OralSurgery

Paul Paterson
Elizabeth Hannah Nichols, Katie Watson and Deborah Boyd

The Importance of Early

Intervention in the Treatment of
Dental Infection
Abstract: With recent reports of increasing hospital admissions relating to dental infection, the authors believe it is time to re-visit the
importance of its effective early treatment. A series of three cases is used to illustrate the potentially life-threatening progression of
what, in the early stages, is an easily treatable condition.
Clinical Relevance: The principles of effective management of dental infection are highlighted in the first instance and then indications
for specialist maxillofacial referral are discussed.
Dent Update 2014; 41: 6872

Recent reports have highlighted a worrying

rise in the number of patients admitted to
hospital for incision and drainage of dental
abscesses under general anaesthetic.1,2
An article reviewing such hospital
admissions in England as a whole found that
the number almost doubled between 1998
and 2006.1 A group of authors in Hull Royal
Infirmary have reported a less dramatic, but
still substantive, increase of 47% in their unit

Paul Paterson, BDS(Hons), MFDS

RCPS(Glasg), Dental Foundation Trainee
in Oral and Maxillofacial Surgery, Oral
and Maxillofacial Surgery Department,
Monklands Hospital, Airdrie, Elizabeth
Hannah Nichols, BDS, MJDF RCS(Eng),
Senior House Officer in Oral and
Maxillofacial Surgery, Queen Margaret
Hospital, Dunfermline, Katie Watson,
BDS, Senior House Officer in Oral and
Maxillofacial Surgery, Monklands
Hospital, Airdrie and Deborah Boyd,
BDS, FDS RCPS, MBChB MRCS, Specialist
Registrar in Oral and Maxillofacial
Surgery, Ninewells Hospital, Dundee, UK.

68 DentalUpdate

between 1999 and 2004.2

Fortunately, death from dental
sepsis is rare in the UK.3,4 However, there is
still the potential for significant associated
morbidity. A series of three cases is presented
which have been referred recently to
maxillofacial departments across Scotland.
We believe these serve to highlight the ease
with which a simple dento-alveolar infection
can become potentially life-threatening.

Spread of infection
A common theme among these
cases is airway compromise due to aggressive
infection spreading through the soft tissue
spaces in the oropharynx and neck. Figures
1 and 2 demonstrate several of the potential
soft tissue spaces, normally filled with loose
areolar connective tissue, which can allow
rapid spread of infection.
Dental abscess can lead to
airway embarrassment and the following
cases highlight the dangers of suboptimal
initial management of dental infection. A
compromised airway often happens via
swelling of the submandibular and sublingual
spaces, resulting in elevation of the tongue.

There is also the possibility of pus entering

the lateral pharyngeal and retropharyngeal
spaces where swelling can lead to tracheal
deviation and also reduce the diameter of the
upper airway. Pus may then track inferiorly
through the deep cervical fascia of the neck
towards
the mediastinum.

Case 1
A 30-year-old fit and healthy male
was originally admitted under the care of ENT
(ear, nose and throat) for the management
of dysphagia and odynophagia. These
symptoms had been present for three days
and were increasing in severity. He received
medical management for tonsillitis and was
discharged from hospital.
He was re-admitted the following
day, again under the care of our ENT
colleagues, for an enlarging swelling in his
left neck with associated trismus. The neck
swelling was described as being 3 cm in
diameter, firm and non-fluctuant. He was
only able to consume liquids due to ongoing
odynophagia. At this point, he remained
afebrile with stable observations. Further
January/February 2014

OralSurgery

Figure 1. Spread of dental infection: mandibular tooth. Key: 1) buccal space; 2) intra-oral buccal
abscess; 3) submandibular space; 4) sublingual space; 5) lateral pharyngeal space; 6) retropharyngeal
space; 7) submasseteric space; 8) pterygomandibular space.

Figure 2. Spread of dental infection: maxillary

tooth. Key: 1) buccal space; 2) intra-oral buccal
abscess; 3) intra-oral palatal abscess.

examination of the head and neck revealed

multiple carious teeth in the upper and lower
left quadrants of his mouth. Routine bloods
revealed a raised CRP (C-reactive protein)
and white cell count, both indicative of acute
infection. The oral and maxillofacial team
were then asked for an opinion (Figure 3).
Clinical and radiographic
examination demonstrated caries and
periapical pathology in teeth UR6, UL7 and
LL8, with collections in the left submasseteric,
submandibular and parapharyngeal fascial
spaces. There was also deviation and
restriction of the airway as demonstrated
by Figure 4. Theatre was expedited for
urgent tracheostomy to secure his airway.
He underwent incision and drainage of the
collections and extraction of UR6, UR5, UL7,
January/February 2014

LL8 and LR8. Post-operatively, he spent one

night in HDU (high dependency unit) before
being transferred to the general ward.
The tracheostomy was removed
after five days and the patient discharged
after a nine-day stay in hospital. He was
finally discharged from oral and maxillofacial
surgery as an outpatient five weeks after his
initial admission. Upon discharge, he had lost
two stones in weight, his trismus had still not
fully resolved, and he was undergoing jaw
physiotherapy.
This case highlights that a delay
in treatment due to referral to the incorrect
specialty may result in a compromised airway
and significant morbidity.

Case 2
A 32-year-old male was
transferred to the maxillofacial department
after an initial referral to ENT. He had a fiveday history of sore throat and worsening left
submandibular swelling, which was tender
and firm. He was unable to swallow his own
saliva.
Recent dental history included
an incomplete root canal treatment on a
lower left molar. Medically, he was fit and well
and his observations on admission included
a temperature of 38.0 C, blood pressure

127/71 mmHg, heart rate 92, and oxygen

saturation 99% on air. His CRP was raised at
153.
Nasoendoscopy revealed a
compromised upper airway and the patient
was therefore intubated. A CT (computed
tomography) scan revealed collections of
pus in the left sublingual space, crossing the
midline, and in the left submandibular space.
All collections were seen to be anterior to the
hyoid bone. Extensive subcutaneous oedema
was noted over the anterior neck but there
was no prevertebral or upper mediastinal
collection (Figure 5).
A diagnosis of Ludwigs angina
was made, necessitating the placement of
a tracheostomy and bilateral incision and
drainage of the fascial spaces. Extractions of
teeth LL6, LL7 (retained roots) and LL8 were
undertaken. As seen in Figure 6, drains were
placed in the left and right submasseteric and
left submental spaces.
Additional treatment involved
aggressive therapy with IV antibiotics
(benzylpenicillin and metronidazole). Culture
and sensitivity testing revealed oral flora
only. The patient remained in HDU for two
nights. The tracheostomy was removed
after five days, and the patient had a total
stay in hospital of eight days. He was finally
discharged from maxillofacial care after
review two weeks later.

Case 3
Again, a case highlighting
the significance of dental infection that
demonstrates airway compromise and
significant morbidity. A 46-year-old man
was referred to the maxillofacial department
by his general dental practitioner initially
complaining of a five-day history of leftsided toothache. He had been prescribed
oral antimicrobial therapy. Over this five-day
period, his pain was increasing and he began
to develop neck swelling. This left-sided
facial and neck swelling was associated with
decreased mouth opening. At presentation
to the maxillofacial unit, the patient was grey
in colour and cold to touch and was finding it
difficult to swallow his saliva.
His temperature was 38.9 C,
blood pressure 132/85mmHg, heart rate 101,
and oxygen saturation on air 98%. He had an
extensive medical history: including a stroke
one year previously; two MIs (myocardial
infarctions); a quadruple heart bypass and
DentalUpdate 69

OralSurgery

Figure 3. Case 1: Dental panoramic radiograph demonstrating sources of infection.

taken to theatre for incision and drainage

of the left-sided submandibular dental
abscess and extraction of teeth, he was
in a rapidly deteriorating condition. He
developed stridor and was unable to be
intubated by a consultant anaesthetist. As
such, an emergency tracheostomy had to
be performed with the patient awake under
local anaesthetic. Teeth LL5, LL6 and LL7 were
extracted.
The high airway pressures
at attempted intubation (and then,
tracheostomy placement) resulted in a rightsided pneumothorax. A chest drain was
inserted in ITU (intensive therapy unit). After
an overnight stay in ITU, the patient returned
to the maxillofacial ward. The intra- and extraoral drains placed in theatre were removed
two and three days post-operatively,
respectively.
The patient remained as an
inpatient for a further seven days on IV
co-amoxiclav, then IV clindamycin as
per advice from microbiology. He was
decannulated four days post-operatively. He
was eventually discharged after being under
the care of the maxillofacial surgery team for
eight days.

Discussion
Figure 4. Case 1: Axial CT (computed
tomography) slice demonstrating deviation of the
airway to the right-hand side (airway circled).

Figure 6. Case 2: Post-operative image of patient

two, showing sites of incision and drainage in the
neck. The tracheostomy tube is also visible.

Figure 5. Case 2: Axial CT slice demonstrating

severe deviation and constriction of the airway
(airway circled). Note the presence of an endotracheal tube in the airway.

70 DentalUpdate

hypertension. Bloods on admission showed

an elevated WCC (white cell count) of 13.2
and a raised CRP of 178. Intra-oral dental
examination was difficult and the patient was
unable to tolerate a panoramic radiograph.
A postero-anterior mandible and a lateral
oblique view were therefore taken and
revealed multiple carious teeth in the lower
left quadrant of his mouth.
By the time the patient was

From the case reports above, it

is immediately obvious how serious dental
infection can be, even in young, fit and well
individuals. It is also apparent that delays in
treatment of the initial toothache are what
make the difference between resolution, with
simple dental treatment, and major surgery
in a hospital setting.
Fortunately, none of these cases
resulted in mortality. However, the airway
was compromised in all three cases. Three
relatively recent reports3,4,5 discuss cases
where dental sepsis resulted in death. The
causes varied from erosion of the subclavian
vein, disseminated intravascular coagulation
and descending necrotizing mediastinitis.
This is all exceptionally worrying as the
mean age for patients admitted to hospital
requiring drainage of dental-related sepsis is
32 (in England).1
Many reasons may be suggested
as to why patients fail to seek treatment
of toothache promptly. One paper2 notes
that more than 60% of patients presenting
with dental sepsis on an emergency basis
were not registered with a dentist. Another
January/February 2014

OralSurgery

Dysphagia: difficulty swallowing

Drooling/inability to swallow saliva
Dysphonia: altered voice sometimes
likened to a hot potato voice
Abnormal airway sounds such as
stridor
Firmness/tenderness of the floor of
the mouth
Elevation of the tongue, obscuring
view of the tonsils, uvula or soft palate
Swelling preventing palpation of the
lower border of the mandible
Swelling involving the lower eyelid
Systemic illness: in particular an
elevated temperature or respiratory rate
Trismus: inter-incisal opening of less
than 40 mm
Table 1. Indications for maxillofacial referral.

report of a fatal case states that the patient in

question cited a fear of doctors and dentists

as the reason for not seeking help.4

All too often, the maxillofacial
service sees cases of patients with dental
abscesses managed with oral antibiotics only,
the cause of the problem being allowed to
persist.
Should a patient present with
a facial swelling, there are several warning
signs to assess as indicators that referral for
maxillofacial management is required. These
are listed in Table 1.

Conclusion
The importance of early
treatment of dental infection is self-evident
and has previously been highlighted.1,3,4 It
is therefore worth emphasizing the local
measures which should be employed:6
Drain pus from a dental abscess by tooth
extraction or through the root canals;
Drain any dento-alveolar soft tissue pus by
incision.
There is clearly also a need to

educate our medical colleagues to ensure the

rapid onward referral of this patient group.

References
1.

2.
3.

4.

5.

6.

Thomas SJ, Hughes C, Atkinson C, Ness AR,

Revington P. Is there an epidemic of admissions
for surgical treatment of dental abscesses in the
UK? Br Med J 2008; 336: 12191220.
Carter L, Starr D. Alarming increase in dental
sepsis. Br Dent J 2006; 200: 243.
Green AW, Flower EA, New NE. Mortality
associated with odontogenic infection! Br Dent
J 2001; 190: 529530.
Currie WJR, Ho V. An unexpected death
associated with an acute dentoalveolar abscess
report of a case. Br J Oral Maxillofac Surg 1993;
31: 296298.
Bulut M, Balci V, Akkse S, Armaan E. Fatal
descending necrotising mediastinitis. Emerg
Med J 2004; 21: 122123.
Scottish Dental Clinical Effectiveness
Programme. Drug Prescribing For Dentistry.
Dental Clinical Guidance 2nd edn. Dundee:
SDCEP, 2011.

Interdental brushes
to suit every need
Angled or straight brush head, long or short
handle, original or extra-soft filaments,
TePes range of interdental brushes
have an option for everyone.
Available in several colour coded sizes, all TePe
Interdental Brushes have plastic-coated wires for
comfort and protection. Developed in collaboration with
dental expertise, TePe Interdental Brushes are thoroughly
tested in terms of quality and durability, and fulfil all
requirements of the international standard,

To receive your
free sample:

ISO 16409:2006.

Visit: tepe.com/
uk/samplerequest
and use code
DUP002a

FREE TEPE ANGLE SAMPLE*

Or, use the QR

code below.

Visit: tepe.com/uk/samplerequest and use code DUP002a.

*Whilst stocks last

For more information call 01934 710022, email infoUK@tepe.com

or search the web: TePe UK

72TePe_Dental_Update_180x125_2017_13.indd
DentalUpdate

January/February
2014
30/12/2013 14:23