Dental Extraction Facial Swelling

Background

Often mixed mixed anaerobic (75%)/ aerobic Strep. [S mutans](25%)
Penetration through damaged (caries or trauma) enamel then tracts through pulp to periodontal space
Usually presents to ED as a peridontal abscess (pain ++)
May perforate into deep fascial planes
Beware sepsis or airway obstruction (retropharyngeal abscess/Ludwig angina), particularly in immunocompromised
More details on localised dental infections on dental pain in the ED

Submental midline tender swelling (incisors)
Sublingual and submental tenderness/swelling if in soft tissue planes
Localised tooth tenderness (to percussion)
Beware trismus (↓jaw opening - masseteric spasm) and "hot potato" voice or stridor (mediastinal spread/deep space)
Rarely Horners or "meningism" or ear pain (deep neck space involvement)
Ludwig angina : rapidly spreading cellulitis of the sublingual, submandibular spaces with tongue oedema, drooling, and airway obstruction
Vincent angina (DDx diphtheria) = extensive gingivitis rather than deep space infection

Most need no immediate investigations
Cultures etc if toxic
Plain films rarely helpful but may show peridontal bone resorption
Lat soft tissue neck (mass ±gas) & CT if suspicion of deep space/retropharyngeal abscess

Analgesia ++
Local peridontal abscess requires dental follow up/extraction (not antibiotics)
If deep space/retropharyngeal/mediastinal infection (signs above) suspected (beware airway, sepsis): full resuscitation
Assume difficult airway (surgical airway preparation) if any airway signs
If patients are not systemically unwell, have no difficulty swallowing, and/or there is no threat to their airway, prescribe analgesics and arrange for the patient to be reviewed by the local dental team