> Table of Contents > Dental Infection
Dental Infection
Hugh Silk, MD, MPH, FAAFP
Sheila O. Stille, DMD
Nina E. Suresh, MD, MS
image BASICS
DESCRIPTION
  • Very painful area ± swelling in the head and neck region arising from the teeth and supporting structures; if left untreated, can lead to serious and potentially life-threatening illnesses
  • Assume any head and neck infection or swelling to be odontogenic in origin until proven otherwise.
EPIDEMIOLOGY
Incidence
  • Caries (a.k.a. tooth decay or cavity) is a contagious bacterial infection that causes demineralization and destruction of the hard tissues of the teeth (enamel, dentin, and cementum).
  • Transmitted vertically from caregivers
  • Completely preventable disease with good oral hygiene and diet
  • The introduction of fluoride has dramatically decreased dental caries.
Prevalence
  • 23% of 2- to 5-year-olds have caries (1)[A].
  • Rates are higher in Hispanic and black children (1)[A].
  • Percentage of children 6 to 19 years with untreated dental caries: 19.1% (2011 to 2012) (2)[A]
  • 92% of adults 20 to 64 years have had dental caries; 23% have untreated dental caries (2005 to 2008) (2)[A]
  • 25% of children 5 to 17 years account for 80% of caries in the United States.
  • 5% of adults age 20 to 64 years has no teeth.
ETIOLOGY AND PATHOPHYSIOLOGY
Caries or trauma can lead to pulpal death, which in turn leads to infection of pulp and/or abscess of adjacent tissues via direct or hematogenous bacterial colonization.
  • Streptococcus mutans vertically transmitted to newly dentate infants from caregivers
  • Acidic secretions from S. mutans are implicated in early caries.
  • Often polymicrobial mix of strict anaerobes and facultative anaerobes in dental abscess
  • Anaerobes, including peptostreptococci, Bacteroides, Prevotella, and Fusobacterium, have been implicated. Lactobacilli not seen in healthy subjects but seen in those with rampant caries (3)[B].
RISK FACTORS
  • Low socioeconomic status
  • Parent and/or sibling with history of caries or existing untreated dental caries
  • Previous caries
  • Poor access to dental and health care
  • Fear of dentist
  • Poor oral hygiene
  • Poor nutrition, including diet containing high level of sugary foods and drinks
  • Trauma to the teeth or jaws
  • Inadequate access to and use of fluoride
  • Gingival recession (increased risk of root caries)
  • Physical and mental disabilities
  • Decreased salivary flow (e.g., use of anticholinergic medications, immunologic diseases, radiation therapy to head and neck)
GENERAL PREVENTION
  • Prevent caries and contagious bacterial infection (S. mutans).
  • Majority of dental problems can be avoided through flossing; brushing with fluoride toothpaste, systemic fluoride (fluoridated bottled water; fluoride supplements for high-risk patients in nonfluoridated areas), and fluoride varnish for moderate- to high-risk pediatric patients; and regular dental cleanings (4)[B].
  • Consider prevention of transmission of S. mutans from mother to infant by improving mother's dentition and decreasing mother's bacterial load through proper dental care, chlorhexidine gluconate rinses, and use of xylitol products. Avoid smoking, which is linked to severe periodontal disease (5)[A].
  • Good control of systemic diseases (e.g., diabetes)
  • Fluoride varnish provided by dental or medical primary care providers twice per year (4)[B]
COMMONLY ASSOCIATED CONDITIONS
  • Rampant caries throughout dentition, faulty restorations, extractions, crowding, and multiple missing teeth
  • Periapical abscesses associated with necrotic teeth
  • Periodontal abscesses
  • Soft tissue cellulitis
  • Periodontitis (deep inflammation ± infection of gingiva, alveolar bone support, and ligaments)
image DIAGNOSIS
PHYSICAL EXAM
  • Gingival edema and erythema
  • Cheek (extraoral swelling) or intraoral swelling
  • Presence of fluctuant mass
  • Suppuration of gingival margin or from tooth
  • Submandibular or cervical lymphadenopathy on side of complaint
  • Severe (systemic) infection may present with dysphagia, fever, and signs of airway compromise.
DIFFERENTIAL DIAGNOSIS
  • Bacterial or viral throat infection
  • Pericoronitis (inflammation ± infection of gum flap over mandibular last molar, typically third molars)
  • Otitis media
  • Sinusitis
  • Viral (HSV1, herpangina, hand-foot-mouth disease) or aphthous stomatitis
  • Temporomandibular joint (TMJ) dysfunction (myofascial pain, +/− internal derangement of TMJ)
  • Parotitis
  • Cyst
  • Jaw pain can be anginal equivalent, especially in women, and especially lower left side of the jaw.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • No initial labs needed, unless patient looks acutely ill
  • If acutely ill
    • Consider CBC with differential.
    • Culture and sensitivity; if abscess present, aspirate pus and culture for aerobes and anaerobes (3)[A].
    • Polymicrobial infections, most likely anaerobic gram-negative rods and anaerobic gram-positive cocci (4)[B]
  • Individual dental films of suspected teeth, including root apices; test with palpation, percussion, and cold sensitivity to diagnose correct tooth
  • Panoramic film of the teeth and jaw for evaluation of the extent of infection
Follow-Up Tests & Special Considerations
  • Panoramic radiograph on patients with trismus
  • In large facial swellings extending below inferior border of mandible or into infraorbital space (eye closing), CT scan can be used to determine the extent and density of the swelling, locating the abscess within the soft tissue and bone, and airway involvement. This aids in determining treatment course and planning need for and location of external drainage by oral and maxillofacial surgeon or ENT.
image TREATMENT
  • Place patient on appropriate antibiotic, if indicated (if systemic). Pain without swelling or systemic signs of infection does not warrant antibiotic use.
  • If localized infection, incision and drainage may be warranted.
  • Appropriate pain control: Anti-inflammatory agents are 1st line; short-course opioids in some cases (6)[A].
  • Refer to dentist as soon as possible for definitive treatment: root canal or extraction or gum therapy (7)[B]
  • If infection is severe (systemic symptoms), consider hospitalization with IV antibiotics until stabilized. Patient may need intraoral or extraoral incision and drainage of abscess as well. Definitive treatment necessary to prevent progression or recurrence.
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GENERAL MEASURES
  • Ibuprofen 600 to 800 mg (peds: 10 mg/kg) q6h or acetaminophen 650 to 1,000 mg (peds: 10 to 15 mg/kg) q4-6h PRN for pain
  • For more severe pain, consider acetaminophen or ibuprofen + short course of opioids.
  • Can consider local anesthetic nerve block with long-acting anesthetic (bupivacaine) as adjunct; avoid penetrating infection with needle to avoid tracking infection.
MEDICATION
First Line
  • Amoxicillin: 500 mg TID for 7 to 10 days; in children, 40 to 60 mg/kg/day divided TID
  • If penicillin-allergic, use clindamycin 300 mg PO TID for 7 days.
Second Line
If long-standing infection or previously antibiotic-treated infection that does not respond to 1st-line treatment
  • Clindamycin: 300 mg PO TID for 7 to 10 days
  • Amoxicillin/clavulanic acid (500 mg/125 mg), 1 tablet PO TID for 7 days
  • If severe infection, consider IV antibiotics (ampicillin-sulbactam, cefoxitin, cefotetan)
  • Consider double coverage with metronidazole 500 mg PO TID for 7 days for better bone penetration and good anaerobic coverage. Do not use metronidazole alone. Will increase development of resistant strains; can be used with amoxicillin or clindamycin
ISSUES FOR REFERRAL
A dentist should be consulted and follow-up definitive care appointment should be secured prior to discharge from medical office, emergency room, or hospital unit.
SURGERY/OTHER PROCEDURES
  • Incision and drainage of abscess should be performed if abscess is large and fluctuant.
  • Root canal or extraction should be performed as definitive treatment.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Criteria for hospital admission include swelling involving deep spaces of the neck, floor of the mouth, or infraorbital region; deviation of the airway; unstable vital signs; fever; chills; raspy voice; confusion or delirium; or evidence of invasive infection or cellulitis.
  • Secure airway, if compromised, with either endotracheal intubation or tracheotomy.
  • IV fluid resuscitation with normal saline may be indicated in acutely ill patients.
Nursing
  • Ensure good oral hygiene.
  • Rinse or swab mouth with chlorhexidine gluconate BID.
  • Use warm saltwater rinses several times per day to encourage drainage, especially after incision and drainage. In conjunction, use ice packs on outside of face to decrease swelling and help encourage drainage into mouth.
Discharge Criteria
Discharge patient if
  • Airway not compromised
  • Abscess and sepsis eliminated
  • Able to take PO intake and ambulate.
image ONGOING CARE
Educate patient in need for proper oral hygiene, need for follow-up dental care, and need for routine dental care and stress medical complications that can and have occurred due to lack of dental care.
FOLLOW-UP RECOMMENDATIONS
  • Follow up with dentist within 24 hours.
  • Ensure adequate PO intake, including protein.
DIET
  • Maintain a healthful diet; bacteria thrive on refined sugar and starch.
  • Avoid sugary foods that stick between the teeth.
  • Avoid continuous sugary/carbonated drinks throughout day; encourage water as beverage of choice between meals.
Pediatric Considerations
In children, limit the frequency of sugary drinks and advise against sleeping with a bottle to decrease the chance of dental caries.
PATIENT EDUCATION
  • Manage dental disease, comprehensively—caries and periodontal disease need to be controlled.
  • Minimally, biannual dental visits after disease control
  • Nutritional education
    • Limit the frequency of sugar/carbonated drinks and sugary or sticky foods.
  • In young children, avoid sleeping with a bottle to decrease the chance of dental caries.
  • Brush twice daily and floss daily
  • Caretakers should tend to their personal oral hygiene ± chlorhexidine gluconate rinses in first 3 years of the child's life to decrease the risk of transmission of the caries-causing microorganisms.
PROGNOSIS
Prognosis is excellent with proper treatment.
REFERENCES
1. Dye BA, Thornton-Evans G, Li X, et al. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS data brief, no 191. Hyattsville, MD: National Center for Health Statistics; 2015. http://www.cdc.gov/nchs/data/databriefs/db191.htm. Accessed 2015.
2. National Center for Health Statistics. Health, United States, 2011: with special feature on socioeconomic status and health. Table 76. Hyattsville, MD: National Center for Health Statistics; 2012. http://www.cdc.gov/nchs/data/hus/hus11.pdf/. Accessed 2014.
3. Robertson D, Smith AJ. The microbiology of the acute dental abscess. J Med Microbiol. 2009;58(Pt 2):155-162.
4. Marinho VC, Higgins JP, Logan S, et al. Topical fluoride (toothpastes, mouth rinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;(4):CD002782.
5. Mickenautsch S, Yengopal V. Anticariogenic effect of xylitol versus fluoride—a quantitative systematic review of clinical trials. Int Dent J. 2012;62(1):6-20.
6. Ong CK, Seymour RA. An evidence-based update of the use of analgesics in dentistry. Periodontol 2000. 2008;46:143-164.
7. Douglass AB, Douglass JM. Common dental emergencies. Am Fam Physician. 2003;67(3): 511-516.
Additional Reading
&NA;
  • Clark MB, Douglass AB, Maier R, et al. Smiles for Life: A National Oral Health Curriculum. 3rd ed. Leawood, KS: Society of Teachers of Family Medicine; 2010. http://www.smilesforlifeoralhealth.com/buildcontent.aspx?tut=555&pagekey=62948&cbreceipt=0. Accessed 2014.
  • Douglas JM, Clark MB. Integrating oral health into overall health care to prevent early childhood caries: need, evidence, and solutions. Pediatr Dent. 2015;37(3):266-274.
  • Dye BA, Li X, Beltrán-Aguilar ED. Selected oral health indicators in the United States, 2005-2008. NCHS data brief, no 96. Hyattsville, MD: National Center for Health Statistics; 2012.
  • Flynn TR. What are the antibiotics of choice for odontogenic infections, and how long should the treatment course last? Oral Maxillofac Surg Clin North Am. 2011;23(4):519-536.
  • Lockhart PB, ed. Oral Medicine and Medically Complex Patients. 6th ed. New York, NY: Elsevier; 2013.
  • U.S. Preventive Services Task Force. Dental caries in children from birth through age 5 years: screening. AHRQ Publication No. 12-05170-EF-2. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/dental-caries-in-children-from-birth-through-age-5-years-screening. Accessed 2014.
Codes
&NA;
ICD10
  • K02.9 Dental caries, unspecified
  • K04.7 Periapical abscess without sinus
  • K12.2 Cellulitis and abscess of mouth
Clinical Pearls
&NA;
  • Do not ignore toothache pain.
  • Treat patients with facial swelling aggressively, as infections can spread quickly, leading to significant morbidity or death.
  • Promote prevention (oral hygiene, fluoride, dental visits) to avoid infections.