Patient Presentation
A 15-year-old male came to clinic because of right ear pain. Initially he said it was only for a couple of days but when asked again he said that he had been having oral pain that now seems to have moved to his ear. He denied fever or chills. The ear did not hurt when he pressed on the tragus and he denied discharge. He recently had moved to the area and had not established health or dental care.

The pertinent physical exam showed he had normal vital signs and his weight was at the 10%. HEENT showed potentially slight swelling near the lower jaw on the right side. He had normal tympanic membranes but he complained when the otoscope speculum was inserted. Oral examination was difficult because the patient would not open the mouth widely due to pain. It showed an extensive dental caries of the last right-sided mandibular molar with just a rim of tooth remaining that looked like a crater. No specific suppuration was seen. The adjacent gingiva looked reddened. The next to last right molar also had two separate brown lesions with one on the lingual surface and the other on the articular surface. There were several other teeth with similar small brown caries throughout the mouth. There was significant tarter and overall poor hygiene but no other area had redness or swelling. The two molars were painful with tapping of the teeth. Palpation of the jaw itself did not elicit pain. There were two submandibular and anterior cervical lymph nodes on the right side that were ~1 cm in size. Movement of the neck did not exacerbate the symptoms. The rest of his examination was normal.

The diagnosis of poor oral hygiene, significant dental caries and possible dental abscess was made. The patient’s clinical course revealed that the father stated that he had been trying to get his son dental treatment before and since moving but it had been challenging because of few providers accepting his insurance. The pediatrician consulted the on call dentist who recommended starting Augmentin® for possible abscess and he would arrange to see the patient the following day. The pediatrician also arranged to provide care to the boy and other children in the family. The sister was seen 6 weeks later for routine care and the boy had had to have the last molar extracted but the second molar was being treated.

Discussion
Dental caries are one of the most common infections. It is usually caused by Streptococcus viridans. Dental caries are also quite preventable with brushing the teeth at least twice a day with a fluoridated dentifrice, use of dental floss, and preventative dental appointments with application of fluoride varnish and sealants as appropriate. Additionally, fluoridation of the community water supply has significantly decreased dental caries and is a very effective public health measure. Fluoride binds within the dental matrix to strength it.

Dental abscesses are usually caused by poor oral hygiene but others are at risk because of malformations and deformation of the dental structure or underlying medical conditions (a review can be found here). Dental abscess often contain poly-organisms with combinations of anaerobic and fastidious organisms. Other odontogenic infections include gingivitis, periodontitis, pulpitis and various periodontal abscesses. They can also lead to regional and systemic infections such as osteomyelitis, deep fascial infections of the head and neck, and hematogeneous spread including bacteremia and sepsis.

Diagnosis is by history, clinical examination and may be aided by panoramic imaging and/or computed tomographic evaluation of osseous structures. Magnetic resonance imaging may be needed if deep tissue infections are suspected. General pain, pain with pressure, eating, temperature changes, and trismus are indications for possible dental disease. Careful inspection of the area may help in diagnosis including for foreign bodies such as popcorn or corn husks or other foreign bodies (e.g. trapped dental floss, plastic piece) Tapping of teeth to try to localize the dental disease can be helpful but isn’t always specific especially in children.

Healthcare providers should also consider if the dental disease is part of a larger health or socio-economic problem. As parents are responsible for children’s dental care for many years and also oversee it when they are older, significant dental disease could be a sign of child neglect and should be evaluated if suspected. Families with lack of resources or knowledge may need social service interventions to be able to locate and receive needed overall health and welfare services and specifically dental services.

Learning Point
Treatment for dental caries depends on the extent of the disease. Usually antibiotics are not necessary for dental caries but more extensive disease may need oral antibiotics or even intravenous antibiotics especially for suspected abscess. Initial outpatient oral antibiotics used for children is amoxicillin but if more expensive disease or abscess is suspected then amoxicillin-clavulanic acid or clindamycin are used to cover the common organisms. Mechanical debridement of the area such as scaling of the teeth, or foreign body removal, or appropriate filling of caries can fix many caries. Abscess however can need surgical debridement of the affected area, and even more extensive care (e.g. root-canal). Patient education and institution of meticulous oral care at home may save the teeth. However, periodontic abscesses are well known as “hopeless” teeth and still with extensive treatment, may need to be extracted.

Questions for Further Discussion
1. What is included in the differential diagnosis of different colored teeth? A review can be found here
2. What are indications for referral to a dentist?
3. What is the difference between a dentist, oral surgeon, and orthodontist?

Related Cases

Disease: Dental Caries and Abscesses | Tooth Disorders | Child Dental Health

Symptom/Presentation: Ear Pain

Specialty: Dentistry / Orthodontia

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Tooth Decay and Child Dental Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Herrera D, Roldan S, Sanz M. The periodontal abscess: a review. J Clin Periodontol. 2000;27(6):377-386. doi:10.1034/j.1600-051x.2000.027006377.

Seow WK. Diagnosis and management of unusual dental abscesses in children. Aust Dent J. 2003;48(3):156-168. doi:10.1111/j.1834-7819.2003.tb00026.

Jenkins GW, Bresnen D, Jenkins E, Mullen N. Dental Abscess in Pediatric Patients: A Marker of Neglect. Pediatr Emerg Care. 2018;34(11):774-777. doi:10.1097/PEC.0000000000001611

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa