Dental Infections

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Acute Odontogenic Infections

The most important element of management is surgical drainage and removal of necrotic tissue with dental extraction where indicated.

Antimicrobial

Localized without systemic symptoms:

Antibiotic use is not recommended

Infection with facial swelling but without severe or systemic symptoms:

Amoxicillin 500mg (child 25mg/kg) PO TID

PLUS

Metronidazole 500mg (child 10mg/kg) PO BID

Alternative:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

OR

Clindamycin 300mg (child7.5mg/kg) PO TID

Infection with severe features or systemic involvement (including Ludwig angina):

Arrange urgent transfer to hospital.

Benzylpenicillin 3 million IU (1.8g) (if in ICU 4 million IU (2.4g)) (child 80 000 IU (50mg)/kg) IV Q4H

PLUS

Metronidazole 500mg (child 12.5mg/kg) IV BID

Alternative:

If benzylpenicillin is not available replace with:

Ampicillin 2g (child 50mg/kg) IV Q4H

OR

Cefazolin 2g (child 50mg/kg) IV TID

OR

Clindamycin 600mg (child 15mg/kg) IV TID (no need for metronidazole if clindamycin is used)

Comments and Duration of Therapy 

For infection requiring hospital admission, take blood cultures and send operative specimens for culture.

Severe features include:

  • Significant facial swelling and pain
  • Neck swelling
  • Trismus
  • Dysphagia
  • Difficulty breathing

Systemic features include:

  • Fever >38 degrees C
  • Tachycardia
  • Pallor
  • Diaphoresis

Duration:

Infection with facial swelling but without severe or systemic symptoms: Treat for 5 days

Infection with severe features or systemic involvement (including Ludwig angina): Change to oral antibiotics once improving. Treat until signs and symptoms of infection have resolved (10-14 days).

Infection following dentoalveolar surgery:

Most infections can be managed by dental treatment alone.

If there are systemic features of infection or the patient is immunocompromised treat as ‘Infection with facial swelling but without severe or systemic symptoms’, or ‘Infection with severe features or systemic involvement’, depending on severity.

See Necrotising Soft Tissue Infection in Chapter 13: Skin and Soft Tissue Infections.

Periodontitis (including Rapidly Progressing Periodontitis)

Antibiotics are rarely needed for periodontitis.

Antimicrobial 

Where antibiotics are indicated:

Amoxicillin 500mg (child 25mg/kg) PO TID

PLUS

Metronidazole 500mg (child 10mg/kg) PO BID

Alternative:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

OR

Clindamycin 300mg (child 7.5mg/kg) PO TID

Comments and Duration of Therapy

First line treatment is mechanical plaque control with scaling and root debridement.
Only consider antibiotics in patients
With the following:

  • Rapidly progressing periodontitis
  • Periodontitis which has not responded to dental treatment
  • Immunocompromised patients (including poorly controlled diabetes).

Duration:

Treat for 7 days

Mandibular osteomyelitis of dental origin

Antimicrobial

For chronic osteomyelitis only commence antibiotics when causative organisms are identified following debridement.

For acute osteomyelitis treat as ‘Infection with severe features or systemic involvement (including Ludwig angina)’.

Change antibiotics according to culture results.

Comments and Duration of Therapy 

Surgical debridement with dental extraction where indicated is important.

Culture and antibiotic sensitivity testing is necessary to guide antibiotic treatment. Send tissue specimens from debridement for culture. If systemically unwell send blood cultures.

Duration:

Acute osteomyelitis: Treat for 6 weeks with at least 4 weeks IV.

Chronic osteomyelitis: Treat for 3 months with at least 2 weeks IV.

Alveolar osteitis (dry socket)

Antimicrobial 

Systemic antibiotic use not recommended

Comments and Duration of Therapy 

Local treatment with saline irrigation and antiseptic/analgesic dressings, in addition to symptomatic relief of pain.

Pulpitis (reversible and irreversible)

Antimicrobial

Systemic antibiotic use not recommended

Comments and Duration of Therapy

Analgesic dressings and symptomatic relief of pain.

Localized Pericoronitis

Antimicrobial

Systemic antibiotic use not recommended

Comments and Duration of Therapy

Local treatment with antiseptic irrigation and mouthwash, and symptomatic relief of pain

Chronic gingivitis

Antimicrobial

Systemic antibiotic use not recommended

Comments and Duration of Therapy

First line treatment is scaling and chemical plaque control, and mouthwash.

Dental caries

Antimicrobial

Systemic antibiotic use not recommended

Prophylaxis for dental procedures

(see also Prophylaxis for Infective Endocarditis Prevention in Antibiotic Prophylaxis chapter)

Antimicrobial

No antibiotic prophylaxis is required for the following procedures:

  • Tooth extraction
  • Third molar surgery
  • Dental implant insertion
  • Periodontal surgery
  • Periapical surgery
  • Soft and hard tissue removal
References

eTG complete. Acute Odontogenic Infections. In: Therapeutic Guidelines [digital]. Melbourne: Therapeutic Guidelines Limited; 2019. http://www.tg.org.au Holmes C, Pellecchia R. Antimicrobial therapy in management of odontogenic infections in general dentistry. Dent Clin North Am 2016; 60 (2):497-507. Doi: 10.1016/j.cden.2015.11.013

Kementrian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Republik Indonesia. Tentang pedoman penggunaan antibiotic. Indonesia; 2021 Ogle O. Odontogenic infections. Dent Clin North Am 2017; 61 (20):235-252. Doi: 10.1016/j.cden.2016.11.004.

Oral health division, Ministry of Health Malaysia. Guidelines for treatment of odontogenic infections in hospitalized adults. 3rd ed. Malaysia; 2019

University of Michigan. Guidelines for treatment of odontogenic infections in hospitalized adult. Michigan; 2021

Wilder R, Moretti A. Overview of gingivitis and periodontitis in adults. In: Deschler D, Kunins L, editors. UpToDate [internet]. Waltham (MA): UpToDate Inc; 2019. https://www.uptodate.com/contents/overview-of-gingivitis-and-periodontitis-in-adults?search=Necrotising%20gingivitis&source=search_result&selectedTitle=1~9&usage_type=default&display_rank=1#H858625715