Management (general and specific)

Patients with isolated dental pain should be referred to their general dental practitioner as most hospitals lack the appropriate equipment required to diagnose and treat these patients in the emergency department

Patients with red flags suggestive of a spreading infection should undergo maxillo-facial review. Red flags include fever, signs of sepsis (tachycardia, tachypnoea, raised white cell count, fever), periorbital cellulitis, and lymphadenopathy. Patients with symptoms or signs of potential airway compromise should undergo urgent anaesthetic and maxillofacial review; trismus (difficulty mouth opening), drooling, difficulty swallowing, voice changes, raised tongue or floor of mouth.

Reference Robertson D, Keys W, Rautemaa-Richardson R, Burns R, Smith A. Management of sever acute dental infections. BMJ 2015;350:h1300

Buccal space or palatal dental abscesses are relatively easy to incise and drain under local anaesthetic; however care should be taken for abscesses in the lower premolar region due to the close relationship to the mental nerve. Copious saline irrigation should be used, and the use of drain may be considered. An emperical prescription of co-amoxiclav or metronidazole will also be beneficial in these patients.

Sublingual space abscesses are more difficult to manage, as the anatomy in this area is more complex. Furthermore, it is often a more difficult space to access, and patients with lingual swellings will often have issues secondarily to a raised floor of mouth.

Patients with difficulty opening, drooling, difficulty swallowing, a firm floor of mouth or voice changes should be admitted for incision and drainage under general anaesthesia with removal of any offending teeth. These patients should be started on IV antibiotics, and SHOULD RECEIVE AN URGENT MAXILLOFACIAL AND URGENT ANAESTHETIC REVIEW. These patients can undergo further airway compromise and should be classed as an acute emergency.

It is important to note that patients with an associated erythema on the skin spreading down to the mediastinum are at risk of a rare condition known as acute purulent mediastinitis. This is where an infection spreads from its odontogenic or oropharyngeal origin through the fascial planes into the mediastinum. This is a life-threatening clinical scenario that requires early diagnosis (consider early CT) aggressive broad spectrum IV antibiotics, and multi-disciplinary team input. While initial mortality rates were as high as 40%, with earlier diagnosis and treatment, this figure has reduced to 4.3%. There was a previous tendency to prescribe antibiotics either prophylactically or as a treatment of this condition. The most recent guidance states that antibiotics should only be considered in those with signs of spreading infection, systemic infections of for immunocompromised patients.

References:

Deu Martin M, Saez-Barba M, Lopez-Sanz I, Alcaraz Penarrocha R, Romero Vielva L, Sole Montserrat J. Mortality risk factors in descending necrotizing mediastinitis. Arch Bronchoneumol. 2010 Apr;46(4): 182-7. Wakahara T, Tanaka Y, Maniwa Y, Nishio W, Yoshimura M. Successful management of descending necrotizing mediastinitis. Asian Cardiovasc Thorac Ann. 2011;19:228231

Scottish Dental Clinical Effectiveness Programme. Management of Acute Dental Problems. March 2013

Medicines and Healthcare products Regulatory Agency. Drug safety update: Chlorhexidine: reminder of potential for hypersensitivity; 2012