01Approach to the Critical Patient/attcp53

Airway and immediate threats

›Time-critical stabilization

›Airway threat features

›Voice change

›Stridor

›Drooling

›Inability to handle secretions

›Rapidly progressive neck or floor of mouth swelling

›Tongue elevation

›Tripod positioning

›Escalation triggers

›If any airway threat feature, resuscitation bay

›If floor of mouth swelling or tongue elevation, early anesthesia and ENT or OMFS involvement

›If impending airway compromise, awake technique planning preferred over paralytic first approach

›Sepsis physiology

›Hypotension

›Tachycardia out of proportion to pain

›Altered mental status

›Lactate elevation if obtained

›Spread beyond alveolar process

›Trismus

›Neck stiffness

›Chest pain

›Facial swelling crossing midline

›Periorbital swelling

›Cranial nerve deficits

›Monitoring and access

›Continuous pulse oximetry for systemic symptoms or deep space concern

02History/hx54

Symptom profile and timeline

›Presenting features

›Dental pain location

›Tooth specific localization

›Diffuse jaw or facial pain

›Swelling timeline

›Hours progression

›Days progression

›Fever and rigors

›Dysphagia

›Odynophagia

›Voice change

›Trismus functional impact

›Dyspnea

›Precipitating factors

›Recent dental procedure

›Known caries

›Cracked tooth

›Trauma

›Poor dentition

›Prior similar episodes

›Prior treatment

›Recent antibiotics

›Analgesic use

›Prior incision and drainage

›Prior dental follow-up barriers

Risk factors and modifiers

›Host factors

03Physical Exam/exam48

Oral and dental exam

›Local exam domains

›Tooth inspection

›Caries

›Fracture

›Loose tooth

›Gingiva and vestibule

›Fluctuance

›Draining sinus

›Erythema

›Percussion tenderness

›Palpation tenderness

›Functional findings

›Trismus measurement

›Interincisal opening

›Finger breadth estimate

›Swallow assessment

›Ability to tolerate saliva

›Ability to tolerate liquids

Head, neck, and airway focused exam

›Airway risk signs

›Voice quality

›Drooling

›Stridor

›Respiratory rate and work of breathing

›Fascial space involvement

›Submandibular swelling

›Submental swelling

04Differential Diagnosis/ddx28

Odontogenic and adjacent infections

›Primary odontogenic causes

›Periapical abscess

›ICD-10 K04.7

›SNOMED CT concept

›Periodontal abscess

›Pericoronitis

›Alveolar osteitis

›Complicated spread

›Cellulitis of face

›ICD-10 L03.211

›Ludwig angina

›Deep neck space infection

›Retropharyngeal abscess

›Parapharyngeal abscess

›Mediastinitis from descending infection

Mimics and alternative causes

›Non-odontogenic head and neck

›Sialadenitis

›Sialolithiasis

›Acute bacterial tonsillitis

›Peritonsillar abscess

›Parotitis

›Facial pain syndromes

›Trigeminal neuralgia

›Temporomandibular disorder

›Systemic and dangerous alternatives

›Necrotizing soft tissue infection

05Laboratory Tests/lt26

Core labs when systemic or deep space concern

›Systemic evaluation set

›Complete blood count for systemic symptoms

›Leukocytosis supporting systemic infection

›Normal count not excluding deep infection

›C-reactive protein for inflammatory severity trend

›Higher values supporting deep space infection likelihood

›Non-specific elevation limitation

›Electrolytes and creatinine for antibiotic dosing safety

›Renal dose adjustments

›Dehydration markers

›Glucose for diabetes and stress hyperglycemia

›Poor control association with severe infection

›Ketoacidosis screening trigger with symptoms

›Sepsis adjuncts when toxic

›Lactate for perfusion assessment

›Elevated lactate supporting sepsis physiology

›Normal lactate not excluding deep infection

›Blood cultures if febrile with systemic toxicity

›Higher yield with bacteremia risk

›Low yield in localized abscess without systemic signs

Targeted tests by context

›Pregnancy related

›Urine pregnancy test if status unknown and imaging planned

›Rh status not routinely required for odontogenic infection

›Immunocompromised

›Neutrophil count for risk stratification

›Consider broader microbiology risk with severe disease

06Diagnostic Tests/dt69

Scoring Systems

›Clinical severity stratification

›Low risk features

›Localized vestibular swelling

›No fever

›No trismus

›No dysphagia

›No floor of mouth involvement

›Moderate risk features

›Fever

›Facial cellulitis without airway symptoms

›Mild trismus

›Mild dysphagia with secretions tolerated

›High risk features

›Stridor

›Drooling

›Tongue elevation

›Rapid progression within hours

›Toxic appearance

›Significant trismus

›Orbital findings

›Disposition linkage

›Low risk suitable for outpatient dental follow-up

›Moderate risk imaging and consult consideration

›High risk admission and airway planning

MRI

›MRI use cases

›Intracranial complication concern

07Disposition/dispo24

Site of care decisions

›Discharge criteria

›Localized infection without airway or deep space signs

›Afebrile or low grade fever with stable vitals

›Oral intake adequate

›Pain controlled with oral regimen

›Reliable dental follow-up within 24 to 48 hours

›Admission criteria

›Airway threat features

›Ludwig angina concern

›Deep neck space infection on imaging or strong clinical suspicion

›Sepsis physiology

›Immunocompromised host

›Inability to tolerate oral intake

›Failed outpatient antibiotics

›Transfer criteria

›Need for OMFS capability not available locally

›Need for ENT and airway support resources

›Need for ICU level airway monitoring

Follow-up planning

›Dental follow-up timing

›Within 24 hours for abscess or significant swelling

›Within 48 to 72 hours for mild localized infection improving

›Return precautions integration

›Explicit airway red flags

›Worsening despite antibiotics within 24 to 48 hours

08Treatment/t105

Analgesia and supportive care

›Symptom control bundle

›Non-opioid analgesia

›Ibuprofen PO 400 mg

›Frequency every 6 to 8 hours as needed

›Maximum 2400 mg per day typical

›Avoid in significant renal disease or active GI bleeding risk

›Acetaminophen PO 1000 mg

›Frequency every 6 hours as needed

›Maximum 3000 mg per day typical

›Lower maximum with chronic liver disease or heavy alcohol use

›Opioid sparing escalation when severe pain

›Short course opioid option if NSAID and acetaminophen inadequate

›Lowest effective dose

›Duration 1 to 3 days typical

›Avoid combined acetaminophen products if already using acetaminophen

›Hydration

›Oral fluids if tolerated

›IV crystalloids if poor intake or sepsis physiology

Antibiotics

›Indications for antibiotics

›Systemic involvement

›Fever

›Malaise

›Lymphadenopathy with cellulitis

›Spreading cellulitis

›Immunocompromised host

›Inability to obtain prompt dental source control

›Antibiotics not routinely indicated

›Localized dental pain without swelling and without systemic signs

›Definitive dental source control immediately available for localized abscess without systemic signs

›First-line oral regimens for uncomplicated infection

›Amoxicillin-clavulanate PO 875 mg

›Frequency twice daily

›Duration 5 to 7 days typical with reassessment

›Coverage for oral aerobes and anaerobes

›Penicillin VK PO 500 mg

›Frequency four times daily

›Pairing with metronidazole for anaerobe coverage when needed

›Duration 5 to 7 days typical

›Metronidazole PO 500 mg

›Frequency three times daily

›Use with penicillin when anaerobe coverage needed

›Avoid alcohol due to disulfiram-like reaction risk

›Penicillin allergy regimens

›Clindamycin PO 300 mg

›Frequency four times daily

›Duration 5 to 7 days typical

›C difficile risk counseling

›IV regimens for complicated infection or inability to take PO

›Ampicillin-sulbactam IV 3 g

›Frequency every 6 hours

›Transition to oral when clinically improved

›Renal dosing adjustments

›Ceftriaxone IV 2 g

›Frequency once daily

›Pairing with metronidazole for anaerobes

›Metronidazole IV 500 mg

›Frequency every 8 hours

›Transition to oral when tolerated

›Piperacillin-tazobactam IV 4.5 g

›Frequency every 6 to 8 hours

›Use for severe infection or broader coverage need

›Renal dosing adjustments

›MRSA coverage considerations

›Add vancomycin IV for severe infection with MRSA risk factors

›Initial dosing 15 to 20 mg per kg

›Frequency based on renal function and trough or AUC monitoring protocols

›Infusion rate considerations for infusion reaction

›Duration principles

›Short course with reassessment when source control achieved

›Longer course only if ongoing infection without definitive dental source control

Source control and procedures

›Dental source control hierarchy

›Definitive therapy

›Extraction of offending tooth

›Endodontic therapy when feasible

›ED temporizing options when appropriate expertise available

›Incision and drainage of fluctuant vestibular abscess

›Anesthesia with local infiltration or nerve block

›Blunt dissection and irrigation

›Culture only if immunocompromised or recurrent or severe

›Needle aspiration for superficial collection

›Ultrasound guidance when helpful

›Avoid deep space aspiration without specialty support

›Regional anesthesia options

›Inferior alveolar nerve block

›Useful for mandibular tooth pain

›Aspiration prior to injection to reduce intravascular risk

›Infraorbital nerve block

›Useful for maxillary anterior pain

›Procedure contraindications and cautions

›Deep neck space concern requiring operative management

›Coagulopathy with uncontrolled bleeding risk

›Airway compromise requiring higher level setting

Airway and severe infection management

›Ludwig angina or deep space infection bundle

›Early airway planning

›Awake technique consideration

›Backup surgical airway planning with ENT

›Broad spectrum IV antibiotics

›Ampicillin-sulbactam or piperacillin-tazobactam

›Add MRSA coverage if risk factors or severe sepsis

›Imaging support

›CT neck with IV contrast when stable for transport

›ICU monitoring triggers

›Airway risk signs

›Rapid progression

›Sepsis physiology

09Special Populations/sp40

Pregnancy

›Pregnancy considerations

›Maternal priorities

›Airway and sepsis management unchanged

›Early obstetric notification if admission

›Antibiotic selection

›Penicillins and cephalosporins generally preferred when appropriate

›Clindamycin option for penicillin allergy

›Metronidazole use acceptable when clinically indicated

›Analgesia

›Acetaminophen preferred baseline agent

›NSAID avoidance in third trimester

›Opioid short course only if severe pain and alternatives inadequate

›Imaging

›CT with contrast if deep neck infection suspected and benefits outweigh risks

›Shielding and dose minimization principles

Geriatric

›Older adult considerations

›Atypical presentation

›Blunted fever response

›Delirium as sepsis marker

›Medication safety

›Renal dosing adjustments for beta lactams

›NSAID renal and GI risk higher

›Comorbidity impact

›Diabetes association with severe infection

›Anticoagulation affecting procedural decisions

10Background/b30

Epidemiology

›Epidemiology overview

›Odontogenic infections as common cause of facial pain and swelling

›Polymicrobial oral flora predominance

›Severe complications uncommon but time-sensitive

›Risk distribution

›Dental caries and poor access to dental care as common drivers

›Diabetes and immunosuppression increasing severity risk

Pathophysiology

›Mechanism

›Pulp necrosis leading to periapical infection

›Periodontal pocket infection leading to periodontal abscess

›Abscess formation as localized pus collection

›Spread pathways

›Cortical bone breakthrough into fascial planes

›Anatomic space dependence on tooth root position

›Submandibular and sublingual space spread risk for mandibular molars

›Complication mechanisms

›Airway compromise from floor of mouth edema

›Orbital cellulitis from maxillary spread

›Descending mediastinitis from deep neck spread

Therapeutic Considerations

›Core management principles

›Source control as definitive treatment

›Antibiotics as adjunct when systemic or spreading infection

›Analgesia as functional enabler for intake and follow-up

›Microbiology considerations

›Mixed aerobes and anaerobes typical

11Patient Discharge Instructions/pdi29

copy discharge instructions

›Dental abscess discharge instructions

›Diagnosis summary

›Infection around a tooth or gum causing pain and swelling

›Definitive treatment needs a dentist for drainage or tooth treatment

›Medications

›Antibiotic course if prescribed

›Take exactly as directed

›Do not stop early unless instructed

›Seek care for rash, facial swelling, or breathing difficulty

›Pain control plan

›Ibuprofen if safe for you

›Acetaminophen if safe for you

›Avoid doubling acetaminophen from multiple products

›Home care

›Warm salt water rinses several times daily

›Soft foods and good hydration

›Avoid smoking and alcohol during healing

›Follow-up

›Dental appointment within 24 to 48 hours

›If you do not have a dentist, use urgent dental clinic resources in your area

›Return to ED now for

›Trouble breathing

›Drooling or cannot swallow saliva

›Voice change

›Rapidly worsening swelling of face, jaw, or neck

›Swelling under the tongue or tongue lifting upward

›Fever with shaking chills

12References/r10

Clinical guidelines and consensus sources

›Guideline sources

›American Dental Association guidance on antibiotic use for urgent management of pulpal and periapical related dental pain and intraoral swelling

›Scottish Dental Clinical Effectiveness Programme guidance on drug prescribing for dentistry

›Emergency medicine references on odontogenic infections and deep neck infections

›Otolaryngology references on deep neck space infections and airway management principles

Evidence-based and review sources

›Evidence sources

›Reviews on microbiology of odontogenic infections

›Reviews on Ludwig angina recognition and airway strategy

›Reviews on imaging selection for deep neck infection

›Antibiotic stewardship literature for dental infections

Evidence & Review

Evidence & Review