Approach
The vast majority of otherwise healthy patients presenting with a dental infection can be managed on an outpatient basis; however, dental abscesses that develop into more severe odontogenic infections can be life-threatening and require early recognition and involvement of an oral and maxillofacial surgeon/head and neck specialist for aggressive medical and surgical management.
The primary principle of management is prompt and aggressive operative intervention to identify and eliminate the source of the infection and provide a path for drainage.
Broad-spectrum antibiotic therapy is indicated until final infection site culture and sensitivity results are available; however, it is important to remember that operative treatment is the cornerstone of successful management, not the choice of antibiotic or length of the treatment.
Antibiotic therapy alone may initially slow or stop a mild odontogenic infection; however, without definitive operative treatment to address the source of the infection, the infection will recur soon after antibiotic therapy ends.
Inpatient versus outpatient management
The choice between inpatient and outpatient management is determined on a case-by-case basis taking into account the history, examination, and other patient-specific factors.
The vast majority of otherwise healthy patients presenting with a dental infection can be managed on an outpatient basis. These patients respond quickly to definitive operative intervention with removal of the source of the infection, along with supportive care and antibiotic therapy as indicated.
Hospital admission is recommended for:
Signs of impending airway compromise (e.g., trismus, dysphonia, dysphagia, drooling, uvular deviation, tongue elevation with inability to protrude tongue, dyspnoea, stridor), anticipated airway difficulty, or need for perioperative airway monitoring
Rapidly progressing infection
Involvement of high-risk or multiple fascial spaces
Unrelenting fever or signs of volume depletion
Central nervous system signs (e.g., decreased level of consciousness, headache, or abnormal eye signs such as proptosis, pupillary dilation, diplopia, papilloedema, and ophthalmoplaegia)
Treatment failure with outpatient therapy
Presence of comorbid conditions that require supportive medical care
Social factors that preclude outpatient therapy
Extremes of age (i.e., very young or old).
When there is doubt, it is generally best to err on the side of caution and admit the patient to hospital.[46]
Airway management and supportive care
First and foremost, when there is a rapidly progressing infection involving high-risk or multiple fascial spaces, the airway should be secured.
Planning and execution of successful airway management requires a team approach involving the anaesthetist, surgeon, and surgical team members.[47] In some cases, needle decompression of the abscess prior to attempted intubation or tracheotomy may be beneficial. In cases where there is a concern for potential airway compromise, a contingency plan for an urgent surgical airway should be in place if intubation attempts are not successful.
Fever increases fluid losses and metabolic demands and can lead to volume depletion. In addition, the physiological stress of an aggressive infection can disturb the balance of other concurrent, otherwise controlled, systemic conditions. Therefore, supportive care includes control of fever with an antipyretic, intravenous fluids, and nutritional support.[46]
Removal of source of infection
The cornerstone of successful management is removal of the source of the infection. Specific treatment depends on the type of abscess.
Periapical abscess:
Necrotic pulpal tissue should be removed with root canal treatment or extraction.
Periodontal abscess:
Periodontal therapy or extraction of a periodontally hopeless tooth is recommended.
Pericoronal abscess:
If the incompletely erupted tooth is a partially impacted wisdom tooth with inadequate space for eruption, extraction is indicated.
A tooth in another site may be salvageable; an operculectomy (i.e., surgical removal of the operculum, the flap of tissue over a partially erupted tooth) to improve cleansing in the area as the tooth fully erupts may be adequate. In some cases, orthodontic assistance with eruption may be indicated.
Surgical incision and drainage with tooth extraction is considered the definitive treatment for periodontally hopeless teeth, partially impacted wisdom teeth, or when root canal treatment is not possible. In some cases, removal of the tooth alone establishes adequate drainage without the need for surgical incision and drainage.
Operative intervention should only be delayed when concurrent systemic illness must first be managed to facilitate a safe operation.
Surgical incision and drainage
In most situations, an incision and drainage are performed concurrently with the removal of the source of infection (e.g., extraction, root canal treatment).
The incision can be intra-oral or extra-oral depending on the site of infection and based on the principle of establishing a patent dependent drainage path. A small incision is made in an appropriate site that avoids vital structures and any areas of skin or mucosal breakdown. The incision should be made through the epithelium or mucosa into the underlying connective tissue. Blunt dissection is used to explore the involved spaces, followed by placement of a Penrose or Jackson-Pratt drain. The drain is usually maintained until drainage ceases (typically 2-5 days) and can be removed gradually or all at once. Culture of abscess contents should be performed.
Despite some physicians advocating initial medical management with antibiotics to control the infection before surgery, this approach is not supported by clinical practice observations or empirical investigations. Some physicians believe that the infection must be at the point of forming a drainable abscess before proceeding with surgical incision and drainage; however, no benefit has been found in delaying drainage until an abscess forms, and often this delay in treatment will only lead to increased potential for complications and morbidity.[48]
Incision and drainage results in decompression, provides a drainage portal, and allows for specimen collection for culture and sensitivity. In addition to this, it facilitates a more aerobic environment in which virulent anaerobic microorganisms are less likely to flourish.[46]
Analgesia
Most patients with a dental abscess require pain relief, and all patients should be offered analgesia. The selection of analgesic depends on the patient's history, allergy profile, and the anticipated level of discomfort. Options include a non-steroidal anti-inflammatory drug (NSAID) and/or an opioid analgesic.
Antibiotic therapy
For mild, localised infections in immunocompetent patients, antibiotic therapy may not be necessary once the source of infection has been removed. There is increasing global concern about antibiotic overuse and antimicrobial resistance, and dentists and other providers are encouraged to question the need for antibiotics in low risk groups.[49][50][51]
One systematic review concluded that further research is required regarding the impact of antibiotic prescribing; the evidence for antibiotics, either alone or as adjuncts to definitive, conservative dental treatment, showed both a benefit and a harm for outcomes of pain and intra-oral swelling and a large potential magnitude of effect in regard to additional harm outcomes.[52]
The American Dental Association has formulated clinical recommendations for the urgent outpatient management of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis and symptomatic apical periodontitis, or pulp necrosis and localised acute apical abscess. The guidelines recommend that, if there is pain only, antibiotics should not be given if definitive conservative dental treatment (i.e., incision and drainage) is immediately available and there is no evidence of systemic infection in immunocompetent patients.[53]
In immunocompetent patients with evidence of systemic involvement, if conservative dental treatment is not immediately available, a delayed prescription for oral amoxicillin or oral phenoxymethylpenicillin should be provided, in the event that symptoms worsen. Interim monitoring should be provided. These patients should also be urgently referred for conservative dental treatment. Patients should be instructed to call their physician if their condition deteriorates or if the referral to receive definitive conservative dental treatment within 1-2 days is not possible.[53]
Immediate antibiotic prescribing (oral amoxicillin or oral phenoxymethylpenicillin) should be provided for immunocompetent patients with pain and swelling, indicating pulp necrosis and localised acute apical abscess, with or without systemic involvement.[53]
Options for patients with penicillin allergies include cefalexin (provided there is no history of a serious allergic reaction to penicillin), clindamycin, or azithromycin. If first-line treatment fails, metronidazole can be added to the first-line treatment, or the first-line treatment can be discontinued and oral amoxicillin/clavulanate prescribed.[53]
In more serious infections that warrant hospital admission, intravenous clindamycin or metronidazole are the antibiotics of choice owing to their anaerobic coverage. Benzylpenicillin is a suitable alternative.[10][40][54][55][56]
In hospitalised patients, intravenous administration is preferred if possible. Ultimately, an antibiotic’s effectiveness is determined by its serum and tissue levels. Aside from a few antibiotics with comparable absorption characteristics whether taken orally or intravenously, the majority of orally administered antibiotics reach lower serum and tissue levels at a delayed rate compared with intravenous administration.[46] One systematic review found insufficient evidence to determine the effect of oral phenoxymethylpenicillin on adults with symptomatic apical periodontitis or acute apical abscess.[57]
Intravenous antibiotics can be switched to appropriate oral antibiotic therapy once the patient shows signs of improvement (e.g., decreasing temperature, oedema/erythema, and white blood cell [WBC] count) and is ready for discharge. However, patients with osteomyelitis may require long-term intravenous antibiotic therapy on an outpatient basis. Deciding when to cease antibiotic therapy is a matter of clinical judgment and should be based on the patient’s recovery course.
Specific patient groups
Infection may spread more rapidly in immunocompromised patients, and treatment in this population should proceed with minimal delay.
Immune compromise is seen with various medical conditions, including malnutrition, diabetes, hepatic or renal disease, cystic fibrosis, chronic lung disease, heart failure, alcohol and/or drug misuse, HIV infection/AIDS, collagen vascular disease, metastatic cancer, transplant patients, recent splenectomy, and use of specific medications (e.g., immunosuppressants, cytotoxic agents, corticosteroids, recent or chronic antibiotic use).[46]
Follow-up
For serious odontogenic infections that warrant hospitalisation, the patient needs to be followed closely for response to therapy. Typically, by 2 to 3 days the patient should be showing definite signs of improvement (e.g., resolution of fever, reduced drainage, decreasing oedema, decreasing WBC count, and improved fatigue/malaise).
If this is not the case, thorough investigation to assess the cause of treatment failure is necessary. A computed tomography scan of the head and neck may be helpful to assess whether the initial operation adequately drained the involved spaces, or if there has been progression of the infection into additional fascial spaces with the need for further operative exploration. Other factors to consider include immunosuppression, the presence of a foreign body, or incorrect antibiotic selection. By this point, the infection site culture and sensitivity results should be available, and antibiotics should be adjusted accordingly.[46][58]
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