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Dental Infections in Emergency Medicine

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

Background

Infections of the teeth have plagued humans constantly, despite a quest for better oral hygiene. As early as 200 BCE, a bronze wire root canal filling was found in the skull of a Nabataean warrior. Infections usually arise from pulpitis and associated necrotic dental pulp that initially begins on the tooth's surface as dental caries. The infection may remain localized or quickly spread through various fascial planes. See the images below.

Obvious swelling of the right cheek. Obvious swelling of the right cheek.
Side view. Fluctuant mass extending toward the buc Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection.
Gingiva with swelling and erythema. Gingiva with swelling and erythema.
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Pathophysiology

Odontogenic infection may be primary or secondary to periodontal, pericoronal, traumatic, or postsurgical infections. A typical odontogenic infection originates from caries, which decalcify the protective enamel. A balance of demineralization and remineralization of the tooth structure occurs in the development of carious lesions. Greater demineralization of the tooth occurs with high bacterial activity and low pH. Greater remineralization occurs with a pH higher than 5.5 and high concentrations of calcium and phosphate from the saliva.

Bahl et al conducted a retrospective study to evaluate the involvement of fascial spaces, their bacteriology, sensitivity to antibiotics and management of odontogenic infection in 100 patients of age less than 60 years. The authors concluded that odontogenic infections were mixed aerobic-anaerobic infections. Anaerobic as well as aerobic cultures were necessary to isolate all pathogens. Successful management of these infections depends on changing the environment through decompression, removal of the etiologic factor and by choosing the proper antibiotic.[1]

Once enamel is dissolved, the infectious caries can travel through the dentinal tubules and gain access to the pulp. In the pulp, the infection may develop a track through the root apex and burrow through the medullar cavity of the mandible or maxilla. The infection then may perforate the cortical plates and drain into the superficial tissues of the oral cavity or track into deeper fascial planes. If the infection does not drain, it will remain localized and develop into a periapical or periodontal abscess.

Serotypes of Streptococcus mutans (cricetus, rattus, ferus, sobrinus) are primarily responsible for causing oral disease.[2] Although lactobacilli are not primary causes, they are progressive agents of caries because of their great acid-producing capacity.

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Epidemiology

Frequency

United States

Dental caries is the most common chronic disease in the world. The late 1970s signaled a decline in caries in certain segments of the world due to the addition of fluoride to public drinking water. In the United States, a 36% decrease in caries occurred from 1972-1980.

International

In the United Kingdom, a 39% decline in caries occurred from 1970-1980. In Denmark, a 39% decline occurred from 1972-1982.[3]

Mortality/Morbidity

Dental caries is not a life-threatening disease; however, if an odontogenic infection spreads through fascial planes, patients are at risk for sepsis, airway compromise (eg, Ludwig angina, retropharyngeal abscess), and odontogenic infection, which accounted for 49.1% of the deep neck abscesses in one study.[4]

Patients with neutropenia undergoing chemotherapy are at risk for certain pathogenic oral microorganisms that cause bloodstream infections, which increases the chance of morbidity and mortality. Odontogenic infections carry significant morbidity of pain and cosmetic defect. The US bill for dental care was estimated at $27 billion in 1985. The oral cavity contains approximately 30-50% viridans group streptococci that are resistant to penicillins and macrolides.

Age

The National Preventive Dentistry Program found that 60% of caries occurred in 20% of children, who were generally minorities or of lower socioeconomic status.[5]

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

Acknowledgements

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.

References
  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].

 
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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.
 
 
 
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