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Home , Apical foramen, Crown (anatomy), Hexetidine, Pericoronitis, Periodontal abscess, Pulpitis

Common Dental in the Primary Care Setting DUC HUU NGUYEN, DO, University of California at Irvine Family Health Center, Anaheim, California JAMES T. MARTIN, Dr.rer.nat., College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California

Family physicians commonly encounter patients with dental infections, such as dental caries and periodontal . Dental caries is caused by that destroy the enamel and ; it can be detected by an oral examination that shows stained pits or fissures on the surface. Use of is the most effective prevention measure for dental caries. Untreated caries may progress to and, eventually, to of the . In irreversible pulpitis, the tooth dies and the patient may have a localized that can spread to surrounding . Periodontal infections are caused by bacteria in the subgingival . In , the inflamed bleed easily with brushing or flossing; the condition can be controlled with good . Periodontitis is characterized by a loss of supportive structure caused by chronic gingivitis; it is also associated with some systemic . Localized periodontitis is treated with mechanical and good oral hygiene, whereas generalized periodontitis requires adjunct . results when food particles become trapped under the gum of an impacted tooth. This condition can be controlled by removal of food debris and good oral hygiene. For patients in whom dental infec- tions are disseminated and have invaded the deeper oral spaces, antibiotic treatment should be initiated at the time of referral. (Am Fam Physician. 2008;77(5):797-802, 806. Copyright © 2008 American Academy of Family Physicians.)

This article exempli- ental infections, including den- infections and, in some circumstances, may fies the AAFP 2008 Annual tal caries and periodontal dis- initiate treatment of serious infections before Clinical Focus on infectious ease, are commonly encountered referral. Family physicians can also advise disease: prevention, diag- nosis, and management. in the primary care setting in patients on how to prevent dental infections.

▲ D the United States. Nationally, dental caries Patient information: is the most common disease in children and Basic Dental A handout on common dental infections, writ- adults. Fifty percent of children between six beings have two sets of teeth: pri- ten by the authors of this and eight years of age have dental caries,1 mary (milk or baby) and permanent. There article, is provided on and 85 percent of adults have at least one are 20 primary teeth, including two inci- page 806. tooth with decay or a filling on the .2 sors, one canine, and two molars in each half According to data from the Third National jaw. These teeth erupt at approximately six Health and Nutrition Examination Survey, months, and the set is complete by two years in the United States 48 percent of adults of age. The primary teeth are shed between between 35 and 44 years of age have expe- six and 12 years of age. These are eventu- rienced gingivitis, and 15 percent of adults ally replaced by starting older than 30 years have destructive peri- at approximately age six and usually end- odontal disease (i.e., periodontitis).3 In ing by age 18. The permanent teeth include 2005, dental services in the United States two , one canine, two , and cost $86.6 billion, 4.4 percent of the total three molars in each half jaw. spent on health care that year.4 Structurally, a tooth has a visible crown that Clearly, the direct costs (i.e., the money projects above the gingiva. Enamel is the out- spent on dental services) and indirect costs ermost layer of the crown and is the hardest (i.e., the number of lost days of productivity structure of the body. In the middle is the den- at work and school) of oral diseases place a tin, a bone-like material, and the innermost high burden on society. Family physicians layer is the pulp chamber (Figure 1). Similarly, are in a good position to address this mor- the roots of the tooth have as the bidity. They can recognize common dental outermost layer, the dentin is in the middle,

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References Comments

Most dentists recommend a six-month interval for dental C 7 There is insufficient evidence checkups for all patients. to support or refute biannual dental visits with a small amount of low-fluoride B 8, 11-13 — should be introduced to children at two years of age. After six years of age, children can safely use regular fluoridated toothpaste. Tooth brushing with fluoridated toothpaste twice a day after meals A 8, 15 The benefits of topical is recommended as an effective way to prevent . have been firmly established Use of powered that have a circular oscillating B 16 Long-term benefits of using motion can reduce plaque and gingivitis more effectively than powered toothbrushes for manual brushing. dental health are unclear Decreasing the amount and frequency of consumption of foods B 5, 8 — with a high content can improve oral health.

A = consistent, good quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 739 or http:// www.aafp.org/afpsort.xml.

and the pulp canal is in the center. The vessels and nerves enter the pulp chamber through the and the pulp canal. The tooth is held in its socket by peri- odontal ligaments () connecting

Enamel the tooth to the alveolar bone structure. Dental Caries Dentin Dental caries is caused mainly by micro- that generate on the tooth Pulp surface from disaccharides and monosac- charides present in sugar-rich foods; this to demineralization of the protective enamel coating and subsequent tooth decay. Certain foods such as sweetened pastries may be more potent than others at inducing den- 5 Periodontal tal caries. Even diet sodas, which contain no ligament , have been implicated in decalcifica- tion caused by low pH from phosphoric . It is the frequency of exposure rather than the amount of substrate that Alveolar bone makes the difference in caries rates. s

ch Initially, dental caries is asymptomatic. As sa the progresses, depending on the olson

y severity of the caries, patients may experience ce

sta sensitivity to thermal changes, mild , or severe pain (when dental caries encroaches Tooth apices on the pulp). Dental caries initially presents

ILLUSTRATION BY as a pit or fissure in the tooth surface that can Figure 1. Anatomy of a tooth. be detected by a dental probe. These pits or

798 American Family Physician www.aafp.org/afp Volume 77, Number 6 ◆ March 15, 2008 fissures will eventually become stained because of demin- eralization of the enamel and dentin (Figure 2). Recession of the gums in aging patients may expose the roots to den- tal caries. Dental caries is also diagnosed by radiographic examination; low-level lasers can detect early tooth decay.

DENTAL CARIES PREVENTION Examinations by a dentist should begin when patients are one year of age.6 Although most dentists have recom- mended a six-month interval for dental checkups, there is insufficient evidence to support or refute the biannual ver- Figure 2. Dental caries of a right lower . sus annual visits.7 The most cost-effective intervention for reducing dental caries is the public health policy of adding changes, such as decreasing the amount and frequency fluoride at a concentration of 0.7 to 1.0 parts per million of consumption of foods with a high sugar content.5,8 (ppm) to the municipal water supply.8 Fluoride forms a complex with the crystals in the enamel and den- Pulpitis tin; where there are lesions, fluoride enhances remineral- Pulpitis, an of the dental pulp, can occur ization at the site of the caries, thereby strengthening the when caries or its bacterial byproducts encroach on the tooth structure. Fluoride also has a bacteriostatic effect. dental pulp, leading to infection, or when pathogens There is a recent trend toward using bottled water instead enter the pulp through the apical foramen or through of water from the municipal supply. Most bottled waters a tooth fracture. Reversible pulpitis occurs when den- contain less than 0.3 ppm of fluoride; therefore, persons tal caries encroaches on the pulp; it is associated with who rely on bottled water alone may need to add oral or mild inflammation of the pulp and mild intermittent topical fluoride to their oral hygiene regimen.9 pain that can be elicited by thermal changes, especially Before prescribing fluoride tablets for young children in cold drinks. The patient should be referred to a dentist; areas where water is fluoride deficient, physicians should treatment involves removal of the carious tissue and consider other sources of fluoride use by the patient and reconstruction. However, the pulp may be irreversibly weigh the risk of enamel fluorosis versus benefits of dental damaged by an ongoing inflammation within the rigid caries prevention.8,10 The benefits of topical fluorides have pulp chamber. In this situation, a rapid buildup of pres- been firmly established, regardless of whether the water sure, of blood vessels at the apical foramen, supply is fluoridated.11 When compared with mouth rinses ischemia, and eventual necrosis of the pulp tissue occur. or gels, fluoridated have a similar degree of In irreversible pulpitis, the pain is often poorly localized, effectiveness for the prevention of dental caries in chil- persistent, and dull. There is insufficient evidence in the dren.12 Parents should introduce tooth brushing with a literature to determine whether are effective pea-size amount of low-fluoride toothpaste to children in relieving pain in patients with pulpitis.17 at two years of age. In children younger than two years, A of pulpitis is periapical abscess in the parental brushing without toothpaste is recommended. periodontal tissue around the apical foramen (Figure 3). After the age of six, children can safely use regular fluo- Symptoms include tenderness on tapping the affected ridated toothpaste.8 Topical fluorides (i.e., mouth rinses, tooth and local . The periapical abscess gels, or varnishes) used in addition to toothpaste for den- is usually a localized infection that does not require anti- tal caries allow high-risk patients to achieve a modest biotic therapy before referral. The dentist will remove the additional reduction in caries compared with toothpaste necrotic pulp tissue, drain the , and reconstruct or alone.13 The use of mouth rinses and gels at home is not extract the tooth. If the abscess has spread to the adja- recommended for children younger than six years.14 cent teeth or to deeper tissue, causing , antibiotic Removing dental plaque helps the patient maintain treatment should be initiated before referral. A broad- good oral health. Tooth brushing with fluoridated tooth- spectrum, -tolerated antimicrobial such as amoxicil- paste twice a day after meals is recommended as an effec- lin/clavulanate (Augmentin) or (Cleocin) tive way to prevent tooth decay.8,15 Powered toothbrushes is recommended.18,19 If facial swelling, , and that have a circular oscillating motion can reduce plaque (inability to open the jaw) are present, indicating severe and gingivitis more effectively than manual tooth brush- cellulitis that involves deeper orofacial spaces, the patient ing.16 Finally, the physician could recommend dietary should be hospitalized to receive intravenous antibiotics.

March 15, 2008 ◆ Volume 77, Number 6 www.aafp.org/afp American Family Physician 799 Common Dental Infections

Necrotic pulp

s Cellulitis— ch spreading of sa

infection into olson surrounding y ce tissues sta Figure 4. Gingivitis of the upper gum.

Periapical abscess Apical periodontitis but there may be halitosis. Good oral hygiene, including ILLUSTRATION BY Figure 3. Pulpitis and its complications: periapical abscess frequent tooth brushing and use of gluco- and cellulitis. nate (Peridex) 0.12% or hexetidine (Oraldene) 0.1% rinse, usually reverses gingivitis.34 A mouth rinse containing Periodontal Diseases essential oils (e.g., ) is as effective is caused mainly by microorganisms as chlorhexidine in the treatment of gingivitis and may within the subgingival dental plaque. The pathogens result in less accumulation and tooth staining.35 can penetrate the gingival epithelium, elicit an inflam- matory response, and ultimately cause the destruction PERIODONTITIS of the periodontium. Periodontal disease can be classi- Periodontitis is characterized by the loss of support- fied into gingivitis and periodontitis. Periodontal infec- ive bone structure caused by chronic gingivitis; this tions may be transmissible by saliva20,21 and occur more results in detachment of the periodontal ligament from readily in susceptible hosts. These infections could be the tooth (Figure 5). Periodontitis can be classified as a cause of fever of unknown origin.22,23 Furthermore, juvenile or adult according to the patient’s age and to dental procedures that treat periodontal diseases may a slight difference in the microbiology and pathogen- to bacteremia that can pose serious risks for older esis. In localized juvenile periodontitis (12 to 17 years of or immunocompromised patients.24-26 Patients who have age),36 there is very little dental plaque involvement, but structural heart disorders are particularly vulnerable to there is a loss of vertical alveolar bone. Adult periodon- endocarditis after certain periodontal procedures, and titis normally occurs in patients older than 30 years, new recommendations on antibiotic prophylaxis are and the periodontitis is usually asymptomatic. Clinical available.27,28 Research supports an associa- tion among periodontal infections, athero- sclerosis, and vascular disease.29-31 Recent studies have shown that successful treat- ment of periodontitis improves endothelial function.32 However, no large-scale studies have tested whether treating or preventing periodontal infections leads to fewer clinical cardiovascular events.33

GINGIVITIS Gingivitis is characterized by localized inflammation of the gums without a loss of the bone that supports the teeth (Figure 4). Symptoms include and swollen, A B gums with brushing or flossing. Figure 5. Radiographs of (A) alveolar bone loss in periodontitis Pain is usually not associated with gingivitis, (arrow) compared with (B) normal alveolar bone structure (arrow).

800 American Family Physician www.aafp.org/afp Volume 77, Number 6 ◆ March 15, 2008 Common Dental Infections

PERICORONITIS Pericoronitis is an acute, localized infection caused by food particles and microorganisms trapped beneath the gingival flaps of a partially erupted tooth or an impacted (Figure 7). Symptoms typically include Figure 6. Advanced periodontitis of the lower teeth. localized pain and limitation of movement on open- ing the jaw, discomfort on chewing and swallowing, examination may show deep gum pockets that bleed eas- and facial swelling. Localized lymphadenopathy may be ily when probed, subgingival dental plaque, and receding noted, and halitosis is common. Treatment of a localized gums that expose the root of the tooth. pericoronitis involves removal of the food particles and is a severe consequence of periodontitis and may present good oral hygiene, which should include hot water as a red, fluctuant swelling of the gingiva that is extremely or chlorhexidine rinses before referral. In severe cases tender to palpation (Figure 6). The abscess may be focal of pericoronitis, the treatment would include antibiotics or, if diffuse, may spread to deeper oral spaces, causing and referral to a dental professional. swelling of the face and jaw and lymphadenopathy. The authors thank Tuyen Nguyen, DDS; Tam Truong, DDS; and William C. Antibiotics are not normally indicated if mechanical Domb, DMD, for their assistance with the manuscript. debridement is successful in the case of localized peri- odontitis. Adding chlorhexidine rinse after surgical Figures 2 and 4 were provided by Tam Truong, DDS, and Figures 5 and debridement contributes to faster recovery of periodon- 6 were provided by Tuyen Nguyen, DDS. tal tissue.37 In generalized periodontitis involving mul- tiple teeth, patients should be treated with antibiotics as The Authors an adjunct therapy. In patients with juvenile periodonti- DUC HUU NGUYEN, DO, is an assistant clinical professor in the Depart- tis, is safe to use after 12 years of age, but the ment of Family Medicine, University of California at Irvine. Dr. Nguyen pathogens in this disease have been increasingly resistant received his medical degree from the College of Osteopathic Medicine of to this treatment regimen.38 Adult periodontitis can be the Pacific, Western University of Health Sciences, Pomona, Calif., and a treated with (Vibramycin), degree in from the University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam. (Flagyl), or topical application of micro- spheres (Arestin). If cellulitis occurs, patients should be JAMES T. MARTIN, Dr.rer.nat., is a professor of physiology and behavioral treated with antibiotics.39,40 science in the College of Osteopathic Medicine of the Pacific, Western Uni- versity of Health Sciences. Dr. Martin received his doctoral degree from the University of Munich, Germany.

Impaction of food Address correspondence to Duc Huu Nguyen, DO, UCI Family Health and bacteria Center, 300 W. Carl Karcher Way, Anaheim, CA 92801 (e-mail: duchn@ uci.edu). Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

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