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Dental Infection

Basics

  • Pain and swelling in head and neck due to odontogenic infection.
  • Assume odontogenic origin in any head/neck swelling until proven otherwise.
  • Antibiotics as adjunct to dental treatment; duration 3 to 7 days.
  • Gingivitis and periodontal disease may respond to oral antibiotics; severe soft tissue infections may require IV antibiotics.

Epidemiology

  • ~20% Americans have untreated dental caries.
  • 75% have had at least one dental restoration.
  • 35% aged 30–90 years have periodontal disease.
  • 1 in 2,600 hospital admissions related to dental infection.
  • Socioeconomic status strongly linked to dental disease prevalence.

Etiology and Pathophysiology

  • 90% of head and neck infections are odontogenic.

  • Caries or trauma lead to pulp death → infection/abscess via direct or hematogenous spread.
  • Streptococcus mutans is main cariogenic bacterium, transmitted from caregivers to infants.
  • Oral microbiome includes anaerobic bacteria; anaerobes predominate near tooth base.

Risk Factors

  • Low socioeconomic status
  • Smoking
  • Family history of caries
  • Previous caries
  • Poor oral hygiene and nutrition (high sugar diet)
  • Trauma to teeth/jaw
  • Lack of fluoride exposure
  • Gingival recession
  • Physical/mental disabilities
  • Systemic disease (e.g., diabetes)
  • Decreased salivary flow (medications, immunologic disease, radiation)

Prevention

  • Daily flossing or interdental brushes.
  • Brushing with fluoride toothpaste.
  • Systemic fluoride supplements or fluoridated water.
  • Fluoride varnish twice yearly for children <6 years and high-risk groups.
  • Prevent S. mutans transmission from mother/caregiver using chlorhexidine rinses, xylitol.
  • Smoking cessation.
  • Good systemic disease control.

Commonly Associated Conditions

  • Extensive caries, crowding, missing teeth.
  • Periapical and periodontal abscess.
  • Soft tissue cellulitis.
  • Periodontitis.

Diagnosis

History

  • Tooth pain possibly referred to ears, jaw, neck.
  • Hot/cold sensitivity.
  • Pain on biting/chewing.
  • Trismus.
  • Bleeding or pus from gums.
  • Fever, difficulty swallowing/breathing, raspy voice in severe infection.

Physical Exam

  • Gingival edema and erythema.
  • Cheek or vestibular swelling.
  • Fluctuant mass.
  • Suppuration of gingiva.
  • Submandibular/cervical lymphadenopathy.
  • Systemic infection signs and airway compromise possible in severe cases.

Differential Diagnosis

  • Bacterial or viral pharyngitis.
  • Pericoronitis.
  • Otitis media/externa.
  • Sinusitis.
  • TMJ dysfunction.
  • Parotitis.
  • Anginal equivalents (jaw pain).

Diagnostic Tests

  • No labs if well-appearing.
  • CBC with differential if ill.
  • Culture of abscess drainage.
  • Dental films, panoramic radiograph, CT/MRI if extensive swelling.
  • Imaging helps determine extent and guide drainage.

Treatment

General Measures

  • NSAIDs or acetaminophen for pain; combination or short-term opioids if severe.
  • Avoid nerve block through infected tissue.

Medications

  • First Line:
  • Amoxicillin
  • Penicillin
  • Amoxicillin/clavulanic acid
  • Clindamycin
  • Second Line:
  • Ciprofloxacin
  • Azithromycin
  • Gentamycin
  • Metronidazole (with aerobic coverage)

Referral

  • Always refer to oral health provider for definitive care (root canal, extraction).

Surgery/Procedures

  • Incision and drainage of abscess.
  • Definitive dental treatment essential.

Admission Criteria

  • Deep neck space involvement.
  • Airway compromise.
  • Systemic signs: fever, chills, altered mental status.
  • Ensure airway security.
  • IV fluids and IV antibiotics.

Ongoing Care

  • Oral hygiene education.
  • Follow-up with dental care within 24 hours.
  • Adequate nutrition, avoid sugar-rich foods.

Diet

  • Healthy diet; avoid sticky, sugary foods.
  • Limit sugary/carbonated drinks; encourage water.

Patient Education

  • Control caries and periodontal disease.
  • Brush twice daily, floss daily.
  • Fluoride supplementation if needed.
  • Avoid bottle use at night in children.
  • Regular dental visits for cleaning and varnish.

Prognosis

  • Excellent with proper treatment.

Complications

  • Ludwig angina.
  • Retropharyngeal and mediastinal infections.
  • Osteomyelitis.
  • Endocarditis/cardiac tamponade.
  • Deep neck infections (submental, submandibular).
  • Can worsen diabetes or heart disease.
  • Brain abscess, death in severe cases.

ICD10 Codes:
- K02.9 Dental caries, unspecified
- K04.7 Periapical abscess without sinus
- K12.2 Cellulitis and abscess of mouth

Clinical Pearls:
- Never ignore tooth pain.
- Treat soft tissue infections aggressively to prevent severe complications.
- Prevention with oral hygiene and regular dental visits is key.
- Amoxicillin and clindamycin are commonly preferred antibiotics.