Caries can be acute or chronic, brown-yellow, and soft or black and hard cavities. Pulp exposure may be seen. Incipient caries is more challenging to identify, and they represent the first clinical manifestation of caries. They are white and opaque irregular spots that may appear on any tooth surface.

Patients with reversible pulpitis can present with a severe toothache induced by stimuli, like hot or cold drinks or food.

On the other hand, irreversible pulpitis presents as unprovoked tooth pain that usually exacerbates overnight.

Patients with gingivitis and periodontitis will often present with a history of halitosis, bleeding after brushing teeth, and gum pain in some cases.

In gingivitis, the gums are swollen, erythematous, with a shiny surface, and they usually bleed on probing, but there are no periodontal pockets. Periodontitis involves the migration of the junctional epithelium and the development of periodontal pockets. Clinical findings of periodontitis may include gingival recession, dental papilla detachment, loss of alveolar bone, tooth mobility, or fremitus, according to the degree of destruction [11].

A periapical abscess may present as a palpable swelling. A dental abscess can be originated from the pulp, periodontal structures, or both.

More serious complaints such as fever, facial edema, trismus, dysphagia, or dysphonia can be symptoms of a more serious dental infection that has extended into deep neck spaces. Patients may be in respiratory distress or hemodynamically unstable with sepsis [12].

Dental infections can be further evaluated using dental radiographs, orthopantomography, CT scans, and MRIs. Imaging studies play an essential role in recognizing the source of infection and the proportions of the disease spread and also can detect any complications.

Radiographs can show the extent of dental caries and periodontitis.

Cone-beam CT (CBCT) is useful in assessing periapical disease, pericoronitis, and osteomyelitis. CT with contrast can help in evaluating the extent and severity of fascial space infection.

MRI is useful for osteomyelitis and deep space infections of the neck. Laboratory studies, including complete blood count, may be helpful in patients with more serious presentations. Patients with facial or deep space infections may present with sepsis and warrant the addition of blood cultures and lactic acid levels [13].

Management of dental infections depends on whether it is a local infection or a severe infection of the fascial spaces, which is rare.

If possible, removal of the source of infection is the most important step in treating dental infections [14].

Dental caries management depends on the extent of dental caries and can range from the insertion of a restorative material, endodontic treatment, to tooth extraction.

Reversible pulpitis treatment with pulp protection and restorative materials is usually sufficient. Irreversible pulpitis treatment involves a root canal and direct or indirect restorations according to the degree of tooth remanent. There is insufficient evidence to recommend antibiotics [15]. Pulp necrosis is also treated with a root canal or tooth extraction as the last resource. A periapical abscess can complicate pulpitis. A periapical abscess is treatable with endodontic treatment and if they have migrated to the mucosa surface and incision and drainage can also be performed. Periapical abscess complicated by systemic symptoms, cellulitis, or in immunocompromised patients should receive antibiotics in addition to drainage [16][17]. Gingivitis is a reversible condition, that can be treated with professional plaque removal. The use of chlorhexidine rinses is suggested only as an adjuvant to mechanical treatment and for a short period of time given its side effects and complications [18]. Periodontitis may be treated with scaling and may require antibiotics in specific cases but not routinely.

Antibiotic therapy for dental infections is necessary for systemic symptoms, fascial space infections, and infections that spread to the bony cortex and surrounding soft tissue [14]. Gram-negative organisms, facultative anaerobes, and strict anaerobes are common organisms found in dental infections, with anaerobes outnumbering aerobic bacteria by a factor of three [19]. Penicillin has traditionally been the drug of choice. Amoxicillin is the most common medication prescribed for dental infections. It is also the recommended medication by the American Heart Association for prophylaxis against endocarditis associated with dental procedures. Metronidazole is not recommended as single coverage but can be used with penicillin as penicillin is not active against aerobes and is moderately active against anaerobic cocci. There is high resistance to macrolides, and they should not serve as first-line agents. Clindamycin and macrolides are also considerations in cases of penicillin allergy.

Severe infections or patients who are immunocompromised should get anti-pseudomonal antibiotics. Piperacillin-tazobactam, meropenem, cefepime, imipenem-cilastatin, or metronidazole with ciprofloxacin can be therapeutic options.

The differential diagnosis of dental infections is variable and based on presenting symptoms. Localized dental infections can be mistaken for salivary gland pathologies such as sialadenitis, sialolithiasis, and salivary gland tumors. Sialadenitis and sialolithiasis can present with localized facial edema, erythema, and tenderness. A salivary gland tumor can present as a unilateral facial mass.

Patients with sinusitis can complain of warm, erythematous skin over the maxillary sinus.

The prognosis for uncomplicated dental infections is good. Dental infections that spread to deeper neck structures carry a worse prognosis and significant mortality rate. Deep neck infections have a mortality rate ranging from 1% to 25%, and mediastinitis can carry a mortality rate of 40% [20][21].

Serious complications can arise from dental infections as they spread to potential fascial planes of the head and neck. There are different paths for the dissemination of the infection. They can spread contiguously to the jaw, causing osteomyelitis. Second and third molars infections can migrate to the sublingual, submandibular and submental space, causing Ludwig angina. In children, dental infections may spread to the retropharyngeal or to the parapharyngeal space causing retropharyngeal or parapharyngeal abscess, respectively. Descending necrotizing mediastinitis is a severe life-threatening infection caused by the descent of dental infection through deep and superficial fascial planes. There have been case reports of dental infections spreading and causing cavernous sinus thrombosis [22]. Very rarely, dental infections can also cause meningitis and subdural empyema [23]. Dental infections and tooth extractions can cause the hematogenous spread of infection-causing bacteremia and endocarditis, especially in patients with valvular disease.

Dental infections and tooth extractions can cause the hematogenous spread of infection-causing bacteremia and endocarditis, especially in patients with valvular heart disease [12]. Angioedema can cause facial swelling that can be more prominent on one side. Osteomyelitis can present with fever, erythema, facial edema, and point tenderness. Ludwig angina presents with facial swelling, trismus, respiratory distress, dysphagia, and dysphonia.

Patients should receive counseling on proper dental hygiene to prevent dental infections. Educating patients and the public on the importance of daily toothbrushing, flossing, and reduction of sugar-containing foods can reduce dental cavities. A dentist should assess patients that are experiencing dentalgia.

• Dental infections originate at the tooth or its supporting structures and can spread to the surrounding tissue.
• Dental infections most commonly occur when bacteria invade the pulp and spread to surrounding tissues. Infections can also affect the gums causing gingivitis, which can later cause periodontal disease.
• More serious complaints such as fever, facial edema, trismus, dysphagia, or dysphonia can be symptoms of a more serious dental infection that has spread into deep neck spaces.
• CT with contrast can help evaluate the extent and severity of fascial space infection.
• In most cases, drainage, along with the removal of the source of infection, are the most important steps in treating dental infections.
• Serious complications from dental infections are rare. They include osteomyelitis, Ludwig angina, retropharyngeal abscess, parapharyngeal abscess, necrotizing mediastinitis, cavernous sinus thrombosis, meningitis, and subdural empyema.

Dental infections that may have migrated to the surrounding facial tissues require an interprofessional team approach, including physicians, dentists, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. Pharmacists review antibiotic prescriptions and check for drug-drug interactions. They also educate the patient's about use, side effects, and the importance of compliance. Usually, patients with dental infections initially present to the emergency department, primary care provider, or urgent care. When systemic symptoms are consistent with a deep neck infection or osteomyelitis should be immediately identified and admitted to the hospital after stabilization. Initial stabilization should include IV antibiotics and close monitoring of the airway. Patients stable enough for outpatient treatment should get a referral to a dentist or other specialists like endodontists or oral and maxillofacial surgeons. Delay in treatment can worsen the dental infection and lead to tooth loss or spread of disease. [Level V]