Management of Odontogenic Infections

By: Dr. Wade Barker DDS, MD – Southern Surgical Arts

Odontogenic infections are a common challenge in private practice. Many Texans do not have access to routine dental care and present to the general dentist, oral surgery practice or even hospital emergency department when they begin to encounter pain and swelling associated with a tooth. 

Upon seeing a patient with an odontogenic infection, physical exam should be performed along with imaging as practical. Frequently patients will have trismus (restricted opening) as well as significant discomfort on examination. It is important to determine the extent of the swelling coming from a combination of the abscess as well as concomitant cellulitis surrounding the area. Signs such as shortness of breath, inability to tolerate secretions, and difficulty swallowing are signs of severe disease and these patients should be sent to the hospital ED immediately for treatment. When examining the patient, a general rule is that if the inferior border of the mandible is palpable, then the infection can likely be treated as an outpatient. Most maxillary infections can also be treated as an outpatient. Infections causing swelling below the jaw line require inpatient treatment performed in an operating room as well as IV antibiotics. In these cases, it is also necessary to obtain a CT with contrast which is only available in the hospital setting. Consideration of the host’s defenses must also be considered:  patients who are immunocompromised or present with significant comorbidities should be treated more aggressively. 

For mild to moderate infections that can be managed as an outpatient, initial steps include medical treatment with antibiotics, along with an incision and drainage of the tooth, as well as extraction of the tooth when possible. Contrary to the myth believed by some patients, an infected tooth can be removed at time of initial presentation and many times prevents worsening of the infection. An exception to this is pericoronitis with third molars. Pericoronitis typically has a higher predominance for virulent anaerobic bacterial flora. Simultaneous extraction of the tooth typically requires a tissue flap and handpiece use, which can spread the bacteria and cause significant worsening of these cases. Antibiotics are recommended prior to extraction in these types of pericoronitis cases.

Local anesthesia with these cases, however, can be challenging due to the acidic pH of the infected tissue, which leads to decreased penetration of the solution. Carbocaine and Marcaine can be especially effective in these cases. Try to avoid injection through infected tissue, which can seed the infection. 

Antibiotic Selection:

Penicillin VK – basic, first line drug for odontogenic infections. Dosing every 6 hours can be challenging for compliance. Cheap and well-tolerated for those without penicillin allergy. 

Amoxicillin – inexpensive and good efficacy. Dosed every 8 hours. Not potent enough for significant infections. 

Augmentin – amoxicillin with clavulanic acid, a beta-lactamase inhibitor that helps with resistant bacteria. Causes more GI upset and probiotics/yogurt are recommended to ease this. Drug of choice for moderate infections. 

Clindamycin – drug of choice for PCN allergic patients. Increasing resistance with oral flora (up to 40% resistance) make it decreasingly useful. 

Azithromycin – useful for PCN allergic patients.