Dental Infection

Basics

Dental caries and periodontal disease are common dental infections.

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. 50% of children 6 to 8 years of age have dental caries and 85% of adults have at least one tooth with decay. 35% of Americans between the ages 30 and 90 years have periodontal disease. One in 2,600 hospital admissions are related to dental infection.

Incidence

Overall incidence of dental caries in children is ~47%.
Rates of untreated dental caries are highest in Latino and non-Latino Black individuals below the poverty line (up to 58%).

Prevalence

Dental caries is the most common chronic disease worldwide with 2.44 billion people suffering permanent tooth decay.
90% of adults aged 20 to 64 years have had dental caries in their permanent teeth.

Etiology and Pathophysiology

Caries are caused by a polymicrobial biofilm matrix (primarily Streptococcus mutans) that produces acid that damages the enamel, dentin, and cementum that is transmissible to household members.
Caries progress to reversible pulpitis (intermittent pain), then irreversible pulpitis, followed by apical periodontitis (persistent tooth pain).

Risk Factors

Low socioeconomic status/lack of dental insurance
Smoking
Household members with untreated dental caries (especially in past 12 months)
Previous dental caries
Gingival recession
Poor oral hygiene; diet consisting of sugary foods and drinks, snacking without brushing; inadequate fluoride use
Trauma to the teeth or jaw
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)

Diagnosis

History

Pain of involved tooth; may refer to ears, jaw, cheek, neck, or sinuses; unexplained headaches
Hot/cold sensitivity
Unprovoked, intermittent, and/or constant pain
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 (herpes simplex, herpangina, hand-foot-mouth disease) or aphthous stomatitis
Temporomandibular joint (TMJ) dysfunction (myofascial pain, ± internal derangement of TMJ)
Parotitis
Retropharyngeal abscess

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

No initial labs needed unless patient looks acutely ill
If acutely ill
- Consider CBC with differential.
- If abscess present, drain/aspirate pus and culture for aerobes and anaerobes.
Individual films of suspected teeth, including root apices; test with palpation, percussion, and cold sensitivity.
Panoramic film or CT scan of the teeth and jaw to evaluate the extent of infection

Follow-Up Tests & Special Considerations

Panoramic radiograph, particularly if trismus present
CT/MRI scan can be helpful if facial swelling extends below inferior border of mandible or into infraorbital space. This helps to locate for potential incision and drainage by oral and maxillofacial surgeon or ENT (1)[C],(2)[C].

Treatment

Early disease (gingivitis, periodontitis) does not typically warrant antibiotic use.
Antibiotics should be prescribed for acute infections with local/systemic spread or when drainage/débridement is not possible.
All antibiotics should be prescribed for the shortest duration possible, which is typically 3 to 7 days.
Consider IV antibiotics only in the case of severe disease such as local infiltration or systemic infection.
Appropriate pain control: anti-inflammatory agents are first line; short-course opioids in some cases
Refer to oral health provider for definitive treatment: incision and drainage, root canal, extraction, pulpectomy, gum therapy
If infection is severe (soft tissue infiltration, systemic symptoms), consider hospitalization with IV antibiotics until stable. It will likely require intraoral or extraoral incision and drainage; definitive treatment (extraction, pulpectomy, or root canal therapy) is necessary to prevent progression or recurrence.

General Measures

NSAIDs typically provide appropriate analgesia; ibuprofen 400 mg (pediatrics: 10 mg/kg) q6h or naproxen 440 mg (pediatrics: 10mg/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 an NSAIDs (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

First Line

Amoxicillin: 500 mg PO TID, 1,000 mg IV BID; (pediatrics: 40 to 60 mg/kg/day PO divided q8h) or
Penicillin: 500 mg PO QID, 1.2 to 2.4 million units IM/IV daily; pediatrics: 25 to 75 mg/kg/day PO divided q6–8h) or
Metronidazole 500 mg PO/IV TID (penicillin allergy alternative or adjunct to above if infection is spreading); pediatrics: 30 mg/kg/day PO/IV divided q8h (2)[C]

Second Line

If no response to first-line treatment or inability to tolerate above medications

Clindamycin 150 mg 4×/day; pediatrics: 10 to 25 mg/kg po divided q8h) or
Amoxicillin/clavulanic acid: 500/125 mg PO TID or 875/125 mg PO BID, 1,000 to 2,000 mg IV TID or
Clarithromycin 250 mg PO BID; pediatrics: 15 mg/kg/day po divided q12h (2)[C]

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 (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

Ongoing Care

Educate regarding proper oral hygiene, need for follow-up dental care, and potential medical complications that arise due to lack of dental care.

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 day; water as beverage of choice between meals

Pediatric Considerations

Include oral health screening and exam at each well-child care visit.
Limit frequency of sugary drinks, in-between meal snacks of sugary/sticky foods, and advise against sleeping with a bottle.
Fluoride varnish twice a year (more for higher risk children) for children age <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 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.
Avoid milk, formula, or juice in bottles in children whose teeth have started to erupt; avoid sleeping with bottle.

Prognosis

Prognosis is excellent with proper treatment.

Complications

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

Authors

Bernadette Pendergraph, MD
Frances Leung, MD, MPH

References

Cheng L, Zhang L, Yue L, et al. Expert consensus on dental caries management. Int J Oral Sci. 2022;14(1):17. [PMID:35361749]
Jevon P, Abdelrahman A, Pigadas N. Management of odontogenic infections and sepsis: an update. Brit Dent J. 2020;229(6):363–370. [PMID:32978579]
Carrasco-Labra A, Polk DE, Urquhart O, et al. Evidence-based clinical practice guidelines for the pharmacologic management of acute dental pain in adolescents, adults, and older adults: a report from the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania. J Am Dent Assoc. 2024;155(2):102–117.e9. [PMID:38325969]

Additional Reading

Krol DM, Whelan K; and AAP Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2023;151(1):e2022060417. [PMID:36530159]
Rajwani AR, Hawes SND, To A, et al. Effectiveness of manual toothbrushing techniques on plaque gingivitis: a systematic review. Oral Health Prev Dent. 2020;18(4): 843–854. [PMID:33028052]
Smiles for Life: A National Oral Health Curriculum. Society of Teachers of Family Medicine Group on Oral Health. http://www.smilesforlifeoralhealth.com/all-courses/. Accessed June 17, 2025.
Stephens MB, Wiedemer JP, Kushner GM. Dental problems in primary care. Am Fam Physician. 2018;98(11):654–660. [PMID:30485039]

Codes

ICD-10

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)

Clinical Pearls

Dental related ED visits continue to rise, especially among the uninsured, underscoring the need for integrated oral health in primary care.
Untreated dental infections can act as a nidus for systemic inflammation and are linked to adverse cardiovascular outcomes.
Do not ignore tooth pain as it may be a sign of impending serious infection.
Treat patients with local signs of soft tissue infection aggressively with an early referral to oral health professional and antibiotics as infections can spread quickly, leading to significant morbidity or even death.
Prevention (oral hygiene, fluoride, dental visits) is the key to avoiding odontogenic infections.
When indicated, amoxicillin and clindamycin are generally the antibiotics of choice for odontogenic infections.

Last Updated: 2027