What should be documented during a physical exam for a tooth infection?

Physical Examination Documentation for Tooth Infection

A thorough physical examination for tooth infection should document focal inflammatory signs including swelling, redness, pain on palpation, and the presence of any purulent discharge, as these findings directly correlate with infection severity and guide treatment decisions.

Extraoral Examination

• Facial swelling: Document location, extent, and consistency (firm vs. fluctuant)
• Lymphadenopathy: Note size, tenderness, and location of involved lymph nodes
• Trismus: Document any limitation in mouth opening (measured in mm)
• Fever: Record temperature if present
• Vital signs: Document pulse, respiratory rate, blood pressure (to assess for systemic involvement)

Intraoral Examination

• Affected tooth:

  • Document tooth number/location
  • Presence of visible caries, fractures, or previous restorations
  • Mobility (grade I-III)
  • Percussion sensitivity
  • Response to pulp vitality testing

• Surrounding tissues:

  • Gingival swelling, redness, or bleeding
  • Presence of fistula or sinus tract (if present, document location)
  • Purulent discharge (document color, consistency, odor if present)
  • Fluctuant areas suggesting abscess formation

Radiographic Findings

• Document findings from appropriate imaging (periapical x-rays are the imaging technique of choice for localized dental trauma and infection) 1
• Note periapical radiolucency, widened periodontal ligament space, or bone loss

Special Considerations

• If a fistula is present, documentation should include findings from an intraoral radiograph taken with a gutta-percha cone inserted inside the fistula to trace the origin 1
• For suspected infection in immunocompromised patients, more detailed documentation of infection extent is warranted 2

Documentation of Infection Severity

• Localized infection: Limited to the periapical region
• Spreading infection: Involving fascial spaces
• Systemic involvement: Presence of fever, malaise, lymphadenopathy

Common Pitfalls to Avoid

1. Failing to document the presence of a sinus tract or fistula, which indicates chronic infection
2. Not assessing and documenting the extent of infection spread into surrounding tissues
3. Overlooking signs of systemic involvement that might require more aggressive treatment
4. Inadequate documentation of radiographic findings that correlate with clinical presentation

Remember that proper documentation is essential not only for diagnosis and treatment planning but also for monitoring treatment response and for medicolegal purposes. The physical examination findings directly inform decisions about immediate extraction versus conservative management 3.