Dental and Related Infections

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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

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

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

Dental Caries

Dental caries, or tooth decay, is the oldest and most common cause of toothache seen in the emergency department and the most common cause of tooth loss worldwide.23 This is not an acute process, but eventually the pain increases until often the patient cannot take it any longer. Pain is associated with exposure of the dentin and, in advanced cases, with irritation of the pulp called pulpitis. Associated periodontal disease, if severe, may contribute to the pain. The process consists of a

Periodontal diseases

Periodontal disease is often thought of as gum disease. The periodontium consists of the supporting structures of the gingiva, periodontal ligament, and alveolar bone and is a group of diseases. The 2 most important in terms of numbers are gingivitis and periodontitis, both of which are discussed later.

The most common cause of periodontal disease is poor dental hygiene, with the subsequent buildup of plaque, resulting in both dental caries and potentially periodontal disease. As with dental

Summary

Emergency physicians should be comfortable treating most dental and related infections. The most common pitfalls are:

  • 1.

    Failing to refer patients for routine dental care after noting poor oral hygiene and dental caries. 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.

  • 2.

    Failing to drain an abscess cavity, when one is noted, in favor of antibiotic therapy.

  • 3.

    Failing to recognize

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      By contrast, periodontitis is associated with loss of bone and surrounding tissue, forming “pockets” around affected teeth. Infection of these pockets can lead to periodontal abscess formation with pus collecting between the teeth and gums and spreading to surrounding tissues (63). I&D is the recommended method for treating a dental abscess in the ED.

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      Pulpitis is inflammation of the pulp cavity of a tooth where the neurovascular structures are located.8 Pulpitis can be caused by caries, trauma, recent dental procedures, defective fillings, and chemical toxins.20 Pulpitis presents as dental pain exacerbated by extremes of temperature.20

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      Tooth percussion is a valuable examination technique to detect a possible dental abnormality in the absence of radiographs. The patient can often identify which tooth is the source of dental pain.18 Multiple decayed or infected teeth, poor oral hygiene, and/or inflamed gingival tissues may be observed, in which case the patient should be referred to a dentist for further evaluation and management.

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      Their replication enables the subsequent adhesion of other bacterial species, which though unable to stick to tooth hard surfaces, are quite capable of attaching themselves to already present microorganisms. During this period, the importance of Streptococcus mutans and related organisms (Streptococcus sobrinus, Streptococcus cricetus, Streptococcus rattus, Streptococcus downei, and Streptococcus macacae) in the etiology of dental caries is established.2,4,5 Briefly, S. mutans and the related mutans streptococci are often found to be elevated in the plaque of incipient lesions, produce abundant acid from dietary sugar, and produce adherent polysaccharides from dietary sucrose that promotes biofilm formation and retards diffusion of acid from the tooth-plaque interface to drive tooth demineralization.6,7

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