see also:

• dental injuries
• dental
• dental caries
• mouthwashes
• faciomaxillary
• RCH guideline - paed. dental problems

• chronic dental infections are now recognized as a key driver of atherosclerosis, heart attacks and strokes
  • in those with apical periodontitis, successful root canal treatment could reduce inflammation linked to heart disease and improve levels of blood sugar and cholesterol¹⁾

• teeth are not tender
• pain may be from a mediastinal condition such as gastro-oesophageal reflux, acute myocardial infarction (AMI/STEMI/NSTEMI)

• consider maxillary sinusitis

• flush socket with warm sterile saline until all debris is removed and no debris is produced from the socket
• insert dressing, if available
• seek dental care
• antibiotics are not indicated

• dull ache, throbbing, may be sore to bite on, but not sensitive to hot/cold/sweet stimuli
• urgent dental assessment as may need endodontic (root canal) treatment or extraction
• antibiotics are not indicated

• usually follows a recent toothache due to dental caries and may be a progression of apical periodontitis
• initially tender to pressure and biting
• later, becomes a tender, painful swelling
• Rx:
  • early dental assessment as may need endodontic (root canal) treatment or extraction
    • consider contacting faciomaxillary registrar or the dental hospital to expedite this if local dentist is not an option
  • analgesics eg. non-steroidal anti-inflammatory drugs (NSAIDs)
  • antibiotics may be indicated
    • depending upon severity:
      • broad spectrum oral antis such as amoxy/clavulonic acid
      • stat dose IV ben pen + metronidazole then orals as above
      • if swelling causing dysphagia or dyspnoea is present, admit to hospital for intravenous antibiotic therapy, consider CT scan and appropriate surgical management

• these may be either:
  • superficial
    • can be treated with local surgical or dental treatment plus oral antibiotics
  • if maxillary, spread into the maxillary sinuses
    • see odontogenic sinusitis
    • tender sinuses
    • consider OPG or CT scan
    • bacteriology is different to usual sinusitis and commonly mixed growth including Peptostreptococcus, Prevotella, and Fusobacterium and thus antibiotic Rx needs to be broad spectrum including anaerobic cover
    • dental Mx such as root canal Rx may be needed
    • endoscopic sinus surgery may be required for patients who fail initial medical management and dental treatment
  • deep into soft tissues
    • spread to the submandibular and pharyngeal spaces in the upper neck are potentially life-threatening, as there is a risk of airway obstruction.
    • Ludwig's angina is a severe bilateral cellulitis involving all of the neck spaces from the mandible to the thoracic inlet, although the term is now incorrectly also used for severe deep neck infections.
    • any patient who has trismus and cannot open their mouth more than 2 cm (interincisal) must be assessed for signs of airway compromise and considered for emergent CT scan
    • signs and symptoms of airway compromise include stridor, dyspnoea, dysphagia, and elevation and firmness of the tongue
    • may further be complicated by Lemiere's syndrome
    • admit to hospital
    • iv fluids, antibiotics
    • consider emergent CT scan
    • drainage of collection, removal of tooth, culture

• short and sharp pain, disappears on removal of the stimulus, sensitive to hot/cold/sweet stimuli
• Rx:
  • avoid foods that cause pain
  • cover any obvious cavity (eg. with chewing gum) until dental care available
  • antibiotics not indicated

• sharp and severe pain, becoming a dull throbbing ache that persists after removal of the stimulus, sensitive to hot/cold/sweet stimuli
• as for reversible pulpitis BUT:
  • analgesics such as NSAIDs
  • consider local anaesthesia
  • seek urgent dental care as either endodontic (root canal) treatment or extraction is usually needed