Odontogenic Infections  

Introduction

• Odontogenic infections involves the alveolus, the jaws, or the face and originates from a tooth or from its supporting structures.
• Most common infections include dental caries, deep fillings or failed root canal treatment, pericoronitis, and periodontal disease.

Synonyms

• Acute dentoalveolar infection
• Orofacial bacterial infection

Epidemiology & Demographics

Incidence

• Percent of children ages 5 to 19 yr with untreated dental caries: 13.2% (2015 to 2018)
• Percent of adults ages 20 to 44 yr with untreated dental caries: 25.9% (2015 to 2018)

Prevalence

• Prevalence of periodontitis in U.S. (2009 to 2014): 42% among dentate adults age 30 yr or older

Predominant Sex & Age

• More common in men than women (73% vs. 27%)

Peak Incidence

• In adults age 65 yr and older, between 9% and 51% have severe periodontitis, and 34% have nonsevere periodontitis

Risk Factors

• Poor oral hygiene
• Lack of fluoridation of the water system

Physical Findings

• Include pain/tenderness, redness, and swelling of involved site; sensitivity to percussion of tooth involved; if infection is deep, fever, possible trismus, trouble swallowing

Clinical Presentation

• Dentoalveolar infection: Swelling of alveolar ridge with periodontal, periapical, and subperiosteal abscess
• Submental space infection: Firm midline swelling under chin usually starts as infection of mandibular incisors
• Submandibular space infection: Involves submandibular triangle and angle of mandible; starts as infection of mandibular molars and can be associated with trismus
• Sublingual space infection: Causes swelling of floor of mouth, which can lead to elevation of tongue and dysphagia
• Retropharyngeal space infection: These patients can be become quite ill with dysphagia, stiff neck, hoarse voice; usually starts in molars and can spread to mediastinum
• Buccal space infection: Causes swelling of the cheek and generally starts in premolar or molar teeth
• Masticator space infection: Starts as third mandibular molar infection associated with trismus and swelling on either side of mandibular ramus
• Canine space infection: Associated with swelling of the anterior cheek with loss of nasolabial fold and possible extension to the infraorbital region

Etiology

• Odontogenic infections are generally polymicrobial with involvement of various facultative anaerobes, most commonly the Streptococcus viridans group and the Streptococcus anginosus group, along with strict anaerobes such as Prevotella and Fusobacterium.
• However, seven different phyla of bacteria have been detected, including spirochetes ( Treponema ), actinobacteria ( Actinomyces and Propionibacterium ), Proteobacteria ( Eikenella ), and Synergistetes ( Pyramidobacter ).
• Specific organisms tend to colonize some oral buccal sites:
  • 1.Tongue and buccal mucosa: Streptococcus salivarius and Veillonella spp.
  • 2.Tooth surface: Streptococcus sanguinis, Streptococcus mutans, and Actinomyces viscosus
  • 3.Gingival crevice: Fusobacterium, Prevotella, and anaerobic spirochetes

Differential Diagnosis

• Ludwig angina
• Lemierre syndrome
• Cavernous sinus thrombosis
• Orbital abscess
• Tetanus if trismus present

Workup

• Aerobic and anaerobic cultures can be obtained by needle aspirate or swab if infection spreads to adjacent tissues or does not respond to initial antibiotic selected
• CBC with differential

Imaging Studies

• X-rays (panoramic or periapical radiographs): May revel presence of periapical abscess or impacted third molar
• CT: Best for assessment of deep space infections
• MRI: Can also be useful for deep space infections extending to head or neck

Acute General Treatment

Oral agents

• Penicillin is the drug of choice for odontogenic infections. Pen Vee K: 500 mg PO q6h.
• Amoxicillin/clavulanate: Broader spectrum than penicillin or amoxicillin alone but not necessarily better than penicillin. Has convenience of q8h to q12h dosing, thereby increasing compliance.
• Clindamycin: Drug of choice or penicillin-allergic patients: 300 to 450 mg q6hr
• Other agents to consider: Moxifloxacin (cannot be used in children), metronidazole (only has anaerobic coverage), and azithromycin (coverage of dental infections is excellent).

Intravenous antibiotics

• Ampicillin/sulbactam: 3 grams IV q6h is treatment of choice.
• Penicillin G: 2 to 4 million units q4-6h plus IV metronidazole: 500 mg IV q8h.
• For penicillin-allergic patients: Clindamycin 600 mg IV q8h plus IV levofloxacin 500 to 750 mg IV qd (clindamycin may not cover some of the streptococci and anaerobes in mouth flora).
• Meropenem: 500 mg to 1 gram IV q8h is another alternative for penicillin-allergic patients and offers the broadest spectrum of coverage.
• Ceftriaxone: 2 grams IV qd plus IV metronidazole 500 mg IV q8h.

Topical antibiotics can be used along with scaling and root planing to reduce pocket depth:

• Minocycline 2% spheres
• Doxycycline hyclate 10% extended-release liquid
• Metronidazole 25% gel

Surgical drainage is necessary for removal of necrotic tissue and to drain pus pockets. This may involve removal of the infected tooth.

Referral

• Referral to dentist and or oral surgeon may be necessary depending on severity of disease.

Pearls & Considerations

Comments

• Chronic poor oral health and tooth loss predisposes to a modest increase in coronary and cerebrovascular diseases.
• Factors include effect of systemic inflammation, intermittent bacteremia, and release of bacterial endotoxins of oral origin into the bloodstream.

Prevention & Patient/Family Education

• Regular brushing with a fluoridated toothpaste and dental flossing after each meal
• Reduction of eating sugar-rich foods and drinks
• High-risk patients should use oral microbial rinses such as chlorhexidine 0.12% to control dental plaque