Odontogenic Infections

Odontogenic Infections

Josh Russell, MD, and Mike Weinstock, MD

Based on the JUCM editorial: 

Patients presenting with symptoms of odontogenic infection
Bains AK, Ali AS, Padaki P. J Urg Care Med. 2021;3:19-23. 

General:

• Odontogenic infections are common in UC, but no studies have defined exactly how common.
• Odontogenic infections are increasing in frequency and represent ~3% of ED visits.
• The vast majority of dental infections begin with dental caries (less commonly after trauma or dental procedures). 

• The pulp of teeth, where nerves and blood vessels reside, is protected by enamel and dentin. 
• Caries result in decay of these protective layers and exposure of the pulp, leading initially to pulpitis, which results in the commonly reported dull, throbbing pain associated with caries.
  • Reversible pulpitis is intermittent (triggered by cold, etc) vs irreversible pulpitis, which is constant.
• If left untreated, pulpitis most commonly progresses to periapical abscess, which will generally result in facial swelling and more focal pain.
• Periapical abscess can then progress to deep space infections in later stages, such as Ludwig’s angina, and lead to airway compromise and septic shock. 

History:

• Location: Differentiate maxillary vs mandibular sites of origin and identify the problematic tooth.
  • If uncertain, you can ask the patient where it hurts most when they bite down.
  • Tooth numbering is an option but can be confusing. It is best to just identify the quadrant, the type of tooth, and location (eg, left second mandibular molar).

• Onset is important. Acute worsening suggests exacerbation of chronic dental infection.
  • Presenting within the first 24 hours of swelling suggests edematous swelling, especially after waking.
    • Early pain is more likely to be severe and less likely to be due to infection.
  • Presenting after 24 hours increases the likelihood that swelling is related to accumulation of purulence and need for drainage/debridement. 
• Dental History: Prior dental care and procedures. 

Physical Exam:

• Extraoral: Extent of facial swelling, palpation of the mandible, submental, and neck soft tissues. 
  • Fluctuance is reassuring. Firmness (“woody” edema) indicates a more advanced infection. Swelling crossing the midline is a red flag. 
  • Severe voice changes, drooling, and stridor are all red flags for airway compromise and necessitate emergency medical services (EMS) activation.
    • Mandibular odontogenic infections are much higher risk for airway compromise than those involving maxillary teeth.
• Mouth opening/trismus: Normal mouth opening is 3-5 cm. Trismus in the setting of dental pain is a red flag for the possibility of a deep space infection, including Ludwig’s angina.
  • Trismus is commonly measured by the number of the patient’s fingers that can be inserted.
• Intraoral: Dental arches focusing on the teeth involved, gum fluctuance, firmness of the floor of the mouth, and presence of tongue elevation (red flag). 

Labs/Imaging:

• Plain radiographs rarely affect management in UC and should not be routinely ordered unless requested by a consulting specialist.
  • Panoramic X-ray (Panorex) will commonly be obtained in the dental office. 
• Computed tomography of the face and neck with IV contrast (if available) is helpful for evaluating for a deep space infection in cases with significant swelling. 
• Laboratory evaluation (eg, “white count”), although commonly referenced in papers discussing dental infections, should not affect the decision for ED referral or specialist consultation. 

Management: 

• Analgesia first: NSAID plus acetaminophen for all without contraindications. 
  • Low-dose opioids in small quantities with extreme caution (eg, morphine IR 7.5 mg every 4 hours as needed for severe pain, #12)
  • Consider a nerve block
• Dentist referral for all: Ensure ALL patients with dental pain and/or mild infection see a dentist ASAP.
• Antibiotics for some: In general, antibiotics won’t help unless there’s swelling. 
  • A Cochrane Review showed no benefit to penicillin for irreversible pulpitis.
  • Poor quality studies exist on which antibiotics to use. Oral is usually OK for most UC cases. Options should cover gram-negative and anaerobes and include
    • Penicillin VK + metronidazole
    • Amoxicillin/clavulanate
    • Third-generation cephalosporin
    • Clindamycin (reserve for more severe cases, given risk of Clostridiodes difficile)
• Incision and drainage for localized gingival/periapical abscess in UC (depending on provider experience and comfort); it is also reasonable to start antibiotics and refer for urgent dental follow-up.
• Teach prevention strategies: Remind patients that the American Dental Association recommends patients brush twice daily with a fluoride-containing toothpaste, avoid sugary drinks and foods, and see a dentist regularly.

When to escalate to the ED:

• Red flags: drooling, fever, trismus, stridor, altered phonation, swelling crossing midline, tongue elevation, firmness to the floor of the mouth
• Ludwig’s angina: deep space infection involving submandibular and submental planes Will usually originate from second or third mandibular molars: 
  • Before antibiotics and mechanical ventilation >50% mortality; now ~10% mortality 
  • Risk factors: poor dentition, immunocompromise, diabetes
  • Usually will present with multiple red flags and warrants EMS referral to ED

REFERENCES:

Antibiotic use for irreversible pulpitis
Agnihotry A, Thompson W, Fedorowicz Z, et al. Cochrane Database Syst Rev. 2019;5(5):CD004969. doi: 10.1002/14651858.CD004969.pub5.

ADA Home Care Guidelines. www.ada.org/resources/research/science-and-research-institute/oral-health-topics/home-care. Accessed August 9, 2022. 

Patients presenting with symptoms of odontogenic infection
Bains AK, Ali AS, Padaki P. J Urg Care Med. 2021;3:19-23. 

Antibiotic use for irreversible pulpitis
​​Fedorowicz Z, van Zuuren EJ, Farman AG, et al. Cochrane Database Syst Rev. 2013;(12):CD004969. doi: 10.1002/14651858.CD004969.pub3.

Management of odontogenic infections and sepsis: an update
Jevon P, Abdelrahman A, Pigadas N. Br Dent J. 2020;229(6):363-370.

The use of antibiotics in odontogenic infections: what is the best choice? A systematic review
Martins JR, Chagas OL, Velasques BD, et al. J Oral Maxillofac Surg. 2017;75(12):2606.e1-2606.e11. 

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