Extensive Odontogenic Infection
Patients will be lethargic, in severe pain, have difficulty speaking or swallowing. Trismus is present most of the time.
- Patients with poor oral hygiene
- Patients who do not receive regular dental care
- Immunocompromised patients (e.g., diabetes, HIV/AIDS, connective tissue disease)
- Patients with restorations
- Fever and lethargy
- Large swelling
- Difficulty to speak and swallow
- Inability to manage secretions (acute onset of drooling is a worrisome sign)
- Inability to recline due to shortness of breath (worrisome sign)
- Extensive caries
- Tooth fracture
- Tooth mobility
- Moderate to severe pain
- Swelling, often associated with surface redness
- Limited mouth opening
- Fever and malaise
- Floor-of-the-mouth edema and decreased tongue mobility
- Rapid and weak pulse
Rule Out Local Pathologies
- Obtain a thorough medical history and record vital signs.
- Inquire whether the patient is immunocompromised.
- Obtain a thorough dental history and inquire about the history of pain (onset, location, duration, progression over time, type of pain).
- Take intraoral and extraoral radiographs, pending on the patient’s cooperation and comfort level.
- Investigate the degree of anatomical site involvement, ensuring that the spaces other than the oral cavity are intact.
Based on the clinical observations and investigation, a diagnosis of extensive odontogenic infection is determined.
Non-odontogenic infections (major salivary gland infections, peritonsillar abscesses, viral infections, cystic lesion infections)
Common Initial Treatments
- Eliminate the source of infection (e.g., the infected teeth).
- If the infection is fluctuant, aspirate to get samples and send for Gram staining and aerobic and anaerobic cultures.
- Incise and drain.
- Prescribe antibiotics:
- IV antibiotics if the patient is in an urgent care facility
- if the infection is mild to moderate, prescribe penicillin V 300–600 mg orally q.i.d. for at least 7 days (if the patient is allergic to penicillin, prescribe clindamycin 300–600 mg orally q.i.d. for 7 days), plus anaerobic coverage:
- metronidazole (e.g., Flagyl®) 500 mg orally t.i.d. for 7 days; or
- amoxicillin 500 mg orally t.i.d. for 7 days; or
- amoxicillin with clavulanate potassium (e.g., Augmentin®) 500 mg orally t.i.d. for 7 days
- To successfully manage the pain, a combination of narcotics and anti-inflammatory drugs is recommended.
- First line of referral should be to an oral surgeon to expedite patient’s treatment, as they have access to hospitals and have the option of performing in-office sedation (if patient’s safety is not compromised).
- If an oral surgeon is not available, refer the patient to the hospital E.R. Contact the emergency doctor directly to convey your findings and ask whether you should prescribe antibiotics before referral.
- Ensure the patient understands the severity of the condition and that it could lead to death if untreated or if seeing the specialist is delayed.
- Emphasize the importance of completing the full dose of antibiotics.
- Miloro M, editor. Peterson’s Principles of Oral and Maxillofacial Surgery. 2nd ed. Hamilton: BC Decker Inc.; 2004.
- Topazian RG, Goldberg MH, Hupp JR. Oral and Maxillofacial Infections. 4th ed. Philadelphia: W.B Saunders Co.; 2002.