Dental Cellulitis

Dental cellulitis is diffuse, spreading soft tissue inflammation arising from a dental source (periapical infection, pericoronitis, periodontal disease), before or without localised pus. Mixed oral flora (viridans streptococci, Prevotella, Fusobacterium, Peptostreptococcus) cause it.

• Risk factors: untreated caries, poor dental hygiene, partially erupted third molar, diabetes, HIV, malnutrition, limited dental access.
• Common in young adults and children in Kenya, where late presentation is frequent.

Toothache, then firm, diffuse, tender facial swelling with warm erythematous skin, trismus, fever and malaise; carious or non vital tooth tender to percussion.

• Spread to adjacent fascial spaces produces more extensive swelling.
• Differential diagnosis: dental abscess, sinusitis, parotitis, lymphadenitis, facial erysipelas, angioedema, osteomyelitis of the jaw, cyst infection, tumour, salivary stone, trigeminal neuralgia.
• Complications: abscess in facial spaces, Ludwig angina, cavernous sinus thrombosis, mediastinitis, brain abscess, airway obstruction, osteomyelitis of the jaw, sepsis.

Clinical, with dental assessment.

• Dental examination and orthopantomogram or periapical radiograph; CT with contrast if swelling is extensive, trismus is severe or airway threat.
• Full blood count, CRP, glucose, blood cultures if febrile; HIV test.

Source control with antibiotics and early dental care.

• Supportive: analgesia (paracetamol 1 g, ibuprofen 400 mg, short course of codeine 30 mg if severe), hydration, soft diet, warm saline rinses, chlorhexidine 0.2 percent rinse, head elevation.
• Pharmacological: amoxicillin 500 mg three times daily with metronidazole 400 mg three times daily for 5 to 7 days (children amoxicillin 25 mg/kg/day in three doses with metronidazole 7.5 mg/kg three times daily); amoxicillin clavulanate 625 mg three times daily as a single alternative; penicillin allergy: clindamycin 300 mg four times daily. Severe: benzylpenicillin 1.2 to 2.4 g IV every 6 hours with metronidazole 500 mg IV every 8 hours, or ceftriaxone 2 g IV daily with metronidazole.
• Procedures: extraction or root canal treatment of the source tooth; incision and drainage when pus forms; admit for airway or extensive spread.
• Special groups: pregnancy, amoxicillin or penicillin and metronidazole after the first trimester; children, weight based doses; diabetes and HIV, lower threshold for IV therapy and admission.
• Red flags: trismus, difficulty swallowing, drooling, stridor, floor of mouth swelling, eyelid swelling, fever, neck swelling.
• Follow-up: dental review within 24 to 48 hours; reassess at 48 hours; restore the tooth or extract.