Dental disorders

Last updated: November 15, 2023

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Summarytoggle arrow icon

Tooth decay (dental caries) is the progressive destruction of dental tissue following enamel damage by acid-producing bacteria in dental plaque. Manifestations include dentalgia and halitosis. Diagnosis is usually clinical and can involve imaging (e.g., x-ray). Treatment often includes caries excavation and surface restoration.

Periodontal disease includes various inflammatory conditions, such as gingivitis, periodontitis, pericoronitis, and acute necrotizing ulcerative gingivitis, that affect tooth-supporting structures, including the gingiva, periodontal ligament, and/or alveolar bone. Management is based on severity but often includes oral hygiene measures, topical antiseptics, systemic antibiotics, and/or referral for dental plaque debridement.

Dental abscesses can arise from infections and/or trauma to dental pulp and/or periodontal tissue and often extend locally. Clinical features include dentalgia, gingival swelling and erythema, and purulent discharge. Signs of regional and/or systemic progression requiring urgent management include dysphagia, facial erythema, and fever. Treatment can include incision and drainage, dental extraction, and antibiotics.

Dental injuries can involve dental avulsion (complete displacement from the socket), dental subluxation and luxation (injury to the periodontal ligament, and dental fracture. Management depends on the injury type and extent and can include manual replantation or reduction, dental splinting, antibiotics, root canal, and surface restoration.

Malocclusion is a deviation from the ideal tooth position that affects dental contact during biting. It is usually asymptomatic but can cause symptoms in pronounced cases. Management includes orthodontic correction and jaw repositioning.

Tooth decaytoggle arrow icon

Periodontal diseasetoggle arrow icon

Consists of various inflammatory conditions that affect the supporting tissues of the teeth, including the gingiva, periodontal ligament, and/or alveolar bone [4][5]

Etiology [5][6][7]

Disease spectrum [4][5][6][8]

Dental infection red flags [6][10]

The following red flags suggest progression to deep tissue or systemic complications of periodontal and dental infections that require urgent management:

In patients presenting with periodontal pain or bleeding, provide appropriate supportive care for periodontal disorders.

In patients with red flags for progression of periodontal infections, consider systemic antibiotics and urgent referral to surgery for management of a possible deep neck infection.

Dental abscesstoggle arrow icon


  • Definition: the accumulation of purulent fluid within the dental pulp or periodontal tissue [10]
  • Etiology [10]
    • Dental caries
    • Poor oral hygiene
    • Trauma
    • Unsuccessful root canal treatment
  • Types [4]
    • Periapical abscess
      • Most common type
      • Tooth decay or trauma → bacterial infection in the pulp of the tooth → collection of pus at the apex of the dental root
      • The infection becomes visible when it extends through the alveolar bone (e.g., via a fistula) to the surrounding tissue. [11]
    • Periodontal abscess
      • Second most common type
      • Periodontitis or impaction of foreign objects (e.g., food, dental floss) → bacterial infection deep in the periodontal pocket → collection of pus between the teeth and gingiva
      • The affected tooth may be mobile.

Periodontal abscesses originate in the periodontal tissue; the tooth itself may be healthy. Periapical abscesses originate in the dental pulp and always involve the tooth.

Dental infections can spread locally to the gums and alveolar bone and to regional structures including the deep neck spaces and intracranial sinuses (see “Complications”).

Clinical features

  • Severe pain can generally be elicited with palpation.
  • Swelling and erythema of the surrounding mucosa
  • Purulent discharge from the gum line may be seen.
  • The affected tooth may be discolored and/or show enamel breaks.

Diagnostics [8][10]

Management [8][9][10]

Manage dental abscesses with incision and drainage; antibiotic therapy alone is not sufficient. [4][13]

If red flags for dental infection progression are present, consult maxillofacial or oral surgery immediately.

Dental injuriestoggle arrow icon

Emergency management of dental injuries includes assessing for concurrent injury, preserving tooth viability, and infection prevention. Follow-up care with a dentist is always required. [9]

Dental avulsion [8][9][14]

Avulsion of a permanent tooth is a dental emergency. Manual replantation is indicated as soon as possible, followed by urgent referral to a dentist. [14]

Do not replant primary teeth. [9]

Dental subluxation and luxation [8][9][15]

Dental fracture [8][9][15]

  • Definition: a partial or complete interruption in the continuity of a tooth
  • Classification and clinical characteristics: Dental fractures may involve the crown, root, and/or alveolar bone.
    • Enamel infraction: enamel crack without disruption of tooth structure
    • Crown fracture
      • Ellis I (limited to enamel): painless, no bleeding
      • Ellis II (dentin is exposed): fracture site appears yellow, no or minimal bleeding
      • Ellis III (pulp is exposed): fracture site appears pink, heat and cold sensitivity, possible bleeding
    • Root fracture: The tooth is mobile, tender to palpation, and often bleeds.
    • Alveolar bone fracture: may cause segmental displacement with movement in multiple adjacent teeth
  • Management
    • Consult dentistry: Urgency is based on the class of fracture. [8]
    • Obtain imaging (e.g., radiography, CT) if a fracture of the dental root or alveolar bone is suspected. [15]
    • Control bleeding and pain; see “Supportive care for dental disorders.”
    • Consider the application of dental cement (calcium hydroxide paste) to Ellis II and Ellis III fractures pending dental consult. [9]
    • Antibiotics are not typically required. [9]
    • Definitive management
      • Enamel infraction: sealing with bonding resin in severe cases
      • Crown fracture
        • Ellis I and II: tooth fragment replantation or tooth edge smoothing
        • Ellis III: pulp therapy, possible root canal
      • Root fracture: splinting, possible root canal
      • Alveolar bone fracture: repositioning and splinting

Malocclusiontoggle arrow icon

  • Definition: any deviation from ideal tooth positioning that leads to irregular contact between the upper and lower teeth when the jaw is closed
  • Types: The most common forms are anterior crowding, vertical overbite, and sagittal overjet. [16]
  • Clinical features
    • Usually asymptomatic
    • In severe cases: discomfort when biting or chewing, frequent biting of cheeks or tongue, speech problems
  • Management: : correction of deviated teeth and jaw positions through orthodontic treatment (e.g., braces) to achieve proper occlusion
  • Prognosis: Whether orthodontic correction of dental alignment has a positive effect on dental health is still subject to debate. [17]

Differential diagnosestoggle arrow icon

Nonodontogenic causes of orofacial pain [9][18]

The differential diagnoses listed here are not exhaustive.

Supportive care for dental disorderstoggle arrow icon

Dentalgia [8][19][20]

The application of dental cement (calcium hydroxide paste) can help relieve pain caused by exposed pulp.

Bleeding [9][22]

The following measures can be attempted in succession until the bleeding is adequately controlled:

Consider an underlying bleeding disorder if bleeding is difficult to control. [9]

If local measures to control bleeding are unsuccessful, consult oral surgery and interventional radiology for consideration of surgical management or embolization. [9]

Complicationstoggle arrow icon

Dental infections are the most common cause of deep neck space infections. [4][8]

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Hodgdon A. Dental and Related Infections. Emerg Med Clin North Am. 2013; 31 (2): p.465-480.doi: 10.1016/j.emc.2013.01.007 . | Open in Read by QxMD
  2. Kinane DF, Stathopoulou PG, Papapanou PN. Periodontal diseases. Nat Rev Dis Primers. 2017; 3 (1).doi: 10.1038/nrdp.2017.38 . | Open in Read by QxMD
  3. Stephens MB, Wiedemer JP, Kushner GM. Dental Problems in Primary Care.. Am Fam Physician. 2018; 98 (11): p.654-660.
  4. Heasman PA, Hughes FJ. Drugs, medications and periodontal disease. Br Dent J. 2014; 217 (8): p.411-419.doi: 10.1038/sj.bdj.2014.905 . | Open in Read by QxMD
  5. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  6. Hammel JM, Fischel J. Dental Emergencies. Emerg Med Clin North Am. 2019; 37 (1): p.81-93.doi: 10.1016/j.emc.2018.09.008 . | Open in Read by QxMD
  7. Ogle OE. Odontogenic Infections. Dent Clin North Am. 2017; 61 (2): p.235-252.doi: 10.1016/j.cden.2016.11.004 . | Open in Read by QxMD
  8. $Contributor Disclosures - Dental disorders. All of the relevant financial relationships listed for the following individuals have been mitigated: Alexandra Willis (copyeditor, is an independent contractor for OPEN Health Communications); Jan Schlebes (medical editor, is a shareholder in Fresenius SE & Co KGaA). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  9. Timmerman A, Parashos P. Management of dental pain in primary care. Aust Prescr. 2020; 43 (2): p.39-44.doi: 10.18773/austprescr.2020.010 . | Open in Read by QxMD
  10. Moore PA, Ziegler KM, Lipman RD, Aminoshariae A, Carrasco-Labra A, Mariotti A. Benefits and harms associated with analgesic medications used in the management of acute dental pain. J Am Dent Assoc. 2018; 149 (4): p.256-265.e3.doi: 10.1016/j.adaj.2018.02.012 . | Open in Read by QxMD
  11. Hersh EV, Ciancio SG, Kuperstein AS, et al. An evaluation of 10 percent and 20 percent benzocaine gels in patients with acute toothaches. J Am Dent Assoc. 2013; 144 (5): p.517-526.doi: 10.14219/jada.archive.2013.0154 . | Open in Read by QxMD
  12. Roberts G, Scully C, Shotts R. ABC of oral health: Dental emergencies. BMJ. 2000; 321 (7260): p.559-562.doi: 10.1136/bmj.321.7260.559 . | Open in Read by QxMD
  13. Ahmadi H, Ebrahimi A, Ahmadi F. Antibiotic Therapy in Dentistry. Int J Dent. 2021; 2021: p.1-10.doi: 10.1155/2021/6667624 . | Open in Read by QxMD
  14. Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2020; 36 (4): p.331-342.doi: 10.1111/edt.12573 . | Open in Read by QxMD
  15. Bourguignon C, Cohenca N, Lauridsen E, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol. 2020; 36 (4): p.314-330.doi: 10.1111/edt.12578 . | Open in Read by QxMD
  16. Reichman E. Emergency Medicine Procedures. McGraw-Hill ; 2013
  17. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. The Journal of the American Dental Association. 2019; 150 (11): p.906-921.e12.doi: 10.1016/j.adaj.2019.08.020 . | Open in Read by QxMD
  18. Rathee M, Sapra A. Dental Caries. StatPearls. 2021.
  19. Yılmaz H, Keleş S. Recent Methods for Diagnosis of Dental Caries in Dentistry. Meandros Medical and Dental Journal. 2018; 19 (1): p.1-8.doi: 10.4274/meandros.21931 . | Open in Read by QxMD
  20. Bernhardt O, Krey KF, Daboul A, et al. New insights in the link between malocclusion and periodontal disease.. J Clin Periodontol. 2019; 46 (2): p.144-159.doi: 10.1111/jcpe.13062 . | Open in Read by QxMD
  21. Bollen AM. Effects of malocclusions and orthodontics on periodontal health: evidence from a systematic review.. J Dent Educ. 2008; 72 (8): p.912-8.
  22. De Laat A. Differential diagnosis of toothache to prevent erroneous and unnecessary dental treatment. J Oral Rehabil. 2020; 47 (6): p.775-781.doi: 10.1111/joor.12946 . | Open in Read by QxMD

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