The Daily Differential — Wednesday, September 2, 2026

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Dental Infections and Atraumatic Dental Pain

Most uncomplicated dental pain is a source-control problem, not an antibiotic problem. The emergency clinician must relieve pain, identify deep-space spread...

Also known astooth infection · odontogenic infection · toothache

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The Case

A 34-year-old warehouse worker leans forward in the triage chair, one hand pressed against the left side of his face. The odor of coffee and cigarette smoke follows him; he says a back tooth has throbbed for three days and he has barely slept. His temperature is normal, his voice is clear, and he can swallow, but the left lower molar is exquisitely tender. He wants “the strongest antibiotic” before his shift begins.

Before You Read

Which dental pain presentations benefit from antibiotics?
What bedside findings indicate spread beyond the tooth?
Which analgesic strategy works better than an opioid-first approach?

Why It Matters

Most uncomplicated dental pain is a source-control problem, not an antibiotic problem. The emergency clinician must relieve pain, identify deep-space spread early, and avoid delaying definitive dental treatment.

When to Think of It

Enter dental infection when toothache is accompanied by caries, percussion tenderness, gingival swelling, localized fluctuance, facial swelling, purulence, fever, malaise, trismus, dysphagia, or regional lymphadenopathy. Atraumatic pain without swelling may reflect pulpitis, apical periodontitis, cracked tooth, or nonodontogenic disease.

Sick or Not Sick

The one call is localized disease versus spreading infection threatening the airway, orbit, deep neck spaces, or systemic circulation. Trismus, floor-of-mouth elevation, tongue displacement, drooling, muffled voice, toxic appearance, rapidly progressive swelling, immunocompromise, or inability to maintain hydration demands escalation.

The First Fifteen Minutes

Uncomplicated pain without systemic illness or spreading swelling → ibuprofen 400 mg PO plus acetaminophen 1,000 mg PO, because combined peripheral anti-inflammatory and central analgesic effects often outperform opioids.
NSAID contraindicated → acetaminophen 1,000 mg PO alone; reduce the maximum daily dose in liver disease, frailty, or heavy alcohol use.
Localized fluctuant abscess accessible intraorally → perform incision and drainage or needle aspiration after local anesthesia; source control removes the bacterial burden that antibiotics cannot reliably eradicate.
Need for local anesthesia → lidocaine 2% with epinephrine 1:100,000, generally up to 7 mg/kg (maximum 500 mg) in adults; aspirate before injection and use lower limits in significant cardiovascular disease.
Systemic symptoms, spreading cellulitis, or immunocompromise without airway compromise → amoxicillin-clavulanate 875/125 mg PO twice daily; it covers common oral aerobes and anaerobes. Confirm renal adjustment and local protocol.
Severe penicillin allergy with an outpatient indication → clindamycin 300 mg PO four times daily is sometimes used, but its C. difficile risk is substantial; verify local guidance, as azithromycin or another alternative may be preferred.
Severe infection, vomiting, or inability to take oral medication → ampicillin-sulbactam 3 g IV every 6 hours, because it provides broad oral flora coverage; adjust for renal function.

Definitive Care & Disposition

Pulpitis and apical periodontitis require dental treatment—root canal, extraction, or restoration—not routine antibiotics. Drain accessible abscesses, but do not attempt unsafe drainage through a nonvisualized floor-of-mouth or deep-space process. CT neck with IV contrast is reserved for suspected deep-space extension, substantial swelling, trismus, systemic toxicity, or unclear anatomy. Discharge stable patients who can swallow and have reliable dental follow-up within 24–48 hours; admit patients with airway risk, sepsis, deep-space infection, rapidly progressive swelling, immunocompromise with progression, or inability to hydrate/follow up.

How This One Kills

The dangerous error is prescribing antibiotics for “toothache” while an apical infection continues to dissect into the submandibular or sublingual spaces. The patient returns with trismus, dysphagia, and a threatened airway after the window for easy source control has narrowed.

The Atypical Presentation

Older adults, patients with diabetes, and those already taking antibiotics may have little fever or swelling despite significant infection. Analgesics can mask progression, and a patient may report only fatigue, poor intake, or new difficulty opening the mouth. Trend function—swallowing, voice, tongue position, trismus, and hydration—rather than relying on temperature or visible pus alone.

Back to Our Patient

Back to the 34-year-old warehouse worker: he has localized molar pain and percussion tenderness without fever, trismus, dysphagia, voice change, floor-of-mouth elevation, or systemic toxicity, so he is not sick by the airway/systemic fork. The likely process is localized odontogenic pain without a spreading infection; he receives a dental block and ibuprofen plus acetaminophen, with drainage only if a visible fluctuant collection is present. Because antibiotics will not cure untreated pulp disease, he is discharged with urgent dental follow-up, return precautions, and no routine antibiotic.

Patient Presentation to Attending

“This is a 34-year-old man with three days of atraumatic left lower molar pain and poor sleep. He has no fever, facial swelling, trismus, dysphagia, drooling, voice change, dyspnea, or immunocompromising history. He is well appearing with normal vital signs, a carious percussion-tender molar, and no floor-of-mouth elevation or fluctuance. My assessment is localized odontogenic pain, most consistent with pulpitis or apical periodontitis without spreading infection. I’ll perform a dental block, treat with ibuprofen and acetaminophen, avoid routine antibiotics, and arrange dental care within 24 to 48 hours with strict airway and systemic-infection precautions.”

Study Directive

Create a two-column list: dental conditions that need antibiotics versus those needing dental procedures only.
Practice three dental blocks on a task trainer or review video anatomy, including aspiration before injection and maximum local-anesthetic doses.
Run a 30-second airway screen for every dental complaint: voice, drooling, swallowing, tongue position, floor of mouth, and mouth opening.
Review local antibiotic guidance and complete five cases deciding discharge versus CT/consultation versus admission.

Key Medications

Ibuprofen 400 mg PO every 6 hours as needed.
Acetaminophen 1,000 mg PO every 6–8 hours as needed; maximum 4,000 mg/day in healthy adults, lower with hepatic risk.
Lidocaine 2% with epinephrine 1:100,000 for dental block; maximum lidocaine dose with epinephrine is commonly 7 mg/kg, maximum 500 mg—check local anesthetic policy.
Amoxicillin-clavulanate 875/125 mg PO twice daily when antibiotics are indicated.
Ampicillin-sulbactam 3 g IV every 6 hours for severe infection requiring IV therapy; renal adjustment required.
Clindamycin 300 mg PO four times daily is an alternative in selected patients but has meaningful C. difficile risk; check current local guidance.
Pediatric antibiotic doses are weight-based and vary by agent; use Lexicomp, UpToDate, or institutional protocol rather than adult dosing.

High-Yield Pearls

Antibiotics without drainage or dental source control may suppress symptoms while the infection progresses into deeper spaces.
A normal temperature does not neutralize the significance of trismus, dysphagia, voice change, or tongue displacement.
Ibuprofen plus acetaminophen is generally more effective and safer than opioid-first therapy for acute dental pain.

The Mimics

Trigeminal neuralgia — brief electric-shock paroxysms with a normal tooth and no swelling; unnecessary extraction does not treat it.
Acute coronary syndrome — exertional jaw/tooth pain with autonomic symptoms; mislabeling it dental delays reperfusion.
Maxillary sinusitis — several upper teeth tender with nasal symptoms and diffuse pressure; dental antibiotics alone may not address the source.
Temporomandibular disorder — pain with chewing and joint/muscle tenderness rather than percussion-sensitive caries; antibiotics add harm without benefit.

Board Question

A healthy adult has severe spontaneous tooth pain worsened by cold and percussion. There is no swelling, fever, or trismus. What is the best ED treatment?

ASeven days of amoxicillin
BImmediate extraction by the ED clinician
CNSAID plus acetaminophen and urgent dental referral
DIV clindamycin and CT neck

Reveal answer

Correct: C

Uncomplicated pulpitis or apical periodontitis requires analgesia and definitive dental treatment, not routine antibiotics or emergency CT. Antibiotics are indicated when there is systemic illness or spreading infection.

Recent Literature

Review or guideline Evidence-based clinical practice guidelines for the management of acute dental pain
Am J Emerg Med, 2025 · cited 7×

Use NSAIDs alone or with acetaminophen as first-line treatment for acute dental pain, reserving opioids for limited situations while arranging definitive dental care.

Full text · open access

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Ludwig Angina

This rapidly progressive infection can convert a stable-appearing patient into a can’t-intubate, can’t-oxygenate emergency. The airway must be secured...

Also known asangina ludovici · submandibular space infection · floor-of-mouth cellulitis

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The Case

A 47-year-old man sits upright on the stretcher, breathing through his mouth as saliva pools on his lower lip. His neck skin is hot and tight beneath a week-old beard, and his speech sounds thick despite his insistence that his throat is “only sore.” He cannot lie flat and points beneath his jaw when asked where it hurts. The monitor is quiet for the moment, but the airway team has not yet been called.

Before You Read

Which finding tells you the airway is about to become difficult?
Should imaging come before securing the airway?
What empiric antimicrobial regimen covers the relevant organisms?

Why It Matters

This rapidly progressive infection can convert a stable-appearing patient into a can’t-intubate, can’t-oxygenate emergency. The airway must be secured before edema and distortion make rescue nearly impossible.

When to Think of It

Think Ludwig angina with rapidly progressive, bilateral submandibular/sublingual/submental swelling—often from a mandibular molar—plus floor-of-mouth elevation, tongue displacement, dysphagia, drooling, muffled voice, trismus, neck induration, or respiratory distress. The swelling is classically firm rather than fluctuant.

Sick or Not Sick

The key decision is whether the patient can safely maintain and protect the airway while definitive airway and surgical teams mobilize. Stridor, hypoxia, tachypnea, inability to handle secretions, tripod positioning, progressive voice change, tongue elevation, or fatigue means airway-now; do not wait for CT.

The First Fifteen Minutes

Any airway concern → sit upright, provide high-flow oxygen, continuous monitoring, suction, and call anesthesiology/ENT/OMFS; maintaining spontaneous ventilation preserves the only reliable airway reserve.
Progressive obstruction or inability to handle secretions → perform awake flexible fiberoptic nasotracheal intubation with an experienced airway operator and surgical-airway backup; avoid routine paralytic-first RSI because loss of spontaneous breathing can make rescue impossible.
If awake intubation fails or obstruction is imminent → prepare immediate cricothyrotomy or tracheostomy by the most experienced operator; this bypasses the distorted upper airway.
Suspected bacterial deep-neck infection → ampicillin-sulbactam 3 g IV every 6 hours, because it covers streptococci, oral anaerobes, and many oral gram-negative organisms.
Severe beta-lactam allergy or need for broader coverage → clindamycin 600–900 mg IV every 8 hours, or another local-protocol regimen; verify current institutional guidance because resistance and C. difficile risk matter.
Septic shock after cultures if this does not delay treatment → norepinephrine 0.05–0.1 mcg/kg/min IV infusion, titrated to MAP ≥65 mm Hg, because alpha-mediated vasoconstriction restores perfusion; use a central line when feasible but do not delay initial vasopressor support for access.
Shock or hypoperfusion → balanced crystalloid 30 mL/kg IV initially, reassessing lungs, perfusion, and blood pressure; excess fluid can worsen airway and pulmonary edema.

Definitive Care & Disposition

Admit to ICU after airway stabilization. Obtain CT neck with IV contrast only after the airway is secure or clearly stable; imaging defines extension and drainable collections. Give prolonged IV antibiotics, culture when feasible, and pursue urgent operative drainage and dental source control with ENT/OMFS. Consider MRSA coverage when risk factors, severe sepsis, healthcare exposure, or local epidemiology support it. Steroids are not a substitute for airway control or drainage; specialist-directed dexamethasone may be considered for edema.

How This One Kills

The fatal sequence is sending a drooling, tripod-positioned patient to CT, administering paralytics for a routine RSI, or waiting for stridor. Once spontaneous ventilation is lost, swollen supraglottic and floor-of-mouth tissues can make both mask ventilation and laryngoscopy fail.

The Atypical Presentation

Diabetic, elderly, and partially treated patients may have minimal fever and deceptively preserved oxygen saturation. The earliest clues may be new dysphagia, a change in voice, inability to lie flat, or a firm “double-chin” appearance. Ask the patient to swallow, listen to speech, inspect the floor of mouth, and repeatedly reassess trajectory; normal pulse oximetry does not exclude a rapidly narrowing upper airway.

Back to Our Patient

Back to the 47-year-old man: drooling, inability to lie flat, thick speech, and firm bilateral submandibular swelling identify a threatened airway, so he is sick regardless of his initially acceptable oxygen saturation. The airway team is called before imaging, he remains upright on oxygen with suction ready, and an experienced operator performs awake fiberoptic intubation with surgical backup. Ampicillin-sulbactam is started, CT is obtained only after airway control, and OMFS/ENT drains the deep-space infection and addresses the mandibular molar source. He is admitted to the ICU for continued airway, antimicrobial, and postoperative management.

Patient Presentation to Attending

“This is a 47-year-old man with one week of worsening mandibular dental pain and 24 hours of progressive bilateral neck and floor-of-mouth swelling. He has drooling, muffled speech, inability to lie flat, and dysphagia, but no vomiting or known trauma. He is sitting upright, tachypneic, with firm submandibular induration, elevated tongue, limited mouth opening, and no focal unilateral tonsillar findings. I’m concerned for Ludwig angina with a threatened upper airway, so I’m calling anesthesia and ENT/OMFS now, keeping him upright on oxygen with suction, and planning awake fiberoptic intubation with surgical-airway backup before CT. I’ll start IV ampicillin-sulbactam and admit him to the ICU for drainage and source control.”

Study Directive

Memorize the Ludwig airway trigger list: drooling, dysphonia, dysphagia, tongue elevation, trismus, tripod posture, stridor, and fatigue.
Rehearse an awake-airway briefing with anesthesia/ENT, including primary plan, backup plan, and surgical-airway readiness.
Review CT anatomy of the sublingual, submandibular, parapharyngeal, and retropharyngeal spaces.
Complete three airway-threat cases and state in one sentence why paralysis-first RSI is hazardous in each.

Key Medications

Ampicillin-sulbactam 3 g IV every 6 hours; adjust for renal function.
Clindamycin 600–900 mg IV every 8 hours when selected for severe beta-lactam allergy; verify local resistance and C. difficile considerations.
Norepinephrine 0.05–0.1 mcg/kg/min IV infusion, titrated to effect; institutional dosing varies, so check protocol if uncertain.
Balanced crystalloid 30 mL/kg IV for septic shock/hypoperfusion, with reassessment to avoid fluid overload.
Vancomycin 20–25 mg/kg IV loading dose may be added when MRSA coverage is indicated; dose and infusion rate vary—check Lexicomp, UpToDate, or institutional protocol.
Dexamethasone 10 mg IV is sometimes used as an adjunct for severe upper-airway edema, but evidence and practice vary; consult ENT/anesthesia and local protocol.
Pediatric cases require weight-based airway planning and antibiotic dosing; involve pediatric anesthesia/ENT early.

High-Yield Pearls

Stridor is a late sign; dysphagia, drooling, voice change, and inability to recline are earlier airway warnings.
Ludwig angina is often firm and bilateral, so absence of a drainable fluctuance does not make it benign.
Never allow imaging logistics to outrank a deteriorating airway.

The Mimics

Epiglottitis — severe odynophagia with less external submandibular induration; confusing them can lead to inappropriate oral examination or delayed airway control.
Peritonsillar abscess — unilateral tonsillar swelling, uvular deviation, and “hot-potato” voice; bilateral floor-of-mouth disease points elsewhere.
Angioedema — abrupt onset, often without fever or dental source; antibiotics alone fail and airway planning differs.
Submandibular sialadenitis — gland tenderness and purulence from Wharton duct without the classic bilateral floor-of-mouth elevation; missed deep-space spread remains dangerous.

Board Question

A patient with bilateral submandibular swelling, drooling, tongue elevation, and progressive voice change is sitting upright but has an oxygen saturation of 98%. What is the next best step?

ACT neck with contrast before treatment
BOral examination with a tongue depressor
CAwake fiberoptic intubation with surgical-airway backup
DDischarge on oral antibiotics

Reveal answer

Correct: C

Oxygen saturation may remain normal until late in upper-airway obstruction. Secure the airway while spontaneous ventilation is preserved; CT should follow stabilization, not delay it.

Recent Literature

Review or guideline Diagnosis and management of Ludwig's angina: An evidence-based review
Am J Emerg Med, 2021 · cited 85×

Provides an emergency-focused framework for early recognition, airway planning, imaging, antibiotics, and prompt surgical consultation in this rapidly progressive floor-of-mouth infection.

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Dental Infections

Odontogenic infections can spread along fascial planes into the orbit, neck, mediastinum, or bloodstream. The emergency clinician’s job is to identify...

Also known astooth infection · odontogenic infection

Listen: EM:RAP podcast →

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The Case

A 62-year-old woman arrives with a damp towel wrapped around her right cheek and a list of medications folded in her hand. Her cheek has doubled in size since yesterday, and she reports chills, poor appetite, and “a bad taste” in her mouth. She can still swallow but pauses between sentences to breathe and says her dentures no longer fit. The swelling is advancing toward the lower eyelid while the next decision remains unmade.

Before You Read

What findings separate a drainable dental abscess from a deep-space infection?
When should facial swelling prompt CT, specialty consultation, or admission?
How do diabetes and immunosuppression change the threshold for escalation?

Why It Matters

Odontogenic infections can spread along fascial planes into the orbit, neck, mediastinum, or bloodstream. The emergency clinician’s job is to identify progression early, stabilize the patient, and secure source control rather than simply suppress symptoms.

When to Think of It

Look for dental pain with facial swelling, gingival erythema, purulence, fever, malaise, lymphadenopathy, trismus, dysphagia, or cellulitis. Maxillary infections can threaten the orbit and cavernous sinus; mandibular infections can descend into submandibular, parapharyngeal, and mediastinal spaces.

Sick or Not Sick

The decisive call is outpatient localized infection versus complicated infection requiring imaging, IV therapy, specialty drainage, or admission. Escalate for systemic toxicity, rapid progression, immunocompromise, diabetes with poor control, significant trismus, orbital signs, dysphagia, voice change, floor-of-mouth swelling, sepsis, dehydration, or unreliable follow-up.

The First Fifteen Minutes

Airway symptoms or inability to handle secretions → upright positioning, oxygen, suction, and immediate anesthesia/ENT/OMFS consultation; airway edema can progress faster than external swelling suggests.
Sepsis or hypoperfusion → balanced crystalloid 30 mL/kg IV initially with reassessment, because restoring circulating volume supports organ perfusion; avoid unexamined fluid loading in heart or renal failure.
Systemic infection, extensive cellulitis, or admission-level disease → ampicillin-sulbactam 3 g IV every 6 hours, because it covers common odontogenic streptococci and anaerobes.
Severe beta-lactam allergy → clindamycin 600–900 mg IV every 8 hours may be used under local protocol, because it covers many oral gram-positive and anaerobic organisms; verify resistance and C. difficile risk.
Pain → ibuprofen 400 mg PO plus acetaminophen 1,000 mg PO when safe, because multimodal analgesia reduces inflammatory and central pain signaling.
Visible, accessible fluctuant abscess → lidocaine 2% with epinephrine 1:100,000 for local anesthesia, generally up to 7 mg/kg or 500 mg maximum; aspiration before injection reduces intravascular injection risk.

Definitive Care & Disposition

Drainage and extraction or root-canal treatment are definitive. Obtain CT face/neck with IV contrast for deep extension, severe trismus, extensive swelling, orbital involvement, systemic toxicity, or uncertain anatomy. Add ophthalmology for visual symptoms, proptosis, pain with extraocular movements, or restricted motility. Admit for airway risk, deep-space infection, orbital complications, sepsis, rapid progression, significant immunocompromise, or inability to tolerate oral therapy. Stable localized infection may be discharged with urgent dental follow-up and a short, protocol-directed antibiotic course when indicated.

How This One Kills

The high-cost error is treating progressive facial swelling as a routine tooth infection while it crosses into the orbit or deep neck. A second failure is allowing an abscess to remain undrained because the patient temporarily improves after analgesia or antibiotics.

The Atypical Presentation

Patients with diabetes, neutropenia, advanced age, or prior antibiotics may have little fever, leukocytosis, or pain despite extensive disease. Dentures can obscure the source, and facial swelling may be the first sign of a mandibular molar infection. Examine the floor of mouth, dentition, palate, eyes, neck, and mouth opening; assess glucose, hydration, immune status, and trajectory rather than using fever alone as the severity marker.

Back to Our Patient

Back to the 62-year-old woman: rapidly progressive cheek swelling, chills, poor intake, and extension toward the eyelid make this a complicated odontogenic infection rather than a simple outpatient toothache. She is currently protecting her airway but is high risk because of progression and possible orbital involvement, so the key call is escalation rather than discharge. IV access, glucose and sepsis assessment, analgesia, and ampicillin-sulbactam are started; CT face/neck with contrast is obtained, and OMFS and ophthalmology evaluate her. Imaging shows a spreading maxillary odontogenic abscess without intracranial disease, so she is admitted for IV therapy, drainage, and definitive dental source control.

Patient Presentation to Attending

“This is a 62-year-old woman with diabetes and two days of rapidly progressive right facial swelling centered around a painful upper molar. She reports chills, poor intake, and foul taste, with no current drooling, dysphagia, or voice change, but the swelling is approaching the lower eyelid. She is tachycardic with right cheek cellulitis, focal dental tenderness, mild trismus, and no proptosis or pain with extraocular movements. I’m concerned for a complicated maxillary odontogenic abscess with possible orbital extension, not simple dental pain. I’ll start IV fluids and ampicillin-sulbactam, obtain CT face and neck with contrast, involve OMFS and ophthalmology, and admit for drainage and source control.”

Study Directive

Sketch the routes from maxillary and mandibular teeth to the orbit, sublingual space, submandibular space, parapharyngeal space, and mediastinum.
Review CT examples of cellulitis versus rim-enhancing abscess and list when IV contrast is essential.
Memorize admission triggers and test yourself with five outpatient-versus-inpatient cases.
Check your institutional dental infection antibiotic pathway and renal-adjustment rules.

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Key Medications

Ampicillin-sulbactam 3 g IV every 6 hours; adjust for renal function.
Amoxicillin-clavulanate 875/125 mg PO twice daily for selected outpatient infections when antibiotics are indicated; verify renal dosing.
Clindamycin 600–900 mg IV every 8 hours or 300 mg PO four times daily in selected beta-lactam-allergic patients; check local protocol because of C. difficile risk.
Ibuprofen 400 mg PO every 6 hours as needed.
Acetaminophen 1,000 mg PO every 6–8 hours as needed; maximum 4,000 mg/day in healthy adults, lower with hepatic risk.
Lidocaine 2% with epinephrine 1:100,000; maximum commonly 7 mg/kg or 500 mg—check institutional policy.
Vancomycin 20–25 mg/kg IV loading dose may be added for selected MRSA-risk severe infections; dosing varies and requires reference-guided renal adjustment.
Pediatric antibiotic therapy is weight-based; do not extrapolate adult doses.

High-Yield Pearls

The direction of spread matters: maxillary disease threatens the orbit, while mandibular molars commonly threaten the floor of mouth and deep neck.
A patient can be afebrile and still have extensive odontogenic infection after antibiotics, diabetes, or immunosuppression.
“Antibiotics started” is not source control; persistent or progressive swelling requires drainage or definitive dental treatment.

The Mimics

Orbital cellulitis — pain with eye movement, proptosis, or vision change; confusing it with simple dental swelling risks blindness and intracranial spread.
Parotitis — preauricular swelling and purulence from Stensen duct rather than a diseased tooth; wrong source treatment delays recovery.
Facial cellulitis from skin disease — cutaneous portal and no focal dental tenderness; missing odontogenic origin leaves the nidus untreated.
Cavernous sinus thrombosis — ophthalmoplegia, cranial neuropathies, or bilateral eye findings; mistaking it for local infection delays neuroimaging and specialist therapy.

Board Question

Which finding most strongly indicates that a patient with odontogenic facial swelling requires urgent escalation rather than routine outpatient dental follow-up?

ADental caries with isolated percussion tenderness
BMild gingival erythema without swelling
CPain with extraocular movements and proptosis
DImprovement after acetaminophen

Reveal answer

Correct: C

Pain with extraocular movements and proptosis suggest orbital involvement, a vision- and life-threatening complication requiring urgent imaging and specialty management. Analgesic response does not establish infection control.

Recent Literature

Review or guideline Antimicrobial management of dental infections: Updated review
Medicine (Baltimore), 2024 · cited 42×

Supports antibiotic stewardship by pairing appropriate antimicrobial selection with definitive dental source control and escalation for spreading or systemic infection.

Full text · open access
Recent clinical A European multicenter retrospective study of hospitalized patients with severe odontogenic infections
J Dent, 2025 · cited 3×

Provides contemporary multicenter data on severe odontogenic infections requiring hospitalization, helping residents recognize presentations that merit early specialty involvement and inpatient care.

5 of 8 · Procedure Corner

Dental Abscess Incision and Drainage

Fluctuant, localized odontogenic abscess amenable to drainage, with pain, swelling, or purulence. Drainage is adjunctive to definitive dental treatment;...

Also known astooth abscess drainage · periapical abscess drainage

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Indications

Fluctuant, localized odontogenic abscess amenable to drainage, with pain, swelling, or purulence. Drainage is adjunctive to definitive dental treatment; antibiotics are reserved for systemic illness, spreading infection, immunocompromise, or inability to obtain source control.

Steps

Assess for airway compromise, deep-space extension, trismus, toxic appearance, or floor-of-mouth elevation; obtain dental/maxillofacial consultation when present.
Provide topical and local anesthesia away from the most inflamed tissue; use a dental block when appropriate. Avoid injecting through infected tissue when possible.
Prepare with antiseptic and use suction, gauze, eye protection, and a guarded scalpel.
Make a small incision at the point of maximal fluctuance, ideally dependent and along the gingival contour, avoiding the parotid duct, mental nerve, and major vessels.
Bluntly spread with a hemostat, allow drainage, and gently irrigate with saline. Break loculations without aggressive deep probing.
Leave the wound open for continued drainage; consider a small drain only for a larger cavity or when reaccumulation is likely.

Confirmation & Success Criteria

Purulent drainage is obtained, the cavity decompresses, pain or pressure improves, and no expanding swelling or airway symptoms develop. Arrange urgent dental follow-up for extraction, root-canal therapy, or other definitive source control.

Complications & Rescue

Bleeding is usually controlled with direct pressure, local anesthetic with vasoconstrictor when appropriate, or hemostatic material. Avoid blind deep dissection, which can injure nerves or vessels or spread infection. Worsening trismus, dysphagia, drooling, voice change, floor-of-mouth elevation, systemic toxicity, or failure to improve requires emergency department reassessment and specialty consultation.

6 of 8 · Procedure Corner

Dental Cement for Dislodged Filling

Temporary protection of a clean, dry cavity after loss of a filling when definitive dental care is not immediately available. Use only when there is no...

Also known astemporary dental cement · temporary filling material

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Indications

Temporary protection of a clean, dry cavity after loss of a filling when definitive dental care is not immediately available. Use only when there is no uncontrolled bleeding, obvious pulp exposure requiring urgent treatment, or rapidly progressive facial swelling.

Steps

Inspect and gently rinse the tooth; remove loose debris without excavating sound tooth structure. Check for sharp edges, exposed pulp, fracture, or significant tenderness.
Dry the tooth and isolate it with gauze or cotton. Moisture control is essential for temporary cement retention.
Mix and handle the over-the-counter temporary dental cement according to its product instructions.
Press a small amount into the cavity, avoiding overfilling. Ask the patient to close gently and remove material that creates a premature bite or contacts the gingiva.
Instruct the patient to avoid chewing on that side until set and to arrange prompt definitive dental repair.

Confirmation & Success Criteria

The cavity is covered, the cement is stable, the bite feels normal, and there is no persistent pulp-exposure pain or gingival impingement. Temporary cement is not a definitive restoration.

Complications & Rescue

Dislodgement, malocclusion, retained debris, gingival irritation, or worsening pain may occur. Remove excess material if it alters the bite. Do not seal a visibly infected tooth or suspected pulp exposure without dental guidance; urgent dental evaluation is needed for spontaneous pain, thermal sensitivity that lingers, swelling, fever, or facial cellulitis.

7 of 8 · Procedure Corner

Dental Splint

Temporary stabilization of a traumatized, mobile, or displaced tooth after repositioning when periodontal or alveolar injury is suspected. Coordinate...

Also known astooth splint

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Indications

Temporary stabilization of a traumatized, mobile, or displaced tooth after repositioning when periodontal or alveolar injury is suspected. Coordinate promptly with dental or oral-maxillofacial services; splint duration depends on the injury pattern.

Steps

Assess occlusion, tooth mobility, soft-tissue injury, alveolar-segment mobility, and neurovascular findings; obtain appropriate dental imaging when available.
Provide local anesthesia if needed and gently reposition the displaced tooth or alveolar segment to its preinjury alignment.
Clean and dry the facial surfaces of the injured tooth and at least two stable adjacent teeth on each side when feasible.
Apply flexible orthodontic wire or an appropriate splinting material across the teeth, bonding it with dental composite while maintaining normal occlusion.
Recheck alignment and occlusion, trim sharp or irritating material, and document the teeth included and the planned removal date.

Confirmation & Success Criteria

The injured tooth is aligned, adequately supported without rigid immobilization, and the patient can close in the preinjury bite. The splint does not impinge on gingiva, restrict hygiene, or create a traumatic occlusal contact.

Complications & Rescue

Malocclusion, splint loosening, gingival injury, plaque accumulation, aspiration of loose material, and pulp necrosis can occur. Correct a traumatic bite or unstable splint urgently. Provide soft diet and meticulous oral hygiene instructions, arrange dental follow-up, and reassess for pulp vitality and periodontal healing; follow-up timing and splint duration should follow dental-trauma guidance for the specific injury.

8 of 8 · Procedure Corner

Ludwig's Angina

Early controlled airway management for suspected Ludwig’s angina with progressive floor-of-mouth or submandibular swelling, dysphagia, drooling, voice...

Also known asangina ludovici · submandibular space infection · floor-of-mouth cellulitis

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Indications

Early controlled airway management for suspected Ludwig’s angina with progressive floor-of-mouth or submandibular swelling, dysphagia, drooling, voice change, stridor, hypoxia, inability to handle secretions, or clinical deterioration. Obtain immediate anesthesia and ENT/oral-maxillofacial support; do not delay airway planning for imaging in an unstable patient.

Steps

Keep the patient upright, provide supplemental oxygen, establish monitoring and IV access, and have suction and a difficult-airway cart immediately available.
Avoid sedative premedication and unnecessary supine positioning; maintain spontaneous ventilation while preparing a definitive airway.
With expert help, perform awake flexible endoscopic intubation when feasible, using topical anesthesia and cautious, incremental sedation only if necessary.
Have a simultaneous surgical-airway plan. If intubation fails or obstruction is imminent, proceed to emergency cricothyrotomy or tracheostomy according to local expertise and equipment.
After securing the airway, obtain cultures when appropriate, begin IV broad-spectrum therapy covering oral aerobes and anaerobes, and obtain urgent surgical evaluation for drainage and source control.

Confirmation & Success Criteria

A cuffed endotracheal tube is confirmed with continuous waveform capnography, bilateral chest movement and breath sounds, and appropriate oxygenation. The airway is secured before transport, imaging, sedation, or operative drainage.

Complications & Rescue

Blind nasotracheal intubation, forceful laryngoscopy, bag-mask attempts that worsen edema, and paralytic-assisted induction without a secured rescue plan can precipitate complete obstruction. Failed or worsening airway management requires immediate expert rescue, preservation of spontaneous ventilation when possible, and surgical airway access. Prepare for aspiration, bleeding, tube displacement, and rapid edema progression.

TheDaily Differential

Dental Trauma

When to Think of It

Sick or Not Sick

The First Fifteen Minutes

Definitive Care & Disposition

How This One Kills

The Second-Day Story

Study Directive

Recent Literature

More in Today's Issue

Dental Infections and Atraumatic Dental Pain

Ludwig Angina

Dental Infections

Dental Abscess Incision and Drainage

Dental Cement for Dislodged Filling

Dental Splint

Ludwig's Angina

Yesterday’s Differential

Journal Watch

Podcast Picks

How Much Oxygen Should Post-Arrest Patients Receive?

EM Quick Hits 72 EMC²: Peds Neurocritical Care, Pulmonary Hypertension, Cytokine Release Syndrome, Peds Wrist Fracture, Bradycardia ECG Interpretation, Coaching the EM Mind Part 2

Annals Journal Watch

Medical Screening of Adult Psychiatric Patients Presenting to the Emergency Department

Critical Care Corner

Ludwig Angina

Pharmacology Corner

Ampicillin-Sulbactam

Ondansetron

ECG of the Day

Case of the Day