By Dr Alan Mann
Specialist oral surgeon

Dr Alan Mann practiced as a general dentist, obtaining a graduate diploma in oral implants and gaining broad dental experience before completing specialist training. He is a fellow of the Royal Australasian College of Dental Surgeons (FRACDS) currently serving as an invited examiner. He founded Specialist Oral Surgery Sydney (SOSS) in 2025 with branches in Rhodes, St Leonards and Kingsgrove, providing collaborative care and support to general dentists, dentists with special interests and dental specialists. He maintains a public appointment as consultant oral surgeon at Royal North Shore Hospital and as a volunteer oral surgeon for the Cerebral Palsy Alliance.

One of the most stressful dental emergencies is severely infected wisdom teeth. Pericoronitis of the mandibular third molars may spread into deep tissue spaces leading to the need for urgent hospitalisation.^₁ Some considerations for general practice are discussed.

Reception staff
As the first point of contact, reception staff can be trained to triage the urgency of care. A flowchart is helpful for non-clinical staff (Figure 1, A4 size printout available on request). The dentist should be notified immediately if patients report facial swelling, neck swelling, trismus, dysphagia or difficulties breathing. The default advice is to present at the emergency department (ED) of a tertiary hospital.

Sepsis
Severe infections can lead to sepsis. The following signs of sepsis can be screened in general practice:^₂

• temperature (38°C or below 36°C)
• tachycardia (>90 beats/min)
• hypotension (systolic BP below 90mmHG)
• tachypnoea (22 breaths per minute or more)
• signs of pallor
• signs of confusion.

Anyone with signs of sepsis should be sent to ED. Immunocompromised patients may not mount the same reaction to infection, lacking these characteristics signs and a lower clinical threshold should be adopted when suspecting sepsis.^₃

Timing of surgical intervention
It was once believed surgical intervention should be deferred in the presence of active infections to avoid seeding infection into deeper spaces. Evidence shows prompt removal of infected teeth and drainage of pus results in faster recovery.^₄ If surgical intervention cannot be performed, such as due to surgical complexity, prompt referral is required. Antibiotics are warranted, with patients informed that surgical intervention remains urgently required.

Antibiotic selection
Australian guidelines recommend amoxicillin or phenoxymethylpenicillin in addition to metronidazole. Alternatively amoxicillin + clavulanate 875+125mg can be prescribed as a single agent. Clindamycin is no longer recommended for patients with mild to moderate hypersensitivity to penicillin due to higher risk of Clostridioides difficile infection.^_5,6 Recent data also report increased resistance.^₇ Cefalexin is now recommended instead, however clindamycin remains recommended for patients with a history of anaphylaxis, hypotension, compromised airway, airway angioedema, or collapse from penicillin use.⁶

Update on surgical treatment options
For mandibular third molars at increased risk of disturbance to the inferior alveolar nerve (IAN), evidence from systematic review support coronectomy as a valid risk minimisation treatment option (Figure _{2, 3).⁸} Recently, 10-year follow-up data has been published further supporting coronectomy._⁹ Careful case selection is required based on anatomical and patient prognostic factors. It is also technique sensitive. The nature and extent of an active infection may contraindicate coronectomy as an option. If there are potentially problematic third molars which can benefit from coronectomy, then it may be best discussed and planned prior to active infection.

Conclusion
A structured approach to managing dental emergencies not only improves clinical outcomes but reduces stresses for both patients, staff and the dentist. Dentists play a pivotal role in the early identification of high risk mandibular third molars. Clear patient education regarding the state of the third molars and thorough discussion of all management options helps minimise uncertainty and avoids surprises should symptoms arise. When prognosis or management is unclear, timely specialist referral supports optimal care.

Fig. 1: Flowchart for reception (A4 size printout available on request).

Fig. 2: Tooth 38 close to IAN.

Fig 3: 24 months after coronectomy.

List of references:

1. Ullah M, Irshad M, Yaacoub A, Carter E, Cox S. Hospitalisations Due to Dental Infection: A Retrospective Clinical Audit from an Australian Public Hospital. Dent J (Basel). 2024 Jun 6;12(6):173
2. Bond AT, Soubra YS, Aziz U, Read-Fuller AM, Reddy LV, Kesterke MJ, Amin D. Are Deep Odontogenic Infections Associated With an Increased Risk for Sepsis? J Oral Maxillofac Surg. 2024 Jul;82(7):852-861.
3. Singer M, Angus DC, Annane D, Bauer M, Kalil AC, Klompas M, Machado FR, Martin GS, Randolph AG, Shankar-Hari M, Shapiro NI, Van den Berghe G. Sepsis. Lancet. 2026 Mar 28;407(10535):1276-1288.
4. Johri A, Piecuch JF. Should teeth be extracted immediately in the presence of acute infection? Oral Maxillofac Surg Clin North Am. 2011 Nov;23(4):507-11
5. Thornhill MH, Dayer MJ, Durkin MJ, Lockhart PB, Baddour LM. Risk of Adverse Reactions to Oral Antibiotics Prescribed by Dentists. J Dent Res. 2019 Sep;98(10):1081-1087.
6. Acute odontogenic infections. In: Oral and Dental Expert Group. Therapeutic guidelines: oral and dental. Version 4. Melbourne: Therapeutic Guidelines Limited; 2025. https://www.tg.org.au
7. Musa AAR, Jensen ED, Richardson R, Cheng A, Sambrook PJ. Post-Operative Infections Following Dentoalveolar Surgery Admitted to an Oral and Maxillofacial Surgery Tertiary Centre. Aust Dent J. 2026 Mar;71(1):59-67.
8. Mann A, Scott JF. Coronectomy of mandibular third molars: a systematic literature review and case studies. Aust Dent J. 2021 Jun;66(2):136-149.
9. Li JTW, Leung YY. Ten-year-plus follow-up study on coronectomy of the mandibular third molar. Int J Oral Maxillofac Surg. 2026 May;55(5):592-598.