Overview of Dental Emergencies

Dental infections

Patients with dental infections often present for emergency care with pain as the initial symptom. Dental infections can include pulpitis (inflammation of the tooth's pulp tissue usually caused by a bacterial infection), pulpal necrosis (necrotic tooth pulp) with bacterial infection spreading to surrounding tissue, localized acute apical abscess (fluctuant swelling in the soft tissue surrounding the jaw), gum swelling around teeth with purulent drainage (pericoronitis), or large caries on a tooth.

Dental radiographs are not required in emergency situations, but they can be used if available to view any spread of infection to the mandible or maxilla. The patient presenting with pain and/or infection should be referred to a dentist by the next day if not sooner. If an immediate dental consultation is not possible, the patient should be medically monitored until such a visit can be arranged.

Analgesia and treatment of dental infections

Oral analgesics, effective for most dental problems, include acetaminophen (650 to 1000 mg every 6 hours) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400 to 800 mg every 6 hours) or naproxen sodium (440 mg every 8 hours). Ibuprofen and acetaminophen also can be used together for a brief period and alternated every 3 hours. For severe pain, these medications may be combined with opioids such as codeine, hydrocodone, or oxycodone (1).

Definitive dental care (eg, pulpotomy, pulpectomy, nonsurgical root canal treatment, extraction, or incision and drainage) is required. Initial management of pericoronitis consists of saline irrigation and analgesics until dental follow-up is available.

Antibiotics should be reserved for patients who exhibit systemic symptoms (eg, fever) or when a localized abscess has spread into surrounding tissues causing regional swelling and/or lymphadenopathy. Appropriate antibiotics for dental infections include amoxicillin or penicillin VK (for patients without penicillin allergy). The duration of antibiotic treatment is dependent on clinical response (2). Patients may be instructed to discontinue antibiotics 24 hours after signs and symptoms resolve, as there is no strong evidence that a shortened course of antibiotics contributes to antimicrobial resistance.

Patients should be reevaluated after 3 days to assess for resolution of or improvement in symptoms. Patients who do not respond to amoxicillin or penicillin can be switched to amoxicillin-clavulanate (2).

In patients who are sensitive or allergic to penicillin or its analogs, azithromycin or clindamycin may be prescribed. Patients should be monitored for possible resistance to azithromycin and for symptoms of Clostridioides difficile infection with clindamycin. Metronidazole should be added to azithromycin or clindamycin if there is an inadequate response to the initial regimen.

The American Heart Association advises that prophylactic antibiotics should be given to high-risk patients before specific definitive dental procedures (2, 3).

References

1. 1. Carrasco-Labra A, Polk DE, Urquhart O, et al. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania. J Am Dent Assoc. 2024;155(2):102-117.e9. doi:10.1016/j.adaj.2023.10.009

2. 2. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc. 150(11):906-921.e12, 2019. doi: 10.1016/j.adaj.2019.08.020

3. 3. Wilson WR, Gewitz M, Lockhart PB, et al. Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation. 143(20):e963-978, 2021.  DOI: 10.1161/CIR.0000000000000969