How should a 50-year-old woman with a history of glioblastoma who presents two weeks after a deep dental cleaning with right-side facial tenderness, a sensation of swelling, and right-ear pain be managed?

Management of Post-Dental Procedure Facial Pain in Glioblastoma Patient

This patient requires immediate evaluation for odontogenic infection, specifically dental abscess or osteomyelitis, given the temporal relationship to deep dental cleaning and the immunocompromised state associated with glioblastoma treatment.

Immediate Clinical Assessment

Key Diagnostic Considerations

The presentation of unilateral facial tenderness, perceived swelling, and ipsilateral ear pain 2 weeks post-dental cleaning strongly suggests:

• Dental abscess - Most likely given the timing and symptom constellation 1
• Osteomyelitis of the mandible - Particularly concerning in immunocompromised patients
• Parotitis or sialadenitis - Can present with similar symptoms
• Temporomandibular joint involvement - Less likely given the acute onset post-procedure

Critical Risk Factors in This Patient

Patients with glioblastoma face significantly elevated infection risk due to:

• Corticosteroid-induced immunosuppression - Standard management includes dexamethasone, which should be tapered as early as possible 2
• Temozolomide-related lymphocytopenia - The standard chemotherapy regimen (75 mg/m² daily during radiotherapy, followed by 150-200 mg/m² for 5 days every 28 days) causes profound immunosuppression 3
• Radiation effects - If the patient received standard radiotherapy (60 Gy in 30 fractions), this may compromise local tissue healing 2

Diagnostic Workup

Essential Imaging

• Panoramic dental radiograph or dental CT - First-line to identify periapical abscess, periodontal infection, or early osteomyelitis
• Contrast-enhanced CT of face/neck - If abscess suspected to define extent and rule out deep space infection
• MRI with contrast - If osteomyelitis suspected or symptoms persist despite initial treatment

Laboratory Evaluation

• Complete blood count with differential - Assess for leukocytosis and degree of chemotherapy-induced lymphocytopenia 3
• Blood cultures - If febrile or systemically ill
• ESR/CRP - Elevated in osteomyelitis

Treatment Algorithm

Immediate Management (Day 1)

1. Urgent dental consultation - Same-day evaluation by oral surgery or dentistry 1
2. Empiric broad-spectrum antibiotics - Start immediately if abscess or osteomyelitis suspected:
   • Amoxicillin-clavulanate 875/125 mg PO twice daily, OR
   • Clindamycin 600 mg PO three times daily (if penicillin allergic)
3. Pain control - Avoid NSAIDs if thrombocytopenic from chemotherapy; use acetaminophen or opioids as needed 1

Definitive Treatment

• Incision and drainage - If abscess identified 1
• Extraction of offending tooth - If source of infection identified
• Extended antibiotic course - Minimum 10-14 days for dental abscess; 4-6 weeks for osteomyelitis
• Hyperbaric oxygen therapy - Consider for refractory osteomyelitis in radiated tissue

Critical Safety Considerations

Infection Prophylaxis Context

Patients receiving temozolomide chemoradiotherapy require mandatory Pneumocystis jirovecii pneumonia (PCP) prophylaxis during concurrent therapy and until lymphocytopenia recovers to Grade ≤1 3. This underscores the profound immunosuppression these patients experience.

Thromboembolism Risk

Glioblastoma patients experience frequent thromboembolic events, particularly those with residual or recurrent tumors 2, 1. If this patient requires surgical intervention:

• Use prophylactic low-molecular-weight heparin perioperatively 2
• Compression stockings recommended 2
• Therapeutic anticoagulation can be safely initiated 4-5 days post-surgery if thromboembolism occurs 2

Corticosteroid Management

If the patient is on dexamethasone for cerebral edema:

• Do not abruptly discontinue - Risk of adrenal insufficiency
• Stress-dose steroids may be needed if surgical intervention required
• Taper as clinically feasible to reduce infection risk 2

Common Pitfalls to Avoid

1. Delaying dental consultation - The 2-week timeframe post-cleaning is classic for evolving odontogenic infection
2. Attributing symptoms to glioblastoma progression - While brain MRI surveillance is standard every 3-4 months 2, these symptoms are clearly localized and temporally related to dental procedure
3. Inadequate antibiotic duration - Immunocompromised patients require longer courses
4. Ignoring drug interactions - Temozolomide causes myelosuppression; avoid additional marrow-toxic antibiotics when possible

Follow-Up Strategy

• Clinical reassessment in 48-72 hours - Ensure response to antibiotics
• Complete antibiotic course - Even if symptoms resolve quickly
• Dental follow-up - Ensure source control achieved
• Resume glioblastoma surveillance schedule - MRI every 3-6 months per standard protocols 2, 4