Acute Oral Medical Conditions
A swelling is a transient abnormal enlargement of a body part or area not caused by proliferation of cells but by accumulation of fluid in tissues. It can occur throughout the body (generalized), or a specific part or organ can be affected (localized).
A swelling may arise intra-orally or externally around the face, jaws and neck and can be caused by trauma (hematoma, swelling due to fracture, TMJ dislocation), infection or inflammation. Swelling can occur in the gums, palate, lips, buccal space, etc. It can happen due to periodontal problems, infection, abscess, cysts, allergic reaction (anaphylactic shock), salivary gland tumour, inflammation or obstruction of salivary gland.
Bacterial infection in the oro-facial region can lead to abscess and swelling. The rapid spread of this infection through connective tissue spaces, is often referred to as cellulitis. The clinical features of cellulitis are a painful, diffuse, brawny swelling. The overlying skin is red, tense and shiny. There is usually an associated trismus, cervical lymphadenopathy, malaise and pyrexia. Cellulitis usually develops quickly, over the course of hours, and may follow an inadequately managed or ignored local dental infection.
If the infection spreads to involve the floor of mouth and pharyngeal spaces, then the airway can be compromised. Initially, the floor of the mouth will be raised and the patient will have difficulty in swallowing saliva; this pools and may be observed running from the patient’s mouth. This sign indicates the need for urgent management.
Cellulitis involving the tissue spaces on both sides of the floor of mouth is described as Ludwig’s angina. Such presentations require immediate attention.
Localised dental abscesses may be appropriately treated by intra-oral drainage via tooth extraction, opening of root canals and/or intra-oral incision and drainage. Wherever there are signs of spreading cervico-facial infection or significant systemic disturbance, however, patients should be referred urgently further management.
Pericoronitis is defined as inflammation in the soft tissues surrounding the crown of a partially erupted tooth. The acute form is characterised by severe pain, often referred to adjacent areas, causing loss of sleep, swelling of the pericoronal tissues, discharge of pus, trismus, regional lymphadenopathy, pain on swallowing, pyrexia, and in some cases spread of the infection to adjacent tissue spaces.
Trismus may be defined as inability to open the mouth due to muscle spasm, but the term is frequently used for limited movement of the jaw from any cause and usually refers to temporary limitation of movement. Trismus can occur as a result of temporomandibular joint disorder, infection, cancer therapy, complicated extraction, arthritis, complication from a mandibular block and fractures.
Whilst haemorrhage from the oro-facial region may present spontaneously, particularly from gingival tissue as a result of a bleeding diathesis or a haematological abnormality such as leukaemia, the most common cause is in response to trauma or a post-operative haemorrhage following dental extraction.
Bony pathology (infection and cyst)
Post-extraction pain, infection and dry socket
Following a tooth extraction, if a blood clot forms inadequately in the socket or it is broken down, a painful infection may develop which is often referred to as a ‘dry socket’. It is clinically characterized by a putrid odor and intense pain that radiates to the ear and neck.
Pain is considered the most important symptom of dry socket. It can vary in frequency and intensity, and other symptoms, such as headache, insomnia, and dizziness, can be present.
Pre-disposing factors to dry socket include smoking, traumatic extraction, history of radiotherapy and bisphosphonate medication. A dry socket can be managed by irrigating the socket with chlorhexidine or warmed saline to remove debris followed by dressing of the socket with bismuth iodoform paraffin paste and lidocaine gel on ribbon gauze to protect the socket from painful stimuli.
If pus is seen in the socket and there is localised swelling and possibly lymphadenopathy, it has become infected and can often be managed as in dry socket, but usually antibiotics should be prescribed. A radiograph is useful to see if there is a retained root or bony sequestrum, which could be the cause of the infection. Clearly, if one or both is present, further treatment is indicated.
Mild inflammatory swelling may follow dental extractions but is unusual unless the procedure was difficult and significant surgical trauma occurred. More significant swelling usually indicates postoperative infection or presence of a haematoma. Management of infection may require systemic antibiotics or drainage. A large haematoma may need to be drained.