Last reviewed: 6 Feb 2021
Last updated: 24 Mar 2020



History and exam

Key diagnostic factors

  • dental pain/toothache
  • thermal sensitivity of teeth
  • fever
  • intraoral and/or extraoral edema
  • intraoral and/or extraoral erythema
  • intraoral and/or extraoral discharge
  • trismus
  • tooth percussion sensitivity
  • mobile teeth
  • deep periodontal pockets, bleeding, gingival recession
  • bone loss around teeth
  • elevated/extruded tooth
  • tachypnea
  • dysphagia/drooling
  • dysphonia
  • dyspnea/respiratory stridor
  • posturing
  • uvular deviation
  • floor of mouth elevation
  • hypotension

Other diagnostic factors

  • halitosis/bad taste in mouth
  • xerostomia
  • neurologic signs

Risk factors

  • poor oral hygiene
  • dental caries
  • periodontal disease
  • partially erupted or impacted tooth
  • dental trauma
  • fractured teeth
  • excessive occlusal wear
  • alcohol or drug abuse
  • low socioeconomic status
  • malnutrition
  • age extremes
  • prior radiation therapy
  • certain medications
  • immunosuppression or comorbidity (higher risk for complications)
  • large dental restorations
  • bruxism
  • prior root canal treatment failure

Diagnostic investigations

Investigations to consider

  • periapical x-ray
  • CT head and neck (with contrast)
  • infection site aspiration Gram stain/culture and sensitivity
  • CRP
  • ESR
  • serum electrolytes
  • plasma fibrinogen level
  • MRI head and neck
  • ultrasound of fascial spaces
  • electric pulp testing
  • thermal testing
  • blood cultures

Emerging tests

  • C-terminal cross-linking telopeptide (CTX)

Treatment algorithm



Melanie S. Lang

Assistant Professor

Department of Oral and Maxillofacial Surgery

University of Washington School of Dentistry




MSL has contributed to Oakstone Audio Reviews in Oral and Maxillofacial Surgery. MSL has published two manuscripts related to perioperative antibiotic use with materials from the AAOMS. She is an AAOMS representative to the ADA for a group studying the use of antibiotics in dentistry.

Thomas B. Dodson

Professor and Chair

Department of Oral and Maxillofacial Surgery

University of Washington School of Dentistry




TBD is a paid Consultant-Associate Editor for the Journal of Oral and Maxillofacial Surgery and Consultant-Surgeon for ClearChoice Seattle and Federal Way. He is an unpaid committee member for the Research and Development Commission of the AOCMF and the Committee on Research for the Oral and Maxillofacial Surgery Foundation. TBD is an unpaid liaison to the Committee on Research and Technology Assessment, American Association of Oral and Maxillofacial Surgery.

Peer reviewersVIEW ALL

Professor and Chairman

Department of Oral and Maxillofacial Surgery

Vanderbilt University




SJM declares that he has no competing interests.

Associate Professor

Lead in Oral Surgery

Plymouth University Peninsula Schools of Medicine & Dentistry




KA declares that he has no competing interests.

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