Dental abscess

Background

Periapical vs Periodontal Abscess

Category	Periapical	Periodontal
Other Names	Tooth abscess, dentoalveolar abscess, apical abscess, endodontic abscess, and lesion of endodontic origin	Gingival, pericoronal, lateral (periodontal) abscess
Epidemiology	More common	Less common
Area	Associated with a nonviable dead tooth (e.g. pulpitis)	Associated with a vital (living) tooth
Cause	Tooth infection	Gum infection

Dental Numbering

Classic dental numbering.

• Adult (permanent) teeth identified by numbers
  • From the midline to the back of the mouth on each side, there is a central incisor, a lateral incisor, a canine, two premolars (bicuspids), and three molars
• Children (non-permanent) teeth identified by letters
• Common landmarks:
  • 1: Right upper wisdom
  • 8 & 9: Upper incisors
  • 16: Left upper wisdom
  • 17: Left lower wisdom
  • 24 & 25: Lower incisors
  • 32: Right lower wisdom

Anatomy of the periodontium. The crown of the tooth is covered by enamel (A). Dentin (B). The root of the tooth is covered by cementum. C, alveolar bone. D, subepithelial connective tissue. E, oral epithelium. F, free gingival margin. G, gingival sulcus. H, principal gingival fibers. I, alveolar crest fibers of the periodontal ligament (PDL). J, horizontal fibers of the PDL. K, oblique fibers of the PDL.

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 has then formed and pus is draining into the mouth via an intraoral sinus (gumboil).

Periodontal abscess between the lower left canine and first premolar.

• 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.

Workup

• Consider CT if concern for a larger or deeper abscess

Diagnosis

• Typically clinical
• Differentiation between periapical and periodontal abscess is not of key importance in the ED, as the initial treatment is the same

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

Disposition

• Outpatient management
  • Follow up with a dentist

See Also

• Dental Problems