What is the best course of treatment for a patient with new onset bilateral temple pain, elevated Erythrocyte Sedimentation Rate (ESR), and an active dental infection, but without jaw claudication or temporal artery tenderness?

Management of Bilateral Temple Pain with Elevated ESR and Active Dental Infection

The dental infection is the most likely cause of both the temple pain and elevated ESR, and should be treated with surgical intervention (extraction or root canal therapy) as the primary treatment, without routine antibiotics unless systemic involvement is present. 1

Primary Treatment Approach

Surgical management of the dental infection is the definitive first-line treatment and should not be delayed. 1 The evidence strongly supports that:

• Root canal therapy for salvageable teeth or extraction for non-restorable teeth is the primary intervention 1
• Antibiotics added to proper surgical management show no statistically significant differences in pain or swelling outcomes 1
• The dental infection is sufficient to explain both the temple pain (referred pain pattern) and the ESR elevation of 61 mm/h 2

Why the Dental Infection Explains the Clinical Picture

The elevated ESR of 61 mm/h is consistent with dental infection as the primary etiology:

• Dental infections commonly cause significant ESR elevation, with documented cases showing ESR values of 110 mm/h from periodontal abscess alone 2
• ESR is elevated in 90% of patients with serious orthopedic infections and inflammatory conditions 3
• The CRP of 0.7 is relatively low, which argues against giant cell arteritis (GCA) where both markers are typically markedly elevated 4

Giant Cell Arteritis Risk Assessment

GCA is unlikely in this clinical scenario and does not require immediate empiric corticosteroid therapy. Here's why:

• Absence of pathognomonic symptoms: Jaw claudication (pain with chewing) and temporal artery tenderness are the hallmark features of GCA 4, 5
• Discordant inflammatory markers: The CRP of 0.7 is not consistent with active GCA, where both ESR and CRP are typically significantly elevated 4
• Competing diagnosis present: The active dental infection provides a clear alternative explanation for both the temple pain and ESR elevation 2

However, maintain vigilance for GCA by:

• Monitoring for development of jaw claudication, visual symptoms, or scalp tenderness 4
• If these symptoms emerge, immediately check ESR and CRP and initiate high-dose corticosteroids (minimum 40 mg prednisone daily) before awaiting biopsy results 4, 5

When to Use Antibiotics for the Dental Infection

Antibiotics are NOT routinely indicated for dental infections when proper surgical drainage can be achieved. 1 Consider antibiotics only if:

• Systemic involvement is present (fever, malaise, lymphadenopathy) 1
• Patient is medically compromised or immunosuppressed 1
• Infection extends into facial spaces or cervicofacial tissues 1
• Diffuse swelling cannot be drained effectively 1
• Failure to respond to surgical treatment alone 1

If antibiotics are indicated, the first-line choice is:

• Amoxicillin for 5 days for acute dentoalveolar abscesses after incision and drainage 1
• Phenoxymethylpenicillin for patients with systemic involvement 1

Critical Pitfalls to Avoid

Do not prescribe antibiotics without surgical intervention - this is ineffective, does not eliminate the source of infection, and contributes to antibiotic resistance. 1, 6 Studies show that 74.4% of antibiotic prescriptions for dental problems are unnecessary. 6

Do not delay dental treatment while pursuing extensive GCA workup - the dental infection requires immediate attention and explains the clinical presentation. 1, 2

Do not initiate empiric corticosteroids for presumed GCA in this scenario - the absence of jaw claudication, temporal artery tenderness, and the presence of low CRP with a competing diagnosis makes GCA unlikely. 4 Unnecessary corticosteroid therapy carries significant risks and may complicate management of the dental infection. 7

Follow-Up Plan

• Dental referral within 24 hours for definitive surgical management 5
• Monitor ESR response to dental treatment (should decrease progressively over weeks if dental infection was the cause) 2
• Reassess at 2-4 weeks: if temple pain persists despite dental treatment resolution, reconsider GCA and check repeat ESR/CRP 4, 5
• Educate patient to immediately report development of jaw claudication, visual changes, or scalp tenderness 4