Differentials
Sinusitis
SIGNS / SYMPTOMS
Headache near the involved sinus; change in head position can aggravate pain.
Foul-smelling, discolored nasal discharge.
Skin overlying involved sinus may be warm and erythematous with associated percussion tenderness and decreased transillumination (with otoscope).
INVESTIGATIONS
CT sinus: opacification of involved sinuses.
Nasal/sinus cultures: presence of pathogen.
Sialadenitis
SIGNS / SYMPTOMS
Often occurs with decreased fluids or recent surgery under general anaesthetic.
Commonly involves the parotid gland with 10% to 25% of cases being bilateral.[43]
Facial swelling over the parotid region, under the tongue, or below jaw.
INVESTIGATIONS
Facial radiograph: presence of sialolith(s).
Ultrasound of gland: presence of sialolith(s).
CT gland: presence of sialolith(s).
Mumps
SIGNS / SYMPTOMS
Unvaccinated status increases risk.
Self-limited parotid swelling (unilateral or bilateral) present in nearly all cases.
Prodrome of low-grade fever, headache, and myalgia.
Orchitis or oophoritis may be present.
INVESTIGATIONS
Salivary mumps IgM: positive.
Serology (IgM/IgG): positive.
Sjogren's syndrome
SIGNS / SYMPTOMS
Chronic dry eye or dry mouth.
Vasculitic skin rash.
INVESTIGATIONS
Schirmer's test (quantitative measure of tear production): positive.
Anti-60 kD (SS-A) Ro and anti-La (SS-B): positive.
Labial minor salivary gland biopsy: positive.
Salivary gland tumour
SIGNS / SYMPTOMS
Parotid gland is most common site.
Facial nerve palsy or paraesthesia more likely to be seen with malignant tumours.
INVESTIGATIONS
MRI/CT scan: solid mass clearly distinct from the surrounding tissues, abscess formation absent.
Fine needle aspiration: positive.
Salivary gland stone or obstruction
SIGNS / SYMPTOMS
Most commonly affects submandibular gland.
Pain and swelling of affected gland, which may occur when eating or smelling food aromas, sometimes with sudden onset, or may be intermittent without any obvious precipitating factor.
INVESTIGATIONS
Panoramic radiograph: calcified stone.
Osteomyelitis
SIGNS / SYMPTOMS
History of dental fracture, contaminated surgical site, soft tissue or periosteal infection, or periapical abscess.
May be acute or chronic.
Low-grade fever.
Occurs most frequently in mandible, but can involve periosteum, cortical, or cancellous bone or marrow.
Exposed bone with sequestrum and paraesthesia.[20][43][44]
Osteoradionecrosis and medication-related osteonecrosis commonly present as osteomyelitis.
INVESTIGATIONS
Erythrocyte sedimentation rate: elevated.
Cultures from bone after debridement: positive.
Panoramic radiograph: infected areas typically appear dark, soft tissue swelling, periosteal thickening, focal osteopenia.
CT bone: demonstrates abnormal thickening of affected cortical bone, sclerotic change, encroachment of the medullary cavity, and abnormal sinus drainage.
Radionuclide scans: increased blood flow activity, blood pool activity, and positive signs of uptake.
Trigeminal neuralgia or other atypical facial pain
SIGNS / SYMPTOMS
Differentiating dental pain from trigeminal neuralgia or other types of atypical facial pain can be difficult.
Slightly more common in females.
Majority of cases involve cranial nerves V2 (maxillary nerve) or V3 (mandibular nerve).
Usually unilateral; however, can be bilateral.
Pain described as mild, dull ache or burning sensation, or later in course as electric shock.
May have trigger point or spasmodic facial muscle contraction.[43]
INVESTIGATIONS
Panoramic or periapical radiograph: periapical radiolucency if dental abscess present.
Angio-oedema
SIGNS / SYMPTOMS
Positive family history of angio-oedema.
Rapid onset of soft tissue swelling.
History of exposure to known (or unknown) stimuli or medication.
INVESTIGATIONS
C4: low in hereditary and acquired angio-oedema.
C1 esterase inhibitor: low or absent in hereditary angio-oedema.
C1q: may be low in acquired angio-oedema.
Erysipelas
SIGNS / SYMPTOMS
Occurs more commonly in children, older, or immunocompromised patients.
Lymphadenopathy.
Skin rash with erythema which is warm to touch; may develop vesicles or bullae.
No associated purulent discharge.
INVESTIGATIONS
Panoramic or periapical radiograph: periapical radiolucency if dental abscess present.
Peritonsillar abscess (quinsy)
SIGNS / SYMPTOMS
Complication of tonsillitis.
Unilateral sore throat.
Earache.
Redness and swelling in tonsil area on affected side.
Swollen and tender jugulodigastric lymph nodes.[20]
INVESTIGATIONS
CT neck: may be helpful to identify pus collection when examination is limited due to presence of trismus.
Infectious mononucleosis
SIGNS / SYMPTOMS
Typically gradual onset, with malaise and fatigue often a prominent feature.
Cervical or generalised lymphadenopathy.
Pharyngitis.
Splenomegaly.
INVESTIGATIONS
FBC: lymphocytosis.
Heterophile antibodies (Monospot test): positive.
Epstein-Barr virus (EBV)-specific antibodies: positive.
PCR: EBV DNA detection.
Trauma
SIGNS / SYMPTOMS
History of facial trauma.
Includes fracture (e.g., maxillary, mandibular, or facial bones), haematoma that becomes secondarily infected, traumatic bone cyst, soft tissue injury.[43]
Haematoma/bruising.
Neurological testing may be abnormal.
INVESTIGATIONS
Imaging: depends on the injury involved; however, CT scan or panoramic radiograph may show pathology.
Surgical site infection
SIGNS / SYMPTOMS
Prior surgery or procedure.
Occurs shortly after procedure; however, can be delayed presentation.
Can involve soft tissue, periosteum, or bone.
Includes needle tract infection, subperiosteal infection due to retained debris, or residual periapical cyst/granuloma/abscess, or post-surgical soft tissue infection.
INVESTIGATIONS
Imaging: depends on the site involved; however, CT scan, MRI, bone scan, or panoramic radiograph may show pathology.
Vascular malformations
SIGNS / SYMPTOMS
Swelling from vascular malformations can mimic odontogenic infection due to hormone-related changes in size, or new swelling due to phlebitis.
May involve soft tissue or bone.
Vascular lesions in soft tissue show blanching when pressure is applied.
With intrabony vascular lesion, teeth may be mobile and, in some cases, bleeding from the gingival sulcus may be present.
High-flow lesions may have a bruit or thrill.
Risk of bleeding (intrabony vascular lesions/arteriovenous malformations [AVM]).[43]
INVESTIGATIONS
Panoramic radiograph: appearance varies, but most frequently shows a multilocular radiolucency, or sometimes a sunburst pattern.
CT scan: may show bone lysis or overgrowth that often accompanies vascular lesions, with or without phleboliths.
Ultrasound: useful for initial screening for superficial lesions; will show vascular channels with high-flow and loss of venous damping on Doppler.
MRI: contrast-enhanced image typically shows a homogeneously-enhancing mass; when associated with high-flow vessels, may see signal flow voids on T1 and T2 images.
Angiogram: standard for evaluation of high-flow lesions (e.g., AVM) and detailing the arterial and venous anatomy; shows contrast accumulation often with multiple feeder vessels.[34][45]
Needle aspiration: positive for blood under low or high pressure.
Neoplasms
SIGNS / SYMPTOMS
Facial or neck swelling may be due to a benign or malignant neoplasm (e.g., odontogenic cysts/tumours, dermoid/epidermoid cysts, lymphoma, multiple myeloma, skin cancer, sarcoma, haemangioma).[43]
Rate of progress is usually slow initially.
History of tobacco or alcohol use, prior malignancy, transplant, or immunosuppressant drugs.
Generally, there is absence of dental pain; however, jaw tumours may present with dental pain.
Neurosensory deficits.
Bruising or bleeding.
Weight loss.
Lymphadenopathy.
INVESTIGATIONS
Depends on neoplasm.
Biopsy: benign or malignant tissue consistent with the specific underlying condition.
Imaging: reveals tumour.
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