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Dental Abscess

Last updated 5th March 2024

Overview

  1. The clinical spectrum of odontogenic infection ranges from pulpitic dental pain without spreading infection in the soft tissues, to severe life threatening complications involving numerous fascial spaces.
  2. In otherwise healthy patients, the vast majority of dental infections can be managed as an outpatient by the patient’s own dentist.
  3. If the patient is a long term inpatient with acute dental problems then they can be reviewed by the Public Dental Service based in Dumfries Dental Centre (Tel: 01387 245536).
  4. A small percentage will require review by Oral and Maxillofacial Surgery (OMFS) due to the risk of airway compromise, sepsis or cavernous sinus or mediastinal spread.

Presentation

  1. Dental pain with or without facial swelling is the most common presenting symptom.
  2. Symptoms of systemic infection may be described.
  3. Concerning symptoms including sepsis, dysphagia, severe trismus, drooling, altered speech/voice or altered mental status suggest the need for prompt referral and operative management.

Assessment

  1. Initial A-E assessment due to risk of airway compromise or life threatening sepsis.
  2. Examination of the head and neck should note the following features:
    • Swelling- site, size and fluctuance/firm/soft.
    • Is swelling extending down neck or up to the eye?
    • Can the lower border of the mandible be palpated?
    • Skin erythema and spreading cellulitis
    • Trismus
    • Is the floor of mouth raised?
    • Deviation of uvula – specify left or right
    • Altered speech (hot potato voice); inability to protrude tongue

Investigations

  1. In the case of clinically obvious minor odontogenic infections that are suitable for management in general dental practice, no hospital based investigations may be necessary.
  2. If the patient is being considered for referral to OMFS then the following initial investigations are indicated:
    • Orthopantomogram (OPT) radiograph
    • FBC, CRP, U+Es, Glucose +/-blood cultures
  3. Further imaging may be requested after discussion with OMFS

Which Patients Require Admission?

  1. Referral to OMFS and emergency admission will be required for patients with:
    • Signs of airway compromise
    • Signs of significant systemic infection – sepsis can occur with odontogenic infection
    • Significant infraorbital (difficulty opening eye), floor of mouth or submandibular swelling
    • Firm swelling/collection
    • Spreading orbital, face or neck cellulitis
    • Neurological signs (suggestive of cavernous sinus thrombosis or brain abscess)
  2. OMFS referral/admission may also be required for the following patients based on clinical judgement:
    • Very young/elderly
    • Immunocompromised
    • Signs of systemic infection

Management of Patients not Requiring Admission

  1. As suggested above most odontogenic infections are managed in general dental practice
  2. Antibiotics are generally not indicated for otherwise healthy people at low risk of complications when there are no signs of spreading infection. The primary treatment is incision and drainage and removal of the source of infection. It is acknowledged that this treatment is frequently not possible in the medical hospital setting.
  3. Antibiotics may therefore be considered for people who are systemically unwell, for those with signs of severe infection (for example fever, lymphadenopathy, cellulitis, diffuse swelling) or for high risk immuncompromised individuals.
  4. An appropriate choice of antibiotic would be Penicillin V. Metronidazole is a suitable alternative in those who are allergic to penicillin. Always emphasise the need to attend a dentist as soon as possible for definitive treatment.
  5. Patients who are registered with a dentist should contact their dental practice to arrange an emergency appointment. If the patient is not registered with a dentist then they can access emergency dental care via NHS 24.

Management of Patients who Require Admission

  1. ABCD emergency management as appropriate
  2. Involve senior anaesthetic assistance early if threat of airway compromise
  3. IV dexamethasone if airway concerns
  4. Investigations as above and refer OMFS (see below)
  5. IV antibiotics
    • IV benzylpenicillin 1.2g QDS and metronidazole 500mg TDS
    • IV clindamycin 600mg QDS if penicillin allergy
  6. Ensure NBM until OMFS review and consider IV fluids

How to Refer Acutely to OMFS in DGRI?

  1. The OMFS service in DGRI operates a resident on-call service Monday-Friday 9am-5pm via switchboard. Out with these hours emergency advice can be sought from the OMFS SHO on-call in Queen Elizabeth University Hospital Glasgow.
  2. The OMFS department in DGRI primarily operates on daycase or single night stay cases. All inpatient and the majority of emergency operating is completed in QEUH Glasgow.

Content by Lee Mackie, Updated by Gary Bell