Common Dental Infections in the Primary Care SettingDUC HUU NGUYEN, DO, University of California at Irvine Family Health Center, Anaheim, CaliforniaJAMES T. MARTIN, Dr.rer.nat., College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California Dental infections, including den-tal caries and periodontal dis-ease, are commonly encountered in the primary care setting in the United States. Nationally, dental caries is the most common disease in children and adults. Fifty percent of children between six and eight years of age have dental caries, 1 and 85 percent of adults have at least one tooth with decay or a filling on the crown. 2 According to data from the Third National Health and Nutrition Examination Survey, in the United States 48 percent of adults between 35 and 44 years of age have expe-rienced gingivitis, and 15 percent of adults older than 30 years have destructive peri-odontal disease (i.e., periodontitis). 3 In 2005, dental services in the United States cost $86.6 billion, 4.4 percent of the total spent on health care that year. 4Clearly, the direct costs (i.e., the money spent on dental services) and indirect costs (i.e., the number of lost days of productivity at work and school) of oral diseases place a high burden on society. Family physicians are in a good position to address this mor-bidity. They can recognize common dental infections and, in some circumstances, may initiate treatment of serious infections before referral. Family physicians can also advise patients on how to prevent dental infections.Basic Dental AnatomyHuman beings have two sets of teeth: pri-mary (milk or baby) and permanent. There are 20 primary teeth, including two inci-sors, one canine, and two molars in each half jaw. These teeth erupt at approximately six months, and the set is complete by two years of age. The primary teeth are shed between six and 12 years of age. These are eventu-ally replaced by permanent teeth starting at approximately age six and usually end-ing by age 18. The permanent teeth include two incisors, one canine, two premolars, and three molars in each half jaw.Structurally, a tooth has a visible crown that projects above the gingiva. Enamel is the out-ermost layer of the crown and is the hardest structure of the body. In the middle is the den-tin, a bone-like material, and the innermost layer is the pulp chamber (Figure 1). Similarly, the roots of the tooth have cementum as the outermost layer, the dentin is in the middle, 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.) This article exempli-fies the AAFP 2008 Annual Clinical Focus on infectious disease: prevention, diag-nosis, and management.▲ Patient information: A handout on common dental infections, writ-ten by the authors of this article, is provided on page 806.Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
