eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Dental, Infections

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
A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon; Willard Peng, MS, Doctor of Dental Surgery Candidate, Department of Oral Medicine, University of Southern California; Rebecca Cheng, University of California at San Diego

Updated: Aug 11, 2009

Introduction

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.

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.

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.

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.¹ Although lactobacilli are not primary causes, they are progressive agents of caries because of their great acid-producing capacity.

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 1972-1982.²

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.³

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.⁴

Clinical

History

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.

Physical

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.⁵ The condition is odontogenic in 90% of cases and arises from the second and third mandibular molars in 75% of cases.⁵ 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.
Gingivitis
- 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.

Causes

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

Workup

Laboratory Studies

In dental infections, a CBC count with differential is not mandatory, but a large outpouring of immature granulocytes may indicate the severity of the infection.
Blood cultures in patients who are toxic may help guide management if the course is prolonged.

Imaging Studies

Panorex and periapical dental films are used to identify involvement of tooth and surrounding bone in the infectious process. A limited facial series may also be performed to help visualize the offending area if these studies are not available; cooperation and communication with the radiology technician and radiologist is necessary.
A soft-tissue radiograph of the neck can be used to identify gas-producing infections and determines any mass effect that may potentially compromise the airway.
CT scan may be used for severe fascial plane infections to determine the extent, size, and location of the infectious process.
- Soft tissue planes may be seen; with increasing infection, inflammation, and fat streaking, the planes may be difficult to differentiate from adjacent muscle.
- CT scan helps elucidate abscesses, venous thrombosis, and lymph node involvement.
MRI is not yet favored because of cost and limited availability. CT scan is preferred for rapid visualization of odontogenic infections.

Treatment

Emergency Department Care

The source of the dental infection must ultimately be removed or controlled. Pain medication and antibiotics may be given if the patient is not systemically ill and appears to have a simple localized odontogenic infection or abscess.

Localized infections
- I&D may be performed if a periapical or periodontal abscess is identified, depending on the physician’s comfort level.
- After anesthesia of the tooth, locally or with a dental block, make an incision in the mucosa large enough to accommodate a quarter-inch Penrose drain.
- Bluntly dissect the abscess cavity with the tips of a hemostat. Suture in the Penrose drain with a silk suture and leave until suppurative drainage is no longer present (about 2-3 d).
Deep fascial infections
- Infections of the neck's deeper fascial layers and masseteric layers have a higher chance of causing impingement on the airway directly or indirectly through extreme trismus.
- Tracheostomy was the prior method of choice for establishing the airway; as of recently, management through fiberoptic nasoendotracheal intubation while the patient is awake is preferred.
- Various drains and incisions are used for drainage of the affected fascial space.
If the patient appears systemically ill with abnormal vital signs and/or is unable to take oral medication, consider admission with further diagnostic studies and intravenous antibiotics. Infections in the various fascial spaces require incision and drainage (I&D) by the consulting physician.
If airway issues are of concern (eg, Ludwig angina, retropharyngeal abscesses), call an anesthesiologist and otolaryngologist as soon as possible to establish an airway. Ensure that equipment for an emergent cricothyroidotomy is located at the bedside until a secure airway can be established.

Consultations

Oral surgeon
Dentist
Otolaryngologist

Medication

The goals of therapy are to treat the dental infection and prevent further complications. Amoxicillin is still the first-line drug of choice but with 34% of Prevotella species resistant to amoxicillin, the alternatives of amoxicillin/clavulanate, clindamycin, and metronidazole need to be considered.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Penicillin VK (Veetids)

Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication. Inadequate concentrations may produce only bacteriostatic effects.

Dosing

Adult

250-500 mg PO q6h

Pediatric

50 mg/kg/d PO divided qid

Interactions

Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal impairment

Amoxicillin and clavulanic acid (Augmentin)

Drug combination that extends the antibiotic spectrum of this penicillin to include bacteria normally resistant to beta-lactam antibiotics. Indicated for skin and skin structure infections caused by beta-lactamase–producing strains of Staphylococcus aureus. Administer for a minimum of 10 d.

Dosing

Adult

500/125 mg PO tid

Pediatric

40 mg/kg/d PO divided tid

Interactions

Coadministration with warfarin or heparin increases risk of bleeding

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Give for a minimum of 10 d to eliminate organism and prevent sequelae (endocarditis and rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci

Erythromycin (EES, E-Mycin, Ery-Tab)

DOC in patients who are allergic to penicillin. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes, inhibiting bacterial growth.

Dosing

Adult

250-500 mg PO q6h

Pediatric

30-50 mg/kg/d PO divided qid

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Clindamycin (Cleocin)

Lincosamide useful to treat serious skin and soft tissue infections caused by most staphylococci strains. Effective against aerobic and anaerobic streptococci, except enterococci.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.

Dosing

Adult

600-900 mg IV q8h

Pediatric

20-40 mg/kg/d IV divided q6-8h

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Ampicillin and sulbactam (Unasyn)

Combination antimicrobial agent that utilizes a beta-lactamase inhibitor with ampicillin. Gives better anaerobic coverage.

Dosing

Adult

1.5-3 g IV q6h

Pediatric

<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Ticarcillin and clavulanate (Timentin)

Used for deep space infections. Inhibits biosynthesis of cell wall mucopeptide and is effective during stages of active growth.
Antipseudomonal penicillin plus a beta-lactamase inhibitor that provides coverage against gram-positive, gram-negative, and anaerobic organisms.

Dosing

Adult

3.1 g IV q6h

Pediatric

75 mg/kg IV q6h

Interactions

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels

Contraindications

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Metronidazole (Flagyl)

An imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually used in combination with other antimicrobial agents except when used for Clostridium difficile enterocolitis in which monotherapy is appropriate. An addition for treating Ludwig angina.

Dosing

Adult

1 g loading dose IV; then 500 mg IV q6h

Pediatric

15 mg/kg loading dose IV; then 7.5 mg/kg q6h

Interactions

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Follow-up

Complications

Complications of dental infections include the following:

Abscess
Sepsis

Patient Education

For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Also, see eMedicine's patient education articles Gingivitis, Dental Abscess, Toothache, and When to Visit the Dentist.

Miscellaneous

Special Concerns

Prophylaxis controversy continues regarding who should have antibiotic prophylaxis for dental procedures and which antibiotics to use.

Current recommendations by the American Heart Association 2007 for dental, oral, respiratory tract, or esophageal procedures, if the patient has one of the following conditions:⁴

Prosthetic cardiac valve
Previous infective endocarditis
Congenital heart disease (CHD)
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy

Recommendations for dental, oral, respiratory tract, and esophageal procedures for patients with one of the conditions listed above include the following:

For adults, administer amoxicillin 2 g PO 1 hour before procedure. Administer amoxicillin 50 mg/kg PO for pediatric patients. If by IV, administer ampicillin 2 g for adults and 50 mg/kg for children within 30 minutes before the procedure.
For patients allergic to penicillin, give clindamycin 600 mg PO/IV 1 hour before the procedure. For pediatric patients, administer clindamycin 20 mg/kg PO/IV. Alternatively, azithromycin or clarithromycin 500 mg PO 1 hour before the procedure may be administered for adults and 15 mg/kg PO may be administered for pediatric patients.

Current recommendations by the American Heart Association for genitourinary/GI procedures are for patients with GI or GU tract infection, if they have any of the conditions listed above (same as for dental), then the patient should undergo prophylaxis and have the antibiotic regimen include an agent active against enterococci, such as penicillin, ampicillin, piperacillin, or vancomycin.⁴

For adults, administer ampicillin 2 g IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 minutes before the procedure; 6 hours later, administer ampicillin 1 g IV or amoxicillin 1 g PO 1 hour before procedure. Administer amoxicillin 50 mg/kg PO for pediatric patients.
For patients allergic to penicillin, administer vancomycin 1 g IV over 1-2 hours plus gentamicin 1.5 mg/kg (not to exceed 120 mg); complete infusion within 30 minutes before the procedure.

Prophylactic regimens are for patients with prosthetic heart valves, previous bacterial endocarditis, congenital cyanotic heart disease, pulmonary shunt placement, cardiac myopathies, acquired valvular disease, and mitral prolapse with regurgitation.⁴

Only 25% of patients who should receive prophylactic antibiotics actually receive them.
With 100% compliance, estimates suggest that the incidence of bacterial endocarditis would be reduced 3-6%.

Multimedia

Media file 1: Obvious swelling of the right cheek.

Media file 2: Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection.

Media file 3: Gingiva with swelling and erythema.

References

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Daramola OO, Flanagan CE, Maisel RH, Odland RM. Diagnosis and treatment of deep neck space abscesses. Otolaryngol Head Neck Surg. Jul 2009;141(1):123-30. [Medline].
[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. Apr 19 2007;[Medline].
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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. Aug 22 2007;1-6. [Medline].
Pogrel MA. Antibiotics in general practice. Dent Update. Sep 1994;21(7):274-80. [Medline].
Pynn BR, Sands T, Pharoah MJ. Odontogenic infections: Part one. Anatomy and radiology. Oral Health. May 1995;85(5):7-10, 13-4, 17-8 passim. [Medline].
Reznick J. Infections of odontogenic origin. Oral Health. 1993;1-6.
Roberts J, Hedges JR. Emergency dental procedures. In: Clinical Procedures in Emergency Medicine. 2^nd ed. Philadelphia: W B Saunders Co; 1991:1045-1069.
Rosen P, Barkins R. Dental emergencies. In: Emergency Medicine: Concepts and Clinical Practice. Vol 3. 3^rd ed. St Louis: Mosby-Year Book; 1992:2381-2398.
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Keywords

dental infection, tooth infection, retropharyngeal space infection, Ludwig angina, Ludwig's angina, gingivitis, odontogenic infection, infection of tooth, dental caries, pulpitis, necrotic dental pulp, Streptococcus mutans, deep neck infection, hot potato voice, Horner syndrome, upper respiratory infection, URI, cellulitis, airway obstruction, lymphadenopathy, erythematous gingiva, treatment, diagnosis

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 and American Society of Anesthesiologists
Disclosure: Nothing to disclose.

Coauthor(s)

A Antoine Kazzi, MD, Chair and Medical Director, 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, MS, Doctor of Dental Surgery Candidate, Department of Oral Medicine, University of Southern California
Disclosure: Nothing to disclose.

Rebecca Cheng, University of California at San Diego
Disclosure: Nothing to disclose.

Medical Editor

Michael Glick, DMD, Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey
Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Further Reading