Medscape is available in 5 Language Editions – Choose your Edition here.


Dental Infections in Emergency Medicine Clinical Presentation

  • Author: Lynnus F Peng, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
Updated: Apr 06, 2016


Patients with superficial dental infections may complain of localized pain, edema, and sensitivity to temperature and air. Patients with deep infections or abscesses that spread along the fascial planes may complain of fever and difficulty swallowing, breathing, and opening the mouth.



Local infections

Typically, the tooth is grossly decayed, although it may be normal with cavitated lesions that may have a surrounding chalky demineralized area and swollen erythematous gingiva. Affected teeth generally are tender to percussion and temperature.

Dentoalveolar ridge edema is evidenced by a periodontal, periapical, and subperiosteal abscess. Infection from the tooth spreads to the apex to form a periapical or periodontal abscess. With further invasion, the infection may elevate the periosteum and penetrate adjacent tissues.

Pericoronal infection occurs in an erupting or a partially impacted tooth when tissue covering the tooth's crown becomes inflamed and infected. An abscess may form and require incision and drainage (I&D). The tooth itself is not usually involved.

Mandibular infections

Submental space infection is characterized by a firm midline swelling beneath the chin and is due to infection from the mandibular incisors.

Sublingual space infection is indicated by swelling of the mouth's floor with possible tongue elevation, pain, and dysphagia due to anterior mandibular tooth infection.

Submandibular space infection is identified by swelling of the submandibular triangle of the neck around the angle of the jaw. Tenderness to palpation and mild trismus is typical. Infection is caused by mandibular molar infections.

Retropharyngeal space infection is identified by stiff neck, sore throat, dysphagia, hot potato voice, and stridor with possible spread to the mediastinum. These infections are due to infections of the molars.

With spread to the deeper areas of the neck, signs and symptoms of vagal injury, Horner syndrome, and lower cranial nerve injury may be seen.

Infection in this space is more common in children younger than 4 years.

Etiology usually is due to an upper respiratory infection (URI) with spread to retropharyngeal lymph nodes.

Because of high potential for spread to the mediastinum, retropharyngeal space infection is a serious fascial infection.

Ludwig angina (name derived from sensations of choking and suffocation) is characterized by brawny boardlike swelling from a rapidly spreading cellulitis of the sublingual, submental, and submandibular spaces with elevation and edema of the tongue, drooling, and airway obstruction.[6, 7] The condition is odontogenic in 90% of cases and arises from the second and third mandibular molars in 75% of cases.[6] If infection spreads through the buccopharyngeal gap (space created by styloglossus muscle between the middle and superior constrictor muscle of the pharynx), adjacent retropharyngeal and mediastinal infection is possible.

Middle and lateral facial edema

Buccal space infection is typically indicated by cheek edema and is due to infection of posterior teeth, usually premolar or molar.

Masticator space infection always presents with trismus manifestation and is due to infection of the third molar of the mandible. Large abscesses may track toward the posterior parapharyngeal spaces. Patients may require fiberoptic nasoendotracheal intubation while awake.

Canine space infection is evidenced by anterior cheek swelling with loss of the nasolabial fold and possible extension to the infraorbital region. This is due to infection of the maxillary canine and potentially may spread to the cavernous sinus.


Acute necrotizing ulcerative gingivitis (Vincent angina, trench mouth) is a condition in which patients present with edematous erythematous gingiva with ulcerated, interdental papillae covered with a gray pseudomembrane.

Patients may have fever and lymphadenopathy and may complain of metallic taste. The condition is caused by invasive fusiform bacteria and spirochetes but is not contagious.



See the list below:

  • Serotypes of S mutans are thought to cause initial caries infection. Infections through the fascial planes usually are polymicrobial (average 4-6 organisms). Dominant isolates are anaerobic bacteria.
  • Anaerobes (75%) - Peptostreptococci, Bacteroides and Prevotella organisms, and Fusobacterium nucleatum
  • Aerobes (25%) - Alpha-hemolytic streptococci
Contributor Information and Disclosures

Lynnus F Peng, MD Assistant Clinical Professor, Department of Anesthesia, University of California at Irvine; Chairman of Anesthesia, Department of Surgery, St Jude Medical Center at Fullerton

Lynnus F Peng, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Anesthesiologists

Disclosure: Nothing to disclose.


A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Willard Peng, DDS, MS Keck School of Medicine of the University of Southern California

Willard Peng, DDS, MS is a member of the following medical societies: American Dental Association, California Dental Association

Disclosure: Nothing to disclose.

Rebecca Cheng Loma Linda University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Michael Glick, DMD Dean, University of Buffalo School of Dental Medicine

Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.


Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center

Disclosure: Nothing to disclose.

  1. Bahl R, Sandhu S, Singh K, Sahai N, Gupta M. Odontogenic infections: Microbiology and management. Contemp Clin Dent. 2014 Jul. 5(3):307-11. [Medline]. [Full Text].

  2. Maruyama F, Kobata M, Kurokawa K, et al. Comparative genomic analyses of Streptococcus mutans provide insights into chromosomal shuffling and species-specific content. BMC Genomics. 2009 Aug 5. 10(1):358. [Medline].

  3. Holmstrup P, Poulsen AH, Andersen L, Skuldbol T, Fiehn NE. Oral infections and systemic diseases. Dent Clin North Am. 2003 Jul. 47(3):575-98. [Medline].

  4. Daramola OO, Flanagan CE, Maisel RH, Odland RM. Diagnosis and treatment of deep neck space abscesses. Otolaryngol Head Neck Surg. 2009 Jul. 141(1):123-30. [Medline].

  5. [Guideline] Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Apr 19. [Medline].

  6. Harwood-Nuss A, Linden C, Luten R, eds. Dental, oral and salivary gland infections. The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins Publishers; 1996. 73-77.

  7. Kim MK, Allareddy V, Nalliah RP, Kim JE, Allareddy V. Burden of facial cellulitis: estimates from the Nationwide Emergency Department Sample. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2012 Jan 25. [Medline].

  8. Hodgdon A. Dental and related infections. Emerg Med Clin North Am. 2013 May. 31(2):465-80. [Medline].

  9. Cachovan G, Phark JH, Schön G, Pohlenz P, Platzer U. Odontogenic infections: An 8-year epidemiologic analysis in a dental emergency outpatient care unit. Acta Odontol Scand. 2013 May-Jul. 71(3-4):518-24. [Medline].

  10. Igoumenakis D, Giannakopoulos NN, Parara E, Mourouzis C, Rallis G. Effect of Causative Tooth Extraction on Clinical and Biological Parameters of Odontogenic Infection: A Prospective Clinical Trial. J Oral Maxillofac Surg. 2015 Jul. 73 (7):1254-8. [Medline].

  11. Rastenienė R, Pūrienė A, Aleksejūnienė J, Pečiulienė V, Zaleckas L. Odontogenic Maxillofacial Infections: A Ten-Year Retrospective Analysis. Surg Infect (Larchmt). 2015 Jun. 16 (3):305-12. [Medline].

  12. Rasteniene R, Aleksejuniene J, Puriene A. Determinants of Length of Hospitalization due to Acute Odontogenic Maxillofacial Infections: A 2009-2013 Retrospective Analysis. Med Princ Pract. 2015. 24(2):129-35. [Medline].

  13. Kuriyama T, Williams DW, Yanagisawa M, Iwahara K, Shimizu C, Nakagawa K, et al. Antimicrobial susceptibility of 800 anaerobic isolates from patients with dentoalveolar infection to 13 oral antibiotics. Oral Microbiol Immunol. 2007 Aug. 22(4):285-8. [Medline].

  14. Marioni G, Rinaldi R, Staffieri C, Marchese-Ragona R, Saia G, Stramare R, et al. Deep neck infection with dental origin: analysis of 85 consecutive cases (2000-2006). Acta Otolaryngol. 2007 Aug 22. 1-6. [Medline].

  15. Pogrel MA. Antibiotics in general practice. Dent Update. 1994 Sep. 21(7):274-80. [Medline].

  16. Pynn BR, Sands T, Pharoah MJ. Odontogenic infections: Part one. Anatomy and radiology. Oral Health. 1995 May. 85(5):7-10, 13-4, 17-8 passim. [Medline].

  17. Reznick J. Infections of odontogenic origin. Oral Health. 1993. 1-6.

  18. Roberts J, Hedges JR. Emergency dental procedures. Clinical Procedures in Emergency Medicine. 2nd ed. Philadelphia: W B Saunders Co; 1991. 1045-1069.

  19. Rosen P, Barkins R. Dental emergencies. Emergency Medicine: Concepts and Clinical Practice. 3rd ed. St Louis: Mosby-Year Book; 1992. Vol 3: 2381-2398.

  20. Sands T, Pynn BR, Katsikeris N. Odontogenic infections: Part two. Microbiology, antibiotics and management. Oral Health. 1995 Jun. 85(6):11-4, 17-21, 23 passim. [Medline].

Obvious swelling of the right cheek.
Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection.
Gingiva with swelling and erythema.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.