Management of severe acute dental infections

The bottom line Dental infection is a common and potentially life threatening condition and in some areas admissions for surgical treatment of dental infections are increasing As many doctors are asked inappropriately to see patients with dental pain, service providers must ensure out of hours access to emergency dental treatment Antibiotics are ineffective in the treatment of pulpal pain evoked by hot and cold and are not appropriate in the absence of signs of spreading infection or systemic upset as they do not prevent the development of severe complications Localised dental abscesses respond well to incision and drainage, root treatment, or extraction and therefore it is important to arrange for prompt dental surgery rather than prescribe unnecessary antibiotics Patients presenting with signs of sepsis, facial swelling, trismus (limited mouth opening), or dysphagia should be reviewed by a dental or maxillofacial surgeon without delay for appropriate surgical and medical management Acute dental infection typically occurs when bacteria invade the dental pulp (nerve) and spread to tissues surrounding the tooth. Expert opinion and case series suggest that management requires admission to hospital for intravenous antibiotics together with airway management and surgical drainage of all infected tissue planes under general anaesthesia and close observation and management of underlying diseases. 25 26 27 Sepsis should be managed according to the international guidelines produced by the Society of Critical Care Medicine. 28 29 Parenteral antibiotic prescribing is based on broad spectrum β lactams, metronidazole, and gentamicin. 25 Further good quality clinical trials of sufficient size and scientific rigour are needed to answer the remaining questions about the ideal treatment of acute severe dental infection.