DESCRIPTION

• Pain ± swelling in the head and neck region with odontogenic (teeth and supporting structures) origin of infection; if left untreated, can lead to serious and potentially life-threatening illnesses.
• Assume any head and neck infection or swelling to be odontogenic in origin until proven otherwise.
• Antibiotics should be prescribed as an adjunct to proper dental intervention. Antibiotics should be prescribed for acute infections for 3 to 7 days.
• Gingivitis and periodontal disease may be treated with oral antibiotics. Soft tissue infections may require IV antibiotic treatment.

EPIDEMIOLOGY

~27% of Americans have untreated dental caries. 75% have had at least one dental restoration. 35% of Americans between the ages 30 to 90 have periodontal disease. 1 in 2,600 hospital admissions are related to dental infection. The presence of odontogenic disease is closely linked to socioeconomic status as fewer Americans have dental insurance than health insurance.

ETIOLOGY AND PATHOPHYSIOLOGY

• >90% of all head and neck infections have an odontogenic origin.
• Caries or trauma can lead to death of the tooth pulp, which can lead to infection and/or abscess of adjacent tissues via direct or hematogenous bacterial colonization.
• Caries (tooth decay; “cavity”) is a common infectious disease that causes demineralization of the hard tissue (enamel, dentin, and cementum).
• Typical oral microbiome includes numerous anaerobic and gram-positive bacteria. The most common pathologic aerobic bacteria is Streptococcus spp. Most dental infections are polymicrobial infections with anaerobic gram-negative rods and anaerobic gram-positive cocci.
• Streptococcus mutans (S. mutans) is easily transmitted to newly dentate infants by caregivers.
• Acidic secretions from S. mutans are implicated in early caries.
• Anaerobic bacteria are more common with infections near the tooth base.

RISK FACTORS

• Low socioeconomic status
• Smoking
• Parent and/or sibling with history of caries or existing untreated dental caries (especially in past 12 months)
• Previous dental caries
• Poor access to dental/health care; lack of dental insurance; fear of dentist
• Poor oral hygiene; poor nutrition, including diet containing high level of sugary foods and drinks; snacking without brushing
• Trauma to the teeth or jaw
• Inadequate access to and use of fluoride
• Gingival recession (increased risk of root caries)
• Physical and mental disabilities
• Poorly controlled systemic diseases (e.g., diabetes)
• Decreased salivary flow (e.g., use of anticholinergic medications, immunologic diseases, radiation therapy to head and neck, methamphetamine use)

GENERAL PREVENTION

• Most dental problems can be avoided through flossing/use of interdental brushes; brushing with fluoride toothpaste, systemic fluoride (fluoridated bottled water; fluoride supplements for high-risk patients and in nonfluoridated areas); fluoride varnish for all children age <6 years and moderate- to high-risk patients; regular dental cleanings.
• Prevent transmission of S. mutans from mother/caregiver to infant by improving maternal dentition, chlorhexidine gluconate rinses, and use of xylitol products for mother especially during first 2 years of a child’s life. Avoid smoking, which is linked to severe periodontal disease. Use of acid neutralization agents such as baking soda wiping after meals/snacks to decrease bacteria colonization.
• Good control of systemic diseases (e.g., diabetes) and changes in lifestyle (e.g., smoking cessation)
• Fluoride varnish provided by dental or medical primary care providers twice per year most cost-effective treatment for prevention of pit and fissure caries (1)[C]

COMMONLY ASSOCIATED CONDITIONS

• Extensive caries, crowding, multiple missing teeth
• Periapical and periodontal abscess
• Soft tissue cellulitis
• Periodontitis (deep inflammation ± infection of gingiva, alveolar bone support, and ligaments)

HISTORY

• Pain of involved tooth; can be referred to ears, jaw, cheek, neck, or sinuses; unexplained headaches
• Hot/cold sensitivity
• Pain can be unprovoked, intermittent, and/or constant.
• Pain with biting or chewing
• Trismus (inability to open mouth)
• Bleeding or purulent drainage from gingival tissues
• When severe infection (systemic): fever, difficulty breathing or swallowing, raspy voice, neck kept in flexed position, mental status changes

PHYSICAL EXAM

• Gingival edema and erythema
• Cheek (extraoral) or vestibular (intraoral) swelling
• Fluctuant mass at involved site
• Suppuration of gingival margin
• Submandibular or cervical lymphadenopathy
• Severe (systemic) infection signs include fever and airway compromise

DIFFERENTIAL DIAGNOSIS

• Bacterial or viral pharyngitis
• Pericoronitis (inflammation ± infection of gum flap over mandibular last molar, typically 3rd molars)
• Otitis media or externa; sinusitis
• Headache/migraine
• Viral (HSV1, herpangina, hand-foot-mouth disease) or aphthous stomatitis
• Temporomandibular joint (TMJ) dysfunction (myofascial pain, ± internal derangement of TMJ)
• Parotitis
• Retropharyngeal abscess
• Jaw pain can be anginal equivalent, especially in women and especially lower left side of the jaw.

DIAGNOSTIC TESTS & INTERPRETATION

GENERAL MEASURES

• NSAIDs typically provide appropriate analgesia. Ibuprofen 400 mg (pediatrics: 10 mg/kg) q6h or naproxen 440 mg (pediatrics: 10 mg/kg) q12h. If there is a contraindication or intolerance to NSAIDS, can use acetaminophen 650 to 1,000 mg (pediatrics: 10 to 15 mg/kg) q6–8h PRN for pain (3)[A].
• For more severe pain, consider adding acetaminophen to a NSAID (synergistic effect). On rare occasions, a short course of opioids may be necessary (3)[A].
• Local nerve block with long-acting anesthetic (0.5% bupivacaine plus 1:200,000 epinephrine) or local infiltration injection (0.5% bupivacaine plus 1:200,000 epinephrine or 4% articaine plus 1:100,000/1:200,000 epinephrine) may decrease need for rescue medications in the first 48 hours; avoid injecting through infection to avoid tracking infection (3)[A].

MEDICATION

ISSUES FOR REFERRAL

Referral to oral health provider should be done in order to determine degree of infection, treat infection, and provide ongoing preventive dental cleanings and surveillance (1)[C].

SURGERY/OTHER PROCEDURES

• Incise and drain large, fluctuant abscesses.
• Root canal or extraction is definitive treatment.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Criteria for hospital admission: swelling involving deep spaces of the neck, floor of the mouth, or infraorbital region; deviation of the airway; unstable vital signs; fever (<101°F); chills; raspy voice; confusion or delirium; or evidence of invasive infection or cellulitis (2)[C]

• Ensure secure airway.
• IV fluid resuscitation if necessary
• Initiate antibiotics as recommended above.
• Ensure good oral hygiene.
• Rinse or swab mouth with chlorhexidine gluconate BID.
• Use warm saltwater rinses several times per day, especially after incision and drainage; ice packs to decrease swelling and encourage drainage
• Discharge patient when
  • Airway not compromised
  • Abscess and sepsis eliminated
  • Able to take PO intake and ambulate

FOLLOW-UP RECOMMENDATIONS

• Follow up with oral health provider within 24 hours.
• Ensure adequate hydration, nutrition, and pain control (2)[C].

DIET

• Maintain a healthy diet; bacteria thrive on refined sugar and starch.
• Avoid sugary foods that stick between the teeth.
• Avoid the use of sugary/carbonated drinks throughout the day; water as beverage of choice between meals

Pediatric Considerations
In children, limit the frequency of sugary drinks and advise against sleeping with a bottle; fluoride varnish twice a year (more for higher risk children) for children aged <6 years; fluoride supplementation for children starting at 6 months of age if their primary water source is deficient in fluoride

PATIENT EDUCATION

• Control caries and periodontal disease.
• Brush at a minimum of twice daily and use floss/interdental brush daily; brushing/flossing after every meal may further improve oral health. Children <2 years of age should use a smear of low fluoride toothpaste while those 2 to 5 years of age should use a pea sized amount of fluoride toothpaste.
• Fluoride supplementation is critical if primary water source is fluoride-deficient
• Biannual dental visits at a minimum for oral care and fluoride varnish, beginning when first primary tooth comes in (1)[C]
• Limit the frequency of sugar/carbonated drinks and sugary or sticky foods.
• In young children, avoid sleeping with a bottle to decrease the chance of dental caries.
• Avoid milk, formula, or juice in bottles in children whose teeth have started to erupt.

PROGNOSIS

Prognosis is excellent with proper treatment.

COMPLICATIONS

• Ludwig angina
• Retropharyngeal and mediastinal infection
• Osteomyelitis
• Endocarditis/cardiac tamponade
• Submental or submandibular infection
• Can worsen metabolic diseases including diabetes
• Brain abscess/death

ICD10

• K02.9 Dental caries, unspecified
• K04.7 Periapical abscess without sinus
• K12.2 Cellulitis and abscess of mouth
• K05.6 Periodontal disease, unspecified

SNOMED

• 427898007 infection of tooth (disorder)
• 80967001 Dental caries (disorder)
• 299709002 dental abscess (disorder)
• 2556008 Periodontal disease (disorder)
• 32620007 Pulpitis (disorder)