Oral and dental infections

Patients presenting with acute oral conditions should be referred to a dental specialist.

Please follow this link to obtain information on the emergency dental service

In exceptional circumstances patients may be unable to access dental services in a timely manner; in which case, the guidance below is designed for the management of acute oral conditions pending review by a dental specialist.

Oral candidiasis

See guidance in section 12.3 Oropharynx

Mucosal ulceration and inflammation

Simple gingivitis

Temporary pain and swelling relief can be attained with saline mouthwash.

Use antiseptic mouthwash if more severe & pain limits oral hygiene to treat or prevent secondary infection.

The primary cause for mucosal ulceration or inflammation (aphthous ulcers, oral lichen planus, herpes simplex infection, oral cancer) needs to be evaluated and treated.

Many of these products are cheap to buy and are readily available, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet

Simple saline mouthwash
  • Half a teaspoon salt dissolved in a glass of warm water
Chlorhexidine 0.12-0.2%
  • Rinse mouth for 1 minute every 12 hours with 5ml diluted with 5-10ml water (do not use within 30 minutes of toothpaste)
Hydrogen peroxide 6%
  • Rinse mouth for 2 minute every 8 hours with 15ml diluted in half a glass of warm water
  • Always spit out after use. Use until lesions resolve or less pain allows oral hygiene.

Acute necrotising ulcerative gingivitis

Commence metronidazole and refer to dentist for scaling and oral hygiene advice.

Metronidazole
  • 400mg every 8 hours for 3 days
  • Use in combination with antiseptic mouthwash if pain limits oral hygiene.
Chlorhexidine 0.12-0.2%
  • Rinse mouth for 1 minute every 12 hours with 5mL diluted with 5-10mL water (do not use within 30 minutes of toothpaste) or hydrogen peroxide 6% rinse mouth for 2 minute every 8 hours with 15mL diluted in half a glass of warm water. Use until oral hygiene possible

Pericoronitis

Refer to dentist for irrigation & debridement.

Amoxicillin
  • 500mg every 8 hours for 3 days
  • If there is persistent swelling or systemic symptoms use metronidazole.
Metronidazole
  • 400mg every 8 hours for 3 days

Use antiseptic mouthwash if pain and trismus limit oral hygiene

Chlorhexidine 0.12-0.2%
  • Rinse mouth for 1 minute every 12 hours with 5mL diluted with 5-10mL water (do not use within 30 minutes of toothpaste) or hydrogen peroxide 6% rinse mouth for 2 minute every 8 hours with 15mL diluted in half a glass of warm water. Use until oral hygiene possible

Dental abscess

Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscess are not appropriate. Repeated antibiotics alone, without drainage are ineffective in preventing spread of infection.

Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications.

Severe odontogenic infections; defined as:

  • Cellulitis plus signs of sepsis
  • Difficulty in swallowing
  • Impending airway obstruction
  • Ludwigs angina

Refer urgently for admission to protect airway, achieve surgical drainage and IV antibiotics.

The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage for most dental patients and should only be used if no response to first line drugs when referral is the preferred option.

If pus drain by incision, tooth extraction or via root canal. Send pus for microbiology.

Metronidazole is a suitable alternative for the management of dental abscess in patients who are allergic to penicillin. It can also be used as an adjunct to amoxicillin in patients with spreading infection (lymph node involvement, or systemic signs i.e. fever or malaise) or pyrexia.

Amoxicillin
  • 500mg every 8 hours for up to 5 days, review at day 3 or
Phenoxymethylpenicillin
  • 500-1000mg every 6 hours for up to 5 days, review at day 3
True penicillin allergy
Metronidazole
  • 400mg every 8 hours for 5 days or
Clarithromycin
  • 500mg every 12 hours for up to 5 days, review at day 3

Prevention of endocarditis

NICE CG64: Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures (July 2016)

 

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