Continuing Education Activity
Dental infections originate in the tooth or its supporting structures and can spread to the surrounding tissue. Dental infections were, historically, a common cause of death. Fortunately, due to improved dental hygiene, modern dentistry, and antibiotics, dental infections are rarely life-threatening today. This activity reviews the evaluation and management of dental infections and highlights the role of the interprofessional team in managing affected patients.
- Identify the etiology of dental infections.
- Describe the presentation of a patient with a dental infection.
- Summarize the treatment options available for dental infections.
- Explain interprofessional team strategies for improving coordination and communication to advance care for patients with dental infection and improve outcomes.
Dental infections originate in the tooth or its supporting structures and can spread to the surrounding tissues. When facial structures are compromised the infection tends to originate from necrotic pulp, periodontal pockets, or pericoronitis. 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 infections as the 5th or 6th leading cause of death . In 1908 it was believed that dental infections were associated with a mortality of 10 to 40% . Fortunately, due to improved dental hygiene, modern dentistry, and antibiotics, dental infections are rarely life-threatening today.
Dental infections most commonly occur when bacteria invade the pulp and spread to surrounding tissues; this can be due to dental caries, trauma, or dental procedures.
Periodontal infections first involve the gingival tissues causing gingivitis and, over time, periodontitis. The periodontal disease mostly results from poor or ineffective dental hygiene leading to plaque and calculus accumulation and subsequent inflammation of tissues that support the teeth, alveolar bone, periodontal ligament, and cementum. The etiology of periodontitis is multifactorial; while bacteria initiate them, the clinical presentation and outcome of the different forms of the disease are in the end determined by the inflammatory response and modifying and predisposing factors. The disease progression seems to be regulated by environmental and genetic factors specific in each patient .
Streptococcus mutans is considered as the primary etiologic agent of dental caries, an infectious disease. This pathogen can access the bloodstream during dental procedures, causing opportunistic systemic infections. Thus, bacteremia, through the adhesion to the endocardium, is involved in infective endocarditis and peripheral arterial disease .
It is estimated that 13% of adults seek dental care for dental infection or toothache within four years and that 1 per 2600 head of the population in the United States is hospitalized due to dental infections . 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 .
More than 1 in 5 people have untreated dental caries, and 3 in 4 people had at least one dental restoration during their life. Periodontal disease is also common, with estimations that 35% of Americans age 30 to 90 are afflicted .
Furthermore, the prevalence of dental caries varies significantly by socioeconomic factors. 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%). The prevalence of dental caries is also dynamic during the patients' lifetime. Dental caries are present in 90% of adults and 42% of children ages 6 to 19 years . Dental caries did not appear to vary much with age except that adolescents age 12 to 19 were found to have a lower rate of untreated dental caries even when compared to children ages 5 to 11.
Dental plaque is an example of a biofilm, which occurs naturally on the teeth structures. Dental biofilm has a diverse composition that stays in microbial homeostasis when there are healthy oral conditions. When this microbial homeostasis breaks down, acid-producing and acid-tolerating bacteria prevail. The microorganisms cause a decrease in pH, thanks to the breakdown of monosaccharides and disaccharides obtained from sugar-rich foods, leading to enamel demineralization. The most associated pathogens are mutans streptococci and lactobacilli .
Infection can then invade the pulp, causing pulpitis and bacterial flora transition from mainly aerobic to anaerobic. Most dental infections are polymicrobial infections, and they can spread towards the alveolar bone, causing a periapical abscess.
On the other hand, biofilms can penetrate gingival epithelium, causing an inflammatory response with neutrophil infiltration and subsequent destruction of periodontal tissues, leading to periodontal disease. Infection can directly spread to adjacent osseous and deep neck structures causing fascial space infections .
History and Physical
Caries can be acute or chronic, brown-yellow, and soft or black and hard cavities. Pulp exposure may be seen. Incipient caries is more challenging to identify, and they represent the first clinical manifestation of caries. They are white and opaque irregular spots that may appear on any tooth surface.
Patients with reversible pulpitis can present with a severe toothache induced by stimuli, like hot or cold drinks or food.
On the other hand, irreversible pulpitis presents as unprovoked tooth pain that usually exacerbates overnight.
Patients with gingivitis and periodontitis will often present with a history of halitosis, bleeding after brushing teeth, and gum pain in some cases.
In gingivitis, the gums are swollen, erythematous, with a shiny surface, and they usually bleed on probing, but there are no periodontal pockets. Periodontitis involves the migration of the junctional epithelium and the development of periodontal pockets. Clinical findings of periodontitis may include gingival recession, dental papilla detachment, loss of alveolar bone, tooth mobility, or fremitus, according to the degree of destruction .
A periapical abscess may present as a palpable swelling. A dental abscess can be originated from the pulp, periodontal structures, or both.
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. Patients may be in respiratory distress or hemodynamically unstable with sepsis .
Dental infections can be further evaluated using dental radiographs, orthopantomography, CT scans, and MRIs. Imaging studies play an essential role in recognizing the source of infection and the proportions of the disease spread and also can detect any complications.
Radiographs can show the extent of dental caries and periodontitis.
Cone-beam CT (CBCT) is useful in assessing 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 facial or deep space infections may present with sepsis and warrant the addition of blood cultures and lactic acid levels .
Treatment / Management
Management of dental infections depends on whether it is a local infection or a severe infection of the fascial spaces, which is rare.
If possible, removal of the source of infection is the most important step in treating dental infections .
Dental caries management depends on the extent of dental caries and can range from the insertion of a restorative material, endodontic treatment, to tooth extraction.
Reversible pulpitis treatment with pulp protection and restorative materials is usually sufficient. Irreversible pulpitis treatment involves a root canal and direct or indirect restorations according to the degree of tooth remanent. There is insufficient evidence to recommend antibiotics . Pulp necrosis is also treated with a root canal or tooth extraction as the last resource. A periapical abscess can complicate pulpitis. A periapical abscess is treatable with endodontic treatment and if they have migrated to the mucosa surface and incision and drainage can also be performed. Periapical abscess complicated by systemic symptoms, cellulitis, or in immunocompromised patients should receive antibiotics in addition to drainage . Gingivitis is a reversible condition, that can be treated with professional plaque removal. The use of chlorhexidine rinses is suggested only as an adjuvant to mechanical treatment and for a short period of time given its side effects and complications . Periodontitis may be treated with scaling and may require antibiotics in specific cases but not routinely.
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 . 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 . 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 penicillin is not active against aerobes and is moderately active against anaerobic cocci. There is high resistance to macrolides, and they 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.
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 tumors. 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 the maxillary sinus.
The prognosis for uncomplicated dental infections is good. 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% .
Serious complications can arise from dental infections as they spread to potential fascial planes of the head and neck. There are different paths for the dissemination of the infection. They can spread contiguously to the jaw, causing osteomyelitis. Second and third molars infections can migrate to the sublingual, submandibular and submental space, causing Ludwig angina. In children, dental infections may spread to the retropharyngeal or to the parapharyngeal space causing retropharyngeal or parapharyngeal abscess, respectively. 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 . Very rarely, dental infections can also cause meningitis and subdural empyema . Dental infections and tooth extractions can cause the hematogenous spread of infection-causing bacteremia and endocarditis, especially in patients with valvular disease.
Dental infections and tooth extractions can cause the hematogenous spread of infection-causing bacteremia and endocarditis, especially in patients with valvular heart disease . 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.
Deterrence and Patient Education
Patients should receive counseling on proper dental hygiene to prevent dental infections. Educating patients and the public on the importance of daily toothbrushing, flossing, and reduction of sugar-containing foods can reduce dental cavities. A dentist should assess patients that are experiencing dentalgia.
Pearls and Other Issues
- Dental infections 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.
- 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, are 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
Dental infections that may have migrated to the surrounding facial tissues require an interprofessional team approach, including physicians, dentists, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. Pharmacists review antibiotic prescriptions and check for drug-drug interactions. They also educate the patient's about use, side effects, and the importance of compliance. Usually, patients with dental infections initially present to the emergency department, primary care provider, or urgent care. When systemic symptoms are 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 the airway. Patients stable enough for outpatient treatment should get a referral to a dentist or other specialists like endodontists or oral and maxillofacial surgeons. Delay in treatment can worsen the dental infection and lead to tooth loss or spread of disease. [Level V]