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Dental, Infections
Last Updated: December 3, 2004

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Synonyms and related keywords: tooth infection, retropharyngeal space infection, Ludwig angina, Ludwig's angina, gingivitis, odontogenic infection

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AUTHOR INFORMATION

Section 1 of 9

Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

Author: Lynnus Peng, MD, Assistant Clinical Professor, University of California at Irvine, Department of Anesthesiology, Vice Chairman, St Jude Medical Center Coauthor(s): Amin Antoine Kazzi, MD, Vice Chair, Associate Professor, Division of Emergency Medicine, University of California at Irvine Medical Center; Willard Peng, BA, BS, Masters Candidate, Biology, CU Denver Lynnus Peng, MD, is a member of the following medical societies: American Society of Anesthesiologists Editor(s): Michael Glick, DMD, Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center, Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of

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Patient Education

Teeth and Mouth Center Gingivitis Overview Gingivitis Causes Gingivitis Symptoms Gingivitis Treatment Dental Abscess Overview Toothache Overview When to Visit the

Medicine, Harvard Medical School; and Barry Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, and Professor of Anatomy and Neurobiology, Chairman, Department of Emergency Medicine, University of Arkansas for Medical Sciences Disclosure

Dentist - Introduction

INTRODUCTION

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Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

Background: Infections of the teeth have plagued humans constantly, despite a quest for better oral hygiene. As early as 200 BCE, a bronze wire root canal filling was found in the skull of a Nabataean warrior. 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. Greater demineralization of the tooth occurs with high bacterial activity and low pH. Greater remineralization occurs with a pH higher than 5.5 and high concentrations of calcium and phosphate from the saliva. 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:

In the US: 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 19721980. Internationally: In the United Kingdom, a 39% decline in caries occurred from 1970-1980. In Denmark, a 39% decline occurred from 1972-1982.

Mortality/Morbidity: 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).

Neutropenic patients undergoing chemotherapy are at risk for certain pathogenic oral microorganisms causing bloodstream infections, which increase the chance of morbidity and mortality. Odontogenic infections carry significant morbidity of pain and cosmetic defect. The US bill for dental care was estimated at $27 billion in 1985. The oral cavity contains approximately 30-50% viridans group streptococci that are resistant to penicillins and macrolides.

Age: The National Preventive Dentistry Program found that 60% of caries occurred in 20% of children, who were generally minorities or of lower socioeconomic status.

CLINICAL

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Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

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 infections
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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. 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 usually is not involved.

Mandibular infections
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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. The condition is odontogenic in 90% of cases and arises from the second and third mandibular molars in 75% of cases. 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

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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
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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
Section 4 of 9

WORKUP

Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

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 limited facial series also may be performed to help visualize the offending area if these studies are not available; cooperation and communication with the radiology technician and radiologist is necessary. 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.
o

Soft tissue planes may be seen; with increasing infection, inflammation, and fat streaking, the planes may be difficult to differentiate from adjacent muscle. CT scan helps elucidate abscesses, venous thrombosis, and lymph node involvement.

MRI is not yet favored because of cost and limited availability. CT scan is preferred for rapid visualization of odontogenic infections.
Section 5 of 9

TREATMENT

Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

Emergency Department Care:

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.

Localized infections
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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).

Deep fascial infections

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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.

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

Consultations:

Oral surgeon Dentist Otolaryngologist

MEDICATION

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Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

The goals of therapy are to treat the infection and prevent further complications.

Drug Category: Antibiotics -- Therapy must cover all likely pathogens in the
context of the clinical setting. Penicillin VK (Veetids) -- Inhibits biosynthesis of cell wall mucopeptide and is effective during active Drug Name replication. Inadequate concentrations may produce only bacteriostatic effects. Adult Dose 250-500 mg PO q6h Pediatric Dose 50 mg/kg/d PO divided qid Contraindications Documented hypersensitivity Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a Interactions decrease in the effectiveness of penicillins when administered concurrently Pregnancy B - Usually safe but benefits must outweigh the risks. Precautions Caution in renal impairment Amoxicillin and clavulanic acid (Augmentin) -- Drug combination that extends the antibiotic spectrum of this penicillin to include bacteria normally resistant to Drug Name beta-lactam antibiotics. Indicated for skin and skin structure infections caused by beta-lactamase producing strains of Staphylococcus aureus. Administer for a minimum of 10 d. Adult Dose 500/125 mg PO tid Pediatric Dose 40 mg/kg/d PO divided tid Contraindications Documented hypersensitivity Coadministration with warfarin or heparin increases Interactions risk of bleeding Pregnancy B - Usually safe but benefits must outweigh the risks. Give for a minimum of 10 d to eliminate organism and prevent sequelae (endocarditis, and rheumatic fever); Precautions following treatment, perform cultures to confirm eradication of streptococci Drug Name Erythromycin (EES, E-Mycin, Ery-Tab) -- DOC in

patients who are allergic to penicillin. Inhibits RNAdependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes, inhibiting bacterial growth. Adult Dose 250-500 mg PO q6h Pediatric Dose 30-50 mg/kg/d PO divided qid Contraindications Documented hypersensitivity; hepatic impairment Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and Interactions cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis Pregnancy B - Usually safe but benefits must outweigh the risks. Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are Precautions common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur Clindamycin (Cleocin) -- Lincosamide useful to treat serious skin and soft tissue infections caused by most staphylococci strains. Effective against aerobic and anaerobic streptococci, except enterococci. Drug Name Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition. Adult Dose 600-900 mg IV q8h Pediatric Dose 20-40 mg/kg/d IV divided q6-8h Documented hypersensitivity; regional enteritis; Contraindications ulcerative colitis; hepatic impairment; antibioticassociated colitis Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; Interactions erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin Pregnancy B - Usually safe but benefits must outweigh the risks. Adjust dose in severe hepatic dysfunction; no Precautions adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis Drug Name Ampicillin and sulbactam (Unasyn) -- Combination antimicrobial agent that utilizes a beta-lactamase inhibitor with ampicillin. Gives better anaerobic

coverage. Adult Dose 1.5-3 g IV q6h 3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h Pediatric Dose >12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin Contraindications Documented hypersensitivity Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has Interactions additive effects on ampicillin rash; may decrease effects of oral contraceptives Pregnancy B - Usually safe but benefits must outweigh the risks. Adjust dose in renal failure; evaluate rash and Precautions differentiate from hypersensitivity reaction Ticarcillin and clavulanate (Timentin) -- Used for deep space infections. Inhibits biosynthesis of cell wall mucopeptide and is effective during stages of active Drug Name growth. Antipseudomonal penicillin plus a beta-lactamase inhibitor that provides coverage against grampositive, gram-negative, and anaerobic organisms. Adult Dose 3.1 g IV q6h Pediatric Dose 75 mg/kg IV q6h Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and Contraindications purulent or septic arthritis should not be treated with oral penicillin during acute stage Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; Interactions effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels Pregnancy B - Usually safe but benefits must outweigh the risks. Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with Precautions hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Metronidazole (Flagyl) -- An imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually employed in combination with Drug Name other antimicrobial agents except when used for Clostridium difficile enterocolitis in which monotherapy is appropriate. An addition for treating Ludwig angina. Adult Dose 1 g loading dose IV; then 500 mg IV q6h Pediatric Dose 15 mg/kg loading dose IV; then 7.5 mg/kg q6h Contraindications Documented hypersensitivity May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of Interactions metronidazole; disulfiram reaction may occur with orally ingested ethanol Pregnancy B - Usually safe but benefits must outweigh the risks. Adjust dose in hepatic disease; monitor for seizures Precautions and development of peripheral neuropathy FOLLOW-UP
Section 7 of 9
Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

Complications:

Abscess Sepsis

Patient Education:

For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Also, see eMedicine's patient education articles Gingivitis, Dental Abscess, Toothache, and When to Visit the Dentist.
Section 8 of 9

MISCELLANEOUS

Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

Special Concerns:

Prophylaxis controversy continues regarding who should have antibiotic prophylaxis for dental procedures and which antibiotics to use. Current recommendations by the American Heart Association for dental, oral, respiratory tract, or esophageal procedures

For adults, administer amoxicillin 2 g PO 1 hour before procedure. Administer amoxicillin 50 mg/kg PO for pediatric patients. If by IV, administer ampicillin 2 g for adults and 50 mg/kg for children within 30 min before the procedure. Give patients who are allergic to penicillin clindamycin 600 mg PO/IV 1 hour before the procedure, and clindamycin 20 mg/kg PO/IV for pediatric patients. Alternatively, azithromycin or clarithromycin 500 mg PO 1 hour before the procedure may be administered for adults and 15 mg/kg PO may be administered for pediatric patients.

Current recommendations by the American Heart Association for genitourinary/GI procedures

o

For adults, administer ampicillin 2 g IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 min before the procedure; 6 hours later, administer ampicillin 1 g IV or amoxicillin 1 g PO 1 hour before procedure. Administer amoxicillin 50 mg/kg PO for pediatric patients. Give patients who are allergic to penicillin vancomycin 1 g IV over 1-2 hours plus gentamicin 1.5 mg/kg (not to exceed 120 mg); complete infusion within 30 min before the procedure.

Prophylactic regimens are for patients with prosthetic heart valves, previous bacterial endocarditis, congenital cyanotic heart disease, pulmonary shunt placement, cardiac myopathies, acquired valvular disease, and mitral prolapse with regurgitation.
o

Only 25% of patients who should receive prophylactic antibiotics actually receive them. With 100% compliance, estimates suggest that the incidence of bacterial endocarditis would be reduced 3-6%.
Section 9 of 9

BIBLIOGRAPHY

Author Information Introduction Clinical Workup Treatment Medication Follow-up Miscellaneous Bibliography

Harwood-Nuss A, Linden C, Luten R, eds: Dental, oral and salivary gland infections. In: The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins Publishers; 1996: 73-77. Holmstrup P, Poulsen AH, Andersen L, et al: Oral infections and systemic diseases. Dent Clin North Am 2003 Jul; 47(3): 575-98[Medline]. Pogrel MA: Antibiotics in general practice. Dent Update 1994 Sep; 21(7): 274-80[Medline]. Pynn BR, Sands T, Pharoah MJ: Odontogenic infections: Part one. Anatomy and radiology. Oral Health 1995 May; 85(5): 7-10, 13-4, 17-8

passim[Medline]. Reznick J: Infections of odontogenic origin. Oral Health 1993; 1-6. Roberts J, Hedges JR: Emergency dental procedures. In: Clinical Procedures in Emergency Medicine. 2nd ed. Philadelphia: W B Saunders Co; 1991: 1045-1069. Rosen P, Barkins R: Dental emergencies. In: Emergency Medicine: Concepts and Clinical Practice. 3rd ed. Vol 3. St Louis: Mosby-Year Book; 1992: 2381-2398. Sands T, Pynn BR, Katsikeris N: Odontogenic infections: Part two. Microbiology, antibiotics and management. Oral Health 1995 Jun; 85(6): 114, 17-21, 23 passim[Medline].
NOTE:

Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER Dental, Infections excerpt

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