Basics
Description
A dental infection is an acute or chronic inflammatory response of the dental pulp (pulpitis) tissue caused by the invasion of bacteria secondary to caries or trauma. Pulpal infection can lead to necrosis of the pulp tissue and cause an abscess (localized collection of pus) to form.
- Reversible pulpitis is a condition when pulpitis can be reversed such as the placement of a filling in a tooth.
- Irreversible pulpitis is a condition that cannot be reversed and rather leads to necrosis of the nerve and eventual abscess deposition.
Epidemiology
- Periapical abscesses account for 47% of all dental-related attendances at pediatric emergency rooms in the United States.
Risk Factors
- Poor diet (high in sugar)
- Poor hygiene (visible plaque on teeth)
- Dental caries
- Low socioeconomic status
- Lack of dental home due to access to care
Pathophysiology
- Most dental infections are a result of the advancement of dental caries from the enamel, into the dentin, and finally, into the pulp tissue of the tooth.
- Advancement occurs due to the production of acid by a group of bacteria that metabolize sugar from diet.
- As more acid is created, the pH of the oral cavity is lowered, which further enhances the cycle.
- Demineralization of the tooth layers occurs. As the caries process progresses, the bacteria then invade the pulp where an inflammatory response is initiated.
- Necrosis of the pulp tissue occurs and forms an abscess at the apex of the root, resulting in bone destruction.
- Depending on host factors, infection may remain localized and drain through a sinus tract or may spread into the marrow, perforate the cortical plate, and invade surrounding tissues and facial planes.
- Typically, once full necrosis of the nerve has occurred, the pain subsides, and abscess formation is present.
- This is particularly dangerous because the abscess can remain localized at the apex of the tooth or proceed between muscles, arteries, and veins into fascial spaces and cause significant and potentially life-threatening problems.
- However, most are self-limiting and establish intraoral localized drainage.
Diagnosis
History
- Nocturnal pain
- Inability to eat due to pain
- Sensitivity to cold
- Fever
- Swelling
- Typically, symptoms of reversible pulpitis include sensitivity to hot/cold/sugary foods or sensitivity to air/brushing. Pain is acute in nature. When the stimulus is removed, the spontaneous pain subsides. When the tooth is restored, the pain disappears.
- Irreversible pulpitis symptoms include a dull achy pain that is constant, whether a stimulus is present or not. Most patients present to the dentist or the emergency room with irreversible pulpitis or abscess/infection.
Physical Exam
- Lymphadenopathy
- Extraoral asymmetry due to swelling
- Intraoral swelling
- Sublingual, submandibular, vestibular, palatal swelling adjacent to tooth
- Sinus tract or fistula adjacent tooth
- Limited oral opening
- Tenderness to palpation
- Low-grade fever
- Dehydration
Diagnostic Tests & Interpretation
Imaging
- Periapical or panoramic radiograph
- Localized bone destruction or widened periodontal ligament (PDL) space
- CT scan in cases of serious extraoral swelling
Diagnostic Procedures/Other
Dentists perform pulp vitality tests to assess the health of the nerve, which can dictate treatment. Depending on the response of the nerve to cold, electricity, or percussion, a proper diagnosis can be reached.
- Percussion test (tapping on tooth elicits pain)
- Vitality test
- Cold test
- Electric pulp test (EPT)
- Mobility of tooth
Differential Diagnosis
- Reversible pulpitis
- Gingival abscess due to foreign body
- Ulceration (herpetic or aphthous)
- Eruption of permanent tooth
Treatment
Medication
Antibiotic use should be considered when symptoms include nocturnal pain, fever, lymphadenopathy, and extraoral swelling.
First Line
- Amoxicillin 20-40 mg/kg/day in divided doses
- Augmentin 25-45 mg/kg/day in divided doses
- Tylenol 10-15 mg/kg/dose every 4-6 hours
- Ibuprofen 4-10 mg/kg/dose every 6-8 hours
Second Line
- Clindamycin 8-20 mg/kg/day in divided doses
- Azithromycin 5-12 mg/kg/day in one dose
Additional Therapies
- Treatment of irreversible pulpitis or dental infection in primary teeth includes extraction of offending primary tooth or pulpectomy (primary tooth root canal). Extraction is preferred, as the goal is to create the most ideal environment for the permanent tooth to continue to develop. It is not uncommon for the permanent tooth to undergo damage in the presence of a long-term chronic infection.
- Treatment of irreversible pulpitis in permanent teeth includes root canal therapy (removal of the nerve and replacing the nerve with a synthetic filling material) followed by crown.
General Measures
- Space maintenance
- Space maintenance is important to allow proper growth and development of the permanent teeth.
- The primary tooth is the best space maintainer.
- Without opposing or adjacent primary teeth, others may drift or tip into the space left by the extracted tooth, causing the development of malocclusions.
- Spacers are used for space maintenance.
Inpatient Considerations
Admission Criteria/Initial Stabilization
- Significant extra- or intraoral swelling due to abscess
- Unusual drowsiness, headache, or a stiff neck; weakness or fainting
- Difficulty swallowing or breathing
- Significant eyelid swelling (e.g., eye swollen shut)
- A rising fever, dehydration, and inability to eat
- Although rare, a dental infection or abscess may spread to fascial planes and cause facial cellulitis.
- An infection in the buccal space can cause extraoral swelling in the infraorbital, zygomatic, and buccal regions. This most often involves maxillary molars.
- An infection in the submental space can cause extraoral swelling secondary to infection the mandibular incisors.
- An infection in the submandibular space can cause extraoral swelling unilaterally in the submandibular region secondary to infection in the mandibular molars.
- The spread of dental infection through the fascial planes can end at the parapharyngeal or retropharyngeal spaces.
- Dental infections can also spread via lymphatics, veins, and arteries. The cavernous sinus is involved in most fatal spread of dental infection due to the lack of retrograde valves in the veins leading into the sinus. The result may be a cavernous sinus thrombosis.
Alert
An infection in the submental, sublingual, and bilateral submandibular spaces is referred to as Ludwig angina. Infection may spread down the anterior cervical triangle to the clavicles. Speaking, swallowing, and breathing are severely compromised. This is a medical emergency and requires establishment of a safe airway (intubation).
Ongoing Care
Follow-up Recommendations
- Referral to pediatric dentist for treatment
- Extraction, root canal therapy, restorative treatment
- Thorough dental workup for other caries
- Resolution of abscess/swelling
- Management of space issues caused by extraction
- Establish proper dental home with proper dietary and hygiene intervention and guidance.
Prognosis
The prognosis for a dental infection or abscess is good with proper medical and dental treatment.
Additional Reading
- American Academy of Pediatric Dentistry. 2014-15 Definitions, oral health policies, and clinical guidelines. http://www.aapd.org/policies/. Accessed September 2013.
- American Academy of Pediatrics, American Society for Microbiology. Your Child and Antibiotics: Unnecessary Antibiotics Can Be Harmful. Atlanta, GA: Centers for Disease Control and Prevention; 1997.
- American Association of Oral and Maxillofacial Surgeons. Parameters of care: clinical practice guidelines for oral and maxillofacial surgery (AAOMS ParCare 07 Ver 4.0). J Oral Maxillofac Surg. 2007;32(Suppl):238-245.
- Centers for Disease Control and Prevention, Food and Drug Administration, National Institutes of Health. A public health action plan to combat antimicrobial resistance. 1999. http://www.cdc.gov/drugresistance/actionplan/aractionplan.pdf. Accessed September 2013.
- Dodson T, Perrott D, Kaban L. Pediatric maxillofacial infections: a retrospective study of 113 patients. J Oral Maxillofac Surg. 1989;47(4):327-330. [View Abstract]
- Graham DB, Webb MD, Seale NS. Pediatric emergency room visits for nontraumatic dental disease. Pediatr Dent. 2000;22(2):134-140. [View Abstract]
- Kaban L, Troulis M. Infections of the maxillofacial region. In: Kaban L, Troulis M, eds. Pediatric Oral and Maxillofacial Surgery. Philadelphia, PA: Saunders; 2004:171-186.
- Seow W. Diagnosis and management of unusual dental abscesses in children. Aust Dent J. 2003;43(3):156-168. [View Abstract]
Codes
ICD09
- 522.0 Pulpitis
- 522.1 Necrosis of the pulp
- 522.5 Periapical abscess without sinus
- 523.30 Aggressive periodontitis, unspecified
ICD10
- K04.0 Pulpitis
- K04.1 Necrosis of pulp
- K04.7 Periapical abscess without sinus
- K05.21 Aggressive periodontitis, localized
SNOMED
- 32620007 Pulpitis (disorder)
- 42711005 Necrosis of the pulp (disorder)
- 196341005 Periapical abscess (disorder)
- 449908004 aggressive periodontitis (disorder)
- 91862002 Acute periodontal abscess (disorder)
FAQ
- Q: It's just a baby tooth. Isn't it going to fall out?
- A: Dental pain can affect a child's daily activities, leading to delayed growth and development and diminished ability to learn. Delayed treatment for a dental infection may cause damage to the permanent teeth or may proceed to a facial cellulitis. Premature primary tooth loss due to infection and extraction can lead to eruption and crowding issues in the permanent dentition.
- Q: I had horrible teeth growing up. Is this genetic?
- A: Genetic variation of the host factors may contribute to increased risks for dental caries; however, research suggests that other risk factors contribute greater such as diet and hygiene.
- Q: I see a pimple on my child's gums, but he does not complain of pain and is sleeping fine. Does this require treatment?
- A: All dental infections involving primary or permanent teeth require some form of treatment. If the body's host factors have localized the infection, drainage may occur with the absence of pain; however, the source of the infection remains. This may lead to damage to succedaneous (permanent) teeth or spread of the infection into a cellulitis.
- Q: I started the course of antibiotics and my child is feeling better. Is it necessary to complete the antibiotic?
- A: It is necessary to complete the entire course of the antibiotic unless an allergic reaction is occurring. Resolution of pain or swelling does not ensure the infection has fully responded to the antibiotic. Follow-up studies suggest that antibiotic use should continue at least 5 days beyond the point of improvement of symptoms.