Treatment
Localized Abscess — Ambulatory
Surgical drainage + elimination of source + antibiotics if spreading
- • Incision and drainage: achieve LA, incise through mucosa with #15 scalpel at point of maximum fluctuance
- • Blunt dissection with curved hemostat to break loculations and release pus
- • Drain placement (penrose drain or folded gauze wick) sutured in place for 24–48 hours
- • Root canal treatment or extraction of offending tooth at same or follow-up visit
- • Amoxicillin 500mg TID x 5–7 days if systemic signs; metronidazole added for anaerobic emphasis
- • Analgesics: ibuprofen 600mg q6h + acetaminophen 1000mg q6h alternating
- • Review 24–48 hours for drain removal and reassessment
Cellulitis / Spreading Infection
Hospital admission for IV antibiotics; drainage when localized
- • Hospital admission; IV access; fluid resuscitation if febrile
- • IV amoxicillin-clavulanate 1.2g q8h + metronidazole 500mg q8h
- • CT scan neck with contrast to map space involvement
- • Surgical drainage in OR when fluctuance develops (under GA for deep spaces)
- • Source control: root canal or extraction of offending tooth
- • Daily wound review; drain removal when drainage ceases
- • Step-down to oral antibiotics when clinically improving
Ludwig's Angina / Airway Compromise
Airway first; immediate hospitalization; aggressive surgical drainage
- • Immediate anaesthesiology consultation for awake fibreoptic intubation or surgical airway (tracheostomy)
- • NEVER sedate without secured airway — sedation relaxes pharyngeal muscles causing complete obstruction
- • IV amoxicillin-clavulanate + metronidazole (or piperacillin-tazobactam for severe cases)
- • Urgent CT neck/chest to exclude mediastinal spread
- • Multiple fascial space drainage in OR: submandibular, sublingual, submental incisions
- • Critical care monitoring (ICU)
- • Source tooth extraction when systemic condition stabilized