Clinical Guideline 7 - Version 4

Valid to: November 2015

Facial Swelling of infectious origin

Purpose
The aim of this Clinical Guideline is to provide advice to public oral health clinicians
regarding the management of acute infective facial swelling. Evidence-based clinical
guidelines are intended to provide guidance, and are not a standard of care, requirement,
or regulation. However, the application of clinical guidelines in publicly-provided oral health
services allows for consistency to occur across large patients cohorts with a variety of oral
health clinicians.
This Clinical Guideline plans to:

Standardise the way in which patients with acute infective facial swellings are
assessed and treated;
Establish standardised treatment choices depending on individual patients
presentation; and
Assist the dental clinician in an emergency situation to choose an appropriate course
of action in cases when patients cannot be satisfactorily treated.

In this clinical guideline the term facial swelling refers to acute infective facial swellings
rather than developmental, traumatic or neoplastic facial swellings. Any patient presenting
with a swelling the cause of which cannot be easily diagnosed (and if applicable, treated),
should be referred to the Oral and Maxillofacial Surgery and/or Oral Medicine Department,
Royal Dental Hospital of Melbourne (RDHM). Completion of the appropriate Specialist
Services Referral form is required and, depending on level of urgency, posted or faxed to
the RDHM.
All patients with facial swelling should receive immediate attention. In the case of swellings
identified by dental therapists (DT), referral to a dentist may be appropriate depending on
the severity, however if there is no dentist available, and the situation is urgent and
requires immediate assessment, the Oral and Maxillofacial Surgery Department, RDHM may
be contacted by telephone for advice, telephone 9341 1277.
Acute infective facial swellings may also be referred to an Accident and
Emergency department in an acute hospital when distance or urgency are
considerations.

Guideline
Selection Criteria
Diagnosis
Diagnosis plays an important role in the management of any facial swelling.
Dental disease is the underlying cause of most inflammatory swellings that occur in and
around the jaws. Differential diagnosis should include infections originating in skin, salivary
glands and lymphnodes.
Facial swelling may be caused by an acute infection and resultant inflammatory reaction.
The cardinal local signs of inflammation include redness, heat, swelling, pain and loss of
function. Fever, increased respiratory rate and increased pulse are systemic symptoms of
inflammation and generally indicate the spread of a localised infection.
Diagnostic steps should be aimed at determining the severity of infection , evaluating the
patients host defense mechanism and determining whether the patient should be treated
by the General Dentist or requires referral to an Oral and Maxillofacial Surgeon.

Page 1 of 4

Clinical Guideline 7 - Version 4

Valid to: November 2015

History taking questions regarding how long swelling has been present, if the
swelling is getting larger or smaller, pain, discharge, trismus, numbness of lip or face,
the presence of fever. Breathing difficulty, swallowing difficulty and restricted mouth
opening indicate more serious swellings requiring more urgent treatment. The
general state of malaise indicate a more generalized reaction. In children,
dehydration requires referral to Emergency Department of an Acute Hospital for
medical management. The patient medical history should be assessed for conditions
that compromise the host response such as uncontrolled metabolic disease, immuno
suppressive disorders or immunosuppressive therapies. These patients require early
vigorous therapies due to the potential of infections to spread more rapidly. Any
previous antibiotic treatment for the facial swelling needs recording.

Clinical examination extra and intra-oral examination is required including size,

shape, attachments of any swelling noted. Swellings around the jaw may be tender
or non-tender, soft or firm, fluctuant or oedematous, or red and hot. Swelling limiting
eye opening requires more urgent treatment. Facial, submandibular and cervical
lymph nodes should be palpated and any enlargement or tenderness noted. Intraorally, the buccal and labial sulci, the tongue, floor of mouth, pharynx and palate
should be inspected. Any teeth present should be inspected and include tests for
mobility and tenderness to percussion. If there is any draining pus, this could be
expressed and recorded. Dizzyness (hypotension), decreased heart rate
(bradycardia), pallor, sweating, or cold peripheries may indicate more generalised
sepsis requiring more urgent treatment.

Special examinations radiographs (intraoral or extraoral) are an essential aid in

diagnosis of a facial swelling. If unable to take intraoral radiographs due to trismus,
the patient should be referred for external radiographs, e.g. orthopantomograph
(OPT), Waters View if specifically looking for sinus or maxillary middle third views, or
Lateral Oblique if specifically looking at the posterior mandible.

Considerations
Once a diagnosis has been made, a decision must be made as to whether definitive
treatment is able to be provided immediately or should be delayed, and whether or not the
patient can be managed locally, or if referral is required.
Consider treatment in the local clinic if:

Swelling is present but the patient is not displaying signs of systemic sepsis;
Local signs of fluctuation are or are not present;
Incision and drainage, or commencement of endodontic treatment is possible; or
The offending tooth is relatively easy to remove; and
Patient is co-operative.

If there are any problems with gaining anaesthesia, or commencing treatment, the patient
should be prescribed antibiotics (e.g. penicillin-based antibiotics, depending on medical
circumstances, as a first choice) and pain relief, and be reviewed the next day locally. In
some cases, escalation of the infection may then necessitate referral.
Consider referral if:

Systemic signs are present, i.e. patient is febrile, or shows signs of generalized
sepsis;
Patient is dehydrated
There is a potential risk of infection spreading into the head and necks anatomical
spaces;
The patient has difficulty with swallowing and/or breathing, or trismus is present;
The dentist has a lack of experience in incision and drainage;
Difficult extraction is predicted;
Patient is not co-operative;

Page 2 of 4

Clinical Guideline 7 - Version 4

Valid to: November 2015

Patient is medically compromised and as a consequence, treatment cannot be

undertaken locally or requires special management.

Patient returns with persistent infection few days after surgical and antibiotic therapy
has been prescribed.

The patient should be referred to the Oral and Maxillofacial Surgery Department, RDHM.
Completion of the appropriate Specialist Services Referral form is required and depending
on level of urgency, posted or faxed to the RDHM. If out of hours / during weekend, the
Emergency Department of the RDHM should be contacted who will then liaise with the Oral
and Maxillofacial registrar on call. Alternatively, Accident and Emergency departments in
major acute hospitals should be considered if distance and timing are a consideration.
Treatment
Note that the majority of the treatment described below is beyond the scope of a DT and
therefore should be undertaken by a dentist.
The aim of treatment is to eliminate the source of infection as soon as possible. Treatment
can be summarised under 2 broad areas: conservative treatment or surgical management.
Conservative treatment
This generally involves provision of medication including antibiotics and analgesics. It is
only to be applied if:

There are no signs of severe systemic infection/sepsis present that will require
referral;
There is no difficulty with breathing or swallowing; or
There are no signs that the infection has spread into the anatomical spaces of the
floor of mouth, or neck.

In this situation, it is also feasible to consider pulpal extirpation of the offending tooth if
possible.
The use of antibiotics may help retard the systemic spread of odontogenic infections; they
are an adjunct to surgical removal of the cause of infection and not a replacement. Their
selection should be judicious and minimize the risk of developing resistance to current
antibiotic regimens. Patients should be reviewed within 3-5 days for the removal of the
cause or referred to Oral Surgery RDHM. Meanwhile patients should be advised to contact
the clinic urgently if their condition does not improve or deteriorates.
Surgical management
This generally involves provision of medication including antibiotics and analgesics, plus
surgical treatment of the patient. This is indicated if:

Adequate local anaesthesia can be achieved;

Pulpal extirpation is possible;
Tooth extraction is feasible and indicated [tooth not restorable]; or
Fluctuation is present and the dentist is satisfied that they are able to perform an
incision and drainage.

Postoperative evaluation:
All patients with dental infections should be advised to contact the clinic 48-72 hours after
infection if there is no resolution. Patients with persistent infection at the review
appointment should be referred at Oral Surgery RDHM for management.
Within normal working hours, on-call Oral and Maxillofacial Surgery personnel at the RDHM
may be called on (03) 9341 1277 for advice or assistance.

Page 3 of 4

Clinical Guideline 7 - Version 4

Valid to: November 2015

Definitions
Nil

Revision date

Policy owner

November 2015

Clinical Leadership Council

Approved by

Date approved

Director of Clinical Leadership, Education

and Research

References and related documents

Nil

Page 4 of 4

May 2012