if looking for a localised dental abscess or mandibular injury then OPG is the usual preferred investigation
if there is swelling in the floor of the mouth or the neck then a CT scan should be considered to exclude an abscess such as in Ludwig's angina
severe dysphagia, trismus or airways issues suggests a large soft tissue abscess which needs emergent Ix with a CT scan and Rx
these may progress down the neck and even into the mediastinum
in severe cases in young adults, it may be complicated by septic thrombophlebitis of the internal jugular vein (Lemiere's syndrome) and possible septic emboli (esp. to the lungs)
Introduction
chronic dental infections are now recognized as a key driver of atherosclerosis, heart attacks and strokes
in those with apical periodontitis, successful root canal treatment could reduce inflammation linked to heart disease and improve levels of blood sugar and cholesterol1)
broad spectrum oral antis such as amoxy/clavulonic acid
stat dose IV ben pen + metronidazole then orals as above
if swelling causing dysphagia or dyspnoea is present, admit to hospital for intravenous antibiotic therapy, consider CT scan and appropriate surgical management
spreading odontogenic infections
these may be either:
superficial
can be treated with local surgical or dental treatment plus oral antibiotics
bacteriology is different to usual sinusitis and commonly mixed growth including Peptostreptococcus, Prevotella, and Fusobacterium and thus antibiotic Rx needs to be broad spectrum including anaerobic cover
dental Mx such as root canal Rx may be needed
endoscopic sinus surgery may be required for patients who fail initial medical management and dental treatment
deep into soft tissues
spread to the submandibular and pharyngeal spaces in the upper neck are potentially life-threatening, as there is a risk of airway obstruction.
Ludwig's angina is a severe bilateral cellulitis involving all of the neck spaces from the mandible to the thoracic inlet, although the term is now incorrectly also used for severe deep neck infections.
any patient who has trismus and cannot open their mouth more than 2 cm (interincisal) must be assessed for signs of airway compromise and considered for emergent CT scan
signs and symptoms of airway compromise include stridor, dyspnoea, dysphagia, and elevation and firmness of the tongue