Case

A 25-year-old man with schizophrenia presented as an emergency with severe pain and swelling of his left jaw and neck. He was febrile (38.9oC) and could only open his jaw 5 mm. Swallowing was difficult and he was dehydrated.

The patient had a history of toothache for three years. For the past two years he had experienced facial swellings. He had attended several medical clinics and received a range of antibiotics, mainly amoxycillin, but also erythromycin, tetracycline, metronidazole and amoxycillin with clavulanic acid. He had no recollection of ever being given a referral or being told that he must seek dental advice.

Two weeks before presentation the patient developed trismus and difficulty in swallowing. He went to an emergency department and was given oral analgesia and amoxycillin with clavulanic acid before being discharged without arranged follow-up. The patient briefly improved, but re-presented a few days later so he was admitted for intravenous amoxycillin and metronidazole. He improved and was discharged with advice to 'next time' go to a hospital with an oral and maxillofacial service.

On presentation, the clinical diagnosis was Ludwig's angina or a spreading neck infection from an acute dental cause. Direct endoscopic examination of the oropharynx showed an extension of the swelling into the lateral oropharynx, a deviation of the uvula and marked swelling with imminent supraglottic obstruction.

An orthopantomograph (Fig. 1) was taken with an oral and maxillofacial surgeon present and the patient was intubated before being placed in a CT scanner (Fig. 2). The left mandibular second molar and six other decayed teeth were removed. Copious amounts of pus were drained intra-orally and via a skin incision.

Microbiological swabs for culture and sensitivity were taken before starting empirical intravenous cefalotin and metronidazole. Culture and sensitivity showed that the bacteria were resistant to the penicillins and tetracyclines, but sensitive to the cephalosporins and metronidazole.

The patient was in intensive care for 48 hours and remained in hospital for a further three days. On review at six months he had fully recovered and had attended the local government dental clinic.

Fig. 1
Orthopantomograph of dental abscess

There is obvious decay on the right side, but these teeth are draining into the mouth. The cause of the infection is the abscess on the left lower second molar which is not draining into the mouth, but is draining into the left submandibular triangle.

Fig. 2
CT scan of a submandibular abscess

There is marked generalised neck swelling. (The patient was intubated before being placed in the scanner.)

Comment

The principles of managing infection, such as, remove the cause, drain the pus and support the host, have been known since the time of Hippocrates. The advent of antibiotics changed the management of life-threatening infections. However, the inappropriate use of antibiotics and increasing resistance have seen the return of severe spreading infections from common causes.

The case reported is not exceptional, but represents the daily or weekly workload of specialist units at major metropolitan hospitals. In the past ten years we have treated over 1000 similar cases and have had three fatalities. One patient died of airway obstruction, another died of septicaemia caused by bacteria with multiple resistances to antibiotics and the third died from cerebral infection with a background of community-acquired methicillin-resistantStaphylococcus aureus. All these cases could have been prevented by timely dental intervention. Antibiotics may temporarily alleviate symptoms, but in the medium to long term the delay in treatment due to the use of antibiotics makes the condition worse.

Recommendation

Dental pain and swelling is a dental problem which should be treated by a dentist. If the patient presents to a doctor they should be referred to a dentist. Access to affordable and timely dental services is crucial.

A patient who presents with upper neck swelling, difficulty in swallowing and who cannot open their jaw 2 cm, no longer just has a dental problem but has an airway problem. Their airway should be secured before transfer to a hospital with the appropriate surgical, medical and anaesthetic facilities.

Do not simply prescribe antibiotics for dental infections.1,2 Emphasise the need for dental treatment as soon as possible.

References

  1. Therapeutic Guidelines: Oral and Dental. Version 1. Melbourne: Therapeutic Guidelines Limited; 2007.
  2. Watterson J. Dental antibiotics [letter]. Aust Prescr 2010;33:167-9.