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Saturday, August 16, 2025

Dental abscess


Introduction

A dental abscess is a localized collection of pus associated with a tooth, typically resulting from bacterial infection. It arises when infection extends beyond the tooth into surrounding tissues, causing inflammation and pus accumulation. Dental abscesses are usually painful and, if untreated, can spread to adjacent anatomical spaces, leading to severe systemic complications.

Types of dental abscess include:

  • Periapical abscess: Originates at the apex of a tooth root due to untreated dental caries or pulp necrosis.

  • Periodontal abscess: Originates in the supporting structures of teeth (gums, periodontal ligament, alveolar bone).

  • Gingival abscess: Localized to the gum tissue without affecting deeper structures.

Epidemiology

  • Common worldwide; one of the most frequent dental emergencies.

  • More prevalent in adults, but also occurs in children with untreated dental decay.

  • Risk factors: poor oral hygiene, untreated caries, trauma, smoking, diabetes, immunosuppression, and periodontal disease.

Etiology and Pathophysiology

  1. Periapical Abscess

    • Begins with dental caries penetrating enamel and dentin, reaching pulp.

    • Pulp infection leads to necrosis.

    • Bacteria spread to the periapical tissues → abscess formation.

  2. Periodontal Abscess

    • Results from infection in a deep periodontal pocket.

    • Associated with plaque, calculus, or food impaction.

  3. Microbiology

    • Mixed infection: anaerobic bacteria predominate (e.g., Prevotella, Porphyromonas, Fusobacterium).

    • Facultative anaerobes such as Streptococcus viridans group also common.

Clinical Features

Symptoms

  • Severe, throbbing, localized toothache.

  • Pain worsens with chewing or biting.

  • Sensitivity to hot and cold.

  • Swelling of face, cheek, or jaw.

  • Fever and malaise (if systemic spread).

  • Difficulty swallowing or opening the mouth (trismus in severe cases).

Signs

  • Tender, mobile, or extruded tooth.

  • Gingival swelling, erythema, or pus discharge (sinus tract/fistula).

  • Regional lymphadenopathy.

  • Fluctuant swelling intraorally or extraorally.

Complications

If untreated, dental abscess can progress to:

  • Cellulitis of face or neck.

  • Osteomyelitis of jaw.

  • Ludwig’s angina: bilateral submandibular infection causing airway compromise.

  • Cavernous sinus thrombosis (from maxillary infections).

  • Sepsis, especially in immunocompromised individuals.

Diagnosis

Clinical Diagnosis

  • Based on history and physical examination.

  • Identify tooth source and extent of swelling.

Investigations

  • Dental X-rays: Show periapical radiolucency.

  • Orthopantomogram (OPG): For larger field assessment.

  • CT scan/MRI: In suspected deep neck space infections.

  • Blood tests: CBC (leukocytosis), CRP if systemic infection suspected.

Management

General Principles

  • Relieve pain.

  • Drain pus (definitive management).

  • Eliminate source of infection.

  • Prevent spread and complications.

1. Definitive Dental Treatments

  • Incision and drainage: Intraoral drainage of pus.

  • Root canal therapy (endodontic treatment): Removes infected pulp and saves tooth.

  • Tooth extraction: If tooth is non-restorable.

  • Periodontal therapy: Scaling, root planing, drainage in periodontal abscess.

2. Antibiotic Therapy

Antibiotics are adjuncts, not substitutes for drainage or dental treatment. Indicated if there is systemic involvement, spreading infection, or inability to achieve immediate drainage.

First-line (oral):

  • Amoxicillin: 500 mg orally every 8 hours for 5–7 days.

  • Amoxicillin–clavulanate: 875/125 mg orally twice daily for 5–7 days (useful for resistant or recurrent infections).

Alternative (penicillin allergy):

  • Clindamycin: 300 mg orally every 6–8 hours for 5–7 days.

  • Azithromycin: 500 mg orally on day 1, then 250 mg once daily for 4 more days.

  • Metronidazole: 400 mg orally every 8 hours (often combined with amoxicillin for anaerobic coverage).

Severe/systemic infections (hospitalized, IV therapy):

  • Ampicillin–sulbactam: 3 g IV every 6 hours.

  • Clindamycin: 600–900 mg IV every 8 hours.

  • Piperacillin–tazobactam: 4.5 g IV every 6–8 hours (severe/life-threatening).

3. Pain Management

  • Paracetamol (acetaminophen): 500–1000 mg orally every 6 hours (max 4 g/day).

  • Ibuprofen: 400–600 mg orally every 6–8 hours (max 2400 mg/day).

  • Combination therapy (paracetamol + ibuprofen) often more effective.

  • Opioids (e.g., codeine 30 mg) may be used short-term for severe pain, but avoided if possible.

4. Supportive Measures

  • Warm saline mouth rinses.

  • Soft diet.

  • Adequate hydration.

  • Good oral hygiene.

Prevention

  • Regular dental check-ups.

  • Good oral hygiene (brushing twice daily, flossing).

  • Limiting sugary foods and drinks.

  • Prompt treatment of dental caries and gum disease.

Prognosis

  • With prompt drainage and treatment, prognosis is excellent.

  • Recurrence is possible if the source (e.g., necrotic pulp or deep periodontal pocket) is not treated.

  • Delay in treatment can lead to severe, potentially life-threatening complications.

Future Directions

  • Development of rapid point-of-care tests to identify bacterial pathogens in oral infections.

  • Minimally invasive endodontic techniques for faster, less painful management.

  • Increasing emphasis on preventive dentistry and early caries detection.

  • Research into antimicrobial resistance patterns in odontogenic infections to refine antibiotic guidelines.




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