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A dental abscess is a localized collection of
pus Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...
associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a
periodontal abscess A periodontal abscess (also termed lateral abscess, or parietal abscess), is a localized collection of pus (i.e. an abscess) within the tissues of the periodontium. It is a type of dental abscess. A periodontal abscess occurs alongside a tooth, a ...
. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead,
pulp Pulp may refer to: * Pulp (fruit), the inner flesh of fruit Engineering * Dissolving pulp, highly purified cellulose used in fibre and film manufacture * Pulp (paper), the fibrous material used to make paper * Molded pulp, a packaging material * ...
of the tooth. This can be caused by
tooth decay Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complicati ...
, broken teeth or extensive
periodontal disease Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main caus ...
(or combinations of these factors). A failed
root canal treatment Root canal treatment (also known as endodontic therapy, endodontic treatment, or root canal therapy) is a treatment sequence for the infected pulp of a tooth which is intended to result in the elimination of infection and the protection o ...
may also create a similar abscess. A dental abscess is a type of
odontogenic infection An odontogenic infection is an infection that originates within a tooth or in the closely surrounding tissues. The term is derived from '' odonto-'' ( Ancient Greek: , – 'tooth') and '' -genic'' (Ancient Greek: , ; – 'birth'). The most common ...
, although commonly the latter term is applied to an infection which has spread outside the local region around the causative tooth.


Classification

The main types of dental abscess are: * Periapical abscess: The result of a chronic, localized
infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dis ...
located at the tip, or
apex The apex is the highest point of something. The word may also refer to: Arts and media Fictional entities * Apex (comics), a teenaged super villainess in the Marvel Universe * Ape-X, a super-intelligent ape in the Squadron Supreme universe *Apex ...
, of the root of a tooth. * Periodontal abscess: begins in a periodontal pocket (see:
periodontal abscess A periodontal abscess (also termed lateral abscess, or parietal abscess), is a localized collection of pus (i.e. an abscess) within the tissues of the periodontium. It is a type of dental abscess. A periodontal abscess occurs alongside a tooth, a ...
) * Gingival abscess: involving only the gum tissue, without affecting either the tooth or the periodontal ligament (see:
periodontal abscess A periodontal abscess (also termed lateral abscess, or parietal abscess), is a localized collection of pus (i.e. an abscess) within the tissues of the periodontium. It is a type of dental abscess. A periodontal abscess occurs alongside a tooth, a ...
) * Pericoronal abscess: involving the soft tissues surrounding the crown of a tooth (see:
Pericoronitis Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, including the gingiva (gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an ''operculum'', an area ...
) * Combined periodontic-endodontic abscess: a situation in which a periapical abscess and a periodontal abscess have combined (see: Combined periodontic-endodontic lesions).


Signs and symptoms

The pain is continuous and may be described as extreme, growing, sharp, shooting, or throbbing. Putting pressure or warmth on the tooth may induce extreme pain. The area may be sensitive to touch and possibly swollen as well. This swelling may be present at either the base of the tooth, the gum, and/or the cheek, and sometimes can be reduced by applying
ice pack An ice pack or gel pack is a portable bag filled with water, refrigerant gel, or liquid, meant to provide cooling. They can be divided into the reusable type, which works as a thermal mass and requires freezing, or the instant type, which cools ...
s. An acute abscess may be painless but still have a swelling present on the gum. It is important to get anything that presents like this checked by a dental professional as it may become chronic later. In some cases, a tooth abscess may perforate bone and start draining into the surrounding tissues creating local facial swelling. In some cases, the
lymph glands A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that inclu ...
in the neck will become swollen and tender in response to the infection. It may even feel like a
migraine Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hou ...
as the pain can transfer from the infected area. The pain does not normally transfer across the face, only upwards or downwards as the nerves that serve each side of the face are separate. Severe aching and discomfort on the side of the face where the tooth is infected is also fairly common, with the tooth itself becoming unbearable to touch due to extreme amounts of pain.


Complications

If left untreated, a severe tooth abscess may become large enough to perforate bone and extend into the soft tissue eventually becoming
osteomyelitis Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...
and
cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of th ...
respectively. From there it follows the
path of least resistance The path of least resistance is the physical or metaphorical pathway that provides the least resistance to forward motion by a given object or entity, among a set of alternative paths. The concept is often used to describe why an object or entit ...
and may spread either internally or externally. The path of the infection is influenced by such things as the location of the infected tooth and the thickness of the bone, muscle and fascia attachments. External drainage may begin as a boil which bursts allowing pus drainage from the abscess, intraorally (usually through the gum) or extraorally. Chronic drainage will allow an epithelial lining to form in this communication to form a pus draining canal (
fistula A fistula (plural: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") in anatomy is an abnormal connection between two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other hollow o ...
). Sometimes this type of drainage will immediately relieve some of the painful symptoms associated with the pressure. Internal drainage is of more concern as growing infection makes space within the tissues surrounding the infection. Severe complications requiring immediate hospitalization include
Ludwig's angina Ludwig's angina (lat.: Angina ludovici) is a type of severe cellulitis involving the floor of the mouth and is often caused by bacterial sources. Early in the infection, floor of the mouth raises due to swelling, leading to difficulty swallowing s ...
, which is a combination of growing infection and
cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of th ...
which closes the airway space causing suffocation in extreme cases. Also infection can spread down the
tissue spaces Tissue may refer to: Biology * Tissue (biology), an ensemble of similar (or dissimilar in structure but same in origin) cells that together carry out a specific function * ''Triphosa haesitata'', a species of geometer moth ("tissue moth") found in ...
to the
mediastinum The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagu ...
which has significant consequences on the vital organs such as the heart. Another complication, usually from upper teeth, is a risk of
sepsis Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
traveling through pathways to which it can possibly lead to
endocarditis Endocarditis is an inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immu ...
,
brain abscess Brain abscess (or cerebral abscess) is an abscess caused by inflammation and collection of infected material, coming from local (ear infection, dental abscess, infection of paranasal sinuses, infection of the mastoid air cells of the temporal bone ...
(extremely rare), or
meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, headache, and neck stiffness. Other symptoms include confusion or ...
(also rare). Depending on the severity of the infection, the sufferer may feel only mildly ill, or may in extreme cases require hospital care.


Diagnostic

A periodontal abscess may be difficult to distinguish from a periapical abscess. Indeed, sometimes they can occur together. Since the management of a periodontal abscess is different from that of a periapical abscess, this differentiation is important to make. * If the swelling is over the area of the root apex, it is more likely to be a periapical abscess; if it is closer to the gingival margin, it is more likely to be a periodontal abscess. * Similarly, in a periodontal abscess pus most likely discharges via the periodontal pocket, whereas a periapical abscess generally drains via a parulis nearer to the apex of the involved tooth. * If the tooth has pre-existing periodontal disease, with pockets and loss of alveolar bone height, it is more likely to be a periodontal abscess; whereas if the tooth has relatively healthy periodontal condition, it is more likely to be a periapical abscess. * In periodontal abscesses, the swelling usually precedes the pain, and in periapical abscesses, the pain usually precedes the swelling. * A history of toothache with sensitivity to hot and cold suggests previous
pulpitis Pulpitis is inflammation of dental pulp tissue. The pulp contains the blood vessels, the nerves, and connective tissue inside a tooth and provides the tooth’s blood and nutrients. Pulpitis is mainly caused by bacterial infection which itself is ...
, and indicates that a periapical abscess is more likely. * If the tooth gives normal results on
pulp sensibility test Dental pulpal testing is a clinical and diagnostic aid used in dentistry to help establish the health of the dental pulp within the pulp chamber and root canals of a tooth. Such investigations are important in aiding dentists in devising a treatment ...
ing, is free of dental caries and has no large restorations; it is more likely to be a periodontal abscess. * A dental radiograph is of little help in the early stages of a dental abscess, but later usually the position of the abscess, and hence indication of endodontal/periodontal etiology can be determined. If there is a sinus, a
gutta percha Gutta-percha is a tree of the genus ''Palaquium'' in the family Sapotaceae. The name also refers to the rigid, naturally biologically inert, resilient, electrically nonconductive, thermoplastic latex derived from the tree, particularly from ' ...
point is sometimes inserted before the x-ray in the hope that it will point to the origin of the infection. * Generally, periodontal abscesses will be more tender to lateral percussion than to vertical, and periapical abscesses will be more tender to apical percussion.


Treatment

Successful treatment of a dental abscess centers on the reduction and elimination of the offending organisms. This can include treatment with
antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention ...
and drainage, however, it has become widely recommended that dentists should improve the antibiotic prescribing practices, by limiting the prescriptions to the acute cases that suffer from the severe signs of spreading infection, in an attempt to overcome the development of antibiotic-resistant bacterial strains in the population. A 2018 Cochrane review has found insufficient evidence to rule out if patients with acute dental abscesses can benefit from antibiotic prescriptions. If the tooth can be restored,
root canal A root canal is the naturally occurring anatomic space within the root of a tooth. It consists of the pulp chamber (within the coronal part of the tooth), the main canal(s), and more intricate anatomical branches that may connect the root c ...
therapy can be performed. Non-restorable teeth must be extracted, followed by
curettage Curettage ( or ), in medical procedures, is the use of a curette (French, meaning scoop Mosby's Medical, Nursing & Allied Health Dictionary, Fourth Edition, Mosby-Year Book 1994, p. 422) to remove tissue by scraping or scooping. Curettages ar ...
of all apical soft tissue. Unless they are symptomatic, teeth treated with root canal therapy should be evaluated at 1- and 2-year intervals after the root canal therapy to rule out possible lesional enlargement and to ensure appropriate healing. Abscesses may fail to heal for several reasons: *
Cyst A cyst is a closed sac, having a distinct envelope and division compared with the nearby tissue. Hence, it is a cluster of cells that have grouped together to form a sac (like the manner in which water molecules group together to form a bubble) ...
formation * Inadequate root canal therapy * Vertical root fractures * Foreign material in the lesion * Associated periodontal disease * Penetration of the
maxillary sinus The pyramid-shaped maxillary sinus (or antrum of Highmore) is the largest of the paranasal sinuses, and drains into the middle meatus of the nose through the osteomeatal complex.Human Anatomy, Jacobs, Elsevier, 2008, page 209-210 Structure It i ...
Following conventional, adequate root canal therapy, abscesses that do not heal or enlarge are often treated with surgery and filling the root tips; and will require a biopsy to evaluate the diagnosis.


See also

*
Barodontalgia Barodontalgia, commonly known as tooth squeeze, is a pain in a tooth caused by a change in ambient pressure. The pain usually ceases at ground level. Dental barotrauma is a condition in which such changes in barometric pressure changes cause dama ...
*
Focal infection theory Focal infection theory is the historical concept that many chronic diseases, including systemic and common ones, are caused by focal infections. In present medical consensus, a focal infection is a localized infection, often asymptomatic, that c ...
*
Intraoral dental sinus Intraoral dental sinus (also termed a parulis and commonly, a gumboil) is an oral lesion characterized by a soft erythematous papule (red spot) that develops on the alveolar process in association with a non-vital tooth and accompanying dental ab ...


References


External links

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