16.3.1. Periapical abscess
This clinical condition arises as a complication of inflammation of the dental pulp or periodontal pocket. The condition may be acute and diffuse, chronic with fistula or localized and circumscribed. It is located in the apical aspect of the supporting bone.
Diagnostic Criteria
- The patient complains of tooth ache
- Pain during intake of hot or cold foods/drinks
- Pain on bringing the tooth on occlusion
- Tenderness on percussion (vertical percussion)
- Swelling of gingiva around the affected tooth
Non-pharmacological Treatment
- For posterior teeth: Extraction of the offending tooth under local anesthesia ( can perform root canal treatment for posterior teeth instead of tooth extraction under good clinical judgement)
- Lignocaine 2% with adrenaline 1:80,000 IU (to establish drainage) is the treatment of choice followed by analgesics.
- For anterior teeth (incisors, canine and premolars: extraction is carried out only when root canal treatment is not possible
Pharmacological Treatment
A: Paracetamol 1gm (PO) 6 hourly for 3 days.
Antibiotics may be given if the condition is chronic and depending on radiological findings such as bone radioluscence to depict bone resorption and periapical granuloma.
A: Amoxicillin 500mg (PO), 8 hourly for at least 7 days
OR
A: Erythromycin 500mg (PO) 8 hourly for 7 days (if allergic to penicillin)
AND
A: Metronidazole 400mg (PO) 8 hourly for 7 days
16.3.2 Infected Socket
A post extraction complication due to infection of the clot due to contamination (infected socket). The condition is painful and if not managed well could lead to osteomyelitis.
Diagnostic Criteria
- Severe painful socket 2–4 days after tooth extraction
- Fever
- Necrotic blood clot in the socket
- Swollen gingiva around the socket
- Sometimes there may be lymphadenopathy and trismus (inability to open the mouth)
Non-pharmacological Treatment
- Socket debridement under local anesthesia with lignocaine 2% and irrigate with hydrogen peroxide 3%. The procedure of irrigation is repeated the 2nd and 3rd day and where necessary can be extended to the 4th day if pain persists. On follow-up visits local anesthesia is avoided unless necessary.
- Patient is instructed to rinse with warm saline (5ml spoonful salt in 200mls cup of warm water) or 3% hydrogen peroxide or 0.5% povidone iodine 3–4 times a day
Pharmacological Treatment
Antibiotics should be prescribed to prevent progression to osteomyelitis:
A: Amoxicillin 500mg (PO) 8 hourly for 5–7 days
OR
A: Azithromycin 500mg (PO) once a day for 3 days
AND
A: Metronidazole 400mg (PO) 8 hourly for 5 days.
Investigation
Periapical X-ray of the socket may be necessary when there is limited improvement despite treatment.
Referral: Maxillofacial unit is considered in case of persistent pain and infection despite treatment for more than two weeks.
16.3.3 Dry Socket
This is a post extraction complication due to failure to form a clot (dry socket). The condition is very painful and it differs from an infected socket by lack of clotting and levels of severity of pain.
Diagnostic Criteria
- Severe pain 2–4 days post-extraction
- Pain exacerbated by entry of air on the site
- Socket devoid of clot
- Surrounded by inflamed gingiva
Non-Pharmacological Treatment
Treatment is under local anesthesia with lignocaine 2%, socket debridement and irrigation with hydrogen peroxide 3%. The procedure of irrigation is repeated the 2nd and 3rd day and where necessary can be extended to the 4th day if pain persists. On follow-up visits local anesthesia is avoided unless necessary. The aim of debridement in this case is to initiate bleeding and formation of fresh clot.
16.3.4 Dental Abscess
Dental abscess is an acute lesion characterized by localization of pus (caused by polymicrobial infection) in the structures that surround the teeth.
Diagnostic Criteria
- Fever and chills
- Throbbing pain of the offending tooth
- Swelling of the gingiva and sounding tissues
- Pus discharge around the gingiva of affected tooth/teeth
- Trismus (inability to open the mouth)
- Regional lymph nodes enlargement and tender
- Aspiration of pus for frank abscess
Investigations:
Pus for Grams stain, culture and sensitivity if the patient doesn’t respond to initial antibiotic treatment.
Non-pharmacological Treatment
- Incision and drainage and irrigation (irrigation and dressing is repeated daily)
- Irrigation is done with 3% hydrogen peroxide followed by 0.9% Normal saline.
- Supportive therapy carried out depending on the level of debilitation (most patients need rehydration and detoxification using IV Normal saline 0.9% or IV Ringers Lactate)
Pharmacological Treatment
A: Amoxicillin 500mg (PO) 8 hourly for 5 days
AND
A: Metronidazole 400 mg (PO) 8 hourly for 5 days.
Severe cases
B: Amoxicillin Clavulanic acid 625mg (PO) 8 hourly for 5 days
AND
A: Metronidazole 400 mg (PO) 8 hourly for 5 days.
If patients are allergic to penicillins:
A: Erythromycin 500 mg (PO) 8 hourly for 5 days
Where parenteral administration of antibiotics is necessary (especially when the patient cannot swallow and has life threatening infection), consider
A: Ampicillin 500mg IM/IV 6 hourly for 5 days
OR
A: Ceftriaxone 1 gm IV once daily for 5 days37
AND
B: Metronidazole 500 mg IV 8 hourly for 5 days
Note: Incision and drainage is mandatory in cases of deeper spaces involvement followed by a course of antibiotics. The practice of prescribing antibiotics to patients with abscess and denying referral for definitive care until pus has established or resolved has been found to lead to more problems for orofacial infections THEREFORE early referral for definitive care is important.
Criteria for Referral to Dental/Maxillofacial Surgeon
- Rapidly progressive infection
- Difficulty in breathing
- Difficulty swallowing
- Fascia space involvement
- Elevated body temperature (greater than 390 C)
- Severe jaw trismus/failure to open the mouth (less than 10mm)
- Toxic appearance
- Compromised host defenses
16.3.5 Ludwig’s Angina
This is a serious life threatening generalized septic cellulitis of the fascia spaces found on the floor of the mouth and tongue. It is an extension of infection from mandibular molar teeth into the floor of the mouth covering the submandibular, sublingual and submental spaces bilaterally.
Diagnostic Criteria
- Brawny induration
- Tissues are swollen, board like, not pitted and no fluctuance
- Respiratory distress
- Dysphagia
- Tissues may become gangrenous with a peculiar lifeless appearance on cutting
- Three fascia spaces are involved bilaterally (submandibular, submental and sublingual)
Non-Pharmacological Treatment
- Quick assessment of airway
- Incision and drainage is done (even in absence of pus) to relieve the pressure and allow irrigation.
- Only when the airway distress is significant and there is evidence that it is not relieved by incision and drainage then tracheostomy is needed
- Supportive care includes high protein diet and fluids for rehydration and detoxification
- During incision and drainage pus should be taken for culture and sensitivity. Offending tooth should be removed at the same sitting if the patient can open the mouth.
Pharmacological Treatment
A: Ampicillin 500 mg IV 6 hourly for 5 days
OR
B: Amoxicillin + clavulanic acid 625mg (PO) 8 hourly for 5 days
AND
B: Metronidazole 500mg IV 8 hourly for 5 days
If allergic to penicillin use
A: Erythromycin (PO) 500mg 6 hourly for 5 days
OR
A: Ceftriaxone 1gm IV once a day for 5 days in case of severe infection.
Once the patient is able to swallow replace IV medicines with oral treatment.
Note: For this condition and other life threatening oral conditions consultation of available specialists (especially oral and maxillofacial surgeons) should go parallel with life saving measures.
16.3.6 Pericoronitis
Inflammation of the soft tissues covering the crown of erupting tooth and occurs more commonly in association with the mandibular third molar (wisdom) teeth. Impaction of food and plaque under the gingiva flap provides a medium for bacterial multiplication. Biting on the gum flap by an opposing tooth causes laceration of the flap, increasing the infection and swelling with a greater likelihood of traumatic biting.
Diagnostic Criteria
- High temperature
- Severe malaise
- Discomfort in swallowing and chewing
- Well localized dull pain, swollen and tender gum flap
- Signs of partial tooth eruption or uneruption in the region
- Pus discharge beneath the flap may or may not be observed
- Foetor-ox oris i.e. bad smell
- Trismus
- Regional lymph nodes enlargement and tenderness
Non-Pharmacological Treatment
- Excision of the operculum/flap (flapectomy) under local anesthesia
- Extraction of the third molar associated with the condition
- Grinding or extraction of the opposing tooth
Pharmacological Treatment
A: Mouth wash with hydrogen peroxide solution 3% 6 hourly for 5 days
A: Amoxicillin 500mg (PO) 6 hourly for 5 days
AND
A: Metronidazole 400 mg (PO) 8 hourly for 5 days
If severe (rarely) refer to section 3.3.4 on treatment of dental abscess
16.3.7 Osteomyelitis of the Jaw
This is an inflammation of the medullary portion of the jaw bone which extends to involve the periosteum of the affected area. The infection becomes established in the bone ending up with pus formation in the medullary cavity or beneath the periosteum obstructs the blood supply. The infected bone becomes necrotic following ischemia.
Diagnostic criteria
- In the initial stage there is no swelling.
- Malaise and fever
- Enlargement of regional lymph nodes
- Teeth in the affected area become painful and loose, thus causing difficulty in chewing
- Later as the bone undergoes necrosis the area becomes very painful and swollen
- Pus ruptures through the periosteum into the muscular and subcutaneous fascia and eventually it is discharged on to the skin surface through a sinus
Investigations:
X-ray – OPG (Orthopantomograph) or mandibular lateral oblique, water’s view for maxilla/midface. The x-ray will show sequestra formation in chronic stage. In early stage features seen in x-ray include widening of periodontal spaces, changes in bone trabeculation and areas of radioluscency. Perform culture and sensitivity of the pus to detect the specific bacteria.
Non-Pharmacological Treatment
- Incision and adequate drainage to confirmed pus accumulation which is accessible
- Removal of the sequestrum by surgical intervention (sequestrectomy) is done after the formation of sequestrum has been confirmed by X-ray
Pharmacological Treatment
A: Amoxicillin 500mg 8 hourly for 5 days
AND
A: Metronidazole 400mg (PO) 8 hourly for 5days. If culture is available treat according to results.
For details on antibiotics see section 16.3.4 above.
Referral: Refer the patient to the next facility with adequate expertise and facilities.
