Facial swelling and odontogenic infection — branching viva

Opening

Examiner: A 6-year-old presents with three days of right-sided facial swelling, toothache and a fever of 38.6 degrees Celsius. The swelling is firm, warm and tender, there is a carious right lower molar tender to percussion, and he has no drooling, trismus or airway compromise. How do you approach this? ^[1]

Candidate: This is a spreading odontogenic cellulitis arising from the carious right lower molar. The periapical abscess has perforated the cortical bone and tracked into the buccal space, which is why the swelling is in the cheek — the buccinator attachment on the mandible determines the direction of spread. The key principle is source control: the offending tooth must be extracted or undergo endodontic treatment and any collection drained, because antibiotics alone cannot sterilise an established abscess. I would give analgesia — paracetamol 15 mg/kg every four to six hours — arrange urgent dental or oral-maxillofacial review for extraction or drainage, and add oral amoxicillin-clavulanate 45 mg/kg/day (amoxicillin component) in two divided doses because this is spreading cellulitis with systemic features. ^{[1] [4]}

Branch 1 — the antibiotic and disposition decision

Examiner: He is penicillin-allergic (non-anaphylactic). How does your antibiotic choice change, and do you admit him? ^[5]

Candidate: For a non-anaphylactic penicillin allergy I would use clindamycin 30 to 40 mg/kg/day orally in three to four divided doses, which covers oral streptococci and anaerobes, or metronidazole 30 mg/kg/day added to a cephalosporin. I would admit him if he is unable to tolerate oral intake, if he is young or systemically unwell, or if there is any doubt about follow-up — in which case I would give intravenous ampicillin-sulbactam (avoided in anaphylactic allergy) or clindamycin with metronidazole. As he is currently well and taking fluids, with a clear safety-net and reliable dental follow-up, he could be managed as an outpatient with early review at 48 to 72 hours. ^[5]