What is Dental Infections (Tooth Infection)?
Dental infections start in the tooth or the structures supporting the tooth and can spread to nearby tissues. If the infection impacts the face, it’s often due to damaged tooth pulp, gum pockets, or inflammation around the wisdom tooth. Historically, dental infections were highly common and a major cause of death. Records from 17th century London ranked teeth infections as the 5th or 6th most common cause of death. Even in 1908, it was believed that dental infections led to a death rate of 10% to 40%. However, advancements in dental hygiene, modern dentistry techniques, and antibiotics mean that dental infections are now rarely life-threatening.
Despite these advancements, dental infections are still a common reason for people to go to medical facilities, especially emergency departments. The most common dental issue seen is dental abscesses. Sometimes, people go to a hospital rather than a dentist for varied reasons, such as lack of money, limited access to dentists, fear of dentists, or the belief that antibiotics will take care of the infection. As a result, general doctors often need to handle dental infections. However, because many doctors lack in-depth knowledge about dental infections, they can find these cases difficult to manage. As such, doctors in primary care have a critical role. They can identify early signs of dental infections, educate patients about oral health, and refer them to a dentist when needed.
What Causes Dental Infections (Tooth Infection)?
Dental cavities or tooth decay occurs due to a combination of factors including the structure of the tooth, bacteria-filled plaque on the tooth surface, and certain sugary components in our diet. How much saliva we produce and our genetic makeup also play a part in developing tooth decay.
In simple terms, the bacteria present in the plaque on our teeth consume sugars from our food and produce acids as a result. These acids lower the pH level in our mouth, which causes the breakdown or demineralization of the outer layer of our teeth. As we swallow and saliva rinses out the sugars, our mouth’s pH levels balance out again. Our saliva, rich in calcium, phosphate, and fluoride, helps stop further mineral loss and even promotes the repair or remineralization of the tooth surface. This cycle repeats each time we eat something sugary. Therefore, people who don’t produce enough saliva are more prone to tooth decay. Also, consistently consuming a lot of sugar can shift the type of bacteria in our mouth to those that are more harmful for our teeth. This can lead to a faster rate of mineral loss than the rate of deposit, causing the first visible sign of decay – a white spot on the tooth surface.
It’s important to remember that these white spots indicate early stages of decay which can be reversed by timely rinsing with fluoride or improving dental hygiene or diet habits. If not managed properly, these spots can progress to deeper tooth decay.
The inflammation of dental pulp, the innermost part of the tooth, is called pulpitis. This can occur if tooth decay lets bacteria reach the pulp or through tooth infections or fractures. Pulpitis leads to toothaches, typically triggered by hot or cold items, and is treatable by removing the decayed tooth area and filling it up. However, prolonged inflammation can irreversibly damage the pulp, causing constant and trigger-less toothaches. As a dentist needs to remove the damaged pulp, it is critical to seek professional help in case of such toothaches. It is important to note that antibiotics aren’t recommended for treating this condition unless there are clear signs of infection. Left untreated, severe pulpitis can cause pulp death and potentially let the infection spread, leading to an abscess around the tooth’s root.
An abscess can be acute or chronic and leads to mild-to-severe toothaches and swelling. An acute abscess can cause fever, tiredness, and swollen lymph nodes. It can also drain into the mouth or spread to the neck region, leading to severe complications. A critical condition known as Ludwig angina can occur if the infection spreads to certain areas beneath the tongue or lower jaw and is not attended to in time. Abscesses usually are localized infections and don’t require antibiotics unless there are signs of a spreading infection. Professional help from a dentist is essential to drain the abscess and treat or remove the affected tooth.
Gingivitis and periodontitis are examples of periodontal diseases, which are infections of the tissues surrounding and supporting the teeth. These are typically caused by poor dental hygiene and can lead to inflammation in these areas. Factors that increase the risk of periodontal diseases include smoking and diabetes. A patient’s specific genetic and environmental circumstances can regulate how fast the disease progresses.
Risk Factors and Frequency for Dental Infections (Tooth Infection)
Dental infections and toothaches are common issues that prompt people to seek dental care. Approximately 13% of adults will visit a dentist for these problems within a four-year period. Additionally, the rate of hospitalization due to dental infections in the United States is 1 per 2600 people. More than 1 in 5 people have untreated cavities, and 3 out of 4 people have had at least one dental restoration. Another widespread dental issue is gum disease, impacting about 35% of Americans aged between 30 and 90.
The likelihood of experiencing dental problems, particularly untreated cavities, greatly depends on socioeconomic status. People living at or below the poverty line are more than 2.5 times as likely to have cavities compared to those who are financially well-off.
- Untreated cavities are 2.5 times more common among those living 100% below the poverty level.
- The percentage of people with cavities is larger in adults (90%) than in children (42% in kids aged 6 to 19).
- Interestingly, teenagers aged 12 to 19 have a lower rate of untreated cavities than younger children aged 5 to 11.
Signs and Symptoms of Dental Infections (Tooth Infection)
Dental caries (commonly known as tooth decay) can be classified as acute or chronic, with appearances varying from brown-yellow and soft to black and hard cavities. Early stages of dental caries, known as incipient caries, are tougher to identify. These appear as white and opaque irregular spots that can be found on any tooth surface, but are especially common in areas where plaque can build-up, such as where the gums meet the tooth surface.
Some symptoms patient can experience include:
- A toothache triggered by hot of cold stimuli, indicating a condition known as reversible pulpitis.
- Unprovoked and persistent tooth pain that worsens at night, showing irreversible pulpitis.
- A palpable swelling, indicating a periapical abscess.
- Fever, facial swelling, difficulty opening the mouth, swallowing, or speaking, which are signs of a severe dental infection that has spread into deeper areas of the neck.
Periodontal disease refers to diseases of the gums, including gingivitis and periodontitis. People with these conditions often have bad breath and experienced bleeding after brushing. Unlike other dental diseases, pain is not usually a symptom of periodontal diseases, with the exception of a specific type called necrotizing periodontal disease.
Gingivitis causes inflammation of the gums due to built-up dental plaque on the teeth. Symptoms include swollen, red gums that bleed easily. In contrast, periodontitis involves a combination of gum inflammation and loss of connective tissue, leading to the development of “pockets” between the teeth and gums. Depending on the severity, other signs can include gum recession, tooth movement or wobble, and loss of bone supporting the teeth (which can be seen on a dental x-ray).
Testing for Dental Infections (Tooth Infection)
When someone has a severe dental infection, different types of imaging tests like x-rays, CT scans, and MRIs can provide more details about the infection. These tests help identify the origin of the infection, how far it’s spread, and any complications that may have resulted. The most common types of x-rays used in oral care are orthopantomography, which is a panoramic view of the mouth, as well as more focused periapical and bitewing x-rays. These usually provide enough information about the scope of a dental infection.
A type of specialized x-ray known as a Cone-beam CT is beneficial in diagnosing specific conditions around the root of a tooth, inflammation around a tooth breaking through the gum, or infection in the bone. A CT scan with a special dye can help doctors understand the depth and intensity of infections in the facial area.
However, before conducting any imaging tests, it’s important that a person with symptoms of severe infections, like difficulty breathing, has their airways protected to prevent further complications. This is typically achieved through inserting a flexible tube for breathing either through the nose or through an opening in the neck. After the airways are secured, more extensive imaging tests may be carried out.
Blood tests may also be done, especially in more serious cases. Patients with deep facial infections may show signs of a life threatening response to infection known as sepsis which may require additional blood tests and monitoring.
Treatment Options for Dental Infections (Tooth Infection)
People often end up in the emergency department due to tooth pain, typically caused by an infection in their tooth or gum. It’s important for patients to be checked for signs that the infection is spreading beyond their mouth, which may need immediate attention. If there’s any chance that the patient’s airway could be blocked, they must be taken to an emergency department where experts can manage the situation. Symptoms that suggest you might require emergency treatment include: trouble opening your mouth, swallowing difficulty, drooling, restricted tongue movement, swelling underneath your tongue, and a muffled voice.
Patients with a condition known as Ludwig angina need to be admitted to a hospital for airway management and intravenous antibiotics. Ludwig angina is a severe infection in the floor of the mouth that can lead to life-threatening complications, including blocked airways.
If you don’t need emergency treatment, you should see a dentist for further management. Surgery is typically needed to control tooth infections. The only permanent solution can be provided by a dentist. If your tooth pain is due to a permanent inflammation of the pulp within the tooth, a root canal is generally the required treatment. If an infected tooth is causing an abscess, initial treatment often involves draining the swelling. This is done through the tooth itself, where an opening is made to remove the infected pulp and clean out the root canal. Sometimes, if the tooth can’t be saved, it might need to be extracted.
Let’s talk about Antibiotic Use.
Antibiotics play a supportive role in managing tooth infections. They’re usually only prescribed to accompany a surgical treatment in cases where there are signs of infection spreading locally or throughout the body. This may include symptoms such as skin infection, fever, swollen lymph nodes or extreme tiredness. Dentists may prescribe antibiotics before referring you to another health professional for further treatment.
Tooth infections are typically caused by a mix of different bacteria. The antibiotic chosen should target these bacteria. For most people, the go-to option is amoxicillin combined with a beta-lactamase inhibitor. If you’re allergic to penicillin, have recently taken it for another infection, or if your infection is mostly due to anaerobic bacteria, you might be given metronidazole instead. This antibiotic is also used alongside penicillin for severe, rapidly spreading infections.
In certain cases when people can’t tolerate other antibiotics due to allergies or drug interactions, clarithromycin or clindamycin might be used as alternatives. But, keep in mind, use of clindamycin may lead to higher chances of stomach upset and a severe infection called Clostridium difficile, which can cause diarrhea.
Pain Management
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often more effective at controlling tooth pain than opioids and are commonly used to manage severe tooth pain. A combination of ibuprofen and paracetamol can provide better relief than either medication on its own. However, if you can’t take NSAIDs, paracetamol can be prescribed alone or with a medication called oxycodone.
What else can Dental Infections (Tooth Infection) be?
When diagnosing dental infections, it’s important to consider a range of possible other conditions that might cause similar symptoms. Sometimes, dental infections can be confused with problems affecting the salivary glands such as salivary gland inflammation (sialadenitis), salivary gland stones (sialolithiasis), or even salivary gland tumors. These conditions can lead to facial swelling, redness, and pain.
A salivary gland tumor may appear as a lump on one side of the face. Another condition that might be mistaken for a dental infection is sinusitis, which is an inflammation or swelling of the tissue lining the sinuses. Patients with sinusitis may experience warm, red skin over the cheekbone area. It’s crucial for medical professionals to accurately identify the source of these symptoms to ensure appropriate treatment.
What to expect with Dental Infections (Tooth Infection)
The outlook for simple dental infections is usually positive. However, dental infections that spread to the deeper parts of the neck may lead to more serious outcomes and even potentially to death. Deep neck infections have a death rate between 1% and 25%, while mediastinitis, a severe complication, can have a mortality rate as high as 40%.
Possible Complications When Diagnosed with Dental Infections (Tooth Infection)
Dental infections can lead to serious issues if they spread to different areas in the head and neck. There are several ways that these infections can cause complications. If the infection goes unchecked, it may spread to the jaw, leading to a condition known as osteomyelitis. Especially dangerous are infections of the lower second and third molars, which can spread to spaces under the tongue, jaw, and chin, leading to a condition called Ludwig angina.
Children are particularly at risk, with these infections spreading to spaces behind the throat, causing abscesses. A very severe infection known as descending necrotizing mediastinitis can occur if the dental infection spreads through various layers of fascial planes. There are also records of dental infections spreading in a way that causes a condition called cavernous sinus thrombosis. Very rarely, these infections can result in meningitis and a collection of pus in the brain’s outer covering.
An interesting, yet worrying point is that dental infections and tooth extractions can spread bacteria through the bloodstream which may result in a dangerous heart infection, especially in patients who have artificial heart valves.
Possible Spread and Complications from Dental Infections:
- Osteomyelitis (spread to the jaw)
- Ludwig angina (spread to spaces under the tongue, jaw, and chin)
- Retropharyngeal or parapharyngeal abscesses in children (spread to spaces behind the throat)
- Descending necrotizing mediastinitis (spread through various layers of fascial planes)
- Cavernous sinus thrombosis (rare spread)
- Meningitis and subdural empyema (very rare)
- Endocarditis (spread of bacteria through the bloodstream, especially in patients with artificial heart valves)
Preventing Dental Infections (Tooth Infection)
It’s important for patients to receive advice on good dental hygiene to stop infections from forming in the mouth. By spreading awareness about daily practices like brushing teeth, using dental floss, and cutting down on foods rich in sugar, we can help reduce the risk of developing tooth cavities.
