Erin A. Lyden The term dental abscess is used to describe any abscess found in the tissues around the tooth. The most common type of dental abscess is an acute infection of the apical tissue.1 These infections are often encountered in the general population among those who have untreated dental caries.2 This type of dental abscess along with toothaches comprise more than half of all nontraumatic dental emergencies.1 Proper evaluation and treatment of these infections are important in the prevention of life-threatening complications.2 Poor dental hygiene resulting in dental caries, trauma, or an unsuccessful root canal can all lead to acute dental abscesses.3 Dental abscesses arise as a result of infection by normal oral flora in a carious tooth or as a result of traumatized gingival mucosa.1 Dental or apical abscesses begin with necrosis of the tooth pulp, leading to bacterial invasion of the pulp chamber and deeper tissues (root canals). Necrosis of these areas can occur with or without pain. However, once the bacteria are able to enter the root canal, bacteria with their toxic materials enter into the periodical space, creating an inflammatory response and pus formation. This response causes acute inflammation, which initiates a cascade of signs and symptoms. The abscess in the periapical tissue, if not handled appropriately, can enter deeper fascial spaces, leading to severe infections and mortality.1,3 Multiple organisms are common in acute dental abcesses.1,3 These infections are usually a blend of both facultative anaerobes and strict anaerobes. Most of the facultative anaerobes found are Streptococcus anginosus or viridans streptococci. The strict anaerobes most frequently identified are species including Prevotella and Fusobacterium.1,3 Abscesses usually occur in the setting of carious teeth or poor dental hygiene and cause localized pain, edema, erythema, and purulent discharge from the affected site.1,3,4 The site may be heat sensitive and friable. The tooth may be partially elevated out of the socket. The pain responds poorly to analgesic agents. If the abscess is minor, systemic signs may not be evident. More advanced infections may be associated with fever and lymphadenitis.3 Althoughpain is a common sign with this type of infection, take special note in patients who have been on glucocorticoids, have diabetes mellitus, and are of an advanced age, because they may deny pain or report only mild pain.5 A detailed history of the pain, symptoms, and previous dental care should be taken, followed by a thorough oral examination. Inspection of the gingiva surrounding the area of pain will reveal edema and erythema of the soft tissues and possibly a purulent discharge from a draining sinus tract.2 The tooth may be mobile and painful to manipulation. The abscess should be visualized and palpated by the practitioner.2 If the infection has progressed beyond the local area, orbital cellulitis, retropharyngeal space invasion, fascial plane invasion, or cavernous sinus thrombosis can occur. Signs of severe infection include trismus, airway compromise, and dysphagia. A patient unable to handle his or her own secretions or with involvement of the fascial spaces of the head and neck needs emergent care. Any patient whose outpatient therapy fails should receive inpatient treatment.2,4,6 Physical examination remains the standard of diagnosis for an acute dental abscess. Routine radiologic screening is not recommended because thickening of the periodontal membrane is the only finding visible before abscess formation, and abscesses develop rapidly. Chronic abscesses may reveal a radiolucent area at the tooth apex.1 A complete blood count (CBC) may be indicated if cellulitis is suspected. Other diagnostics depend on complications.
Dental Abscess
Definition and Epidemiology
Pathophysiology
Clinical Presentation
Physical Examination
Diagnostics
Dental Abscess
Chapter 95
