Dental Infection

Reno Rudiman

Background

Infections of the teeth have plagued humans constantly, despite a quest for better oral hygiene. 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.

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.

Once enamel is dissolved, the infectious caries can travel through the microporous dentin 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.

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

Frequency

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 US, a 36% decrease in caries occurred from 1972-1980. In the United Kingdom, a 39% decline in caries occurred from 1970-1980. In Denmark, a 39% decline occurred from 19721982.

Morbidity/Mortality

Dental caries is not a life-threatening disease; however, if an odontogenic infection spreads through fascial planes, patients are at risk for sepsis and airway compromise (eg, Ludwig angina, retropharyngeal abscess). Odontogenic infections carry significant morbidity of pain and cosmetic defect.

History

Patients with superficial 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 Infection

Typically, the tooth is grossly decayed, though 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.

Physical: Local Infection

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.

Physical: Local Infection

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 usually is not involved.

Physical: Mandibular Infection

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.

Sublingual space

Spread of infection

Physical: Mandibular 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.

Submandibular space infection

Physical: Mandibular Infection

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. More common in children younger than 4 years. Etiology: URTI with spread to retropharyngeal lymph nodes. High potential for spread to the mediastinum

Ludwig angina

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. Odontogenic in 90% of cases and arises from the second and third mandibular molars in 75% of cases.

Ludwig angina

If infection spreads through the buccopharyngeal gap (space created by styloglossus muscle between the middle and superior constrictor muscle of the pharynx), potential exists for adjacent retropharyngeal and mediastinal infection.

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.

Middle and lateral facial edema

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 organisms, and Fusobacterium

nucleatum

Aerobes (25%) - Alpha-hemolytic streptococci

Lab Studies

Complete blood count (CBC) 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 soft-tissue x-ray 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.

CT Scan: Ludwig Angina

Treatment

The infectious odontogenic source 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.

Treatment: Localized infections

I&D may be performed if a periapical or periodontal abscess is identified, depending on physician 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 days).

Treatment: Deep fascial infection

Infections of the neck's deeper fascial layers and masseteric layers have a higher chance of causing impingement upon 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 patient is awake is preferred. Various drains and incisions are used for drainage of the affected fascial space.

Treatment: Emergency Care

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 IV antibiotics. Infections in the various fascial spaces require I&D by the consulting physician.

Treatment: Emergency Care

If airway issues are of concern (eg, Ludwig angina, retropharyngeal abscesses), call anesthesiology and surgeon 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.

Cricothyroidotomy