Infections of Teeth and Jaws 

Introduction 

Facial infections are relatively common.  Since the advent of antibiotics and improved access to care, they are now rarely life threatening.  Yet they still remain as one of the major reasons for seeking treatment in medical and dental facilities.  Superficial infections are usually easily treated and are rarely serious.  Deeper infections are more complex and potentially more serious.  If left untreated, they could endanger life.  Possible sources are salivary glands, sinuses, tonsils, teeth, and jaws.   Teeth are the most common cause of facial swelling in the area of the jaws.  

Treatment of facial infection usually requires a team approach involving physicians and dentists as well as radiography/imaging, laboratory, operating room, and possibly hospital inpatient facilities. 

What are the signs and symptoms of facial infection? 

Infections, regardless of the site, may present with;

• Pain
• Swelling
• Redness
• Warmth
• Decreased function
• Discharge
• Fever/chills
• Malaise or feeling unwell

Note the redness and swelling on the right cheek of the patient.

 

   

In the facial region, a seriously infected individual may have difficulty with mouth opening, swallowing and eating.   Breathing can be affected as can vision.

Who is at risk for facial infection? 

Infections occur when infective microorganisms overwhelm the individual’s immune system.  Even though infections may happen to anyone, individuals with a compromised immune status are at greater risk.  These include young children, the elderly, poorly controlled diabetics, hospitalized/institutionalized patients, HIV/AIDS patients or patients on steroid therapy or chemotherapy. 

How do teeth cause infections?  

Dental infections (odontogenic) may be localized to the gum tissues or may spread to the face and neck, eyes, throat, and can even spread systemically to other parts of the body.  Common ways that teeth may cause infection are noted in the diagram below; 

Deep decay infecting the nerve (root canal) Infection spreading beyond the tooth root, into bone Periodontal (gum) infection Submerged/impacted teeth, such as wisdom teeth Retained/broken roots of teeth at or below gum level

How does infection spread? 

Infections spread via the path of least resistance.  Severe pain can result when the pressure buildup of infection is contained in the tooth or within hard bone.  Once the infection leaves the apex (tip) of a tooth, it then erodes through the bony housing until it reaches the soft tissues.  Pain might even diminish at this stage, only to return later.  At this point, the location of muscle attachments can dictate the path of the spread of infection.   Even though, there are no real spaces for the infection to collect, there are “potential spaces” along muscles that could allow for accumulation of infected material.  Because of this common anatomy, most infections have common features in their presentation. 

What is pus? 

As a response to infection, the body mobilizes its white blood cells to fight and destroy the offending organism.  In this process the bacteria and some white blood cells die.  The collection of these dead cells and other debris forms pus. 

Is there always going to be pus in infected patients? 

No.  If the infection is dealt with early, there will not be adequate time for significant collection of pus to be visible to the eye.  This does not mean that treatment should be delayed until pus forms.  

What organism causes dental infection? 

The mouth harbours numerous bacteria.  There are bad, disease causing, bacteria as well as “good” ones, which keep the balance of health.  If this balance is altered for any reason in a susceptible host, infection will result.  Even though, certain bacteria dominate, the majority of cases of oral and facial infections involve a mix multiple organisms.

When should I seek treatment for an infection? 

As soon as you feel pain and any swelling or puffiness in the mouth or face, you should consult your dentist.  Note that a toothache may or may not be present at the time of swelling.  

How are dental/facial infections dealt with?  

The primary goal of treatment is removal of the offending source.  If this is a decayed tooth, the options will be root canal treatment or extraction.  Every attempt should be made at salvaging functional teeth, but in certain circumstances, the only choice will be the removal of an offending tooth or teeth.  If the infection is due to facial trauma, fractures or impaled foreign material, treatment may be more involved.  One should always be mindful that facial infections may be caused by sinus, tonsil, or salivary gland infections. 

In more serious infection, incision and drainage may be required.  The location of the drain placement will be dictated by the severity and type of infection and gravity dependant drainage.  It may be placed inside the mouth or on the skin of the face and neck.   

This is a patient with significant facial swelling who has had incision and drainage done through the skin. 

The arrows point to the drain in the neck.

 

Can I have treatment if I have an acute infection? 

The chemical environment of an infected site is more acidic.  This means that local anesthetic (freezing) will not be as effective using the usual dosages and techniques.

In some cases a patient may be given a prescription of antibiotics to allow for the acute phase of the infection to subside before definitive treatment.  This approach however, is not advisable in cases of potentially serious infection.

In cases of serious infection, when treatment needs to be rendered immediately, the doctor may use different nerve block techniques, sedation or general anesthesia, if possible, to keep the patient comfortable during the procedure.  This is why some patients may be referred to other practitioners, such as oral and maxillofacial surgeons or endodontists, or to facilities that are equipped to provide the necessary care. 

How long do I need to be on antibiotics? 

For most infections, once treatment is initiated, a 7-10 day course of antibiotics will be prescribed.  In some cases where there is concern about the type of infection or the patient’s ability to fight infections, a longer course may be required. 

Why did my doctor(s) change my antibiotics? 

Most infections are caused by the “usual suspects” of bacteria.  That is why the majority of antibiotic treatments start with the more commonly effective medications.  In some cases, the causative predominant organism(s) are not susceptible, or are resistant, to the drug chosen.  That is why your doctor may choose to change your antibiotics or add another one to the regimen. 

Why are x-ray films necessary before treatment? 

Even though clinical examination is very important, it only shows what is on the surface.  At times a seemingly routine dental abscess may mask a more serious problem.  Patients with facial fractures, or malignancies, may not experience any other symptoms but a “toothache”.  The x-ray film provides a more complete picture for your doctor and is invaluable for proper diagnosis. 

The typical dental film provides excellent detail.  It is however, limited in its field of view. In uncomfortable patients or those who can not open their mouths, this technique poses a challenge. The arrow is pointing to infection at a root apex (within bone)

 

The panoramic film is the most useful film for evaluation of facial infections or fractures.  It has a wide area of coverage.  It is well tolerated by patients, since does not involve placing a film in the mouth.  This film, however  lacks the detail of the typical dental film

Dr. Keyvan Abbaszadeh is a maxillofacial surgeon and partner at Interface, a maxillofacial surgical centre with locations in London and St. Thomas.  Their website can be found at www.interfacelondon.com

Dr. Abbaszadeh is a member of the Medical Staff at St. Thomas-Elgin General Hospital.