If you work long enough in the Pediatric Emergency Department – like half a shift – you will see a child with complaints of dental pain. This edition of Briefs focuses on odontogenic infections, including management and complications.

What are some of the odontogenic infections and problems seen in the Pediatric Emergency Department?

Dental caries

Caries are seen at the crown or root of the tooth and develop slowly, not becoming painful until involvement of the pulp. Pain should be managed with Ibuprofen or acetaminophen, oral hygiene and follow up with a dentist. Antibiotics are not needed.


This includes gingivitis. The gums can be swollen, red to purplish. The gums bleed easily after eating and brushing. Patients may also have halitosis. Treatment centers around improved oral hygienic, chlorhexidine mouth rinse and follow up with a dentist.

Pulpitis and periapical abscesses

Early pulpits manifests in toothache exacerbated by temperature changes – like cold drinks. Once the pulp is infected pus can drain through the crown or through the adjacent periodontal tissue (the gums etc,.). Draining pus comes from abscesses. Typically they appear as a pus bubble along the gum line.

From wikimedia commons

Treatment depends on whether or not the abscess is draining. If it is antibiotics are not necessarily warranted. A non-draining abscess should be treated with oral antibiotics and follow up in 1-2 weeks with a dentist. See below for antibiotic recommendations. Resist the temptation to drain the abscess – you can actually do more harm than good. Premature I&D through an area of cellulitis can actually compromise intact barriers to the spread of infection. If you want to drain an abscess through needle aspiration discuss with a pediatric dentist first if possible. They may ask you to wait.


Complications and spread of infection

Abscesses and periodontal disease can extend and cause local and systemic complications. For infections with diffuse spread CT is the imaging test of choice. See the below images for examples;

Patients present with facial swelling pain and redness. Fever is often seen as well. Diagnosis is clinical. Oral antibiotics are appropriate for most patients – see later in this post for admission criteria recommendations. Follow up should be within 72 hours. From healio.com

Maxillary sinusitis occurs when the tooth erodes superiorly. These are often associated with significant cellulitis as well.  From wikimedia commons

Ludwig’s Angina – bilateral submandibular cellulitis/abscess that can occlude the airway. it is potentially life threatening and requires a trip to the OR. from Brotherton et al.

Infections can also spread to the brain, the deep spaces of the neck, cause osteomyelitis of the jaw or spread hematogenously. These patients are obviously more ill appearing.

What are the antibiotic recommendations?

  • Amoxicillin is the best first choice – 20-40 mg/kg/day tid
  • Amoxicillin/clavulanate 20 mg/kg bid
  • Clindamycin is preferred in penicillin allergy or infection worsening after 72 hours on amox – 8-20 mg/kg/day tid
  • Azithromycin is an alternative to Clindamycin – 5-12 mg/kg once daily – check local resistance patterns and recommendations as Azithromycin may not adequately cover flora
  • Metronidazole may be used in addition to amoxicillin in a resistant infection – 30 mg/kg/day qid

For admitted patients who need IV antibiotics discuss with the Dentist on call. Common ones used frequently include Ampicillin/Sulbactam and Clindamycin.

Who should be admitted?

Patients with any of the following should be admitted;

  • Toxic appearance
  • Rapid progression
  • Immunocompromised or comorbidities (like diabetes)
  • Difficulty breathing
  • Difficulty swallowing
  • Dehydration
  • Trismus
  • Signs of Ludwig’s Angina or Cavernous Sinus Thrombosis
  • Failed outpatient treatment
  • Cellulitis encroaches upon the orbit, spreads inferior to the body of the mandible, or posterior to the mandibular ramus