Dental infections — MSF Clinical guidelines — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 10: Medical and minor surgical procedures · Médecins Sans Frontières, Current online edition, 2026

MSF clinical guidance on diagnosis and management of dental infections from localised abscess to life-threatening cervico-facial cellulitis.

In one sentenceDental infections require surgical treatment (drainage/extraction); antibiotics (amoxicillin 25 mg/kg or 1 g twice daily for 5 days) are added only when infection extends beyond the tooth to adjacent structures.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Clinicians in resource-limited settings, humanitarian healthcare workers
Evidence: Expert consensus based on MSF field experience
Reviewed: 22 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 22 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline section addresses dental infections arising as secondary complications of dental pulp inflammation. The guidance stratifies management according to three levels of severity: infections localised to the tooth, infections extending to adjacent anatomical structures, and infections extending into cervico-facial tissues.

For localised acute dental abscesses, treatment is exclusively surgical (root canal therapy or extraction), as antibiotics cannot access the source of infection. For acute dento-alveolar abscesses extending to adjacent structures, surgical drainage or extraction is followed by 5 days of amoxicillin therapy. Life-threatening cervico-facial cellulitis with tissue necrosis requires intensive care, high-dose antibiotics, and tooth extraction.

The guideline emphasises that surgical intervention is primary in all cases, with antibiotics reserved for infections extending beyond the tooth itself. Pain management with paracetamol or ibuprofen is recommended throughout.

Key points

For clinicians — doses and thresholds as stated in the guideline

Acute dental abscess localised to the tooth requires only surgical treatment (root canal therapy or extraction); antibiotics are not indicated as the infection source is inaccessible to antibiotics.
Acute dento-alveolar abscess requires surgical drainage or extraction first, then amoxicillin for 5 days: children 25 mg/kg twice daily, adults 1 g twice daily.
If dental procedure must be delayed due to inflammation or significant trismus, start antibiotic therapy but complete the dental procedure within the following days.
If no improvement occurs 48 to 72 hours after the dental procedure, do not change antibiotic but perform a new dental procedure on the tooth.
Acute gangrenous cellulitis (crepitations on palpation) should be treated as cervico-facial tissue infection.
Cervico-facial cellulitis with tissue necrosis and septicaemia requires intensive care unit treatment, high-dose antibiotics, and tooth extraction.
Pain management with paracetamol or ibuprofen is appropriate for all dental infection presentations.
Clinical signs distinguishing acute dento-alveolar abscess include painful gingival and buccal swelling, warm and tender skin, trismus (particularly posterior teeth), and systemic signs (fever, fatigue, cervical lymphadenopathy).

Classification and management of dental infections by severity

Table extracted from the guideline

Type	Clinical features	Surgical treatment	Antibiotic treatment	Duration
Localised (acute dental abscess)	Swelling limited to gum, purulent exudate, no extension or systemic signs	Root canal therapy or extraction	None	—
Adjacent structures (dento-alveolar abscess)	Gingival/buccal swelling, warm tender skin, trismus, fever, lymphadenopathy	Incision/drainage or extraction	Amoxicillin: Children 25 mg/kg 2×/day; Adults 1 g 2×/day	5 days
Cervico-facial tissues	Rapidly spreading necrosis, septicaemia	Extraction	High-dose (see necrotising soft tissue infections)	ICU management

Source: Médecins Sans Frontières, Dental infections — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“Treatment is only surgical (the source of infection is inaccessible to antibiotics): root canal therapy (disinfection of the root canal) if possible or extraction of the tooth.”

— Médecins Sans Frontières, Dental infections — MSF Clinical guidelines, Infection localised to a tooth and its surroundings (acute dental abscess) — Treatment (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal, I recognise this MSF guidance addresses a common presentation in Georgian emergency departments and primary care settings, where antibiotic overprescription for dental problems remains a concern for antimicrobial stewardship. The clear message that localised dental abscesses require only surgical intervention—not antibiotics—is critical for Georgian clinicians to internalise, as it runs counter to common prescribing patterns. The specific amoxicillin dosing for dento-alveolar abscesses (25 mg/kg or 1 g twice daily for 5 days) provides practical guidance that aligns with Georgia's essential medicines list. Implementation will require strengthening emergency dental surgical capacity, particularly in regional centres where delayed referral might currently prompt empirical antibiotic use instead of definitive surgical management.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026

Applicability

Georgia and the South Caucasus

Dental infections remain a significant burden in Georgia and the South Caucasus, where access to specialist dental care may be limited in rural areas. This guideline’s emphasis on surgical intervention as primary treatment and judicious antibiotic use aligns with antimicrobial stewardship priorities relevant to the region. Georgian primary care clinicians and emergency departments should note the clear criteria distinguishing infections requiring antibiotics from those needing only surgical management. National oral health programmes would need to ensure availability of emergency dental surgical capacity and amoxicillin in appropriate formulations, whilst ICU referral pathways for rare but life-threatening cervico-facial infections should be established, particularly given geographic challenges in mountainous regions.

Questions this guideline answers

Quick answers

When should antibiotics be prescribed for dental infections?

Antibiotics are indicated only when infection extends beyond the tooth to adjacent anatomical structures (acute dento-alveolar abscess) or cervico-facial tissues. For infections localised to the tooth itself (acute dental abscess), antibiotics are not effective as the source is inaccessible, and only surgical treatment is required.

What antibiotic dose should be used for acute dento-alveolar abscess?

Amoxicillin for 5 days following surgical drainage or extraction: children 25 mg/kg twice daily, adults 1 g twice daily. Treatment begins after the surgical procedure, unless the procedure must be delayed due to local inflammation or trismus.

What should be done if there is no improvement 48-72 hours after dental surgery?

Do not change the antibiotic. Instead, perform a new dental procedure on the tooth. The lack of improvement indicates inadequate surgical source control rather than antibiotic failure.

How can acute gangrenous cellulitis be recognised and what is the management?

Crepitations on palpation indicate acute gangrenous cellulitis. This should be managed as an infection extending into cervico-facial tissues, requiring intensive care unit treatment, high-dose antibiotics (as per necrotising soft tissue infection protocols), and tooth extraction.

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Dental infections — MSF Clinical guidelines

What this guideline says

Key points

Classification and management of dental infections by severity

From the guideline