Oral and neck space infections

• Infections of the mouth and neck range from a small gum abscess to the bilateral floor-of-mouth cellulitis of Ludwig angina, which can close the airway.
• A dental abscess is managed by drainage and source control; antibiotics are added for spreading infection, systemic illness or immunocompromise.
• Vincent angina is acute necrotising ulcerative gingivitis produced by oral anaerobes; metronidazole and gentle debridement are the key.
• Oral herpes is usually self-limiting; acyclovir, valacyclovir or famciclovir help severe or recurrent disease.
• Ludwig angina is an airway emergency of bilateral submandibular and sublingual cellulitis, usually from lower molar roots.
• Acute neck lymphadenitis is usually viral or bacterial, but scrofula (tuberculous) and cat-scratch disease are important exceptions. ^[10]
• Parotitis may be viral (mumps) or bacterial; bacterial suppurative parotitis favours Staphylococcus aureus in dehydrated or frail patients and needs admission.

By the end of this page you should be able to:

1. Explain how a dental infection can spread into the deep spaces of the head and neck.
2. Recognise Vincent angina and Ludwig angina as clinical entities, including the airway risk.
3. Diagnose and treat acute neck lymphadenitis, including when to suspect scrofula and cat-scratch disease.
4. Distinguish viral mumps from acute bacterial suppurative parotitis and treat each.
5. Lay out an emergency approach to a patient with a rapidly progressive neck or floor-of-mouth infection.
6. List the first-line antibiotic choices and durations for the infections covered, with low-resource alternatives.

These infections sit at the junction of dentistry, ENT and emergency medicine. For teaching they fall into five groups, each covered in its own section below:

• Odontogenic and periodontal infections: periapical (dental) abscess and periodontal abscess.
• Mucosal infections: Vincent angina (acute necrotising ulcerative gingivitis, ANUG) and oral herpes.
• Deep fascial space infections: Ludwig angina (bilateral submandibular and sublingual cellulitis).
• Lymph node infections: acute (mainly pyogenic) lymphadenitis, tuberculous (scrofula) lymphadenitis, cat-scratch disease.
• Salivary gland infections: viral (mumps) and bacterial (suppurative) parotitis, including recurrent disease.

All of these can present as a swollen neck or a swollen mouth. The first clinical question is always the same: is the airway safe?

Precise global incidence figures are not available for the group as a whole. What the literature does establish is useful for weighting effort:

• Dental abscess and periodontal infection are among the commonest reasons for emergency dental and medical attendance worldwide; they arise from untreated caries or periodontal disease.
• Ludwig angina is uncommon but serious. It is most often reported in adults with a dental source, and the reported mortality has historically been high where airway control and drainage are delayed.
• Cat-scratch disease disproportionately affects children under the age of 15, though it can occur at any age.^[9]
• In one United States blood-survey meta-analysis, pooled mean seroprevalence of herpes simplex virus type 1 (HSV-1) was 63.5% among adults and 38% among children in the general population.^[7]
• Tuberculous lymphadenitis ("scrofula") is seen most in people from endemic areas or with immunocompromise; in the United States most mycobacterial lymphadenitis (70% to 95%) is due to nontuberculous strains.^[10]
• Acute bacterial suppurative parotitis is seen mainly in older, dehydrated or frail patients.^[8]

• Dental caries and pulp necrosis lead to a periapical abscess; neglected oral hygiene and smoking drive periodontal disease.
• Malnutrition, smoking, sleep deprivation, stress and immunodeficiency (including HIV infection) predispose to Vincent angina.^[6]
• Lower second and third molars are the typical source of Ludwig angina, because their roots lie near the mandible and the submandibular space.
• Dental caries or periodontal disease in older children predisposes to anaerobic cervical lymphadenitis.
• Cat exposure (especially kittens) is the risk for cat-scratch disease; fleas contaminate scratches.
• Dehydration, recent major surgery, diabetes, immunosuppression, hypothyroidism and malnourishment predispose to acute bacterial parotitis.^[3]
• Mumps is highly contagious; no antibiotic is needed because a virus causes it.

Dental and periodontal infection. A tooth pulp dies (usually from caries), bacteria multiply in the root canal and spread into the periapical tissues, producing a localised abscess. A periodontal abscess forms within the supporting tissues of the tooth, often in a deepened periodontal pocket. Either can track along fascial planes into the cheek, floor of the mouth, or neck.

Vincent angina. Mixed oral anaerobes (fusiforms and spirochaetes, with Treponema, Selenomonas, Bacteroides melaninogenicus and Fusobacterium) invade damaged, poorly oxygenated gingiva and produce necrosis of the interdental papillae. The necrotic slough gives the "punched-out" papillae and foul breath. Host factors (poor hygiene, smoking, immunodeficiency) decide who gets it.^[6]

Oral herpes. After primary infection (often in childhood) HSV-1 stays dormant in the trigeminal ganglion and reactivates under stress, fever, sun or immunosuppression. Primary infection can produce widespread gingivostomatitis with fever and dehydration.^[7]

Ludwig angina. Infection begins around a lower molar, spreads to the submandibular space, then crosses the midline to involve both submandibular and both sublingual spaces. The floor of the mouth rises, the tongue is elevated and displaced, and the airway narrows. This is a cellulitis, not a single abscess, which is why it can strangulate the airway before it can be drained.

Cervical lymphadenitis. Lymph nodes draining the mouth and pharynx enlarge as part of a normal immune response. Acute bacterial adenitis is most often Staphylococcus aureus or Streptococcus pyogenes in young children; anaerobes are more likely with dental disease. Lymphadenitis due to Mycobacterium tuberculosis ("scrofula") follows a slower, granulomatous course. Cat-scratch disease follows inoculation of Bartonella henselae and is regional. ^[10]

Parotitis. Mumps virus travels haematogenously to the parotid and causes bilateral parotitis (both glands in 75% to 80% of cases) and sometimes submandibular or sublingual swelling.^[4] Bacterial parotitis arises when reduced salivary flow (dehydration, surgery, anticholinergics) lets mouth flora travel up Stensen's duct; Staphylococcus aureus is the commonest pathogen.^[3][8]

• A pointing, fluctuant swelling next to a carious tooth; the tooth is tender to percussion.
• Pain, sometimes with fever and cheek or facial swelling.
• Drainage through a sinus may briefly relieve pain.

• A tender, swollen gingival pocket (often beside a periodontally damaged tooth), sometimes with purulent discharge when the pocket is pressed.
• Pain on biting and on hot or cold.

• Abrupt onset of acutely painful, bleeding gums, excessive salivation and (sometimes) an overwhelming bad breath.^[6]
• Pathognomonic "punched-out" interdental papillae covered by a grey pseudomembrane.
• May also affect the tonsils or buccal mucosa (much less often).
• Malaise or low fever; risk factors include smoking, poor hygiene, stress, malnutrition and immunodeficiency.

• In children: sudden painful mouth ulcers, gingivitis, fever, difficulty eating and drinking and possible dehydration.^[7]
• Vesicles on an erythematous base that rupture within hours to 1 or 2 days to form shallow ulcers. ^[7]
• Recurrent infection is herpes labialis: clustered vesicles on the lip border (cold sores) healing in 8 to 10 days.^[7]
• Triggered by sun, fever, stress, menstruation or immunosuppression.

• Bilateral swelling of the floor of the mouth and submandibular regions; the tongue is pushed up and back.
• Drooling, dysphagia, difficulty speaking, voice change.
• Severe trismus (mouth opening less than 10 mm), rapid progression over hours.
• Fever, toxic appearance, dehydration.
• Stridor, tachypnoea or tachycardia are late, dangerous signs.

• Age and anatomy guide the cause: large (over 2 cm), solitary, tender, unilateral nodes in a preschool child are usually S. aureus or S. pyogenes.^[10]
• Often follows sore throat, otitis media, impetigo or a dental infection.
• Nodes are softer and slightly mobile when infectious, firmer and fixed when neoplastic.
• Fluctuance means abscess formation (about 25% of acute bacterial cases).^[10]
• Viral adenitis is usually bilateral, multiple and small, and follows a cold.

• Slow-growing submandibular or supraclavicular nodes, often painless and firm, sometimes with pink or lilac skin and sinus formation.
• Usually afebrile; most nodes stay under 3 cm. Spontaneous drainage with sinus tract formation occurs in about 10% of nontuberculous cases.^[10]
• Tuberculous nodes usually strongly positive on tuberculin skin testing.

• Typical progression: a small skin papule at the inoculation site, then regional lymphadenopathy 5 days to 2 months later, often when the papule has already healed.
• Most often affects the axilla (52%) and the neck (28%).^[10]
• Single, large (over 4 cm), tender node; constitutional upset is usually mild.
• Suppuration occurs in 30% to 50% of cases.^[10]
• Children under 15 are most affected.^[9]

• Mumps: parotid swelling with an ear lobe pushed outwards, non-purulent saliva, bilateral in 75% to 80% of cases, sometimes with fever and malaise.^[4]
• Bacterial (suppurative): sudden, very painful parotid swelling, purulent fluid expressible from Stensen's duct, fever, marked systemic upset; more common in the elderly, dehydrated or post-operative patient.^[3][8]
• Recurrent parotitis (especially in children) may be idiopathic and relapses after resolution; underlying obstruction (stone, stricture) should be sought in adults.

Oral and neck swelling has a wide differential; separating features are the key.

Dental and periodontal infection. A periapical radiograph shows the abscess; no laboratory test is needed in simple disease. If swallowing is difficult, if there is fever with a facial swelling, or if the patient is immunocompromised, take bloods and consider drainage under specialist care.

Vincent angina. Diagnosis is clinical; swab only if it does not respond or immunocompromise is present.

Oral herpes. Usually clinical. Polymerase chain reaction (PCR) of a mucosal swab is the most sensitive and specific test if confirmation is needed (for example in pregnancy or immunocompromise).^[7]

Ludwig angina. This is a clinical diagnosis. FBC, culture and sensitivity and bedside skull or chest views are used in the Malawian guideline, but the airway comes first.^[3] Ultrasound or cross-sectional imaging later clarifies collections.

Lymphadenitis. Acute disease rarely needs tests; aspirate fluctuant nodes for Gram stain and culture. Subacute and chronic disease needs serology (for Bartonella and others), tuberculin testing, chest X-ray and, where needed, node biopsy. Nodes larger than 10 mm are abnormal, and fine-needle or excision biopsy is appropriate for persistent or hard nodes.^[10]

For suspected tuberculosis, a strongly positive tuberculin skin test together with an abnormal chest film and a contact history has 92% sensitivity for tuberculous lymphadenitis.^[10]

Parotitis. Bacterial: swab purulent Stensen's duct fluid; blood cultures if febrile. Mumps: clinical plus a buccal swab for mumps PCR or specific IgM. Ultrasound confirms glandular inflammation and detects stones or abscesses; CT or MRI is used when malignancy or sialolithiasis is suspected.^[8]

There is no formal score for these conditions, but the following yardsticks matter:

• Neck node size: nodes over 10 mm are abnormal; neck nodes over 2 to 3 cm with acute unilateral cervical lymphadenitis are usually bacterial.^[10]
• Tuberculin criteria: two of three of a positive tuberculin skin test, an abnormal chest radiograph or contact with a person with infectious tuberculosis, gives 92% sensitivity for tuberculous lymphadenitis.^[10]
• Trismus: severe jaw trismus (under 10 mm) is part of the Ludwig angina syndrome.^[3]
• Suppuration: fluctuance in 25% of acute bacterial adenitis and aspiration yields an organism in 60% to 88% of cases.^[10]
• Mumps: both glands are involved in 75% to 80% of cases.^[4]

The cause is a necrotic pulp or a focus of infection in a periodontal pocket, so source control is the treatment: drainage (incision if needed), extraction of the offending tooth, or root-canal therapy.^[1] Antibiotics are adjuncts for spreading infection, systemic signs or immunocompromise.

• Amoxicillin 250 to 500 mg by mouth every 8 hours for 7 days, plus metronidazole 200 to 400 mg (children: 7.5 mg per kg per dose) every 8 hours for 7 days.^{[1] [2][3]}
• Benzylpenicillin 1 to 2 million units (children 25,000 units per kg per dose) intramuscularly or intravenously every 6 hours for 7 days, plus metronidazole 250 to 500 mg intravenously every 8 hours for 7 days, for patients admitted or with systemic signs.^[1]
• Penicillin allergy: erythromycin 250 to 500 mg every 6 hours for 7 days.^{[1] [6]}
• Analgesia: aspirin 300 to 600 mg every 8 hours or, as alternatives, paracetamol 1 g every 8 hours in adults (children 250 mg every 8 hours) and ibuprofen 400 mg every 8 hours in adults and 200 mg every 8 hours in children.^[1]
• Admit if the patient is febrile, dehydrated and weak, has severe trismus, or has severe spreading swelling; use injectable therapy (crystalline penicillin 2 to 4 million units every 6 hours for 5 days combined with IV metronidazole 500 mg) and reassess after culture if there is no response at 2 weeks.^[1]
• Warm saline and povidone-iodine rinses, plus oral hygiene measures.^[1]

Posterior teeth: extraction of the offending tooth under local anaesthesia (2% lidocaine with adrenaline 1:80,000) to drain it, followed by analgesia (paracetamol 500 mg to 1 g every 8 or 6 hours for 3 days; in children 10 to 15 mg per kg every 8 or 6 hours for 3 days).^[2]

When antibiotics are needed (anterior teeth, root-canal not possible):

• Amoxicillin 500 mg by mouth every 8 hours for 5 to 7 days (children: 25 mg per kg in 8-hourly doses for 5 days).^[2]
• Plus metronidazole 400 mg every 8 hours for 5 to 7 days (children aged 7 to 10 years: 200 mg every 8 hours).^[2]

• Gentle debridement with a hand scaler or ultrasonic device, often over several days; the patient wipes the teeth with a soft toothbrush.^[6]
• Rinses hourly with warm normal saline or twice daily with 1.5% hydrogen peroxide or 0.12% chlorhexidine.^[6]
• Supportive care: oral hygiene, nutrition, hydration, rest, analgesia, avoid smoking and hot or spicy foods. Marked improvement is expected within 24 to 48 hours.^[6]
• Antibiotics only if debridement is delayed or there is spreading infection or systemic illness: metronidazole 500 mg every 8 hours or amoxicillin 500 mg every 8 hours, continued until 72 hours after symptoms resolve.^[6]
• Penicillin allergy: clindamycin 300 mg every 6 hours, erythromycin 250 mg every 6 hours, or tetracycline 250 mg every 6 hours.^[6]
• Definitive papillary surgery later if papillae are lost.

• Many mild cases need only symptomatic care: fluids, analgesia and (for severe gingivostomatitis) topical anaesthetics such as viscous lidocaine or dyclonine, with attention to aspiration risk in children.^[7]
• Acyclovir cream applied 5 times daily for 4 days can shorten a recurrent mild cold sore if started early.^[7] Penciclovir 1% cream every 2 hours while awake for 4 days, or docosanol 10% cream 5 times a day, are alternatives.^[7]
• Severe cases of gingivostomatitis can be treated with oral acyclovir, valacyclovir or famciclovir.^[7]
• Recurrent or severe herpes labialis: famciclovir 1500 mg as a single dose, or valacyclovir 2 g by mouth every 12 hours for 1 day.^[7]
• Antiviral therapy of a primary episode does not prevent future recurrence (HSV remains latent).^[7]
• For immunocompromised patients, disseminated or central nervous system disease use intravenous acyclovir.^[7]

This is an emergency. The priority order is airway, then broad-spectrum antibiotics, then source control.

1. Admit and secure the airway. Give oxygen. If there is any stridor, hypoxia, rising respiratory rate or progressive neck swelling, call anaesthesia and ENT/oral surgery at once. Very severe obstruction may require a tracheostomy.^[3]
2. Hydrate and feed: 2 to 3 litres of fluid per 24 hours and high-calorie nutrition.^[3]
3. Broad-spectrum antibiotics:
   • Amoxicillin 250 to 500 mg every 8 hourly for 7 days, or benzylpenicillin 0.5 to 2.0 million units intramuscularly or intravenously every 6 hours for 7 days, plus metronidazole 200 to 400 mg every 8 hours for 7 days (or 250 to 500 mg intravenously every 8 hours for 7 days).^[3]
   • Penicillin allergy: erythromycin 250 to 500 mg every 8 hours for 7 days, or clindamycin 150 to 300 mg (plus metronidazole as above).^[3]
   • If there is no response, ceftriaxone 2 g once daily for 5 days.^[3]
4. Source control: extraction of the offending tooth, root-canal treatment, or sequestrectomy of necrotic bone.^[3]
5. Escalate: any worsening after 48 hours, or abscess formation on imaging, needs surgical consultation.

Steroids and anticoagulation are not part of the standard regimen in the sources used here and should not be added on habit alone.

• Outpatients with uncomplicated disease can be treated with a beta-lactamase-resistant oral antibiotic (for staphylococci and streptococci), usually for 10 days and at least 5 days beyond resolution of the acute signs; symptomatic improvement is expected within 2 to 3 days.^[10]
• For older patients with dental or periodontal disease, add anaerobic cover (penicillin V or clindamycin).^[10]
• Hospitalisation and parenteral therapy are needed for very young patients or for severe symptoms (cellulitis, high fever, respiratory distress).^[10]
• Fluctuant nodes: manage with antibiotics plus needle aspiration under local anaesthesia where possible; operative drainage is reserved for loculated or uncooperative children.^[10]
• Culture and aspiration (yielding an organism in 60% to 88% of cases) and an alternative antibiotic if there is no improvement at 48 to 72 hours.^[10]
• Increasing frequency of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) means no response to first-line therapy should raise MRSA coverage.^[10]

• Multi-drug antituberculous therapy for 12 to 18 months; nodes usually regress within 3 months.^[10]
• Surgery is reserved for non-tuberculous (atypical) mycobacteria, where surgery is the treatment of choice because these organisms respond poorly to drugs.^[10]
• Excise the involved node, sinus tracts and overlying skin en bloc, taking care to avoid nerves.^[10]

• Most cases are self-limiting: nodes resolve spontaneously over 1 to 3 months.^[10][9]
• Symptomatic treatment (analgesics, local heat) plus aspiration of a suppurative node for pain relief.
• Azithromycin can be used in selected patients with bulky, painful adenopathy; it speeds nodal shrinkage, though overall outcomes in otherwise healthy patients are not clearly better than no treatment.^[9][10]
• Antibiotics are warranted when the patient is immunocompromised, or when disease is severe or systemic (rifampin, ciprofloxacin, gentamicin, co-trimoxazole, clarithromycin, or azithromycin).^[9]
• Disseminated disease (retinitis, peliosis hepatis, endocarditis) needs long, multi-drug therapy and infectious disease involvement.^[9]

Mumps (viral): treat symptomatically. Paracetamol 1 g by mouth every 8 hours or as needed in adults (30 to 40 mg per kg per 24 hours, divided 4 to 6 doses in children); tramadol 100 mg every 8 hours is an alternative in adults (not recommended in children under 12). Massage the gland, hydration and rest. No antibiotics.^[4]

Bacterial suppurative parotitis should be assumed to involve Staphylococcus aureus in a dehydrated patient.^[3][8]

• Admit frail, dehydrated, systemically unwell or trismic patients and treat as inpatient.
• Intravenous hydration, analgesia, sialagogues (lemon drops), warm compresses, gland massage and oral hygiene to promote salivary flow.^[3][8]
• Empirical antibiotics providing S. aureus (plus haemophilus and streptococcal and oral anaerobic) cover:
  • Ampicillin-sulbactam, or cefuroxime/ceftriaxone/levofloxacin plus metronidazole or clindamycin; add vancomycin, linezolid or daptomycin if MRSA is a concern.^[8]
  • In low-resource settings, cloxacillin 500 mg every 12 hours for 7 to 10 days (adults) or clindamycin (150 to 300 mg by mouth 6 hourly, or 300 mg intramuscularly or intravenously 6 hourly; 20 mg per kg per 24 hours in 4 doses in severe infection), or cephalexin.^[5]
• If a penicillin allergy: cefalexin 50 mg to 1 g by mouth every 6 hours in adults (6 to 12 mg per kg every 6 hours in children), or co-trimoxazole-based therapy plus gentamicin in severe cases, following local guidance. Where MRSA is suspected, tailor to culture.
• Typical duration for uncomplicated bacterial parotitis: 10 to 14 days, switching to oral therapy (amoxicillin-clavulanic acid, cefuroxime plus metronidazole, levofloxacin plus metronidazole, or moxifloxacin) once clinically improved.^[8]
• Severe immunocompromised or healthcare-associated disease needs MRSA, Enterobacterales and Pseudomonas cover from the start (vancomycin/linezolid/daptomycin plus cefepime plus metronidazole, or piperacillin-tazobactam, or imipenem/meropenem).^[8]
• If no improvement at 48 hours: repeat imaging and cultures and broaden.
• Parotidectomy is reserved for chronic or refractory cases; smaller procedures (sialendoscopy, duct stones removal) may be needed.^[8]

The following findings mean the airway is threatened and action is required now, not later:

• Stridor, rising respiratory rate, dropping oxygen saturation or exhaustion.
• Rapidly progressive floor-of-mouth swelling or tongue elevation.
• Trismus under 10 mm or inability to swallow saliva.
• Drowsiness or inability to cope with secretions.

Immediate steps:

1. Keep the patient sitting upright, give high-flow oxygen, and do not give sedatives.
2. Call anaesthetics and airway-experienced surgery now; discuss awake fibreoptic intubation, but the safest route may be surgical tracheostomy if anatomy is distorted.
3. Evacuate any foreign body or pus only if it can be done safely; never force an examination.
4. Give the first dose of broad-spectrum antibiotics, hydrate aggressively and get the patient to definitive care.
5. Tracheostomy is the definitive step when severe difficulty in breathing occurs in Ludwig angina.^[3]

For recurrent parotitis with airway compromise: admission, antibiotics, possible imaging for deep collections.

• Airway obstruction is the lethal complication of Ludwig angina and of a deep neck infection; never wait for imaging before securing it when red flags are present.
• Mediastinitis and descending necrotising infection can follow a dental or pharyngeal space infection; rising pain, fever or chest signs merit urgent surgical review.
• Aspiration and dehydration in oral herpes or a painful mouth.
• Dental abscess can perforate into the maxillary sinus or evolve into osteomyelitis of the jaw.
• Stroke or local invasion is a known risk of infected thrombophlebitis in deep neck infections.
• Post-streptococcal immune complications can follow pyogenic cervical adenitis (guttate psoriasis, glomerulonephritis, rheumatic fever).
• Parotitis scarring can lead to recurrent swelling and strictures.

• Inappropriate antibiotics for a viral process (mumps) waste resources and encourage resistance.
• Over-promise of resolution; patients should be told nodes or salivary swellings can take weeks to resolve while the infection has already been treated.

• Most dental and periodontal abscesses resolve fully once drained and the source is removed.^[1]
• Vincent angina improves within 24 to 48 hours of debridement and supportive care.^[6]
• Oral herpes primary infection heals within 2 to 3 weeks; recurrent herpes labialis within 8 to 10 days.^[7]
• Mortality of Ludwig angina is now much lower than it once was when airways are secured early, but it remains dangerous.
• Most acute pyogenic lymphadenitis resolves within weeks; TB nodes regress within 3 months of antituberculous therapy.^[10]
• Cat-scratch nodes resolve over 1 to 3 months; disseminated disease can be serious.^{[9] [10]}
• Bacterial parotitis clears in most cases after 10 to 14 days of antibiotics and hydration.^[8]

• Twice-daily brushing and fluoride, dental review, and smoking cessation reduce dental and periodontal disease.
• Mumps (MMR) vaccination protects against mumps parotitis.
• Good hand hygiene and flea control on cats reduce, but do not eliminate, cat-scratch disease.
• Hydration, oral care and sialagogues reduce the risk of bacterial parotitis in very ill patients.

Children. Most herpetic gingivostomatitis and cat-scratch disease occur in children. Doses are weight-based throughout (Malawi doses above are paediatric where given). toddlers who cannot drink need admission for rehydration.^[1][7][9]

Pregnancy. Mumps in pregnancy requires medical review; oral herpes may need antiviral therapy depending on gestational age and severity; drug choice should follow a current pregnancy formulary. Antibiotic and antiviral doses in this page are typical adult ones.

Immunocompromised people. Expect more severe Vincent angina, disseminated herpes, and systemic cat-scratch disease; fungal and opportunistic causes of lymphadenitis must be considered too. Antiviral and antibiotic therapy should be started promptly and continued longer; cover MRSA early in deep infections.

Older adults. Bacterial parotitis and Ludwig angina are more common; dehydration, dental disease and anticholinergic drugs are the usual setting.

• Dental and periodontal infection: warm saline or povidone-iodine rinses, extraction of the offending tooth, and local measures first. Where laboratory access is minimal, use the doses and durations in the Malawi tables above with clinical reassessment at 48 hours.^[1][2]
• Ludwig angina: protect the airway first (sitting, oxygen, readiness to tracheostomise); begin amoxicillin plus metronidazole by the oral, nasogastric or injectable route; hydrate; extract the tooth once the airway is safe. Refer early if no specialist anaesthetic support is available.^[3]
• Lymphadenitis: most acute pyogenic cases need an oral staphylococcal/streptococcal antibiotic; if there is no improvement at 72 hours, reassess and consider aspiration. Tuberculin testing and (where available) chest X-ray guide scrofula; treat TB with the standard multi-drug regimen and refer confirmed or drug-resistant cases.^[10]
• Parotitis (suppurative): push hydration and salivary flow (sialagogues such as citrus, gum or boiled sweets); use cloxacillin, clindamycin or cephalexin as listed above; refer for drainage if a collection is suspected.^[5]
• Mumps: no antibiotics, vaccination and isolation are the public-health response; treatment is supportive.^[4]
• Acute necrotising ulcerative gingivitis in a resource-limited setting can be the first sign of HIV-related disease or malnutrition, so test and treat the underlying condition.
• Stock problem pockets: if benzylpenicillin or metronidazole solution is unavailable, use the oral equivalents and the penicillin-allergy alternatives given above.

• See also any MedGrasp topic on toothache or periodontal disease, HIV infection, tuberculosis, infectious mononucleosis and mumps vaccination where available.
• Planned related topics on airway obstruction, ENT infections and dental infections can be linked once published.