BRS Emergency Medicine - L. Stead (Lippincott, 2000)

9. Orofacial Emergencies

I. Dental Emergencies

A. Dental caries

1.   Overview

§  For purposes of describing pathology and identifying the specific tooth involved, each tooth is assigned a number (Figure 9-1).

b.   Definition

§  Dental caries is the most common cause of odontogenic pain.

c.   Risk factors include:

§  consumption of large amounts of sweets and hard candy

§  poor oral hygiene

2.   Clinical features

 .    Symptoms may include:

§  toothache

§  jaw pain

§  earache (referred pain)

§  radiation of pain of MI to the jaw

a.   Physical examination findings may include tenderness to percussion of the tooth.

3.   Diagnostic tests

§  Diagnosis is made on the basis of clinical examination, so laboratory testing is unnecessary.

§  Extreme tenderness, especially at the periapical area, may represent a periapical abscess.

§  If caries are not readily apparent, consider other diagnoses.

4.   Treatment

 .    Dental wax placed into the cavity to protect dentin and exposed pulp from irritation from heat, cold, and chemicals in food

a.   Anesthetic nerve block for analgesia

b.   Acetaminophen with codeine or oxycodone as necessary for further pain relief

c.   Drainage of any periapical abscess

d.   Definitive treatment is placement of a filling by a dentist.

5.   Disposition

§  Patients can be discharged home with outpatient follow-up in 24 hours.

Figure 9-1. Numbering of the permanent teeth. (Adapted from LifeART Super Anatomy 3 Collection. Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.)

Osteitis sicca (dry socket)

1.   Overview

a.   Definition

§  Dry socket sometimes occurs after extraction of a tooth when the blood clot is lost or disintegrates, resulting in exposure of the bone in the socket.

b.   Risk factors include:

§  smoking (associated with poor wound healing)

§  trauma to or infection of the alveolar bone

§  excessive mouth rinsing (disrupts clot formation)

2.   Clinical features

a.   Symptoms may include:

§  severe pain in the socket of the tooth that was extracted, due to loss of clot or poor clot formation

§  pain that begins 24 to 96 hours after extraction and may last up to 3 weeks

§  a foul odor emanating from the socket

b.   Physical examination findings include an empty hole or space at the site where the clot should have been.

3.   Diagnostic tests

§  A radiograph of the alveolar bone and socket is obtained to look for retained debris or root tip

4.   Treatment

 .    Local block with long-acting anesthetic (e.g., bupivacaine) with a vasoconstrictor

a.   Irrigation with warm saline

b.   Packing of socket with petroleum gauze soaked in zinc oxide–eugenol mixture. This prevents food impaction, prevents infection, and prevents exposure to air, thereby decreasing pain.

c.   Systemic analgesia. The pain often is refractory to nonopiate analgesics.

5.   Disposition

§  Patients can be discharged home with outpatient follow-up 24–48 hours after socket packing is placed.

§  Packing must be replaced every 48–72 hours until granulation tissue begins to form and the patient starts to experience relief.

C. Post-extraction bleeding

1.   Clinical features

a.   Symptoms include:

§  bleeding, either pulsatile (arterial) or oozing (venous)

§  primary bleeding, which is bleeding from an injured vessel or soft tissue, or bleeding due to perforation of bone

§  secondary bleeding, which is due to disruption of a clot or a coagulation defect

b.   Physical examination findings may include:

§  swelling of the soft tissues of the oral cavity.

§  discolored or purplish soft tissue.

§  signs of hypovolemia (a rare, late presentation)—e.g., tachycardia, a weak thready pulse, hypotension, and pallor.

2.   Diagnostic tests

a.   Local assessment comes first, before any laboratory studies.

§  The field is debrided, suctioned, and cleared.

§  The area is visualized, and the bleed is localized.

§  If bleeding persists, laboratory and imaging studies are obtained.

b.   Laboratory studies

§  Coagulation profile to look for clotting factor defects (including bleeding time)

§  Liver function tests (LFTs) to look for liver disease as the cause of coagulation defects

§  CBC to look for drop in hematocrit and thrombocytopenia

c.   Imaging studies include an arteriogram, which may be necessary if arterial bleeding is not controllable (very rare).

3.   Treatment

a.   Clearance and maintenance of patent airway

b.   Isolation of the bleeding site:

§  Direct pressure is applied over the site for 45 minutes using an absorbable gelatin sponge, with or without pressure packs containing hemostatic agents such as epinephrine, thrombin, or fibrinogen.

§  If bleeding persists, control may be obtained by electrocoagulation or, if technically feasible, by ligating the bleeding vessel.

c.   Placement of a deep suture across the soft tissue of the bleeding site

d.   Debridement of large obstructive hematomas

e.   Antibiotics if local infection is suspected

4.   Disposition

a.   Patients whose bleeding has been successfully controlled may be discharged home with outpatient follow-up in 48 hours. Written postoperative care instructions should be given to the patient, as follows:

§  If re-bleeding occurs, bite on moist gauze for 45 minutes with constant pressure.

§  Avoid spitting, smoking, sucking through a straw, and eating hard candy.

§  Follow a soft mechanical diet (i.e., pureed foods) for 2–3 days.

b.   Patients in hypovolemic shock (very rare) must be admitted to the ICU.

D. Subluxed Tooth

§  A subluxed tooth is a tooth that is loose, but still present in its socket.

1.   Clinical features

a.   Symptoms include a loose or movable tooth or teeth.

b.   Physical examination findings include:

§  movement of the involved teeth

§  blood at the cementogingival junction

2.   Diagnostic tests

§  Diagnosis is made on the basis of clinical examination, so laboratory testing is unnecessary.

§  Periapical radiographs may be considered if alveolar bone trauma is suspected.

3.   Treatment

 .    Stabilization of teeth via wire ligatures or arch bars by a dentist, to be maintained for 2 weeks

a.   Temporizing measures, including stabilization of teeth with a resin-catalyst mixture (as if cementing) until dental consultation can be obtained

b.   Avoidance of hot liquids

c.   Soft mechanical diet

4.   Disposition

§  Patients can be discharged home with outpatient follow-up within 24 hours.

E. Avulsed tooth

§  An avulsed tooth is one that has been expelled from its socket.

§  This is a true dental emergency.

1.   Clinical features

a.   Symptoms may include:

§  oral pain

§  bleeding

b.   Physical examination findings include:

§  blood in the empty socket

§  a missing tooth or teeth

2.   Diagnostic tests

§  Diagnosis is made on the basis of clinical examination, so laboratory testing is unnecessary.

§  Periapical radiographs may be obtained if alveolar bone trauma is suspected.

3.   Treatment

 .    Primary (deciduous) teeth in children younger than 6 years old are not replaced, to avoid ankylosing of tooth to alveolar bone

a.   The avulsed tooth is returned to its socket in adults and children older than 6 years old.

§  The best preservative until the tooth is replaced is saliva (the patient should be instructed to transport the tooth under the tongue or inside of the cheek) or Hank's solution, a commercially available pH-balanced solution.

§  The next best transportation medium is milk, followed by saline, and then by a wet handkerchief.

§  The worst transportation medium is none at all (dry).

b.   Once the tooth is replaced into the socket, stabilization is done as for a subluxed tooth (see I D 4).

c.   Dental consult should be obtained if available

4.   Disposition

§  Patients can be discharged home with outpatient follow-up within 24 hours.

F. Tooth fracture

1.   Definition. Tooth fractures (Figure 9-2) can be classified according to the extent of fracture penetration:

§  Ellis I: into enamel only

§  Ellis II: into dentin

§  Ellis III: into pulp (true dental emergency)

2.   Clinical features

a.   Symptoms include tooth pain.

b.   Physical examination findings may include:

§  an obviously chipped tooth

§  enamel that has a chalky white surface

§  dentin that has an ivory yellow color

§  pulp that has a pinkish tinge to it

§  frank bleeding vessels inside the pulp

Figure 9-2. Types of tooth fractures. (Adapted from LifeART Super Anatomy 3 Collection. Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.)

3.   Diagnostic tests

§  Diagnosis is made on the basis of clinical examination, so laboratory testing is unnecessary.

§  Periapical radiographs may be considered if alveolar bone trauma is suspected.

4.   Treatment

 .    For Ellis I fracture:

§  Any sharp edges should be filed down with an emery board.

a.   For Ellis II fracture:

§  A calcium hydroxide dressing should be placed and covered with dental foil, a metal band, gauze, or enamel-bonded plastic.

b.   For Ellis III fracture:

§  Immediate consultation with a dentist or oral surgeon

§  In adults, moist cotton should be placed over the pulp and then covered with dry dental foil. Pulpotomy should not be done. Nerve block may be considered for analgesia.

§  In children, pulpotomy should be performed and the space packed with calcium hydroxide or commercially available root canal sealer. Nerve block or acetaminophen may be used for analgesia. Older children can have codeine.

5.   Disposition

§  Patients can be discharged home with outpatient follow-up with a general dentist or endodontist within 24 hours.

II. Infections

A. Ludwig's angina

1.   Overview

a.   Definition

§  Ludwig's angina is a life-threatening cellulitis of the floor of the mouth involving the submental, sublingual, and submandibular spaces.

b.   Causes

§  The most common cause is infection of the 2nd or 3rd molars, which spreads into the spaces above the teeth

c.   Risk factors include:

§  recent dental work

§  oral trauma

§  salivary gland infection

2.   Clinical features

a.   Symptoms may include:

§  moderate to severe pain

§  dysphagia for both liquids and solids

§  increased salivation

§  glossitis

b.   Physical examination findings may include:

§  a swollen neck

§  tachypnea

§  labored breathing

§  edema of the oral cavity with elevation of the floor of the mouth

§  drooling

3.   Diagnostic tests

a.   Complete blood cell count (CBC) to look for leukocytosis

b.   Chemistry panel to look for electrolyte abnormalities

c.   Throat culture and blood culture to look for the causative organism

4.   Treatment

a.   The airway must be secured.

b.   IV fluids and oxygen are given, and the patient is placed on a cardiac monitor.

c.   Antibiotics against gram-positive organisms and anaerobes. Options include:

§  for adults: penicillin 2.4 million units intravenously (IV) by continuous infusion or in divided doses every 6 hours, plus metronidazole 1 g IV loading dose, then 0.5 g IV every 6 hours

§  for children: penicillin 50,000–100,000 U/kg/day IV, plus metronidazole 7.5 mg/kg every 6 hours

§  for penicillin-allergic patients, clindamycin 900 mg IV every 8 hours (adults) or 5 mg/kg IV every 6 hours (children)

d.   Immediate consultation with an oral surgeon or otorhinolaryngologist for incision and drainage of involved fascial planes followed by wide excision in the operating room. If odontogenic infection is present, the involved teeth are removed.

5.   Disposition

§  Patients should be admitted to the hospital for intravenous antibiotics and surgical exploration.

Cavernous sinus thrombosis

1.   Overview

a.   Definition

§  Cavernous sinus thrombosis usually is a septic process that results from spread of infection from other sinuses or occurs as a suppurative process of infections of the upper half of the face.

§  It usually begins unilaterally and then spreads rapidly to become bilateral via the circular sinus.

b.   Causes

§  The organisms most commonly involved are Streptococcus spp, Bacteroides spp, and Eikenella spp.

c.   Risk factors include:

§  blowout fracture of the medial orbital wall

§  ethmoid sinusitis

§  infections of upper face (i.e., ear, dental, sinuses)

2.   Clinical features

a.   Symptoms may include:

§  sudden onset of fever and chills

§  headache

§  purulent nasal discharge

§  facial pain

§  eye pain

§  worsening of headache when head is down (e.g., when patient leans over)

b.   Physical examination findings may include:

§  papilledema on funduscopic examination

§  proptosis due to orbital edema

§  chemosis of conjunctiva and eyelids

§  ophthalmoplegia

§  diplopia

§  ptosis

§  exophthalmos

§  decreased visual acuity

§  periorbital tenderness

§  swelling

§  erythema

3.   Diagnostic tests

a.   Laboratory studies

§  CBC to look for leukocytosis

§  Blood culture to identify causative organism

b.   Computed tomographic (CT) scan or magnetic resonance imaging (MRI) of cavernous sinus, orbit, and paranasal sinuses to look for fluid collections

4.   Treatment

a.   Antibiotics as for Ludwig's angina (see section II A 4 c)

b.   Analgesia

c.   Immediate consultation with an oral surgeon or otorhinolaryngologist

d.   Incision and drainage in the operating room in cases of infected paranasal sinuses

e.   Removal of involved teeth if odontogenic infection is present

5.   Disposition

§  Patients are admitted to the intensive care unit (ICU).

§  The mortality rate is high (up to one third of cases), even with appropriate treatment

C. Acute Necrotizing Ulcerative Gingivitis

1.   Overview

a.   Definition

§  Acute necrotizing ulcerative gingivitis is one of the few dental infections that actually penetrates non-necrotic tissue.

§  The most common locations are the anterior incisor area and the posterior molar regions.

§  Vincent's angina is an extension of this infection into the tonsils.

b.   Causes

§  The organisms most commonly involved are oral flora, Spirochetes spp, and Fusobacterium spp.

c.   Incidence and prognosis

§  It is commonly seen in adolescents and young adults.

2.   Clinical features

a.   Symptoms may include:

§  oral pain

§  fever

§  malaise

§  cervical adenopathy

§  a metallic taste

b.   Physical examination findings may include:

§  edematous, ulcerated, bright red interdental papillae

§  a gray pseudomembrane covering the gingiva, which bleeds when the membrane is removed

§  halitosis

3.   Diagnostic tests

§  Diagnosis is made on the basis of clinical examination, so little laboratory testing is necessary.

§  The following tests may be helpful:

a.   CBC and blood culture in patients who may be immunocompromised and colonized with more than the typical organisms

b.   Periapical dental radiographs to look for the extent of infection if further pathology is suspected

4.   Treatment

 .    Irrigation with warm saline solution

a.   Antibiotics

0.   Tetracycline 250 mg orally 4 times a day (adults) or 20–50 mg/kg/day in divided doses 4 times a day (children > 8 years old)

1.   For children < 8 years old, penicillin 25–50 mg/kg in divided doses 4 times a day to avoid tooth discoloration

b.   Topical viscous lidocaine for analgesia (maximum dose is 3 mg/kg)

c.   Peroxide rinses

5.   Disposition

§  Patients can be discharged home with outpatient follow-up with a general dentist or periodontist in 48 hours

III. Fractures and Skeletal Disorders

A. Temporomandibular joint (TMJ) dislocation

1.   Overview

a.   Definition

§  Temporomandibular joint dislocation occurs when the mandibular condyle is displaced forward from the articular eminence of the temporal bone.

b.   Risk factors include:

§  trauma

§  yawning

§  dystonic reaction

2.   Clinical features

a.   Symptoms may include:

§  jaw pain

§  dysarthria

§  dysphagia

§  inability to close down or bite on the anterior teeth (so the mouth stays open)

§  malocclusion

b.   Physical examination findings may include:

§  tenderness to palpation

§  inability to move or articulate the jaw

§  in unilateral dislocation, deviation of the jaw toward the intact side

3.   Diagnostic tests

§  Mandibular radiographs to look for fracture

4.   Treatment

 .    Manual reduction

§  The mandible is pulled downward, then posteriorly, then superiorly (Figure 9-3).

§  Muscle relaxation with a benzodiazepine may be necessary before manual reduction can be done.

a.   An elastic bandage wrapped circularly from the bottom of the chin to the top of the head may be used to keep the jaw closed for extra support, especially in recurrent dislocation.

5.   Disposition

§  Patients can be discharged home with outpatient follow-up in 1 week.

§  Instructions include soft mechanical diet for 1 week, with muscle relaxants and NSAIDs as needed (see Tables 11-2 and 11-5 in Chapter 11).

Midface fracture

1.   Overview

a.   Definition

§  Midface fractures include LeFort fractures (Figure 9-4) and the trimalar fracture.

 

Figure 9-3. Manual reduction of a dislocated temporomandibular joint (TMJ). (A) Dislocated TMJ. (B) In manual reduction of TMJ, pressure is applied downward, then posteriorly and, finally, superiorly. (C) TMJ returned to normal position with the condyle sitting in the mandibular fossa behind the articular eminence. (Adapted from LifeART Super Anatomy 3 Collection. Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.)

1.   LeFort I: separation of the lower maxilla, hard palate, and pterygoid processes from the rest of the maxilla (free-floating jaw)

2.   LeFort II: separation along the nasofrontal suture, the floor of the orbit, the zygomatico-maxillary sutures, and the pterygoid processes

3.   LeFort III: separation of the midface from the rest of the cranium.

4.   Trimalar: a complex fracture that involves the zygomatico-frontal suture, the zygomatic arches, the posterolateral wall of the maxillary sinuses, and the rim and floor of the orbit.

b.   Risk factors include:

§  motor vehicle accidents

§  facial trauma

2.   Clinical features

a.   Symptoms may include:

1.   for LeFort fractures:

§  jaw pain

§  diplopia

§  bleeding

Figure 9-4. LeFort fractures. (Adapted from LifeART Super Anatomy 3 Collection. Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.)

2.   for trimalar fractures:

§  flattening of the cheek

§  palpable step-off

§  diplopia

b.   Physical examination findings may include:

§  CSF rhinorrhea (especially with LeFort I and II fractures)

§  malocclusion of the teeth

§  massive soft tissue swelling

§  subconjunctival hemorrhage

§  sensory deficits in the distribution of the trigeminal nerve

3.   Diagnostic tests

§  CT of the facial bones is done to look for air–fluid levels and fractures.

4.   Treatment

 .    The airway must be secured (this is especially important with LeFort II and III fractures).

a.   The head of the bed should be elevated.

b.   Antibiotics: ceftriaxone 2 g every 12 hours IV (adults) or 75 mg/kg/day IV (children).

c.   Nasal packing if epistaxis is present.

d.   Tetanus prophylaxis (see Table 19-5 in Chapter 19)

e.   Neurosurgery consult if cerebrospinal fluid (CSF) rhinorrhea or otorrhea is present

5.   Disposition

§  Patients should be admitted to the oral or plastic surgery service for open reduction and internal fixation.

C. Mandibular Fracture

1.   Overview

a.   Definition

§  The most common site of fracture is the angle of the mandible.

§  The mandible often fractures in more than one location (Figure 9-5).

b.   Risk factors include facial trauma.

Figure 9-5. Sites of mandibular fractures. (Adapted from LifeART Super Anatomy 3 Collection. Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.)

2.   Clinical features

a.   Symptoms may include:

§  jaw pain

§  bleeding

§  inability to articulate the jaw

§  dysarthria

§  facial deformity

b.   Physical examination findings may include:

§  a step-off in dentition at the fracture site

§  malocclusion of the teeth

§  ecchymosis in the floor of the mouth

§  decreased sensation over the chin (mental nerve anesthesia)

3.   Diagnostic tests

a.   A mandibular radiographic series to look for fracture

b.   A CT scan may be necessary to look for condylar fracture

4.   Treatment

a.   The airway must be secured.

b.   Antibiotic prophylaxis using penicillin or a 1st-generation cephalosporin

c.   Tetanus prophylaxis (see Table 19-5)

5.   Disposition

§  Patients should be admitted to the oral surgery service for open or closed reduction

IV. Soft Tissue Disorders

A. Sialolithiasis and sialoadenitis

1.   Overview

a.   Definition

§  Sialolithiasis is the obstruction of one of the salivary glands by a stone composed of calcium deposits surrounding a foreign body, mucin, or bacterial nidus. Sialoadenitis results when the obstructing stone produces a local inflammation

b.   Causes

§  The organism most commonly involved is S. aureus.

2.   Clinical features

a.   Symptoms may include:

§  pain and swelling over the infected salivary gland

§  exacerbation of pain on eating tart, sour, or bitter foods

b.   Physical examination findings may include:

§  an enlarged, tender, and indurated gland

§  a palpable firm mass (stone) along the duct of the salivary gland and floor of the mouth (submandibular gland)

§  purulence at the ductal orifice if infection is present secondary to obstruction

§  expression of clear saliva on palpation of the duct if there is no infection

§  pain and swelling that is reproducible with exposure to sour or bitter foods

3.   Diagnostic tests

§  Most cases are managed with antibiotics and warm compresses without any prior studies.

§  The following tests are done in severe, chronic, or refractory cases:

a.   Occlusal radiograph for the submandibular gland or CT for the parotid to look for radiopacity (stone) in the duct

b.   In the absence of infection, sialography to check for a filling defect

4.   Treatment

 .    Analgesia with nonsteroidal antiinflammatory drugs (NSAIDs)

a.   Antibiotics against Staphylococcus spp if infection is suspected

b.   Warm compresses applied over the face

c.   The stone may be removed via:

§  dilatation of the duct with a lacrimal probe followed by manual removal of the stone (rarely successful)

§  open incision over the site of obstruction (creates scar tissue)

§  surgical removal of the stone by excising the involved portion of the gland

d.   The gland may be removed (sialectomy) if the stone is impacted in the parenchyma of the gland.

5.   Disposition

§  Patients can be discharged home with outpatient follow-up in 48 hours.

Oral Ulcers (Table 9-1)

1.   Clinical features

a.   Symptoms may include:

§  a blister in the oral cavity that may or may not be painful

§  pain that is aggravated by salty, sour, or spicy foods

b.   Physical examination findings may include a white fibrin clot surrounded by erythematous mucus.

2.   Diagnostic tests

§  CBC if the lesion is suspicious for infection

§  Biopsy if the lesion is present for more than 2 weeks to look for malignancy

3.   Treatment is supportive:

§  gargling with warm salt water

§  application of topical anesthetic gel as needed

§  avoidance of aggravating foods

 

Table 9-1. Causes of Oral Ulcers

Trauma
   Mechanical
   Chemical (aspirin)
   Temperature (hot foods)
   Squamous cell carcinoma

Neoplasia

Autoimmune disease
   Systemic lupus erythematosus
   Pemphigous

Hereditary disease
   Epidermolysis bullosa

Infection
   Candidiasis
   Herpes gingivostomatitis
   Syphilis
   Varicella zoster
   Epstein-Barr virus
   Acute necrotizing gingivitis

Miscellaneous
   Aphthous stomatitis
   Lichen planus
   Drug reaction

4.   Disposition

§  Patients can be discharged home with outpatient follow-up in 1 week.

Review Questions

1. Which one of the following statements regarding the management of tooth fractures is true?

Ellis III fracture in adults is treated with a pulpotomy.

Ellis II fracture in children is treated by filing down exposed dentin.

Ellis I and II fractures require immediate dental consult.

Ellis III fractures in children are treated with a pulpotomy.

Ellis II fractures are considered a true dental emergency.

1-D. Ellis III fractures in children are treated with a pulpotomy. The key to this question is that the treatment for Ellis type fractures is different in children, who require pulpotomy, from that in adults, who do not. See section I F 1 for a description of Ellis fractures, types I through III, and their appropriate management.

2. Which of the following statements regarding avulsed teeth is false?

It is especially important to replace avulsed teeth in toddlers and small children.

The best medium for transporting an avulsed tooth is saliva or Hank's solution.

The worst way to preserve an avulsed tooth is to let it dry out (no medium).

Avulsed teeth are replaced directly into the socket as early as possible.

All of the above statements are correct.

2-A. Avulsed teeth are not replaced into the socket in children under the age of 6 years, to prevent ankylosing of the tooth to the alveolar bone.

3. Which of the following is a risk factor for osteitis sicca (dry socket)?

Cigarette smoking

Alveolar bone trauma

Multiple dental caries

Excessive mouth washing

All of the above

3-E. Osteitis sicca occurs as a result of either poor clot formation or disruption of an existing clot. Poor clot formation is seen in smokers, diabetics, and patients by poor oral hygiene or trauma to the alveolar bone. An existing clot can be disrupted by sucking through a straw, excessive mouth washing, and eating hard candy. See section I B 1 for more information.

4. Which one of the following statements regarding cavernous sinus thrombosis is false?

It is a life-threatening condition.

Treatment consists of outpatient antibiotics, analgesia, and close follow-up.

Incision and drainage of the sinuses may be necessary.

The antibiotic of choice is nafcillin.

Swelling of optic discs and double vision are common findings.

4-B. Cavernous sinus thrombosis usually is a septic process with a very high (30%) mortality despite appropriate treatment. Appropriate treatment consists of intravenous antibiotics and admission to the intensive care unit (ICU). See section II B 4 for further details.

5. Which of the following statements regarding Ludwig's angina is true?

Physical examination findings include papilledema, ptosis, and proptosis.

The most common cause for this condition is oral trauma.

It is a life-threatening condition.

Treatment consists of outpatient antibiotics, analgesia, and close follow-up.

None of the above statements are true.

5-C. Ludwig's angina is considered a life-threatening infection because of its potential for occluding the airway by raising the floor of the mouth. Papilledema, ptosis, and proptosis are findings on physical examination noted in cavernous sinus thrombosis, not Ludwig's angina. The most common cause for Ludwig's angina is odontogenic infection of the 2nd or 3rd molars, not oral trauma. Treatment consists of intravenous antibiotics and hospital admission, not outpatient management.