Buccal Space Infection

Buccal space infection is infection of the potential space of the cheek, between the buccinator muscle and the overlying skin and fat. It arises mostly from maxillary or mandibular molars and premolars whose roots perforate above or below the buccinator attachment, and sometimes from parotid or skin sources.

• Mixed oral flora (streptococci, anaerobes) is responsible.
• Risk factors: untreated caries, periodontal disease, diabetes, HIV.

Swelling of the cheek, extending from the corner of the mouth toward the ear, with erythema, tenderness, and mild or no trismus; fever.

• Extraoral swelling obliterates the nasolabial fold and may extend to the lower eyelid.
• Differential diagnosis: parotitis, masseteric space infection, canine space infection, cellulitis, odontogenic cyst infection, angioedema, tumour, buccal lymphadenitis, buccal mucosa abscess.
• Complications: abscess pointing intraorally or through the skin, spread to masticator or infratemporal spaces, cavernous sinus thrombosis, facial scarring, sepsis.

Clinical.

• Dental examination and orthopantomogram; ultrasound or CT with contrast for abscess extent.
• Full blood count, CRP, glucose; pus culture; blood cultures if febrile; HIV test.

Antibiotics, source control and drainage of pus.

• Supportive: analgesia (paracetamol 1 g, ibuprofen 400 mg), hydration, warm saline rinses, chlorhexidine 0.2 percent, soft diet.
• Pharmacological: amoxicillin 500 mg three times daily with metronidazole 400 mg three times daily for 5 to 7 days (or amoxicillin clavulanate 625 mg three times daily; clindamycin 300 mg four times daily if penicillin allergic); children, amoxicillin 25 mg/kg/day in three doses with metronidazole 7.5 mg/kg three times daily. Moderate or severe: benzylpenicillin 1.2 to 2.4 g IV every 6 hours with metronidazole 500 mg IV every 8 hours.
• Procedures: intraoral incision and drainage through the buccal mucosa (with blunt dissection to avoid the facial artery and parotid duct), or extraoral incision for large collections; extraction of the source tooth.
• Special groups: pregnancy, penicillin and metronidazole after the first trimester; children, weight based doses; diabetes and HIV, admit and treat with IV therapy.
• Red flags: trismus, eyelid swelling, airway symptoms, fever with toxicity, spreading beyond the cheek, diabetes.
• Follow-up: review at 24 to 48 hours; dental treatment after drainage; wound check at 1 week.