What is the appropriate treatment for an adult patient with no significant medical history presenting with acute swelling of the left jaw and cheek?

Acute Swelling of Left Jaw and Cheek in Adults

For an adult with acute swelling of the left jaw and cheek, immediately initiate empiric antibiotic therapy with amoxicillin while urgently arranging imaging (CT or ultrasound) to identify the source and determine if surgical drainage is required, as dental and dentoalveolar infections are the most common causes and surgical drainage is the definitive treatment when abscess is present. 1, 2

Immediate Assessment and Diagnostic Approach

Critical Features to Identify

• Assess for airway compromise: Check for tongue swelling, difficulty breathing, or stridor—these require immediate emergency management with epinephrine and potential tracheotomy 3
• Determine infection source: Examine for dental pain, carious teeth, or recent dental procedures suggesting odontogenic infection 1, 2
• Look for systemic involvement: Fever, lymphadenopathy, trismus (inability to open mouth), or cellulitis extending beyond the jaw indicate severe infection requiring urgent intervention 1, 4
• Rule out allergic angioedema: Rapid onset (minutes to hours), associated urticaria, recent allergen exposure (foods, medications, insect stings), or ACE inhibitor use suggest angioedema rather than infection 3

Imaging Requirements

• Obtain maxillofacial CT scan to identify fluid collections, lymph nodes, or deep space involvement in the subcutaneous tissue 1
• Imaging is essential before attempting drainage to map anatomical spread and avoid complications 5

Treatment Algorithm

For Odontogenic Infections (Most Common Cause)

Surgical Management is Primary 1

• Acute dental abscess: Root canal therapy or tooth extraction is the definitive treatment—antibiotics alone are insufficient 1
• Acute dentoalveolar abscess: Perform incision and drainage, then prescribe amoxicillin for 5 days 1
• Infections extending to soft tissues: Extract the tooth and treat aggressively as potential necrotizing fasciitis 1

Antibiotic Therapy 1

• First choice: Amoxicillin (standard dosing for 5-7 days) 1
• Second choice: Amoxicillin-clavulanic acid if no response to amoxicillin or suspected resistant organisms 1
• Important caveat: The European Society of Endodontology emphasizes that antibiotics provide no benefit over drainage alone for localized abscesses, but are indicated when systemic complications are present (fever, lymphadenopathy, cellulitis, diffuse swelling) 1

For Allergic Angioedema

Immediate Treatment 3

• Antihistamines and glucocorticoids are first-line for most cases 3
• Epinephrine must be administered immediately if laryngeal edema is suspected 3
• Tracheotomy is indicated if airway obstruction develops 3
• Identify and remove the allergen (common culprits: eggs, shellfish, nuts, bee/wasp stings, medications) 3

For Non-Infectious Inflammatory Conditions

If infection and allergy are ruled out, consider chronic inflammatory conditions 4, 6:

• Chronic osteomyelitis: Presents with recurrent pain, cheek swelling, and trismus over months to years 4, 6
• These conditions require specialist referral and may need anti-inflammatory drugs, antiresorptive therapy, or surgical intervention 6

Critical Pitfalls to Avoid

• Never rely on antibiotics alone for dental abscesses—surgical drainage or extraction is mandatory for cure 1
• Do not delay imaging when infection extends beyond localized swelling, as deep space infections can rapidly progress to life-threatening complications 5
• Do not miss angioedema—failure to recognize and treat laryngeal involvement can be fatal 3
• Avoid empiric antibiotics in isolated dental pain without abscess—they provide no benefit and promote resistance 1

When to Refer Urgently

• Immediate referral to oral surgery: Diffuse swelling, trismus, systemic involvement, or infections extending to cervicofacial tissues 1
• Emergency department: Any signs of airway compromise, inability to swallow, or suspected deep space infection 3, 5
• Specialist evaluation: No improvement after 48-72 hours of appropriate treatment, or recurrent episodes suggesting chronic inflammatory disease 4, 6