›Dentist or oral surgeon contact details available
›Operative note availability
›Caregiver observations
Family history relevant to complications
›Bleeding and clotting disorders
›Hemophilia
›von Willebrand disease
›Early thrombosis
Household exposures
›Infection exposure context
›Sick contacts
›Shared smoking exposure
07Risk Factors/rf25
Procedure related risk
›Extraction risk factors
›Mandibular third molar extraction
›Difficult or prolonged procedure
›Traumatic extraction
›Poor oral hygiene baseline
Patient related infection risk
›Host risk factors
›Diabetes mellitus (E11.9)
›Immunosuppression
›Chemotherapy
›Chronic kidney disease (N18.9)
›Malnutrition
Dry socket risk
›Alveolar osteitis risk factors
›Smoking
›Oral contraceptive use
›Prior dry socket
›Early vigorous rinsing
›Straw use
Bleeding risk
›Hemorrhage predisposition
›Anticoagulants
›Antiplatelets
›Liver disease (K76.9)
›Known coagulopathy
Special populations
›Pregnancy and pediatrics
›Pregnancy trimester
›Pediatric age and weight based dosing needs
08Differential Diagnosis/ddx79
Life threatening
›Deep neck space infection
›Ludwig angina
›Submandibular space abscess
›Parapharyngeal abscess
›Retropharyngeal abscess
›Clues
›Trismus
›Dysphagia
›Drooling
›Floor of mouth elevation
›Toxic appearance
›Airway compromise
›Clues
›Stridor
›Voice change
›Respiratory distress
›Sepsis (A41.9)
›Clues
›Hypotension
›Altered mental status
›Persistent fever
›Necrotizing soft tissue infection (M72.6)
›Clues
›Pain out of proportion
›Rapid progression
›Crepitus
Common
›Alveolar osteitis
›Clues
›Pain peak day 2 to 4
›Severe socket pain with radiation
›Empty socket appearance
›Halitosis
›No prominent facial swelling
›Postoperative inflammatory pain
›Clues
›Expected peak first 24 to 72 hours
›Gradual improvement
›Minimal systemic symptoms
›Localized odontogenic infection
›Periapical abscess (K04.7)
›Post extraction socket infection
›Clues
›Purulence
›Increasing swelling
›Fever possible
›Hemorrhage from socket
›Clues
›Oozing with clot disruption
›Antithrombotic use
Less common
›Retained root fragment or foreign body
›Clues
›Persistent focal pain
›Poor healing
›Osteomyelitis of jaw (M27.2)
›Clues
›Persistent pain
›Fever
›Exposed bone
›Oroantral communication
›Clues
›Fluid regurgitation into nose
›Unilateral sinus symptoms
›Temporomandibular disorder (M26.60)
›Clues
›Jaw pain with opening
›Joint tenderness
Mimics and pitfalls
›Trigeminal neuralgia (G50.0)
›Clues
›Electric shock pains
›Triggered by light touch
›Otitis media (H66.90)
›Clues
›Ear symptoms predominate
›Tympanic membrane findings
›Giant cell arteritis (M31.6)
›Clues
›Age over 50
›New headache
›Visual symptoms
09Past Medical History/pmh17
Medical conditions
›Comorbidities affecting management
›Diabetes mellitus (E11.9)
›Chronic kidney disease (N18.9)
›Liver disease (K76.9)
›Immunocompromise
›Valvular heart disease
Prior oral and dental history
›Prior relevant history
›Prior dry socket
›Recurrent dental infections
›Prior jaw surgery
Prior bleeding or anesthesia issues
›Procedure history
›Prior bleeding complications
›Prior difficult airway
›Prior sedation complications
Baseline function
›Baseline status
›Baseline swallowing ability
›Baseline mouth opening
10Physical Exam/exam40
Vitals and general appearance
›Initial clinical status
›Temperature
›Heart rate
›Blood pressure
›Respiratory rate
›Oxygen saturation
›Toxic appearance
›Hydration status
Airway and oropharynx
›Airway and oropharyngeal exam
›Voice quality
›Drooling
›Stridor
›Uvular deviation
›Posterior pharyngeal bulge
›Floor of mouth elevation
›Tongue displacement
Oral cavity and socket
›Local oral findings
›Extraction socket appearance
›Visible clot
›Exposed bone appearance
›Purulence
›Foul odor
›Active bleeding
›Gingival erythema and fluctuance
Face and neck
›Face and neck exam
›Facial swelling distribution
›Induration
›Crepitus
›Neck range of motion
›Cervical lymphadenopathy
›Trismus measurement estimate
Neurologic
›Cranial nerve screening
›Facial sensation distribution
›Tongue sensation
›Facial motor function
Cardiopulmonary
›Systemic impact exam
›Work of breathing
›Lung auscultation
›Perfusion
›Mental status
11Lab Studies/labs19
When labs are useful
›Indications for labs
›Systemic toxicity
›Suspected deep space infection
›Immunocompromised host
›Significant swelling with fever
›Persistent bleeding with concern for coagulopathy
Suggested labs by scenario
›Infection evaluation
›CBC
›CRP
›Basic metabolic panel
›Blood cultures if febrile and toxic
›Bleeding evaluation
›INR if warfarin
›Platelet count
›PT and aPTT if coagulopathy suspected
Interpretation pearls and pitfalls
›Limitations
›Normal WBC does not exclude deep space infection early
›CRP supportive but nonspecific
›INR target ranges are local protocol dependent for hemostasis decisions
12Imaging/img39
Scoring Systems
›Severity and escalation frameworks
›Airway risk stratification
›Drooling
›Stridor
›Voice change
›Floor of mouth elevation
›Sepsis screening
›Hypotension
›Tachypnea
›Altered mental status
MRI
›When MRI can help
›Suspected osteomyelitis with nondiagnostic CT
›Soft tissue extension assessment when CT contraindicated
›Limitations
›Limited availability in emergent airway risk
›Motion artifact with severe pain and trismus
CT
›CT neck with IV contrast
›Indications
›Suspected deep neck space infection
›Trismus with systemic symptoms
›Rapidly progressive swelling
›Interpretation pearls
›Abscess
›Gas in soft tissues
›Airway narrowing
›Contraindications and cautions
›Contrast allergy
›Chronic kidney disease
›CT maxillofacial
›Indications
›Suspected retained root fragment
›Suspected fracture
›Suspected osteomyelitis
Ultrasound
›Point of care ultrasound
›Superficial facial abscess assessment
›Guidance for superficial drainage when appropriate
›Limitations
›Poor evaluation of deep neck spaces
›Limited by gas and bony structures
13Special Tests/spec11
Bedside dental and ENT focused checks
›Focused bedside assessments
›Gentle socket inspection for clot and exposed bone
›Palpation for fluctuance adjacent to socket
›Bimanual floor of mouth palpation
›Trismus functional assessment
Bleeding source confirmation
›Hemostasis assessment
›Identification of oozing versus arterial bleeding
›Assessment for clot disruption behaviors
Oroantral communication screen
›Sinus communication clues
›Nasal regurgitation with fluids
›Unilateral nasal symptoms after maxillary extraction
14ECG/ecg11
When ECG is relevant
›ECG triggers in dental presentations
›Chest pain
›Syncope or presyncope
›Significant tachycardia with fever
Key findings to note
›High risk patterns
›ST elevation
›New ischemic changes
›Wide complex tachycardia
Serial ECG logic
›Repeat ECG scenarios
›Ongoing chest pain
›Evolving symptoms during ED stay
15Assessment/ax28
Working diagnosis framework
›Likely category
›Alveolar osteitis
›Pain worsening day 2 to 4
›Minimal swelling
›Halitosis
›Localized infection
›Purulence
›Increasing swelling
›Fever possible
›Deep space infection concern
›Trismus
›Dysphagia
›Neck swelling
›Toxic appearance
›Bleeding complication
›Persistent oozing
›Antithrombotic exposure
Severity and risk stratification
›High risk features present
›Airway threat signs
›Sepsis physiology
›Rapid progression
›Immunocompromised status
Complications to rule out
›Cannot miss complications
›Ludwig angina
›Deep neck abscess
›Necrotizing infection
›Significant hemorrhage
›Oroantral communication
16Plan/plan73
First 5 minutes
›Time critical priorities
›Airway risk screen
›Drooling
›Stridor
›Voice change
›Floor of mouth elevation
›Monitoring
›Continuous pulse oximetry if swelling or respiratory symptoms
›Cardiac monitor if toxicity
›IV access criteria
›Toxic appearance
›Concern for deep space infection
›Ongoing significant bleeding
›Immediate consult activation
›ENT or OMFS for airway threat signs
›Anesthesia for anticipated difficult airway
Analgesia and symptom control
›Adult analgesic options
›Acetaminophen 1000 mg PO
›Maximum 3000 mg per day if liver risk
›Maximum 4000 mg per day if no liver risk
›Ibuprofen 400 mg PO
›Every 6 to 8 hours as needed
›Avoid in high bleeding risk or renal disease
›Naproxen 500 mg PO
›Then 250 mg PO every 8 to 12 hours as needed
›Avoid in pregnancy third trimester
›Oxycodone 5 mg PO
›Every 6 hours as needed for severe pain
›Avoid with other sedatives
›Nonpharmacologic adjuncts
›Ice packs for swelling first 24 hours
›Warm compresses after 24 hours if swelling persists
Local socket management
›Suspected alveolar osteitis management
›Dental or OMFS follow up for socket irrigation and medicated dressing
›Avoid empiric antibiotics if no infection signs
›Suspected localized infection management
›Antibiotics when signs of spreading infection
›Amoxicillin 500 mg PO every 8 hours
›Duration 5 days
›Local protocol dependent
›Penicillin allergy option
›Clindamycin 300 mg PO every 6 hours
›Duration 5 days
›C difficile risk
Hemorrhage control
›Initial measures
›Direct pressure with gauze bite
›Duration at least 20 to 30 minutes without checking
›Escalation measures
›Tranexamic acid topical
›Soaked gauze application
›Local protocol dependent
›Local anesthetic with vasoconstrictor for focal bleeder
›Suture consideration
›OMFS consultation for refractory bleeding
Deep space infection pathway
›If deep space infection concern
›CT neck with IV contrast if stable airway
›Broad spectrum IV antibiotics
›Ampicillin sulbactam 3 g IV every 6 hours
›Penicillin allergy option
›Clindamycin 600 mg IV every 8 hours
›Add levofloxacin 750 mg IV daily if severe and gram negative concern
›Local protocol dependent
›Early airway planning
›Awake technique consideration
›Surgical airway readiness if obstruction risk
Reassessment loop
›Reassessment timing
›Pain response within 30 to 60 minutes of therapy
›Airway and swelling reassessment every 30 to 60 minutes if concern
›Triggers to change plan
›Increasing trismus
›New dysphagia
›Worsening swelling
›New fever or instability
17Disposition/dispo26
ICU and step down criteria
›ICU level care indicators
›Airway threat signs
›Need for intubation planning
›Sepsis with hypotension
›Rapidly progressive deep space infection
›Inpatient admission indicators
›CT proven abscess
›Failed outpatient antibiotics
›Immunocompromised with facial infection
›Inability to tolerate oral intake
›Uncontrolled pain despite ED regimen
Observation pathway
›Short stay considerations
›Moderate swelling without airway signs
›Pain control requiring serial reassessment
›Bleeding controlled but high rebleed risk
Discharge criteria
›Safe discharge features
›No airway symptoms
›No rapidly progressive swelling
›Afebrile or improving
›Oral intake adequate
›Pain controlled with oral regimen
›Reliable follow up
Follow up timing
›Recommended follow up
›Dentist or OMFS within 24 to 48 hours for suspected dry socket
›Earlier same day follow up if persistent bleeding
›ENT or OMFS urgent follow up if swelling progression risk
18Discharge Instructions/di23
Copy discharge instructions
›You have pain after a tooth extraction that can be normal in the first few days, but it should steadily improve
›If your pain suddenly gets worse after initially improving, this can be a dry socket
›If you develop swelling, fever, trouble opening your mouth, trouble swallowing, drooling, a muffled voice, or any breathing trouble, go to the emergency department right away
›Pain control
›Acetaminophen as directed on the label or as prescribed
›Ibuprofen or naproxen only if you have no kidney disease, stomach ulcer history, pregnancy third trimester, or blood thinner use unless your clinician said it is ok
›If you were given an opioid, do not drive, do not drink alcohol, and do not take other sedating medicines
›Bleeding care
›If bleeding starts again, bite firmly on gauze for 20 to 30 minutes without checking
›Avoid spitting and avoid vigorous rinsing for the first day
›Healing care
›Avoid smoking or vaping because it increases the risk of dry socket and infection
›Avoid using straws for several days
›Soft foods until chewing is comfortable
›Follow up
›Contact your dentist or oral surgeon within 24 to 48 hours if pain is not improving or if you suspect dry socket
›If you were started on antibiotics, take them exactly as prescribed
›Return now or call emergency services
›Trouble breathing
›Drooling or trouble swallowing saliva
›Rapidly increasing swelling of the face or neck
›Fever with feeling very unwell
›Uncontrolled bleeding
19References/r15
Guidelines and evidence
›American Association of Oral and Maxillofacial Surgeons clinical guidance on odontogenic infections and management
›Local protocol dependent variability
›Emphasis on airway risk and early surgical consultation
›Scottish Dental Clinical Effectiveness Programme guidance on acute dental problems and dental abscess management
›Antibiotic stewardship emphasis
›Criteria for urgent referral
›American Dental Association guideline on antibiotic use for dental pain and swelling
›Avoid antibiotics when localized and no systemic signs
›Use antibiotics when systemic involvement or spreading infection
›NICE antimicrobial prescribing guidance relevant to dental infections
›Antibiotic choice and duration principles
›Stewardship framework
›Cochrane reviews on interventions for alveolar osteitis
›Dressing and irrigation symptom relief focus
›Limited role for antibiotics without infection
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.