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History
HPI
Dental infection symptom profile
Tooth pain
Gingival swelling
Facial swelling
Purulent drainage
Recent dental procedure
Recent dental trauma
Recent URI
Recent sinus symptoms
OPQRST
Onset
Sudden
Gradual
Provocation and palliation
Worse with chewing
Worse with temperature exposure
Better with analgesics
Quality
Throbbing
Pressure
Region and radiation
Localized tooth
Jaw
Ear
Neck
Severity
Pain score 0 to 10
Sleep disruption
Timing
Constant
Intermittent
Progression over hours to days
Associated symptoms
Infectious and airway symptoms
Fever
Chills
Trismus
Dysphagia
Odynophagia
Drooling
Voice change
Neck stiffness
Baseline and prior episodes
Prior dental infections
Similar episodes
Prior antibiotic courses
Prior drainage
Prior hospital admission
Functional impact
Oral intake and hydration
Unable to eat solids
Unable to tolerate liquids
Reduced urine output
Alarm Features
Airway and deep space red flags
Immediate airway concern
Stridor
Respiratory distress
Drooling with inability to handle secretions
Muffled voice
Floor of mouth elevation
Tongue displacement
Severe infection and sepsis red flags
Systemic toxicity
Altered mental status
Rigors
Persistent vomiting
Vital sign danger thresholds
SBP less than 90 mmHg
HR at least 120 per minute
RR at least 22 per minute
SpO2 less than 92 percent on room air
Temperature at least 38.5 C
Orbital and intracranial red flags
Orbital involvement concern
Pain with extraocular movements
Proptosis
Decreased visual acuity
Ophthalmoplegia
Intracranial complication concern
Severe headache
Focal neurologic deficit
Seizure
High risk hosts
Immunocompromise
Neutropenia
Solid organ transplant
High dose steroids
Metabolic risk
Diabetes with poor control
Chronic kidney disease
Escalation triggers
Immediate resuscitation bay triggers
Any airway red flag
Any shock threshold
Rapidly progressive swelling over hours
Medications
Current meds and recent changes
Medication exposure
Recent antibiotics
Recent dental anesthetic
Recent opioid use
Recent NSAID use
Allergies and adverse reactions
Antibiotic allergy history
Penicillin allergy
Cephalosporin allergy
Clindamycin intolerance
High risk medication classes
Bleeding risk agents
Warfarin
DOACs
Antiplatelets
Immunosuppressants
Prednisone
Biologics
Analgesics and antipyretics
Adult dosing examples
Acetaminophen PO 1000 mg every 6 to 8 hours
Maximum 3000 mg per 24 hours local protocol dependent
Ibuprofen PO 400 mg every 6 to 8 hours
Avoid NSAIDs with CKD stage 4 to 5 or active GI bleed
Antibiotics
Adult dosing examples for odontogenic infection
Amoxicillin clavulanate PO 875 mg 125 mg every 12 hours
Penicillin V PO 500 mg every 6 hours
Metronidazole PO 500 mg every 8 hours
Clindamycin PO 300 mg every 6 to 8 hours
Cephalexin PO 500 mg every 6 hours
Pregnancy and lactation cautions
Medication safety considerations
Avoid tetracyclines in pregnancy
Avoid fluoroquinolones in pregnancy unless compelling indication
NSAID avoidance in third trimester
Diet
Intake and hydration
Recent intake pattern
Reduced solids
Reduced liquids
Dehydration indicators
Triggers and exposures
Diet related pain triggers
Cold beverages
Hot beverages
Sugary foods
Substance exposure
Tobacco and vaping
Current use
Recent escalation
Alcohol exposure
Recent heavy intake
Withdrawal risk
Review of Systems
HEENT
Local and regional symptoms
Tooth pain
Gingival bleeding
Halitosis
Facial swelling
Sinus pressure
Ear pain
Respiratory
Airway and breathing symptoms
Dyspnea
Stridor
Cough
GI
Tolerance and systemic symptoms
Nausea
Vomiting
Poor oral intake
Constitutional
Infection symptoms
Fever
Chills
Malaise
Neuro
Neurologic symptoms
Headache
Confusion
Focal weakness
Skin and soft tissue
Spreading infection symptoms
Neck swelling
Erythema tracking
Collateral History and Family History
Collateral sources
Source and reliability
Family report
Caregiver report
Dental clinic note
Family history
Relevant conditions
Bleeding disorder
Congenital heart disease
Immunodeficiency
Exposures and contacts
Household and community exposure
Sick contacts
Shared living environment barriers to follow up
Risk Factors
Dental and anatomic risk
Local risk factors
Poor dentition
Periodontal disease
Dental caries
Recent extraction
Host risk
Comorbid risk factors
Diabetes mellitus (E11.9)
HIV disease (B20)
Malignancy (C80.1)
Medication and device risk
Infection modifiers
Immunosuppressants
Chemotherapy
Social and access risk
Follow up reliability risk
Housing insecurity
No dental access
Substance use disorder (F19.90)
Procedure related risk
Spread risk patterns
Manipulation of infected tooth
Inadequate prior drainage
Differential Diagnosis
Life threatening
Cannot miss
Ludwig angina
Rapidly progressive submandibular swelling
Floor of mouth elevation
Airway compromise risk
Deep neck space infection
Trismus
Neck swelling
Toxic appearance
Necrotizing soft tissue infection
Pain out of proportion
Crepitus
Systemic toxicity
Orbital cellulitis
Pain with eye movement
Proptosis
Vision change
Cavernous sinus thrombosis
Ophthalmoplegia
Severe headache
Cranial nerve deficits
Common
Likely etiologies
Periapical abscess
Localized tooth tenderness
Fluctuant gingival swelling
Periodontal abscess
Gum swelling
Purulent drainage
Pericoronitis
Partially erupted tooth pain
Inflamed operculum
Odontogenic cellulitis
Diffuse facial swelling
No focal fluctuance
Less common
Other considerations
Acute bacterial sinusitis (J01.90)
Purulent nasal discharge
Maxillary tenderness
Sialadenitis
Pain with salivation
Swollen salivary gland
Herpes zoster
Dermatomal pain
Vesicular rash
Mimics and pitfalls
Noninfectious and alternate sources
Temporomandibular disorder
Jaw clicking
Reproducible TMJ tenderness
Trigeminal neuralgia (G50.0)
Electric shock pain
Trigger zones
Giant cell arteritis (M31.6)
Jaw claudication
Temporal tenderness
Past Medical History
Comorbidities
High impact conditions
Diabetes mellitus (E11.9)
Chronic kidney disease (N18.9)
Valvular heart disease (I38)
Prosthetic heart valve (Z95.2)
Prior infections and procedures
Dental history
Prior abscess
Recent extraction
Root canal history
Devices and anticoagulation
Bleeding and procedural risk
Anticoagulation indication
INR goals if warfarin
Baseline function
Ability to follow instructions
Cognitive baseline
Caregiver availability
Physical Exam
General and vitals
Illness severity
Toxic appearance
Hydration status
Fever pattern
Airway and oral cavity
Airway risk findings
Voice quality change
Drooling
Trismus degree
Floor of mouth elevation
Tongue displacement
Oral exam findings
Gingival fluctuance
Purulence
Dental caries
Tooth mobility
Face and neck
Soft tissue spread
Facial swelling location
Submandibular swelling
Neck tenderness
Erythema
Lymphatic
Regional nodes
Cervical lymphadenopathy
Submandibular lymphadenopathy
Eyes
Orbital involvement screening
Visual acuity
Extraocular movements
Proptosis
Cardiopulmonary
Sepsis physiology
Tachycardia
Hypotension
Increased work of breathing
Neuro
Neurologic screening
Mental status
Cranial nerves
Focal deficits
Lab Studies
Initial labs for systemic illness
Infection and organ dysfunction evaluation
CBC
Electrolytes and creatinine
Glucose
CRP
Sepsis and severe infection labs
When toxicity or shock concern
Venous blood gas
Lactate
Blood cultures before antibiotics if feasible
Pregnancy and medication safety
When applicable
Beta hCG
Liver enzymes for medication selection
Pitfalls and limitations
Interpretation cautions
Normal WBC does not exclude deep space infection
Early lactate may be normal in evolving sepsis
Imaging
Scoring Systems
Not routinely used
No validated ED score for odontogenic abscess disposition
Risk stratification driven by airway findings and deep space features
MRI
Limited ED role
Suspected intracranial complication when CT nondiagnostic
Contrast contraindication alternatives local protocol dependent
CT
Contrast enhanced CT indications
Suspected deep neck space infection
Rapidly progressive swelling
Trismus with systemic toxicity
Concern for orbital involvement
CT cautions
Contrast allergy history
Renal dysfunction risk
Ultrasound
Soft tissue assessment
Superficial fluctuant collection localization
Distinguish cellulitis from abscess
Pitfalls
Deep spaces poorly visualized
Gas and bone artifact limits
Special Tests
Bedside maneuvers
Focused oral and airway tests
Mouth opening measurement
Tongue protrusion
Swallow tolerance
Dental focused exam
Localization aids
Tooth percussion tenderness
Gingival palpation for fluctuance
Assessment for draining sinus tract
Procedural diagnostics
When fluctuance present
Aspiration of suspected collection
Culture only for severe infection or immunocompromise local protocol dependent
ECG
Indications
When clinically relevant
Sepsis with tachycardia
Chest pain
Electrolyte abnormality concern
High risk patterns
Unstable findings
Wide complex tachycardia
Ischemic ST segment changes
Assessment
Working diagnosis
Odontogenic infection phenotype
Localized abscess versus cellulitis
Deep space infection concern stratification
Severity stratification
Low risk
Localized pain and swelling
No trismus
No systemic toxicity
High risk
Trismus
Dysphagia or drooling
Rapid progression
Immunocompromised host
Complications to exclude
Extension and spread
Ludwig angina
Deep neck space infection
Orbital cellulitis
Diagnostic uncertainty
Alternate diagnoses supported by features
Sinusitis pattern
TMJ pattern
Neuropathic pain pattern
Plan
Approach to the critical patient
First 5 minutes workflow
Continuous pulse oximetry
Cardiac monitor if systemic illness
Two large bore IV if toxicity
Early airway backup activation if any airway red flag
Immediate ENT or anesthesia involvement if floor of mouth elevation
Analgesia and symptom control
Pain and nausea control
Acetaminophen PO 1000 mg
Ibuprofen PO 400 mg
Ondansetron ODT 4 mg
Antibiotics
Outpatient regimens when no airway risk and no toxicity
Amoxicillin clavulanate PO 875 mg 125 mg every 12 hours
Penicillin V PO 500 mg every 6 hours plus metronidazole PO 500 mg every 8 hours
Clindamycin PO 300 mg every 6 to 8 hours for penicillin allergy
IV regimens when severe infection or deep space concern
Ampicillin sulbactam IV 3 g every 6 hours
Ceftriaxone IV 2 g daily plus metronidazole IV 500 mg every 8 hours
Clindamycin IV 600 mg every 8 hours
Source control
Drainage planning
Dental extraction or root canal definitive management
Incision and drainage when superficial fluctuant collection and safe anatomy
Avoid blind intraoral drainage near major vessels
Consultation and escalation
Specialty involvement
Dentistry or oral and maxillofacial surgery for source control
ENT for suspected deep neck space infection
Ophthalmology for orbital signs
Reassessment loop
Timed reassessment
Repeat airway exam every 30 to 60 minutes if swelling evolving
Repeat vitals after analgesia and fluids
Escalate if new trismus progression or dysphagia
Disposition
ICU criteria
Highest acuity
Any airway compromise
Septic shock physiology
Need for advanced airway monitoring
Inpatient admission criteria
Admit indications
Deep neck space infection concern
Rapidly progressive swelling
Trismus with dehydration
Immunocompromised host
Failed outpatient antibiotics
Observation pathway criteria
Short stay candidates
Moderate swelling without airway signs
IV antibiotics with clinical response
Reliable follow up within 24 to 48 hours
Discharge criteria
Safe outpatient management
No airway red flags
No systemic toxicity
Able to tolerate oral fluids
Reliable dental follow up arranged
Follow up timing
Time sensitive follow up
Dental or oral surgery within 24 to 48 hours
Primary care within 3 to 7 days for comorbid optimization
Discharge Instructions
Copy discharge instructions
Dental infection treated today
Symptoms consistent with tooth or gum infection
Antibiotics started
Medications
Take antibiotics exactly as prescribed
Pain control with acetaminophen and ibuprofen as directed
Avoid alcohol if taking metronidazole
Activity and diet
Soft foods as tolerated
Hydration with frequent sips
Follow up
Dental appointment within 24 to 48 hours for definitive treatment
Return sooner if unable to arrange follow up
Return to ED now for
Trouble breathing
Drooling or inability to swallow saliva
Worsening mouth opening
Rapidly increasing swelling
Fever not improving
Vision changes
Severe headache
Confusion
References
Guidelines and high quality sources
Scottish Dental Clinical Effectiveness Programme guidance on acute dental problems year varies local protocol dependent
Primary care and emergency management pathways
Antibiotic stewardship emphasis
American Dental Association evidence based recommendations for antibiotic use in dental pain and swelling year varies
Antibiotics limited to systemic involvement or spreading infection
Definitive dental treatment prioritized
Infectious Diseases Society of America guidance on skin and soft tissue infections year varies
Principles for cellulitis and abscess antibiotic selection
Source control and severity stratification
Surviving Sepsis Campaign guidelines year varies
Shock recognition and lactate guided resuscitation
Early antibiotics in sepsis physiology
Otolaryngology references for deep neck space infection management year varies
Airway first framework
CT with contrast for suspected deep space infection
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.