Dental Infections


Article Author:
David Erazo


Article Editor:
David Whetstone


Editors In Chief:
Jon Parham
Jon Sivoravong


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
5/26/2019 9:18:55 PM

Introduction

Dental infections are infections that originate at the tooth or its supporting structures and can spread to the surrounding tissue. Dental infections have always been common and were one of the leading causes of death hundreds of years ago. The London England Bills of mortality in the 1600s reported “teeth” as the 5th or 6th leading cause of death.[1] In 1908 it was believed that dental infections were associated with a mortality of 10 to 40%.[2] Fortunately, due to improved dental hygiene, modern dentistry, and antibiotics, dental infections are rarely life-threatening today.

Etiology

Dental infections most commonly occur when bacteria invade the pulp and spread to surrounding tissues; this can occur due to trauma, dental caries, and dental procedures. Periodontal infections affect the gums, causing gingivitis and over time, periodontitis. Periodontal infections mostly result from poor or ineffective dental hygiene leading to plaque formation and subsequent inflammation of tissues around the teeth.

Epidemiology

Despite an improvement in dental health over the last few decades, a significant portion of our population seeks dental care every year. Estimates are that 13% of adults seek dental care for dental infection or toothache within four years.[3] Another estimate is that 1 per 2600 head of population in the United States is hospitalized due to dental infections.[4] More than 1 in 5 people have untreated dental caries, and 3 in 4 people had at least one dental restoration during their life. Periodontitis is also common, with estimations that 35% of all Americans age 30 to 90 are afflicted.[5]

Furthermore, the prevalence of dental caries varies significantly by race and socio-economical factors. According to data from the National Health and Nutrition Examination Survey, among people age 20 to 64, non-Hispanic blacks had almost twice the amount of untreated dental caries (39.7%), as non-Hispanic whites (19.3%). In the same age group, untreated dental caries were more than 2.5 times as common in those living 100% below the poverty level (41.9%) relative to those living 200% above the federal poverty level or higher (16.6%).[5]

The prevalence of dental caries is also dynamic during peoples’ lifetime. Dental caries are present in 90% of adults and 42% of children ages 6 to 19 years.[6] Dental caries did not appear to vary much with age except that adolescents age 12 to 19 who were found to have a lower rate of untreated dental caries (13%) even when compared to children ages 5 to 11 (20%).

Pathophysiology

Dental infections usually begin as a result of metabolic reactions that take place in dental plaques. Dental plaques are a biofilm (mass of bacteria) that can give rise to dental caries and periodontal infection. In dental caries, bacteria cause numerous pH fluctuations leading to enamel demineralization. Initially, the major pathogen found are members of the viridans streptococci family. Infection can then invade the pulp, causing pulpitis. After bacteria invade the pulp, bacterial flora transition from mainly aerobic bacteria to anaerobic bacteria. Most dental infections are polymicrobial infections. Infection can spread towards the alveolar bone, causing a periapical abscess. These bacteria generate acids and pH changes with the breakdown of monosaccharides and disaccharides obtained from sugar-rich foods. Biofilms can penetrate gingival epithelium, causing an inflammatory response with neutrophil infiltration and subsequent destruction of surrounding tissue, leading to periodontal disease. Infection can directly spread to adjacent osseous and deep neck structures causing fascial space infections.

History and Physical

Clinicians should have a high suspicion for dental infections in patients with poor dental hygiene complaining of dental pain. A high index of suspicion should exist for patients with a history of dental infections, recent dental trauma, or dental procedure. Patients with reversible pulpitis can present with a severe toothache that becomes exacerbated with temperature stimuli. On the other hand, irreversible pulpitis can present with sporadic unprovoked tooth pain. Patients with gingivitis and periodontitis will often present with halitosis, bleeding after brushing teeth, and gum pain. A periapical abscess will present with localized tooth pain and occasionally palpable swelling. More serious complaints such as fever, facial edema, trismus, dysphagia, or dysphonia can be symptoms of a more serious dental infection that has extended into deep neck spaces.  On exam, patients with dental infection may have signs of tooth decay with yellow or black cavities. They may also have erythema, edema, or bleeding in their gums and can be partially edentulous. A periapical abscess may sometimes be present. Patients with more serious dental infections may be toxic appearing, in respiratory distress, or hemodynamically unstable with sepsis.

Evaluation

Dental infections can be further evaluated using dental radiograph, CT scan, and MRI. Radiographs can show the extent of dental caries and periodontitis. Cone beam CT (CBCT) is useful in assessing dental caries, periodontitis, pulpal disease, periapical disease, pericoronitis, and osteomyelitis.  CT with contrast can help in evaluating the extent and severity of fascial space infection. MRI is useful for osteomyelitis and deep space infections of the neck. Laboratory studies, including complete blood count, may be helpful in patients with more serious presentations. Patients with fascial or deep space infections may present with sepsis and warrant the addition of blood cultures and lactic acid levels.[7]

Treatment / Management

Management of dental infections depends on whether it is a low-level local infection or a severe infection of the fascial spaces. If possible, removal of the source of infection is the most important step in treating dental infections.[8] Dental caries management depends on the extent of dental caries and can range from the insertion of restorative material (filling) to tooth extraction. Reversible pulpitis results from dental caries and is treated accordingly. Irreversible pulpitis treatment includes root canal and extraction, and there is insufficient evidence to recommend antibiotics.[9] A periapical abscess can complicate pulpitis. An uncomplicated periapical abscess is treatable with incision and drainage only. Periapical abscess complicated by systemic symptoms, cellulitis or in immunocompromised patients should receive antibiotics in addition to drainage.[10][11] Gingivitis can be treated with chlorhexidine or hexetidine rinse as well as good oral hygiene.[12] Periodontitis may be treated with scaling and root planning as well as antibiotics.

Antibiotic therapy for dental infections is necessary for systemic symptoms, fascial space infections, and infections that spread to the bony cortex and surrounding soft tissue. It is not required to give every dental infection antibiotics, as noted above with irreversible pulpitis, and uncomplicated periapical abscess, and therefore clinicians should use their judgment.[8] Gram-negative organisms, facultative anaerobes, and strict anaerobes are common organisms found in dental infections, with anaerobes outnumbering aerobic bacteria by a factor of three.[13] Penicillin has traditionally been the drug of choice. Amoxicillin is the most common medication prescribed for dental infections. It is also the recommended medication by the American Heart Association for prophylaxis against endocarditis associated with dental procedures. Metronidazole is not recommended as single coverage but can be used with penicillin as it is not active against aerobes and moderately active against anaerobic cocci. Macrolides have high resistance and should not serve as first-line agents. Clindamycin and macrolides are also considerations in cases of penicillin allergy.

Severe infections or patients who are immunocompromised should get anti-pseudomonal antibiotics.  Piperacillin-tazobactam, meropenem, cefepime, Imipenem-cilastatin, or metronidazole with ciprofloxacin can be therapeutic options.

Differential Diagnosis

The differential diagnosis of dental infections is variable and based on presenting symptoms. Localized dental infections can be mistaken for salivary gland pathologies such as sialadenitis, sialolithiasis, and salivary gland tumor. Sialadenitis and sialolithiasis can present with localized facial edema, erythema, and tenderness. A salivary gland tumor can present as a unilateral facial mass. Patients with sinusitis can complain of warm, erythematous skin over maxillary sinus. Other more acute life-threatening pathology should also be considerations. Angioedema can cause facial swelling that can be more prominent on one side. Osteomyelitis can present with fever, erythema, facial edema, and point tenderness. Ludwig angina presents with facial swelling, trismus, respiratory distress, dysphagia, and dysphonia. Lemierre syndrome, which is a complication involving internal jugular vein thrombosis from pharyngeal infection, and necrotizing infections of the head and neck will lead to sepsis, with patients appearing hemodynamically unstable and in respiratory distress.

Prognosis

The prognosis for uncomplicated dental infections is excellent. Dental infections that spread to deeper neck structures carry a worse prognosis and significant mortality rate. Deep neck infections have a mortality rate ranging from 1 to 25%, and mediastinitis can carry a mortality rate of 40%.[14][15]

Complications

Serious complications can arise from dental infections as they spread to potential fascial planes of the head and neck. Dental infections can spread contiguously to the jaw, causing osteomyelitis. Dental infections of the second and third molars can spread to sublingual space, submandibular and submental space, causing Ludwig angina. Dental infections in children can spread to the retropharyngeal space, causing retropharyngeal abscess and to the parapharyngeal space, causing parapharyngeal abscess. Descending necrotizing mediastinitis is a severe life-threatening infection caused by the descent of dental infection through deep and superficial fascial planes. There have been case reports of dental infections spreading and causing cavernous sinus thrombosis.[16] Very rarely, dental infections can also cause meningitis and subdural empyema.[17] Dental infections and tooth extractions can cause the hematogenous spread of infection-causing bacteremia and endocarditis, especially in patients with valvular disease.

Deterrence and Patient Education

Patients should receive counseling on proper dental hygiene to prevent dental infections. Educating patients as well as the public on the importance of the daily toothbrushing, flossing, and reduction of sucrose-containing foods can reduce dental cavities. A dentist should assess patients that are experiencing dentalgia.

Pearls and Other Issues

  • Dental infections are infections that originate at the tooth or its supporting structures and can spread to the surrounding tissue.
  • Dental infections most commonly occur when bacteria invade the pulp and spread to surrounding tissues. Infections can also affect the gums causing gingivitis, which can later cause periodontal disease.
  •  Dental infections are prevalent in an estimated 13% of adults seeking dental care for dental infection or toothache within 4 years.
  •  Dental infections originate from dental plaques that generate acids and pH changes, causing damage to the enamel and gums, causing dental plaques and periodontal disease, respectively. Infection can then spread to adjacent osseous and deep neck structures through fascial planes.
  • More serious complaints such as fever, facial edema, trismus, dysphagia, or dysphonia can be symptoms of a more serious dental infection that has spread into deep neck spaces.
  • CT with contrast can help evaluate the extent and severity of fascial space infection.
  • In most cases, drainage, along with the removal of the source of infection, is the most important steps in treating dental infections.
  • Serious complications from dental infections are rare. They include osteomyelitis, Ludwig angina, retropharyngeal abscess, parapharyngeal abscess, necrotizing mediastinitis, cavernous sinus thrombosis, meningitis, and subdural empyema.

Enhancing Healthcare Team Outcomes

Patients with dental infections may initially present to the emergency department, primary care provider, or urgent care. Patients with systemic symptoms and signs or symptoms consistent with a deep neck infection or osteomyelitis should be immediately identified and admitted to the hospital after stabilization. Initial stabilization should include IV antibiotics and close monitoring of airway. Patients stable enough for outpatient treatment should get a referral to a dentist or other specialists like endodontist or oral and maxillofacial surgeon.  Delay in treatment can worsen the dental infection and lead to tooth loss or spread of infection.

Dental infections require an interprofessional team approach, including physicians, dentists, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]


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Dental Infections - Questions

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A patient with no prior medical history is complaining of dentalgia. His vitals included a temperature of 99.1 F, heart rate 80 bpm, respiratory rate 16/minute, and blood pressure was 120/80 mmHg. On exam, he has an erythematous, fluctuant mass in the buccal aspect of his right maxillary canine. What is the most appropriate treatment?



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A 45-year-old female with poor dental hygiene presents to the clinic with dental pain that is elicited by cold drinks. Her vital signs are within normal limits. Her exam shows a full set of teeth with moderate decay and yellow cavities. Which of the following is the next best step in the management of this patient?



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A 55-year-old male with a history of diabetes presents to the emergency department complaining of respiratory distress. His vital signs include a temperature of 102.5 F, heart rate of 120/min, blood pressure of 130/80 mmHg, respiratory rate of 30/minute and oxygen saturation of 87% on 6L of O2 via nasal cannula. On exam, he appears toxic and has a decayed, right mandibular molar with purulent discharge. He has induration of submandibular and sublingual space and is in significant respiratory distress with drooling. Which of the following is the next best step in the management of this patient?



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A 66-year-old female with a history of hypertension presents to the emergency department with jaw pain. Her vital signs include a temperature of 101.5 F, heart rate of 105/min, blood pressure of 120/80 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on room air. On exam, she has a decayed, left mandibular premolar with purulent discharge. She is tender to palpation in her jaw and has overlying erythema that is warm to palpation. What is the most sensitive imaging modality for the patient’s suspected condition?



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A 66-year-old male presents to the clinic with gum bleeding. The patient states that he had been diagnosed with gingivitis ten years ago by his dentist but has neglected to perform good oral hygiene. He complains of intermittent gum bleeding as well as bad breath for the last ten years. His vital signs are within normal limits. His exam is significant for gum recession, halitosis and erythematous, bleeding gums. Which of the following is the next best step in the management of this patient?



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Dental Infections - References

References

Robertson D,Smith AJ, The microbiology of the acute dental abscess. Journal of medical microbiology. 2009 Feb;     [PubMed]
Thomas TT, III. Ludwig's Angina (Part II): An Anatomical, Clinical and Statistical Study. Annals of surgery. 1908 Mar;     [PubMed]
Boykin MJ,Gilbert GH,Tilashalski KR,Shelton BJ, Incidence of endodontic treatment: a 48-month prospective study. Journal of endodontics. 2003 Dec;     [PubMed]
Wang J,Ahani A,Pogrel MA, A five-year retrospective study of odontogenic maxillofacial infections in a large urban public hospital. International journal of oral and maxillofacial surgery. 2005 Sep;     [PubMed]
Dye BA,Li X,Beltran-Aguilar ED, Selected oral health indicators in the United States, 2005-2008. NCHS data brief. 2012 May;     [PubMed]
Beltrán-Aguilar ED,Barker LK,Canto MT,Dye BA,Gooch BF,Griffin SO,Hyman J,Jaramillo F,Kingman A,Nowjack-Raymer R,Selwitz RH,Wu T, Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis--United States, 1988-1994 and 1999-2002. Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002). 2005 Aug 26;     [PubMed]
Mardini S,Gohel A, Imaging of Odontogenic Infections. Radiologic clinics of North America. 2018 Jan;     [PubMed]
Martins JR,Chagas OL Jr,Velasques BD,Bobrowski ÂN,Correa MB,Torriani MA, The Use of Antibiotics in Odontogenic Infections: What Is the Best Choice? A Systematic Review. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2017 Dec;     [PubMed]
Agnihotry A,Fedorowicz Z,van Zuuren EJ,Farman AG,Al-Langawi JH, Antibiotic use for irreversible pulpitis. The Cochrane database of systematic reviews. 2016 Feb 17;     [PubMed]
Siqueira JF Jr,Rôças IN, Microbiology and treatment of acute apical abscesses. Clinical microbiology reviews. 2013 Apr;     [PubMed]
Henry M,Reader A,Beck M, Effect of penicillin on postoperative endodontic pain and swelling in symptomatic necrotic teeth. Journal of endodontics. 2001 Feb;     [PubMed]
Fouad AF,Rivera EM,Walton RE, Penicillin as a supplement in resolving the localized acute apical abscess. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 1996 May;     [PubMed]
Ernst CP,Canbek K,Dillenburger A,Willershausen B, Clinical study on the effectiveness and side effects of hexetidine and chlorhexidine mouthrinses versus a negative control. Quintessence international (Berlin, Germany : 1985). 2005 Sep;     [PubMed]
Almuqamam M,Kondamudi NP, Deep Neck Infections 2019 Jan;     [PubMed]
Sanders JL,Houck RC, Dental Abscess 2019 Jan;     [PubMed]
Yeo GS,Kim HY,Kwak EJ,Jung YS,Park HS,Jung HD, Cavernous sinus thrombosis caused by a dental infection: a case report. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2014 Aug;     [PubMed]
Cariati P,Cabello-Serrano A,Monsalve-Iglesias F,Roman-Ramos M,Garcia-Medina B, Meningitis and subdural empyema as complication of pterygomandibular space abscess upon tooth extraction. Journal of clinical and experimental dentistry. 2016 Oct;     [PubMed]

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