Oral and Maxillofacial Surgery and Oral Emergencies
Odontogenic infection
Spread follows fascial planes. Ludwig's angina is a bilateral, board-like cellulitis of the submandibular, sublingual and submental spaces with tongue elevation, drooling and airway compromise. It is a clinical emergency: secure the airway first, then give IV antibiotics (for example amoxicillin–clavulanate plus metronidazole), perform aggressive incision and drainage, and remove the causative tooth. Antibiotics alone never suffice.
Exodontia and complications
Assess radiographs for root morphology, sinus proximity and the inferior alveolar canal. Dry socket (alveolar osteitis) presents 2–4 days after extraction with severe pain, an empty socket and exposed bone; treat with irrigation and a medicated dressing, not repeated antibiotics. For an oroantral communication, test with a Valsalva manoeuvre; small defects close with a sutured flap, larger ones need a buccal advancement flap. Document pre-operative sensation, since nerve injury may cause persistent paraesthesia.
Trauma and emergencies
Avulsed permanent tooth: handle by the crown, store in saline or milk, replant within 60 minutes, apply a flexible splint for two weeks, give systemic antibiotics (doxycycline, dose-adjusted for age), check tetanus status and follow up for inflammatory resorption. Never replant a primary tooth - it risks the developing successor. Anaphylaxis: 0.5 mg epinephrine intramuscularly (0.5 mL of 1:1000) into the anterolateral thigh, repeated every five minutes. Vasovagal syncope: lay the patient supine with legs elevated.
Worked example
A patient with a swollen floor of the mouth, raised tongue and stridor should not be sent for extraction. Sit them upright, call for emergency airway support, give oxygen and IV antibiotics, and prepare for drainage in theatre.
Traps
- Treating dry socket with antibiotics rather than local measures.
- Replanting a primary incisor.
- Missing that trismus, dysphagia and a raised floor of mouth signal deep-space infection.
- Giving epinephrine subcutaneously instead of intramuscularly.