Dental Abscess requires a Dentist for Definitive Treatment

Symptoms:

• Dental Pain
• Unpleasant taste
• Fever and Malaise
• Trismus
• Dysphagia
• Facial Swelling
• Regional Lymphadenopathy
• Tooth Decay
• Gum Swelling or tenderness
• Purulent Exudate

Differential Diagnosis

• Other infections
  • Sinusitis
  • Mumps
  • Acute otitis Media
  • Facial Cellulitis
• Salivary Gland obstruction

When to Admit?

 

• Airway compromise: symptoms include: difficulty breathing; high pitched breathing sound (stridor); difficulty swallowing (dysphagia); hoarse or muffled sounding voice (dysphonia).
• SEPSIS
• Significant Mandibular /submandibular or infraorbital swelling
• Floor of Mouth Swelling – may indicate Ludwigs Angina (Lateral parapharyngeal abscess / deep neck infection)
• Spreading infection
• Neurological signs
• Dehydration

Careful clinical judgment if: elderly/young/severe pain despite analgesia

Treatment

Definitive treatment needs a dentist – advise patient to call 111 for an emergency appointment if they are not registered

For Discharge: –

• Analgesia – Paracetamol, Co-codamol 8/500 and Ibuprofen are bought from pharmacy. Prescribe TTO Codeine for those whose pain is not controlled despite this.
• Antibiotics – Do not prescribe antibiotics unless there are signs of spreading infection (e.g. facial or neck swelling), symptoms of systemic infection, or judged appropriate for an immunocompromised patient.
  • 3-5Days
    • Phenoxymethylpenicillin First-Line (less likely to cause resistance)
    • Metronidazole appropriate in penicillin allergy

Use of second-line broad spectrum antibiotics offer no clinical benefit but increase risk of C. Diff.

Admission

• Regular Analgesia -IV if necessary
• IV Antibiotics
  • Benzypenicillin 2.4g IV 6 hourly and Metronidazole 500mg IV 8 hourly
  • Penicillin Allergy –  IV Clindamycin 600mg 6 hourly
• OPT X-ray and request images sent to BRI
• Refer MaxFax BRI

Complications of dental abscess include:

• Loss of the affected tooth.
• A fistula or sinus tract may develop that can discharge intraorally or into the overlying skin.
• Spread of infection (more common in immunocompromised and elderly people), for example:
  • Maxillary sinusitis.
  • Cellulitis/periorbital cellulitis.
  • Osteomyelitis.
  • Retropharyngeal abscess.
  • Cavernous sinus thrombosis. 
  • Encephalitis and meningitis.
  • Brain abscess.
  • Mediastinitis.
  • Ludwig’s angina — a serious, potentially life-threatening infection of the tissues of the floor of the mouth. Symptoms include swelling, pain on raising of the tongue, swelling of the neck and the tissues of the submandibular and sublingual spaces. Malaise, fever, dysphagia (difficulty swallowing), trismus and, in severe cases, stridor or difficulty breathing can occur.
• Sepsis — rarely, sepsis can develop from odontogenic infections.
• Airway obstruction — caused by spread of infection into the fascial spaces around the oropharynx.

NICE CKS

SDCEP.org.uk