Dental and Related Infections

Dental and Related Infections Alan Hodgdon, MD, MBA KEYWORDS Intraoral infection Periapical abscess Periodontal abscess Necrotizing ulcerative gingivitis (NUG) Ludwig’s angina Facial cellulitis KEY POINTS Emergency physicians should be comfortable treating most dental and related infections. Failing to refer patients for routine dental care after noting poor oral hygiene and dental caries is a common pitfall. Tooth loss is often preventable when follow-up dental care is made available and used. In addition, recent studies have linked dental health to overall long-term health status. Another pitfall is failing to drain an abscess cavity, when one is noted, in favor of antibiotic therapy. The potential critical nature of a deep space infection of the face or neck should be recog- nized, such as Ludwig’s angina or facial cellulitis. Adequate analgesia should be provided for intraoral procedures, such as incision and drainage. This analgesia can be provided via supraperiosteal injection by the individual tooth or inferior alveolar nerve block for the lower teeth, with a long-acting anesthetic such as bupivacaine. INTRODUCTION Pain in the jaw and other facial structures is a common presenting complaint in most emergency departments. It is the job of the emergency physician to determine which of these complaints demands immediate therapy and which can be ameliorated until a dentist or oral-maxillofacial surgeon (OMFS) is available. Most dental-related problems can be treated with simple therapies and are within the realm of well-trained emergency physicians. Some of the more important dental-related problems are related to infections originating in the tooth that then spread to adjacent tissues, including gingiva, surrounding soft tissues of the face and neck, or to the alveolar bone of the jaw.1 As with all good medicine, a thorough medical history and review of systems should be obtained before oral examination begins, providing the airway does not require intervention. Although emergency clinicians are concerned with acute disease, many chronic diseases, from clotting disorders to cancers, can manifest with oral Department of Emergency Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 500, Pittsburgh, PA 15213, USA E-mail address: [email protected] Emerg Med Clin N Am 31 (2013) 465–480 http://dx.doi.org/10.1016/j.emc.2013.01.007 emed.theclinics.com 0733-8627/13/$ – see front matter Published by Elsevier Inc. 466 Hodgdon disorders and these should not be ignored. A basic review of the patient’s medical history can reveal information important in weighing risk/benefit in the use of medica- tions and treatment options. For example, a history of splenectomy, neutropenia, sepsis, regurgitant heart valve, recent dental work, mandible fracture, and other medical history are important details that potentially influence not only the examination but the treatment options. For example, the risk of serious bacterial infection must be weighed against the risk of anaphylaxis and other side effects when antibiotics are prescribed for oral infections. Because manipulation of the oral cavity often causes transient bacteremia, those patients who should have prophylaxis with antibiotics should be identified before doing invasive procedures of the mouth. A good history helps identify these individuals. This article presents a brief overview of infections associated with the oral cavity and supporting structures, beginning with the most common and superficial. Under- standing and dealing with these in day-to-day practice makes it easier to diagnose and treat sicker patients whose disorders are related to, but not confined within, the oral cavity. TOOTH ANATOMY To understand how an apical abscess develops and how other common tooth disorders cause pain, it is important to briefly review some points about tooth anatomy. The enamel is the hard outer surface of the tooth. Intact enamel is white and shiny. Although this appearance can be dulled by plaque and tooth staining, it can usually be ascertained whether the enamel is intact by looking closely at the surface of the tooth. Besides plaque disguising the enamel of the tooth, long-term plaque supports the growth of organisms that destroy enamel, and this is the underlying disorder of dental caries, so significant plaque warrants referral for routine care. Under the enamel lies the dentin. It is off-yellow in color, and sensate. If the dentin is exposed, it becomes inflamed and painful. In addition, unprotected dentin is sensitive to infection because it is composed of porous microtubules that connect directly to the pulp cavity. In the pulp cavity lie the nerve and blood supplies of the tooth and so the dentin is an important structure. When it is exposed by either caries or trauma, it should be covered. This reduces pain and lessens the chance for infection to track along the microtubules to the dental pulp. It also lessens the chances of pulp necrosis. Although there is a specific tooth numbering system, the more practical method is just to name the tooth involved, keeping in mind the general dental formula. The dental formula states that the mouth can be divided into 4 quadrants, each having the following teeth from the midline: central incisor, lateral incisor, canine, 2 premolars, and 3 molars (the last or third molar is the wisdom tooth). Using this simple formula, all teeth can be properly identified when documenting disorders and discussing them with specialists. ORAL EXAMINATION Emergency department management is based on a thorough history and a meticulous physical examination of the face, mouth, and neck. If the patient appears acutely ill, airway assessment should take precedence. There are several algorithms regarding potentially difficult airways, but, even without touching the patient, an evaluation of the size and mobility of the neck, the interincisor distance, and the appearance of the submental area can be done to see if this is likely to be a difficult intubation.2 If the airway is not in any danger of occluding, proceed to the patient’s general appearance, concentrating on facial symmetry. Evaluate for facial edema, localized Dental and Related Infections 467 external areas of tenderness, erythema, and obvious lesions. The lymph nodes in the neck, including those in the submandibular and preauricular regions are palpated. Then proceed to examine the mouth. It is best to evaluate the mouth with a tongue blade in each hand, with good lighting from either a headlamp or a good overhead light. Both hands should be free to feel in the mouth and hold the tongue blades. After you have gloved and are holding a tongue blade in each hand, ask the patient to open his or her mouth. Evaluate first for trismus, which is noted almost immediately by the inability to fully open the mouth. The interincisor distance can be objectively measured by the distance between the maxillary and mandibular central incisors. A normal measurement is anything greater than 35 mm (approximately the width of 2 adult fingers). Measurements less than 30 mm (trismus) make intraoral examination more difficult and ultimate airway management more problematic. This distance can usually be estimated by the ability of the patient to open the mouth, but, if this looks difficult or impaired in any way, measure this distance. When mouth opening is limited by pain not associated with temporomandib- ular joint disorder, it usually indicates infection in the muscles of mastication, and is an indication for a more in-depth examination.3–5 According to Christian,6 writing about oromaxillofacial infections, “The hallmark of infection in any or all of the secondary spaces of the mandible (the masticator space) and by extension, the deep neck spaces, is trismus.” Proceeding from the outside in (labial mucosa), and from the anterior of the mouth posteriorly, evaluate the soft tissue structures for abnormality. Do this first before examining the teeth, because most tooth disorders cause problems with the surrounding gingiva. Begin at the inferior lip, looking for erosions, state of dentition, erythema, abscess, and for areas of inflammation. Proceeding to the posterior mucosa, evaluate the posterior oropharynx, then the tongue. Palpate along the base of the vestibule looking for signs of swelling, tenderness, or purulence. After evaluating these supporting structures, evaluate the teeth, focusing on areas noted in the initial visual inspection or by evaluating areas of pain as described by the patient. There are ways to use heat or cold to stress the nerves of the teeth, but the percussion test works best, is simple, and is sensitive.7 Percussing the occlusal surface of a tooth that has an inflamed nerve usually elicits pain. When tenderness is elicited on examination in an area, be specific (ie, try to determine which tooth the disorder is coming from, rather than just a region). This method helps in determining whether the tooth disorder is old or new and helps guide therapy. In most cases, old dead teeth are usually not markedly tender, because the root of the tooth is already necrotic. It is acutely infected and inflamed teeth that tend to be painful. After the gingiva and tooth structures are evaluated with the tongue blades, repeat the examination with a focus on the area of complaint, carefully identifying the disorder found. This repeat percussion and examination helps localize the disorder. Look closely at the involved tooth surfaces, the gingiva associated with the suspect tooth, and attempt to move the tooth. Loose teeth and recession of the gingival structures indicate advanced periodontal disease. Palpate the tongue and floor of the mouth and examine the mucosa for lesions. The patient should have a reproducible examination, and not simply complain of generalized areas of pain. Although it is helpful to know that old areas of decay are not sensitive to percussion or palpation, caution is needed.

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