Dental abscess

Background

• Associated with dental caries or nonviable teeth
• Significant erosion of the pulp with bacterial overgrowth

Clinical Features

Abscess originating from a tooth that has spread to the buccal space. Above: deformation of the cheek on the second day. Below: deformation on the third day.

A decayed, broken down tooth, which has undergone pulpal necrosis. A periapical abscess (i.e. around the apex of the tooth root) has then formed and pus is draining into the mouth via an intraoral sinus (gumboil)

• Acute pain, swelling, and mild tooth elevation
• Exquisite sensitivity to percussion or chewing on the involved tooth
• Swelling in surrounding gingiva, buccal, lingual or palatal regions
• May see small white pustule (parulis) in gingival surface characteristic for abscesses

Differential Diagnosis

Dentoalveolar Injuries

• Dental fracture
• Dental subluxation
• Dental avulsion
• Bleeding dental socket

Odontogenic Infections

• Acute alveolar osteitis (dry socket)
• Acute necrotizing ulcerative gingivitis (trench mouth)
• Dental abscess
  • Periapical abscess
  • Periodontal abscess
• Ludwig's angina
• Pulpitis (dental caries)
• Pericoronitis
• Peritonsillar abscess (PTA)
• Retropharyngeal abscess
• Vincent's angina - tonsillitis and pharyngitis

Other

• Scurvy
• Gingival hyperplasia
  • Phenytoin
  • Cyclosporine
  • Nifedipine, Amlodipine
  • Leukemia

Evaluation

CT scan showing a large left tooth abscess with significant inflammation of fatty tissue under the skin.

• Clinical evaluation
• Radiographs

Management

• Analgesia with NSAIDs, opioids and/or local anesthetics
• Dental follow-up within 48 hrs.
• Emergent oral surgeon follow-up if complicated (Ludwig's angina, Lemierre's syndrome)

Antibiotics

Treatment is broad and focused on polymicrobial infection

• Amoxicillin-clavulanate 875 mg PO q12 hours x 7-14 days
• Clindamycin 450 mg PO q8 hours x 7-14 days
• Penicillin VK 500 mg PO q6 hours x 7-14 days (frequently prescribed but no longer recommended as monotherapy)
• Ampicillin/Sulbactam 3g IV q6 hours x 7 days

I&D

• Can be performed in ED depending on provider comfort or by a dental consultant

Procedure

• 11 or 12 blade stab incision
• Hemostat blunt dissection +/- packing

See Also

• Dental Problems

References

• ER Atlas