Tooth abscess: what to do, when it's urgent and when to pull the tooth

An abscess is a pocket of pus from a tooth or gum infection. Guidelines say the cause comes first — draining it, treating the nerve or taking the tooth out — and antibiotics are reserved for an infection that spreads or causes fever. If the tooth can no longer be saved, I remove it atraumatically, without breaking the bone that will later hold an implant. I'm an oral and maxillofacial surgeon (UNAM), a University of Costa Rica dentistry professor since 2006, and I've lectured on atraumatic extraction and socket preservation, including in Honduras (2018).

Anesthesia

Local; sedation depending on the case

Imaging

X-ray; CT scan if the case calls for it

Abscess

The cause is treated first

Consultation

60,000 colones · by video, 20,000

When it's indicated

• An abscess: swelling, pus, a sensitive gum and toothache.
• A broken tooth, or decay that can no longer be restored.
• A root infection that a root canal didn't or can't clear up.
• A loose tooth from gum disease, the kind that starts with bacterial plaque.
• Roots left behind, trapped teeth, or baby teeth that don't fall out on time.

Before surgery

• If you have an X-ray or CT scan, send it ahead; we can review it by video.
• Bring a list of your medications. Don't stop blood thinners on your own (stopping them is associated with a higher risk of blood clots): I coordinate with your doctor.
• Tell me if you take osteoporosis medication or have a weakened immune system: we plan with your doctor.
• If you smoke, stop before and while you heal: dry socket is more common in smokers.
• With sedation: fast as I instruct and come with someone; you can't drive that day.

How I plan it

How I do it

1. 01ConsultationI examine you with the imaging and tell you frankly whether the tooth can be saved.
2. 02If there's an abscess, the source firstDrainage through a small incision inside the mouth (sometimes from outside in extensive cases) and treatment of the cause. I prescribe antibiotics for fever, feeling unwell, diffuse swelling or swollen lymph nodes, or if your health calls for it.
3. 03Atraumatic extractionWith local anesthesia (plus sedation, if we agree on it) I free the tooth from the bone without fracturing the walls: you'll feel pressure; if anything hurts, tell me and I'll add more anesthesia. If it's broken, trapped or has curved roots, I open the gum, remove as little bone as possible and close with stitches.
4. 04Socket preservation, if an implant followsI fill the socket with particulate graft covered by a collagen membrane; when possible, without lifting the gum, which in trials gave similar bone changes with less pain. It reduces shrinkage but doesn't eliminate it.
5. 05When we finishI control the bleeding and give you written instructions. I decide on preventive antibiotics based on your health and infection risk. You can message me while you recover.

Recovery

• First hours: bite on the gauze and use a cold pack outside; some blood in your saliva is normal.
• First day: no vigorous rinsing, spitting, straws or smoking, to protect the clot.
• Discomfort usually lasts a few days: prescribed pain medication, soft food and gentle brushing.
• If severe pain starts between day 1 and day 5, it may be dry socket: message me.
• After drainage, the swelling should keep going down; if it grows or you get a fever, go to the ER.
• If we preserve the socket, studies measured the bone at 3 to 6 months; I schedule the implant with a new scan.

Risks and how I prevent them

Bleeding

It's almost always controlled with pressure or stitches. With newer oral blood thinners, bleeding after mouth procedures was similar whether people continued them (11.8%) or stopped them (13.5%); all were controlled with local measures.

Dry socket

The clot is lost: severe pain that usually starts between day 1 and day 5, sometimes with bad breath. It's associated with smoking: about 13.2% in smokers versus 3.8% in non-smokers. Protecting the clot helps prevent it; it's treated at the office.

The infection spreading

Among people seen in US emergency departments for a dental infection, 9.8% had a severe complication; among hospitalized surgical patients, 3.8% had systemic complications, more often with older age, chronic lung disease, alcohol dependence or infection in several areas (different populations: not combined). That's why it's treated early.

Osteonecrosis with bisphosphonates

With oral bisphosphonates, it's the most reported complication after an extraction, mostly in the back of the lower jaw (limited evidence). Tell me beforehand: I plan it with your doctor.

Root, sinus or nerve

Uncommon: a root fragment, an upper molar opening into the sinus or, near the nerve, a numb lip. That's why I study the imaging first.

The bone shrinking

If the socket heals on its own, within 6 months it loses 29% to 63% of its width and 11% to 22% of its height. Preservation prevented, on average, 1.18 to 1.99 mm of width loss depending on the review (very uncertain evidence, per Cochrane), with no serious adverse events reported.

Other options

Saving the tooth

If it can be restored, a root canal treats the infection and keeps the tooth, even if that means no surgery.

Antibiotics alone

They aren't proven to resolve an abscess without treating the tooth. The American Dental Association advises against them in most cases of localized pain or swelling in adults with a healthy immune system.

Monitoring, without surgery

A baby tooth that will fall out on its own, or a root with no infection or symptoms, can sometimes just be monitored.

Frequently asked questions