CME information and disclosures
To see contributor disclosures related to this article, hover over this reference: 
Physicians may earn CME/MOC credit by searching for an answer to a clinical question on our platform, reading content in this article that addresses that question, and completing an evaluation in which they report the question and the impact of what has been learned on clinical practice.
AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.
For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see "Tips and Links" at the bottom of this article.
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.
- Pathophysiology: oral bacteria metabolize carbohydrates → acid production (e.g., lactic acid) → demineralization of tooth enamel
- Clinical features
- Differential diagnosis
Treatment: depends on the size and extent of the lesion
- Very small lesion in which remineralization is still possible: The application of fluoride gel, varnishes, pit, and/or fissure sealant usually suffices.
- Lesions that involve hard tissues but do not involve the pulp: caries excavation and restoration of the dental surface
- Lesions that involve both enamel and dentin in proximity to the pulp:
- Lesions that involve enamel, dentin, and pulp: root canal treatment, followed by extracoronal restoration
- Complications: mostly caused by inflammation of the pulp
- Proper oral hygiene
- Use of toothpaste supplemented with fluoride
- Caused by bacteria in dental plaque (see “Etiology” in “Tooth decay”)
- Risk factors
Disease spectrum 
- Gingivitis: reversible inflammation of the gums
Periodontitis: a nonreversible inflammatory condition involving the gingiva, periodontal ligament, and/or alveolar bone
- Risk factors
- Clinical features
- Management: Refer all patients to a dentist for evaluation and treatment including the removal of dental plaque and dental tartar
Pericoronitis: inflammation and/or infection of the gingiva at the site of tooth eruption 
- Clinical features: pain and localized gingival swelling, typically at the site of the third mandibular molar
Acute necrotizing ulcerative gingivitis (ANUG): a polymicrobial gingival infection characterized by tissue necrosis
- Clinical features
Dental infection red flags 
The followingsuggest progression to deep tissue or systemic that require urgent management:
- Swelling of the face, neck, and/or floor of the mouth
- Facial erythema
- Regional lymphadenopathy
- Difficulty swallowing or handling secretions
- Dyspnea and/or airway compromise
- Headache or stiff neck
In patients presenting with periodontal pain or bleeding, provide appropriate .
- Definition: the accumulation of purulent fluid within the dental pulp or periodontal tissue 
- Dental caries
- Poor oral hygiene
- Unsuccessful root canal treatment
- Periapical abscess
- Periodontal abscess
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”).
- 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.
- An oral examination is usually sufficient to make a diagnosis.
- Obtain diagnostic studies if
- Laboratory studies: CBC (may show leukocytosis, neutrophilia) 
- Imaging: x-ray, CT, or MRI of the head and neck
- See also “Diagnostics” in “Deep neck infections.”
- Consult a dentist or oral surgeon for abscess , and, if necessary, removal of the affected tooth.
- Start empiric antibiotic treatment for systemic symptoms (e.g., fever) or if surgical intervention is delayed. 
- Provide .
If surgery immediately. are present, consult maxillofacial or oral
Dental avulsion 
- Definition: the complete displacement of a tooth from its socket
Replant a permanent tooth as quickly as possible. ; 
- Handle the tooth by the crown only.
- Rinse off debris with saline (do not scrub or sterilize).
- Gently reduce the tooth into the correct anatomical position.
- Splint the tooth in the correct position with wax or dental cement.
- Begin antibiotic prophylaxis: doxycycline for adults, penicillin for children < 12 years of age 
- Provide if indicated. 
- If unable to replant the tooth:
- If an avulsed tooth is unaccounted for:
- Replant a permanent tooth as quickly as possible. ; 
Do not replant primary teeth. 
Dental subluxation and luxation 
- Definition: partial or complete disruption of the periodontal ligament, resulting in tooth mobility within the socket
Dental fracture 
- 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
- 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
- Consult dentistry: Urgency is based on the class of fracture. 
- Obtain imaging (e.g., radiography, CT) if a fracture of the dental root or alveolar bone is suspected. 
- 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. 
- Antibiotics are not typically required. 
- Definitive management
- 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. 
- 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. 
- Systemic analgesia
- Local and regional analgesia
The following measures can be attempted in succession until the bleeding is adequately controlled:
- Direct pressure for 15–30 minutes
- Topical tranexamic acid 
- Local anesthetic with epinephrine injection
Consider an underlying if bleeding is difficult to control. 
If local measures to control bleeding are unsuccessful, consult oral surgery and interventional radiology for consideration of surgical management or embolization. 
- Local and regional complications
- Systemic complications
Dental infections are the most common cause of deep neck space infections. 
We list the most important complications. The selection is not exhaustive.