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. 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 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.
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. Another estimate is 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.
Furthermore, the prevalence of dental caries varies significantly by race and socioeconomic 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%).
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. 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%).
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.
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.
Dental infections can be further evaluated using dental radiographs, CT scans, and MRIs. 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.
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. 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. 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. Gingivitis can be treated with chlorhexidine or hexetidine rinse, as well as good oral hygiene. 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. 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 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.
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%.
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. 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.
Patients should receive counseling on proper dental hygiene to prevent dental infections. Educating patients as well as the public on the importance of daily toothbrushing, flossing, and reduction of sucrose-containing foods can reduce dental cavities. A dentist should assess patients that are experiencing dentalgia.
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 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 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. 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. [Level V]
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