It can be challenging to determine when a patient’s odontogenic infection warrants specialist consultation in the ED, operative treatment, or inpatient admission.
High risk odontogenic infections
The patient will require inpatient admission and likely operative treatment for these following conditions in the setting of an odontogenic infection:
- Involvement of the airway or deeper fascial spaces
- Rapid progression of the infection
- Need for general anesthesia
- Dehydration or the inability to take fluids orally
- Immunocompromised status
- Lack of improvement on oral antibiotics
These patients should be monitored for progression of the infection, as cases may rapidly progress to life-threatening conditions. If the infection is evident on the skin, mark the edge of the erythematous regions of the infection to monitor spread.
Odontogenic infections which do NOT require specialty consultation
Intra-oral maxillary and mandibular vestibular and buccal space swellings are infections limited to relatively safe, low-risk areas. These abscesses are amenable to incision and drainage by the emergency physician under local anesthesia. These are fascial spaces that will not cause airway obstruction and generally do not require general anesthesia or extraoral incisions to achieve adequate drainage. In these cases, patients normally do not complain of trismus, difficulty breathing, or swallowing. CT imaging is usually unnecessary.
1. Vestibular Abscess
Vestibular abscesses are infections that spread through bone to buccal tissues when the apex of the involved tooth is within the confines of the buccinator muscle attachment. The infection remains between the oral mucosa and the nearby facial muscle.
2. Buccal Abscess
3. Buccal Space Abscess
The buccal space lies superficial to the buccinator muscle and deep to the overlying skin and subcutaneous tissue. In these cases, the involved tooth’s apex is either superior or inferior to the insertion of the buccinator muscle. This potential space may become involved via infection of maxillary or mandibular molars.
A) When the tooth root apex is within the confines of the attachment for the buccinator muscle (in red), a vestibular space abscess localized medial to the buccinator muscle results.
B) When the tooth root apex is outside of the confines of the attachment for the buccinator muscle (in red), a buccal space abscess localized lateral to the buccinator muscle results.
Odontogenic infections which DO require specialty consultation
Progression of infections to deeper spaces beyond the vestibular and buccal spaces increases the severity of the infection and thus requires specialty consultation. Indications for specialty consultation include any of the following:
- The spread of infection to potentially dangerous fascial spaces, potentially leading to airway compromise
- Difficulty swallowing
- Systemic signs of infection, such as a toxic appearance, respiratory distress, or altered mental status
In these cases, CT imaging is usually needed to determine the location and extent of the infection.
What deep space areas are especially dangerous?
Dangerous fascial planes include infection which spread:
- Beyond the alveolar process (such as to the submental, sublingual, or submandibular spaces)
- To the palatal spaces (medial relative to the maxillary dentition)
- To the masticator space involving the muscles of mastication
- To the more posterior oropharyngeal/retropharyngeal spaces
- To the superiorly-located sinuses or orbital spaces
- To any nearby vital structures such as major nerves and arteries (mental, lingual, facial, and ophthalmic bundles).
When in doubt, CT imaging should be obtained to determine proximity to nearby vital structures. In more severe cases, odontogenic infections may potentially lead to but are not limited to cavernous sinus thrombosis, Ludwig’s angina (the bilateral involvement of the submandibular, sublingual, and submental spaces), sinusitis, brain abscess, or mediastinitis. These more severe cases often require airway management, CT imaging, IV antibiotics, or emergent I&D in the operating room by specialty surgical services.
Examples of High-Risk Cases
The following figures indicate common regions involved in odontogenic infections for which escalation of care with specialty consultation is recommended. These complex infections include: palatal space abscesses on the palate of the mouth medial to the maxillary dentition, sublingual and submandibular space abscesses inferior to the tongue and floor of mouth, and abscesses that extends superiorly to involve the sinuses or orbits. To reiterate, any abscess requiring an extra oral approach for management requires specialist consultation.
Abscesses in the Mandibular Premolar Region:
Abscesses located in the mandibular premolar region are located near the mental neurovascular bundle. Those that require I&D need a cautious approach to avoid this vital structure. These may be better served with
Palatal Space Abscesses:
Found medial to the maxillary dentition. I&D should be escalated to specialty care to avoid damaging the greater and lesser palatine neurovascular bundles.
Sublingual Abscesses:The sublingual space lies between the oral mucosa and the mylohyoid muscle and can become infected from the mandibular premolar and first molar teeth. I&D should be escalated to specialty care as abscesses in this space are at high risk for rapid spread and airway compromise.
The submandibular space lies between the mylohyoid muscle and anterior layer of the deep cervical fascia, just deep to platysma muscle. It includes the lingual and inferior surfaces of the mandible below the mylohyoid muscle attachment. I&D should be escalated to specialty care as abscesses in this space are at high risk for rapid spread and airway compromise.