Clinical assessment and risk stratification

When a patient attends with dental pain and/or dental abscess, it is important to do a full set of observations, and as well as a good history, the following questions should be asked:

• Any difficulty with breathing, or difficulty with drooling saliva?
• Medical history
• Has the patient got a current dentist?
• Any difficulty with mouth opening?
• Any swellings?
• Any voice changes?
• Any restriction on eye opening?
• Any bad taste (associated with the drainage of pus into the mouth)?

Patients may often confuse dental pain with a dental abscess, and may describe a swelling sensation (although there may in fact be no swelling). Also patients may report not being able to chew due to dental pain as not being able to swallow, and a good way to further enquire about this is whether the patient has been able to swallow fluids.

Warning signs to look out for are:

• Patients with a raised floor of mouth
• Patients drooling, with difficulty swallowing and/or talking
• Patients with hot potato voice, or alteration to voice
• Patients who are having difficulty opening the eye
• Patients who are febrile, tachycardia, tachypnoea, hypotensive. It should be noted it is exceedingly rare to get sepsis from a dental origin
• Erythema associated with the dental abscess spreading down the neck and towards the mediastinum

It is important to examine the patient, feeling for raised lymph nodes, and palpating abscesses. The floor of mouth should be soft, and not firm/raised. Any draining sinuses should be noted, and pressure applied to suspicious teeth. Teeth causing abscesses will generally be tender to touch.