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Dental, Infections: Treatment & Medication
Updated: Aug 11, 2009
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Treatment
Emergency Department Care
The source of the dental infection must ultimately be removed or controlled. Pain medication and antibiotics may be given if the patient is not systemically ill and appears to have a simple localized odontogenic infection or abscess.
- Localized infections
- I&D may be performed if a periapical or periodontal abscess is identified, depending on the physician’s comfort level.
- After anesthesia of the tooth, locally or with a dental block, make an incision in the mucosa large enough to accommodate a quarter-inch Penrose drain.
- Bluntly dissect the abscess cavity with the tips of a hemostat. Suture in the Penrose drain with a silk suture and leave until suppurative drainage is no longer present (about 2-3 d).
- Deep fascial infections
- Infections of the neck's deeper fascial layers and masseteric layers have a higher chance of causing impingement on the airway directly or indirectly through extreme trismus.
- Tracheostomy was the prior method of choice for establishing the airway; as of recently, management through fiberoptic nasoendotracheal intubation while the patient is awake is preferred.
- Various drains and incisions are used for drainage of the affected fascial space.
- If the patient appears systemically ill with abnormal vital signs and/or is unable to take oral medication, consider admission with further diagnostic studies and intravenous antibiotics. Infections in the various fascial spaces require incision and drainage (I&D) by the consulting physician.
- If airway issues are of concern (eg, Ludwig angina, retropharyngeal abscesses), call an anesthesiologist and otolaryngologist as soon as possible to establish an airway. Ensure that equipment for an emergent cricothyroidotomy is located at the bedside until a secure airway can be established.
Consultations
- Oral surgeon
- Dentist
- Otolaryngologist
Medication
The goals of therapy are to treat the dental infection and prevent further complications. Amoxicillin is still the first-line drug of choice but with 34% of Prevotella species resistant to amoxicillin, the alternatives of amoxicillin/clavulanate, clindamycin, and metronidazole need to be considered.
Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting.
Penicillin VK (Veetids)
Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication. Inadequate concentrations may produce only bacteriostatic effects.
Adult
250-500 mg PO q6h
Pediatric
50 mg/kg/d PO divided qid
Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal impairment
Amoxicillin and clavulanic acid (Augmentin)
Drug combination that extends the antibiotic spectrum of this penicillin to include bacteria normally resistant to beta-lactam antibiotics. Indicated for skin and skin structure infections caused by beta-lactamase–producing strains of Staphylococcus aureus. Administer for a minimum of 10 d.
Adult
500/125 mg PO tid
Pediatric
40 mg/kg/d PO divided tid
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Give for a minimum of 10 d to eliminate organism and prevent sequelae (endocarditis and rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci
Erythromycin (EES, E-Mycin, Ery-Tab)
DOC in patients who are allergic to penicillin. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes, inhibiting bacterial growth.
Adult
250-500 mg PO q6h
Pediatric
30-50 mg/kg/d PO divided qid
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Clindamycin (Cleocin)
Lincosamide useful to treat serious skin and soft tissue infections caused by most staphylococci strains. Effective against aerobic and anaerobic streptococci, except enterococci.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.
Adult
600-900 mg IV q8h
Pediatric
20-40 mg/kg/d IV divided q6-8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Ampicillin and sulbactam (Unasyn)
Combination antimicrobial agent that utilizes a beta-lactamase inhibitor with ampicillin. Gives better anaerobic coverage.
Adult
1.5-3 g IV q6h
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Ticarcillin and clavulanate (Timentin)
Used for deep space infections. Inhibits biosynthesis of cell wall mucopeptide and is effective during stages of active growth.
Antipseudomonal penicillin plus a beta-lactamase inhibitor that provides coverage against gram-positive, gram-negative, and anaerobic organisms.
Adult
3.1 g IV q6h
Pediatric
75 mg/kg IV q6h
Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Metronidazole (Flagyl)
An imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually used in combination with other antimicrobial agents except when used for Clostridium difficile enterocolitis in which monotherapy is appropriate. An addition for treating Ludwig angina.
Adult
1 g loading dose IV; then 500 mg IV q6h
Pediatric
15 mg/kg loading dose IV; then 7.5 mg/kg q6h
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
More on Dental, Infections |
| Overview: Dental, Infections |
| Differential Diagnoses & Workup: Dental, Infections |
Treatment & Medication: Dental, Infections |
| Follow-up: Dental, Infections |
| Multimedia: Dental, Infections |
| References |
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References
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Further Reading
Keywords
dental infection, tooth infection, retropharyngeal space infection, Ludwig angina, Ludwig's angina, gingivitis, odontogenic infection, infection of tooth, dental caries, pulpitis, necrotic dental pulp, Streptococcus mutans, deep neck infection, hot potato voice, Horner syndrome, upper respiratory infection, URI, cellulitis, airway obstruction, lymphadenopathy, erythematous gingiva, treatment, diagnosis
Treatment & Medication: Dental, Infections