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This guidance is designed for the management of acute oral conditions pending review by a dental specialist.
Please follow this link to obtain information on the emergency dental service
Oral thrush is often over-diagnosed in the immuno-competent. Prescribing is only recommended where symptomatic thrush has been identified. Oral thrush tends to be more problematic in some patients e.g. cancer patients, other immunocompromised patients, and those on corticosteroids.
Failure to respond to treatment (particularly in the immuno-compromised) may indicate mouth ulceration due to herpes. Swabs may be helpful in the case of treatment failure; requests must include details of agents that have not been successful.
Fungal infections of the mouth are usually caused by Candida spp. (candidiasis or candidosis). Underlying conditions, medications or devices which predispose to infection should also be managed in order to optimize the chances of successful treatment.
Acute infections should normally resolve with good oral hygiene and topical treatment.
Dentures or orthodontic braces with plates:
If possible, eliminate or manage any precipitating factors for candidiasis alongside prescribing treatment for the infection.
Miconazole greatly enhances the anti-coagulation effect of warfarin, avoid concomitant use. Refer also to MHRA Drug Safety Update (June 2016).
Refer to the BNF or manufacturer's Summary of Product Characteristics (SPC) for a full list of interactions with miconazole.
Acute oropharyngeal candidiasis presents as a speckled white "cream cheese" deposit on mucosal surfaces around the mouth and throat which may be associated with discomfort or difficulty swallowing.
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
Commence metronidazole and refer to dentist for scaling and oral hygiene advice.
Use in combination with antiseptic mouthwash if pain limits oral hygiene.
Refer to dentist for irrigation & debridement.
If there is persistent swelling or systemic symptoms use metronidazole.
Use antiseptic mouthwash if pain and trismus limit oral hygiene
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:
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.