A tooth infection can turn into sepsis, although it is uncommon, and a dental swelling with fever or shivering, a racing heart, fast breathing, confusion or blotchy skin means calling 000 or going to the nearest emergency department, not waiting for a dental appointment. healthdirect describes sepsis as a life-threatening condition in which the body damages its own tissues and organs in response to infection, with the risk of dying rising each hour before treatment. In one German hospital series, 16 of 483 people admitted with dental infections, about 3 per cent, developed a septic course.
Written by Dr James Tran, BDent (University of Sydney), MICOI, GradDip (Oral Implants), general dentist at Lumi Dental in Melrose Park.
The short version
- Most tooth infections stay around the tooth. Sepsis is the rare case where the body's response starts to harm the organs.
- Swelling on its own needs a dentist that day. Swelling plus feeling very unwell, with fast breathing, a fast heart rate, confusion, shivering, blotchy skin or very little urine, needs 000 or an emergency department.
- Swelling under the tongue or jaw that makes swallowing or breathing hard is an airway emergency.
- A normal temperature does not rule out a serious infection. In one Sydney hospital audit, only around one in five people admitted with a dental infection had a raised temperature.
- Antibiotics slow an infection but do not remove its source. Our article on antibiotics for a tooth infection explains why the tooth still needs treatment.
What sepsis is, and how a tooth infection gets there
An abscess starts when bacteria reach the nerve inside a tooth through decay or a crack, and pus builds up at the root tip. Usually it stays there. Sometimes it tracks into the soft tissues of the face and neck, the spreading swelling covered in our article on facial swelling from a spreading dental infection.
Sepsis is a different step. healthdirect explains that sepsis is the body's extreme response to an infection, leading to widespread inflammation and organ dysfunction, and that it is not the same as septicaemia, which means bacteria in the bloodstream. Sepsis Australia adds that in sepsis the inflammatory response is uncontrolled and may start mildly before escalating quickly. Fever alone is covered in our article on whether a tooth infection can cause a fever; this article is about the point beyond that.
Severe cases do reach Sydney hospitals: an audit at Nepean Hospital counted 102 admissions for dental infection over 12 months. Around 40 per cent could not open their mouth fully, just over a quarter had difficulty swallowing, and complications, mainly to the airway, were reported in about 9 per cent.
The single rule: swelling plus feeling very unwell means hospital first
If there is a dental swelling and the person feels sicker than ever before, is getting worse quickly, or has any serious sign in the table below, the next call is 000 or the nearest emergency department. A dentist can drain an abscess, but a dental chair has no intravenous fluids, blood tests or intensive care.
Sepsis Australia describes two stages. If you are unwell and concerned, call healthdirect on 1800 022 222 and ask whether it could be sepsis. If you are seriously unwell, call 000 or go straight to the emergency department. In my experience, people delay because they assume a toothache belongs with the dentist. When the whole body is involved, it does not.
Warning signs of sepsis in adults and children
NSW Health stresses that you do not need every symptom to have sepsis. The table draws on the NSW Health guide and healthdirect.
| Who | Serious signs: call 000 or go to hospital | Signs of infection to watch closely |
|---|---|---|
| Adults and older children | Feeling more sick than ever before; getting very sick quickly; trouble breathing or very fast breathing; confusion or slurred speech; not passing urine all day; blue, blotchy or pale skin; a new rash that does not fade when pressed | Fever or shivering, feeling very tired, headache, joint and muscle pain, fast heartbeat, vomiting or diarrhoea |
| Young children and babies | Fever under 3 months of age; floppy, quiet or hard to wake; weak or high-pitched cry; few wet nappies; fast breathing; fitting; a rash that does not fade | Fever in a child older than 3 months, vomiting or diarrhoea, not eating or behaving unusually |
| Pregnant or has just given birth | The adult signs, plus stomach pain or unexpected bleeding or discharge | The adult infection signs |
| Dental red flags at any age | Swelling under the tongue or jaw with trouble swallowing, breathing or drooling; swelling spreading down the neck or towards the eye | Growing swelling, or a mouth that will not open fully |
For children with a tooth abscess the threshold is lower, because healthdirect notes that sepsis can develop more quickly in young children and babies; our article on dental abscesses in children covers the dental side.
Ludwig's angina and deep neck infections in plain words
Some dental infections spread downwards. Ludwig's angina is a rapidly spreading infection of the floor of the mouth, under the tongue and below the jaw on both sides. The StatPearls clinical review describes firm swelling of the neck and floor of the mouth with pain, difficulty swallowing, limited opening and drooling. The tongue can be pushed up and back, so the main danger is to the airway.
The review reports that lower second and third molars account for around 90 per cent of cases and that airway compromise remains the leading cause of death. Before antibiotics, more than half of people with it died. If swallowing saliva has become difficult, do not wait for a fever.
Who is at higher risk of a tooth infection becoming serious
healthdirect lists groups at higher risk of sepsis: children under one and older people; people with diabetes, cancer, kidney disease or heart disease; people with a weakened immune system, including during chemotherapy or radiation therapy; Aboriginal and Torres Strait Islander people; and anyone who has had sepsis before. The NSW Health guide adds extra warning signs during pregnancy and after birth.
In the German series, every patient whose dental infection became septic had at least one risk factor, such as diabetes, obesity, smoking, heavy alcohol use or poor oral hygiene, and in all 16 the source was a decayed lower molar or premolar. For anyone in these groups, I usually suggest a swelling is seen the same day and any general sign prompts a hospital visit.
What not to do while a dental infection is getting worse
Do not rely on antibiotics alone
In the Nepean audit, more than half of the people admitted had already been prescribed antibiotics before they reached hospital, mostly by medical practitioners. Antibiotics can hold an infection back, but pus at the root of a dead tooth stays until the tooth is treated or removed. A swelling still growing on antibiotics needs urgent review.
Do not lance or squeeze the swelling at home
Piercing a swelling can push bacteria deeper and leaves the source untouched.
Do not put heat packs on a facial swelling
I advise against heat on a dental swelling because it may draw the infection towards the skin. A cold pack wrapped in a cloth is a better choice.
Do not wait for a weekday appointment
Around two thirds of the Nepean admissions arrived on weekends, after hours or on public holidays. Our guide to dental emergencies after hours and on public holidays lists the options when a practice is closed.
What happens in hospital
healthdirect lists the usual sepsis treatment: antibiotics as soon as sepsis is suspected, intravenous fluids, oxygen, medicines to support blood pressure and organs, and sometimes surgery to remove the source. For a dental infection, the source is the tooth. In the German series every septic patient needed intensive care and a temporary breathing tube. Most admissions are shorter: the Nepean audit reported an average stay under three days, with more than half treated under local anaesthetic.
How we approach this at Lumi Dental
Lumi Dental offers emergency appointments for toothache and swelling during opening hours, where a dentist examines the tooth and treats the source of infection. If you call about a swelling and also have trouble breathing or swallowing, or any of the serious signs in the table above, the advice is to go to hospital first; the tooth can be treated once you are stable. Opening hours change, so check current hours on the contact page, and read about emergency dental appointments at Lumi Dental.
Questions patients ask
How do I know if my tooth infection has spread to my blood?
You cannot tell from the tooth. The signs are in the whole body: fast breathing, a fast heart rate, confusion, shivering, blotchy skin or very little urine. With a dental swelling, any of these means 000 or the emergency department.
How quickly can a tooth infection become sepsis?
There is no fixed timeline, and most never do. It may start mildly and escalate quickly, so a swelling growing over hours, or a person getting worse, needs urgent care.
Should I go to the emergency department or the dentist for a swollen face?
See a dentist the same day if you otherwise feel well. Go to the emergency department if swallowing or breathing is difficult, the swelling is under the tongue or spreading down the neck, or any serious sepsis sign is present. Our article on tooth abscess signs and treatment covers the dental side.
Can you have sepsis from a tooth without a fever?
Yes. healthdirect lists a low temperature and chills among adult symptoms, and in the Nepean audit only around one in five admitted patients had a raised temperature. Judge by how unwell the person is, not the thermometer.
Will antibiotics from my GP stop a tooth infection turning into sepsis?
They may slow it, but they do not remove the cause. The tooth still needs drainage, root canal treatment or removal, and worsening symptoms on antibiotics need urgent review.
Toothache or swelling? Emergency dental appointments in Melrose Park
If you have a toothache or a swelling and otherwise feel well, the team at Lumi Dental in Melrose Park can see you for an emergency appointment during opening hours; book through the emergency dentist page, and see current offers. If a dental swelling comes with feeling very unwell, call 000 or go to the nearest emergency department first. Patients visit from Ryde, Parramatta, Ermington and Rydalmere, with on-site parking at Melrose Central.
Sources
- healthdirect: Sepsis, what it is and triggers
- NSW Health: What are the symptoms of sepsis? (easy read guide)
- Ullah M and colleagues. Hospitalisations due to dental infection: a retrospective clinical audit from an Australian public hospital (PMC)
- Weise H and colleagues. Severe odontogenic infections with septic progress: a retrospective analysis (PMC)
About the author
Dr James Tran is a general dentist at Lumi Dental in Melrose Park. He holds a BDent from the University of Sydney and a Graduate Diploma in Oral Implants, and is a Member of the International Congress of Oral Implantologists (MICOI).
This article is general information only and is not a substitute for an examination and individual advice from a registered dental practitioner. Suitability for any treatment varies from person to person.
