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Dentists are responsible for a substantial proportion of all antibiotic prescriptions, thus it is important that dentists know optimal principles and practices of using antibiotics. In Nordic countries, national guidelines have an important role as a source of up to date knowledge and expert opinion on treatment of dental infections including the use of antibiotics. The Nordic guidelines highlight that antibiotics should be prescribed only with strict indications and the use of broad-spectrum antibiotics should be avoided. At the same time, it should be kept in mind that common, localised dental infections may occasionally develop into severe life-threatening infections. Whenever antibiotic treatment is considered in addition to surgical drainage it should be started an hour before the procedure to avoid spread of the infection when manipulating infected tissues. It is essential that dentists can identify the patients with systemic infection or increased infection risk. Antibiotics are needed in severe infections and for patients with increased risk of infection complications, but primarily, acute dental infections are always treated by efficient drainage and elimination of the infection focus.

Key points

Acute dental infections should primarily be treated by drainage and removal of the infection focus

Antibiotics should only be prescribed if there are signs of spreading infection and in suspicion of systemic infection or when local infection is judged not to heal with local treatment alone

Although the Nordic guidelines differ in some details they share the common feature that the base for treatment of dental infections is Pencillin V

Unnecessary use of antibiotics should be avoided because of the growing problem of antibiotic resistance

Susceptibility of bacterial pathogens to antibiotics has significantly decreased globally over the past two decades. Increasingly many bacteria are also resistant to three or more antibiotics (multidrug resistant strains), all or nearly all current antibiotics (extensively drug resistant strains). WHO has stated that antibiotic resistance is one of the most important public health threats globally. In addition to their activity on targeted pathogens, antibiotics also have an impact on the normal microbiota by creating a selection pressure that favours resistant bacterial strains. Appropriate and constrained use of antibiotics is one of the most important ways of minimising development of drug resistance. () The aim of antibiotic stewardship is both to preserve the future effectiveness of antibiotics and to improve patient outcomes. Giving the right drug to the right patient at the right dose at the right time for the right duration via the right route is key in this, and antibiotic guidelines are an important tool for clinical decision-making.

Dentists prescribe a substantial proportion (7 - 11 %) of all oral antibiotics. Although many of these antibiotic prescriptions may be appropriate and decrease morbidity and mortality to odontogenic infections some are unnecessary or inappropriate Dentists look after patients with increasingly complex medical histories whereby it can be challenging to identify the patients that would need antibiotic therapy. Severely immunocompromised patients can lack typical symptoms of infection because of their deficient immune system and this can make it challenging to diagnose a severe infection. Correct treatment of an acute infection reduces the risk for complicated prolonged infections but will also have the benefit of minimizing the need for antibiotic treatment. The purpose of this review is to give an overview on etiology and diagnosis of local acute dental infections and their recommended treatment principles in outpatient care, and to discuss the current guidelines in the Nordic countries.

Etiology and pathogenesis of acute dental infections

Origins of dental infections

Significant proportion of head and neck infections originate from teeth. Most common sources of dental infections are apical periodontitis, pericoronitis, surgical sites, surgical tooth extraction sites and periodontitis The most common route of infection is through the root canal: necrotic pulp becomes infected which leads to the development of apical periodontitis as the immune system is not able to eradicate the microbes in the absence of access to the root canal. The pulp tissue can be infected via various routes: dental caries, tooth fractures, open restoration margins or periodontal disease (). Acute periodontal infections include periodontal abscess and necrotizing ulcerative gingivitis (NUG Pericoronitis, local infection of the gingiva and soft tissues adjacent to a partially erupted tooth, is frequently associated with impacted third molars. Most common postoperative complications of surgical tooth extraction are localized surgical site infections and dry socket (). These mild, localized dental infections may in some cases lead to abscess formation and even to spreading or systemic infections.

Microbiology of dental infections

Purulent dental infections are polymicrobial in nature and usually originate from oral normal microbiota. A typical finding is a mix of strict anaerobic and facultative anaerobic bacteria with anaerobes as dominating species (). The most common anaerobic isolates in dental abscesses are gram-negative rods, such as Prevotella, Porphyromonas and Fusobacterium species and anaerobic streptococci. Streptococcus anginosus group bacteria among viridans group streptococci are the dominating facultative anaerobic findings. Infrequently also bacterial species considered as transient colonizers (e.g. staphylococci, beta-hemolytic streptococci and enteric rods) may be found in oral infections. These transient colonizers are generally not considered as cause of infection. It