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DENTALINFECTION

Sheila O. Stille, DMD Hugh Silk, MD, MPH, FAAFP

BASICS

DESCRIPTION

Pain ± swelling in the head and neck region from infection in the teeth and supporting structures; if left untreated, can lead to serious and potentially lifethreatening illnesses

Assume any head and neck infection or swelling to be odontogenic in origin until proven otherwise.

System(s) affected: oropharynx, throat, dental, gastrointestinal

Synonym(s): odontogenic infections, dental abscess

EPIDEMIOLOGY

18% of 5- to 19-year-olds have untreated dental caries (1).

28% of individuals age >20 years have untreated dental caries (1).

Rates are higher in Hispanic (21.7%) and black (23%) children/teens (1)[A].

92% of adults 20 to 64 years have had dental caries (1).

25% of children 5 to 17 years account for 80% of caries in the United States.

17% of adults age >64 years are edentulous (1).

ETIOLOGYAND PATHOPHYSIOLOGY

Caries or trauma can lead to death of the tooth pulp, which can lead to infection and/or abscess of adjacent tissues via direct or hematogenous bacterial colonization.

Caries (tooth decay; “cavity”) represent a contagious bacterial infection causing demineralization and destruction of the tooth tissue (enamel, dentin, and cementum).

Streptococcus mutans is vertically transmitted to newly dentate infants from caregivers.

Acidic secretions from S. mutans are implicated in early caries.

Often there is polymicrobial mix of anaerobes in dental abscess (viridans streptococci and Streptococcus anginosus).

Anaerobes, including peptostreptococci, Bacteroides, Prevotella, and Fusobacterium, have also been implicated. Lactobacilli not seen in healthy

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subjects but is common in patients with extensive caries (2).

Preventable with good oral hygiene, low cariogenic diet, access to fluoride, and professional dental care

Fluoride has dramatically decreased dental caries.

RISK FACTORS

Low socioeconomic status

Parent and/or sibling with history of caries or existing untreated dental caries (especially in past 12 months)

Previous dental caries

Poor access to dental/health care; lack of dental insurance

Fear of dentist

Poor oral hygiene

Poor nutrition, including diet containing high level of sugary foods and drinks

Trauma to the teeth or jaw

Inadequate access to and use of fluoride

Gingival recession (increased risk of root caries)

Physical and mental disabilities

Decreased salivary flow (e.g., use of anticholinergic medications, immunologic diseases, radiation therapy to head and neck)

GENERALPREVENTION

Prevent caries and contagious bacterial infection (S. mutans).

Most dental problems can be avoided through flossing/use of interdental brushes; brushing with fluoride toothpaste, systemic fluoride (fluoridated bottled water; fluoride supplements for high-risk patients and in nonfluoridated areas); fluoride varnish for moderateto high-risk patients and all children age <6 years; regular dental cleanings (1,3).

Prevent transmission of S. mutans from mother/caregiver to infant by improving maternal dentition, chlorhexidine gluconate rinses, and use of xylitol products for mother especially during first 2 years of a child’s life. Avoid smoking, which is linked to severe periodontal disease (2).

Good control of systemic diseases (e.g., diabetes)

Fluoride varnish provided by dental or medical primary care providers twice per year (2,3)

COMMONLYASSOCIATED CONDITIONS

Extensive caries, crowding, multiple missing teeth

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Periapical and periodontal abscess

Soft tissue cellulitis

Periodontitis (deep inflammation ± infection of gingiva, alveolar bone support, and ligaments)

DIAGNOSIS

HISTORY

Pain at involved tooth; can be referred to ears, jaw, cheek, neck, or sinuses; unexplained headaches

Hot/cold sensitivity

Pain can be unprovoked, intermittent and/or constant.

Pain with biting or chewing

Trismus (inability to open mouth)

Bleeding or purulent drainage from gingival tissues When severe infection (systemic)

–Fever

–Difficulty breathing or swallowing

–Raspy voice

–Mental status changes

Evaluate children <4 years with stiff neck, sore throat, and dysphagia for retropharyngeal abscess.

PHYSICALEXAM

Gingival edema and erythema

Cheek (extraoral) or vestibular (intraoral) swelling

Fluctuant mass at involved site

Suppuration of gingival margin

Submandibular or cervical lymphadenopathy

Severe (systemic) infection may present with dysphagia, fever, and signs of airway compromise.

DIFFERENTIALDIAGNOSIS

Bacterial or viral pharyngitis

Pericoronitis (inflammation ± infection of gum flap over mandibular last molar, typically 3rd molars)

Otitis media or externa

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Sinusitis

Headache/migraine

Viral (HSV1, herpangina, hand-foot-mouth disease) or aphthous stomatitis

Temporomandibular joint (TMJ) dysfunction (myofascial pain, ± internal derangement of TMJ)

Parotitis

Jaw pain can be anginal equivalent, especially in women and especially lower left side of the jaw.

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

No initial labs needed, unless patient looks acutely ill. If acutely ill

–Consider CBC with differential.

–If abscess present, aspirate pus and culture for aerobes and anaerobes (4).

–Typically polymicrobial infections with anaerobic gram-negative rods and anaerobic gram-positive cocci (4)

Individual films of suspected teeth, including root apices; test with palpation, percussion, and cold sensitivity.

Panoramic film or CT scan of the teeth and jaw to evaluate the extent of infection

Follow-Up Tests & Special Considerations

Panoramic radiograph, particularly if trismus present

CT scan can be helpful if facial swelling extends below inferior border of mandible or into infraorbital space. This helps to location for potential incision and drainage by oral and maxillofacial surgeon or ENT.

TREATMENT

Appropriate antibiotic, if indicated. Isolated pain (no swelling or systemic signs of infection) does not warrant antibiotic use.

If localized, consider incision and drainage.

Appropriate pain control: Anti-inflammatory agents are first line; short-course opioids in some cases (5)[A]

Refer to oral health provider as soon as possible for definitive treatment: root canal, extraction, gum therapy (4).

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If infection is severe (systemic symptoms), consider hospitalization with IV antibiotics until stable. May need intraoral or extraoral incision and drainage; definitive treatment (extraction or root canal therapy) necessary to prevent progression or recurrence

GENERALMEASURES

Ibuprofen 600 to 800 mg (peds: 10 mg/kg) q6h or acetaminophen 650 to 1,000 mg (peds: 10 to 15 mg/kg) q4–6h PRN for pain

For more severe pain, consider acetaminophen with ibuprofen (synergistic effect) + short course of opioids.

Local nerve block with long-acting anesthetic (bupivacaine); avoid penetrating infection to avoid tracking infection.

MEDICATION

First Line

Amoxicillin: 500 mg TID for 7 to 10 days; in children, 40 to 60 mg/kg/day divided TID

If penicillin allergic, use clindamycin 300 mg PO TID for 7 days.

Second Line

If long-standing infection or no response to first-line treatment

Clindamycin: 300 mg PO TID for 7 to 10 days

Amoxicillin/clavulanic acid (500 mg/125 mg), 1 tablet PO TID for 7 days

If severe infection, consider IV antibiotics (ampicillin-sulbactam, cefoxitin, cefotetan).

Consider double coverage with metronidazole 500 mg PO TID for 7 days for better bone penetration and good anaerobic coverage. Do not use metronidazole alone; will increase development of resistant strains; can be used with amoxicillin or clindamycin

ISSUES FOR REFERRAL

Consult an oral health provider, and ensure definitive follow-up.

SURGERY/OTHER PROCEDURES

Incise and drain large, fluctuant abscesses.

Root canal or extraction is definitive treatment.

ADMISSION, INPATIENT, AND NURSING

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CONSIDERATIONS

Criteria for hospital admission: swelling involving deep spaces of the neck, floor of the mouth, or infraorbital region; deviation of the airway; unstable vital signs; fever (>101°F); chills; raspy voice; confusion or delirium; or evidence of invasive infection or cellulitis

Ensure secure airway.

IV fluid resuscitation if necessary

Ensure good oral hygiene.

Rinse or swab mouth with chlorhexidine gluconate BID.

Use warm saltwater rinses several times per day, especially after incision and drainage; ice packs to decrease swelling and encourage drainage

Discharge patient when

–Airway not compromised

–Abscess and sepsis eliminated

–Able to take PO intake and ambulate

ONGOING CARE

Educate regarding proper oral hygiene, need for follow-up dental care, and potential medical complications that arise due to lack of dental care.

FOLLOW-UPRECOMMENDATIONS

Follow-up with oral health provider within 24 hours.

Ensure adequate PO intake, including protein.

DIET

Maintain a healthy diet; bacteria thrive on refined sugar and starch.

Avoid sugary foods that stick between the teeth.

Avoid the use of sugary/carbonated drinks throughout day; water as beverage of choice between meals

Pediatric Considerations

In children, limit the frequency of sugary drinks and advise against sleeping with a bottle to decrease the chance of dental caries. Fluoride varnish twice a year (more for higher risk children) for children age <6 years (3).

PATIENT EDUCATION

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Control caries and periodontal disease.

Biannual dental visits at a minimum

– Limit the frequency of sugar/carbonated drinks and sugary or sticky foods. In young children, avoid sleeping with a bottle to decrease the chance of

dental caries.

Brush twice daily and use floss/interdental brush daily.

PROGNOSIS

Prognosis is excellent with proper treatment.

COMPLICATIONS

Ludwig angina

Retropharyngeal and mediastinal infection

Osteomyelitis

Endocarditis/cardiac tamponade

Submental infection

Submandibular infection

Can cause unstable diabetes in diabetics/worsen preexisting heart disease

Brain abscess/death

REFERENCES

1.National Center for Health Statistics. Health, United States, 2016: with chartbook on long-term trends in health. Hyattsville, MD: 2017. https://www.cdc.gov/nchs/data/hus/hus16.pdf. Accessed August 31, 2017.

2.Chaffee BW, Gansky SA, Weintraub JA, et al. Maternal oral bacterial levels predict early childhood caries development. J Dent Res. 2014;93(3):238–244.

3.Chou R, Cantor A, Zakher B, et al. Preventing dental caries in children <5 years: systematic review updating USPSTF recommendation. Pediatrics. 2013;132(2):332–350.

4.Robertson D, Smith AJ. The microbiology of the acute dental abscess. J Med Microbiol. 2009;58(Pt 2):155–162.

5.Bali RK, Sharma P, Gaba S, et al. Areview of complications of odontogenic infections. Natl J Maxillofac Surg. 2015;6(2):136–143.

ADDITIONALREADING

Clark MB, Douglass AB, Maier R, et al. Smiles for Life: A National Oral Health Curriculum. 3rd ed. Leawood, KS: Society of Teachers of Family

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Medicine; 2010. http://www.smilesforlifeoralhealth.com/buildcontent.aspx? tut=555&pagekey=62948&cbreceipt=0. Accessed December 7, 2016.

Flynn TR. What are the antibiotics of choice for odontogenic infections, and how long should the treatment course last? Oral Maxillofac Surg Clin North Am. 2011;23(4):519–536.

Lockhart PB, ed. Oral Medicine and Medically Complex Patients. 6th ed. New York, NY: Wiley; 2013.

U.S. Preventive Services Task Force. Dental caries in children from birth through age 5 years: screening. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation- summary/dental-caries-in-children-from-birth-through-age-5-years-screening. Accessed December 7, 2016.

CODES

ICD10

K02.9 Dental caries, unspecified

K04.7 Periapical abscess without sinus

K12.2 Cellulitis and abscess of mouth

CLINICALPEARLS

Do not ignore tooth pain.

Treat patients with facial swelling aggressively, as infections can spread quickly, leading to significant morbidity or even death.

Prevention (oral hygiene, fluoride, dental visits) is the key to avoiding odontogenic infections.

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DEPRESSION

Naureen Rafiq, MBBS Michael G. Kavan, PhD

BASICS

DESCRIPTION

Aprimary mood disorder characterized by a sustained feeling of sadness and/or decreased interest in all or most activities once enjoyed (anhedonia), which represents a change from previous functioning

Variants: disruptive mood dysregulation disorder, major depressive disorder (MDD), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, unspecified depressive disorder

EPIDEMIOLOGY

Incidence

In United States, 6.9% of 18 years of age or older in past year

Prevalence

16.2% lifetime risk of having MDD

Patients can relapse; risk decreases with longer remission period but increases in patients with severe episodes, episodes at a younger age, and multiple episodes.

Predominant age

–Low risk before early teens but highest prevalence in teens and young adults

Predominant gender

– Females > males (2:1)

ETIOLOGYAND PATHOPHYSIOLOGY

There are diverse theories on the pathophysiology of depression.

Monoamine-deficiency hypothesis: symptoms related to decreased levels of norepinephrine (dullness and lethargy) and serotonin (irritability, hostility, and suicidal ideation) in multiple regions of the brain; other neurotransmitters

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involved include dopamine, acetylcholine, γ-aminobutyric acid (GABA), glutamate.

Stress/hypothalamic–pituitary–adrenal axis: Abnormalities in cortisol response lead to depression; elevated cortisol levels can be associated with depression, but cortisol tests are not indicated for diagnosis.

Depression as inflammatory disorder: Proinflammatory marker levels are reported to be elevated in depressed patients. Examples of these markers are C-reactive protein (CRP), interleukin (IL)-6, IL-1, and tumor necrosis factor-α (TNF-α).

Hormones and depression: Reduction in thyroid hormone, estrogen levels, and elevation in vasopressin has been seen in people with depression.

Other areas of research interest: abnormal circadian rhythms; impaired synthesis/metabolism of neurotransmitters

Environmental factors and learned behavior may affect neurotransmitters and/or have an independent influence on depression.

Genetics

Multiple gene loci place a person at increased risk when faced with environmental stressor; twin studies suggest 37% concordance (1).

RISK FACTORS

Female > male (2:1)

Severity of first episode

Persistent sleep disturbances

Presence of chronic disease(s), recent myocardial infarction (MI), cardiovascular accident (CVA)

Strong family history (depression, bipolar, suicide, substance abuse), spouse with depression

Childhood trauma/maltreatment

Substance abuse and dependence, domestic abuse/violence

Losses, stressors, unemployment

Single, divorced, or unhappily married

COMMONLYASSOCIATED CONDITIONS

Bipolar disorder, cyclothymic disorder, grief reaction, anxiety disorders, somatoform disorders, schizophrenia/schizoaffective disorders

Medical comorbidity Substance abuse

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