Emergency Department Care
The source of the dental infection must ultimately be removed or controlled. Pain medication and antibiotics may be given if the patient is not systemically ill and appears to have a simple localized odontogenic infection or abscess. [9, 10]
Igoumenakis et al reported that in odontogenic maxillofacial infections, extraction of the causative tooth is associated with a faster clinical and biological resolution of the infection compared to treatment that did not include extraction. [11]
Localized infections
Incision and drainage (I&D) may be performed if a periapical or periodontal abscess is identified, depending on the physician’s comfort level.
After anesthesia of the tooth, locally or with a dental block, make an incision in the mucosa large enough to accommodate a quarter-inch Penrose drain.
Bluntly dissect the abscess cavity with the tips of a hemostat. Suture in the Penrose drain with a silk suture and leave until suppurative drainage is no longer present (about 2-3 d).
Most dental abscesses respond to surgical treatment (I&D, root canal, or extraction) and elimination of the source of infection. The addition of antibiotics is not recommended for a localized dental abscess. [12]
Deep fascial infections
Infections of the neck's deeper fascial layers and masseteric layers have a higher chance of causing impingement on the airway directly or indirectly through extreme trismus.
Tracheostomy was the prior method of choice for establishing the airway; as of recently, management through fiberoptic nasoendotracheal intubation while the patient is awake is preferred.
Various drains and incisions are used for drainage of the affected fascial space.
Other
If the patient appears systemically ill with abnormal vital signs and/or is unable to take oral medication, consider admission with further diagnostic studies and intravenous antibiotics. Infections in the various fascial spaces require incision and drainage (I&D) by the consulting physician.
If airway issues are of concern (eg, Ludwig angina, retropharyngeal abscesses), call an anesthesiologist and otolaryngologist as soon as possible to establish an airway. Ensure that equipment for an emergent cricothyroidotomy is located at the bedside until a secure airway can be established.
Consultations
Consultations include the following:
-
Oral surgeon
-
Dentist
-
Otolaryngologist
Surgical Care
Caries
Silver diamine fluoride is the first drug to receive Breakthrough Therapy Designation for the arrest of tooth decay by the FDA It has been used previously in other countries such as Japan for over 80 years with much success.
The silver in SDF acts as an antimicrobial killing bacteria allowing for the slowing down and stopage of tooth decay. The fluoride is used to prevent further demineralization. SDF plugs the lesion forming a protective layer decreasing dentinal sensitivity. As the lesion becomes more shallow, the lesion gradually remineralizes while simultaneously inhibiting proteins that break down the dentin matrix.
After drying the tooth, apply SDF to the lesion for sixty seconds. SDF hardens the tooth structure and common side effects consist only of staining gum tissues. When applied to caries, SDF plugs the lesion forming a protective layer decreasing dentinal sensitivity. As the lesion becomes more shallow, the lesion gradually remineralizes while simultaneously inhibiting proteins that break down the dentin matrix.
-
Obvious swelling of the right cheek.
-
Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection.
