Overview of Dental Emergencies

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, 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.

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. Ibuprofen and acetaminophen also can be used together for a brief period and alternated every 3 hours. For severe pain, these drugs may be combined with opioids such as codeine, hydrocodone, or oxycodone.

Definitive dental care (eg, pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage) is required. However, antibiotics should be administered if patients have systemic symptoms (eg, fever) or signs of a localized abscess that has spread to surrounding tissue causing regional swelling and/or lymphadenopathy.

Appropriate antibiotics for dental infections include amoxicillin 500 mg orally every 8 hours for 3 to 7 days, or penicillin VK 500 mg orally every 6 hours for 3 to 7 days. The duration of antibiotic treatment is dependent on clinical response (1). 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 500/125 mg 3 times a day for 7 days (1).

In patients who are sensitive or allergic to penicillin or its analogs, azithromycin is recommended with an initial loading dose of 500 mg followed by 4 days of 250 mg. Alternatively, clindamycin 300 mg orally every 6 hours for 3 to 7 days may be prescribed. Patients should be monitored for possible resistance to azithromycin and symptoms of Clostridium difficile infection with clindamycin. Metronidazole 500 mg 3 times a day for 7 days should be added to azithromycin or clindamycin if there is an inadequate response to the initial regimen.

The American Dental Association (ADA) (2) and the American Heart Association (3) both recommend prophylactic antibiotics for the prevention of infective endocarditis in patients undergoing dental procedures who have or have had any of the following (2, 3):

• Prosthetic cardiac valves, including transcatheter-implanted prostheses or those that use prosthetic material for valve repair

• Infective endocarditis

• Specific congenital heart diseases (CHDs) (eg, unrepaired CHD, repaired CHD with prosthetic material)

• Valvulopathy in the aftermath of a cardiac transplant

For patients with prosthetic joint implants, the ADA guidelines (2) state that prophylactic antibiotics are not typically recommended. However, there may be a subset of such patients for whom antibiotics may be appropriate (eg, a patient with a history of prior joint infection undergoing a procedure that involves gingival incision).

Dental procedures requiring prophylaxis are those that require manipulation or perforation of gingival or oral mucosa or that involve the root end area of the teeth (ie, those most likely to cause bacteremia). The preferred medication is amoxicillin 2 g once orally 30 to 60 minutes before the procedure. For those who cannot tolerate penicillins, alternatives include cephalexin 2 g, azithromycin or clarithromycin 500 mg, or doxycycline 100 mg. All of these alternatives are also given once orally 30 to 60 minutes before the procedure. Clindamycin is no longer recommended for prophylaxis.

1. 1. 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

2. 2. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015;146(1):11-16.e8. doi:10.1016/j.adaj.2014.11.012

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