have a spreading facial infection.
• Have a history of being immunocompromised.

• Consider (if available) speaking to the oral and maxillofacial doctor on call in the local hospital for advice before a referral is made.
• Referral to secondary care or admission to hospital may be required if the person is showing signs of worsening systemic upset or is known to be at risk of complications.
• The cause and duration of immunodeficiency affects the degree of risk of infection. Consider further advice in people with:
• Haematological malignancies.
• AIDS with low CD4+ counts.
• Bone marrow or other organ transplants.
• Splenectomy.
• Genetic disorders, such as severe combined immunodeficiency.

• These admission criteria are based on pragmatic advice and include criteria from the British Society for Antimicrobial Chemotherapy [BSAC, 2007].

• The treatment of dental abscesses includes a combination of mechanical treatment, systemic antibiotics, and possibly surgery.
• Mechanical treatment and surgery [Dahlen, 2002]:
• The most important and immediate step in treating a dental abscess is to mechanically incise the abscess and create drainage to reduce the load of infectious bacteria.
• Periapical abscesses are normally managed by root canal treatment. The dentist will drill into the dead tooth and allow pus to escape through the tooth, and then remove necrotic pulpal tissue. A root filling is then placed into the tooth to prevent further infection. If the infection persists despite root canal treatment the dentist may have to extract the tooth, or consider referring to an oral surgeon who may surgically remove diseased tissue.
• Periodontal abscesses are normally managed by drainage of the abscess and thorough cleaning of the periodontal pocket. Following this procedure the dentist will usually smooth out the root surfaces (subgingival scaling and root planing) of the tooth to promote healing and prevent the infection reoccurring. A repeat radiograph will normally be carried out at 3–6 months. Sometimes a referral to an oral surgeon may be needed (for repeated infections) to allow reshaping of the gum tissue. Reshaping of the gum will help the individual keep the area clean, reducing the risk of further infection.
• Systemic antibiotics [Dahlen, 2002; American Academy of Periodontology, 2004; Jaramillo et al, 2005]:
• Systemic antibiotic treatment is of secondary importance to surgical incision and drainage of abscesses. Its role is aimed at preventing bacterial spread and serious complications.