Spreading odontogenic infections without severe or systemic features
A spreading odontogenic infection that has caused facial swelling but no severe or systemic features can be managed in an outpatient dental setting. Management involves:
- drainage of pus, with culture and susceptibility testing of pus samples
- surgical or dental treatment (endodontic or periodontal treatment, or tooth extraction) to address the source of infection
- oral antibiotic therapy, ideally started after samples are taken for culture.
It may not be possible to achieve adequate analgesia with local anaesthetics in patients with spreading odontogenic infection; however, this should not delay dental treatment. Anxiolysis (minimal sedation) or general anaesthesia may be required. Once the source of infection has been addressed, start antibiotic therapy.
Patients with spreading odontogenic infection may present to a medical practitioner; refer the patient to a dentist for prompt treatment. If dental treatment is not likely to be received within 24 hours, start antibiotic therapy (as below). However, antibiotic therapy is not a substitute for dental treatment so ensure the patient sees a dentist. Offer systemic analgesics for the treatment of dental pain (see Choice of analgesic for acute dental pain).
For antibiotic therapy of spreading odontogenic infections without systemic or severe features, use:
1 metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, 12-hourly for 5 days odontogenic infection, spreading, without severe or systemic features metronidazole
PLUS EITHER
1 phenoxymethylpenicillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days odontogenic infection, spreading phenoxymethylpenicillin
OR
2 amoxicillin 500 mg (child: 15 mg/kg up to 500 mg) orally, 8-hourly for 5 days odontogenic infection, spreading amoxicillin
OR (as a single preparation)
2 amoxicillin+clavulanate 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly for 5 days. odontogenic infection, spreading, without severe or systemic features amoxicillin + clavulanate
For patients with hypersensitivity to penicillins, use:
clindamycin 300 mg (child: 7.5 mg/kg up to 300 mg) orally, 8-hourly for 5 days1. odontogenic infection, spreading, without severe or systemic features clindamycin
Review the patient 48 to 72 hours after starting treatment to check response. Advise the patient to seek prompt dental review if their condition deteriorates or if the infection has not resolved within 5 days.
If the infection has not responded to treatment, ensure:
- the source of infection has been addressed
- pus was drained adequately—computed tomography (CT) may be required to check for locules requiring drainage
- the infection is susceptible to the current antibiotic regimen—if the results of culture and susceptibility testing are available, modify antibiotic therapy accordingly.
Failing this, or if the patient’s condition has deteriorated, seek expert advice from an oral and maxillofacial surgeon—transfer to an inpatient facility may be required.