Family physicians commonly encounter patients with dental infections, such as dental caries and periodontal disease.
Dental caries is caused by bacteria that destroy the enamel and dentin; it can be detected by an oral examination that
shows stained pits or fissures on the tooth surface. Use of fluoride is the most effective prevention measure for dental
caries. Untreated caries may progress to pulpitis and, eventually, to necrosis of the pulp. In irreversible pulpitis, the
tooth dies and the patient may have a localized abscess that can spread to surrounding tissue. Periodontal infections
are caused by bacteria in the subgingival dental plaque. In gingivitis, the inflamed gums bleed easily with brushing or
flossing; the condition can be controlled with good oral hygiene. Periodontitis is characterized by a loss of supportive
bone structure caused by chronic gingivitis; it is also associated with some systemic diseases. Localized periodontitis
is treated with mechanical debridement and good oral hygiene, whereas generalized periodontitis requires adjunct
antibiotic therapy. Pericoronitis results when food particles become trapped under the gum of an impacted tooth.
This condition can be controlled by removal of food debris and good oral hygiene. For patients in whom dental infec-
tions are disseminated and have invaded the deeper oral spaces, antibiotic treatment should be initiated at the time of
referral. (Am Fam Physician. 2008;77(5):797-802, 806. Copyright 2008 American Academy of Family Physicians.)
D
This article exempli- ental infections, including den- infections and, in some circumstances, may
fies the AAFP 2008 Annual tal caries and periodontal dis- initiate treatment of serious infections before
Clinical Focus on infectious ease, are commonly encountered referral. Family physicians can also advise
disease: prevention, diag-
nosis, and management.
in the primary care setting in patients on how to prevent dental infections.
the United States. Nationally, dental caries
Patient information: Basic Dental Anatomy
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Common Dental Infections
Evidence
Clinical recommendation rating References Comments
Most dentists recommend a six-month interval for dental C 7 There is insufficient evidence
checkups for all patients. to support or refute biannual
dental visits
Tooth brushing with a small amount of low-fluoride toothpaste B 8, 11-13
should be introduced to children at two years of age. After six years
of age, children can safely use regular fluoridated toothpaste.
Tooth brushing with fluoridated toothpaste twice a day after meals A 8, 15 The benefits of topical fluorides
is recommended as an effective way to prevent tooth decay. have been firmly established
Use of powered toothbrushes that have a circular oscillating B 16 Long-term benefits of using
motion can reduce plaque and gingivitis more effectively than powered toothbrushes for
manual brushing. dental health are unclear
Decreasing the amount and frequency of consumption of foods B 5, 8
with a high sugar content can improve oral health.
A = consistent, good quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 739 or http://
www.aafp.org/afpsort.xml.
Dental Caries
Dentin
Dental caries is caused mainly by micro-
organisms that generate acids on the tooth
Pulp surface from disaccharides and monosac-
charides present in sugar-rich foods; this
leads to demineralization of the protective
enamel coating and subsequent tooth decay.
Certain foods such as sweetened pastries may
be more potent than others at inducing den-
Periodontal tal caries.5 Even diet sodas, which contain no
ligament sugars, have been implicated in decalcifica-
tion caused by low pH from phosphoric acid.
It is the frequency of exposure rather than
Alveolar bone
the amount of carbohydrate substrate that
makes the difference in caries rates.
Initially, dental caries is asymptomatic. As
ILLUSTRATION BY stacey olson sachs
798 American Family Physician www.aafp.org/afp Volume 77, Number 6 March 15, 2008
fissures will eventually become stained because of demin-
eralization of the enamel and dentin (Figure 2). Recession
of the gums in aging patients may expose the roots to den-
tal caries. Dental caries is also diagnosed by radiographic
examination; low-level lasers can detect early tooth decay.
March 15, 2008 Volume 77, Number 6 www.aafp.org/afp American Family Physician 799
Common Dental Infections
Necrotic pulp
Cellulitis
ILLUSTRATION BY stacey olson sachs
spreading of
infection into
surrounding
tissues
Figure 4. Gingivitis of the upper gum.
GINGIVITIS
800 American Family Physician www.aafp.org/afp Volume 77, Number 6 March 15, 2008
Common Dental Infections
PERICORONITIS
Pericoronitis is an acute, localized infection caused by
food particles and microorganisms trapped beneath the
gingival flaps of a partially erupted tooth or an impacted
wisdom tooth (Figure 7). Symptoms typically include
Figure 6. Advanced periodontitis of the lower teeth. localized pain and limitation of movement on open-
ing the jaw, discomfort on chewing and swallowing,
examination may show deep gum pockets that bleed eas- and facial swelling. Localized lymphadenopathy may be
ily when probed, subgingival dental plaque, and receding noted, and halitosis is common. Treatment of a localized
gums that expose the root of the tooth. Periodontal abscess pericoronitis involves removal of the food particles and
is a severe consequence of periodontitis and may present good oral hygiene, which should include hot salt water
as a red, fluctuant swelling of the gingiva that is extremely or chlorhexidine rinses before referral. In severe cases
tender to palpation (Figure 6). The abscess may be focal of pericoronitis, the treatment would include antibiotics
or, if diffuse, may spread to deeper oral spaces, causing and referral to a dental professional.
swelling of the face and jaw and lymphadenopathy.
The authors thank Tuyen Nguyen, DDS; Tam Truong, DDS; and William C.
Antibiotics are not normally indicated if mechanical Domb, DMD, for their assistance with the manuscript.
debridement is successful in the case of localized peri-
odontitis. Adding chlorhexidine rinse after surgical Figures 2 and 4 were provided by Tam Truong, DDS, and Figures 5 and
6 were provided by Tuyen Nguyen, DDS.
debridement contributes to faster recovery of periodon-
tal tissue.37 In generalized periodontitis involving mul-
tiple teeth, patients should be treated with antibiotics as The Authors
an adjunct therapy. In patients with juvenile periodonti-
DUC HUU NGUYEN, DO, is an assistant clinical professor in the Depart-
tis, tetracycline is safe to use after 12 years of age, but the ment of Family Medicine, University of California at Irvine. Dr. Nguyen
pathogens in this disease have been increasingly resistant received his medical degree from the College of Osteopathic Medicine of
to this treatment regimen.38 Adult periodontitis can be the Pacific, Western University of Health Sciences, Pomona, Calif., and a
degree in dentistry from the University of Medicine and Pharmacy in Ho
treated with doxycycline (Vibramycin), metronidazole Chi Minh City, Vietnam.
(Flagyl), or topical application of minocycline micro-
spheres (Arestin). If cellulitis occurs, patients should be JAMES T. MARTIN, Dr.rer.nat., is a professor of physiology and behavioral
treated with antibiotics.39,40 science in the College of Osteopathic Medicine of the Pacific, Western Uni-
versity of Health Sciences. Dr. Martin received his doctoral degree from
the University of Munich, Germany.
Impaction of food Address correspondence to Duc Huu Nguyen, DO, UCI Family Health
and bacteria Center, 300 W. Carl Karcher Way, Anaheim, CA 92801 (e-mail: duchn@
uci.edu). Reprints are not available from the authors.
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