Dental Infections in Emergency Medicine Clinical Presentation

Updated: Jan 04, 2018
  • Author: Lynnus F Peng, MD; Chief Editor: Jeff Burgess, DDS, MSD  more...
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Presentation

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.

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Physical

Caries

Coloquially referred to as cavities, caries are caused by bacteria that erode the enamel outside shell of the tooth and the dentin underneath. Bacteria builds up on the surface of teeth as plaque which consists of both bacteria as well as food and saliva. As the starches in the mouth turn into acid, it dissolves the enamel and forms a pit that gradually grows in size.

Patients may not have symptoms when tooth decay is small, yet as the decay grows the tooth may become sensitive.

Caries can be prevented by brushing and flossing daily as well as using antibacterial mouthwash in order to reduce the amount of bacteria in 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.

A retrospective study that included 270 patients with deep neck infections reported symptoms at presentation included throbbing pain (81%), neck swelling (77%), difficulty in swallowing (39%), ear ache (31%) and restricted mouth opening (30%). [8]  

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.

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Causes

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

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