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Dental Abscess

A dental abscess (DA) refers to the accumulation of pus in the tissues around the tooth; in the periodontal tissues. While this condition is usually associated with local swelling and moderate to severe pain, morbidity and mortality mainly result from the spread of the infection to other areas of the oral and maxillofacial region or even more distant tissues.


Presentation

Anamnestic data may point out recent trauma or dental procedures, e.g., deep fillings or root canal treatment. However, DA may also develop as a complication of caries, and affected individuals may not report any prior symptoms [1].

Local swelling and toothache predominate the clinical picture in case of acute DA. The affected tooth is very sensitive to percussion, and the patient may describe acute pain on biting [2]. Moreover, patients may present with constitutive symptoms like malaise, fever, and lymphadenopathy [3]. Trismus has been observed and has been associated with spreading dental infection [4]. The spread of the disease may also cause intraoral swelling and spontaneous drainage of pus or cellulitis, depending on the route of propagation. Patients may develop life-threatening sepsis [5] [6]. Airway obstruction due to swelling of submandibular tissues has been described and may require emergency attention [7]. Chronic disease is not usually associated with any complaints, but symptoms may develop upon an exacerbation of the inflammatory process.

Fatigue
  • Headache, fever and general fatigue. A significant amount of green and foul-smelling pus that eventually drifts out and the pain stops right after.[studiodentaire.com]
  • […] complications include: Fever Headache Nausea Diarrhoea Swollen lymph glands Pain spreading to the jaw, ear or neck on the same side as the infected tooth Difficulty opening your mouth (trismus) Difficulty breathing or swallowing (dysphagia) General fatigue[dentaly.org]
  • Adverse effects as reported in one study were diarrhoea (one participant, placebo group) and fatigue and reduced energy postoperatively (one participant, antibiotic group).[doi.org]
  • Many who do survive are left with life-changing effects, such as post-traumatic stress disorder (PTSD), chronic pain fatigue, organ dysfunction (organs don’t work properly) and/or amputations.[sepsis.org]
Rigor
  • In the ED, he appeared systemically ill with fever, mottling, delayed capillary refill, and rigors. Physical examination by three different physicians failed to reveal any focus of infection.[ncbi.nlm.nih.gov]
Constitutional Symptom
  • Moreover, patients may present with constitutive symptoms like malaise, fever, and lymphadenopathy. Trismus has been observed and has been associated with spreading dental infection.[symptoma.com]
Dental Abscess
  • The risk of potential serious consequences arising from the spread of a dental abscess is still relevant today with many hospital admissions for dental sepsis.[ncbi.nlm.nih.gov]
  • CKS found very little evidence looking at the duration of antibiotic therapy in the management of dental abscesses.[web.archive.org]
  • Assuming that the patient who was lost to follow-up had dental abscess, the sensitivity and specificity of US in diagnosing a dental abscess were 92% and 100%, respectively.[ncbi.nlm.nih.gov]
  • A dental abscess is a localized collection of pus associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess.[en.wikipedia.org]
  • A multiple logistic regression model was performed to evaluate the association of each variable with the healing time required for dental abscess.[ncbi.nlm.nih.gov]
Difficulty Opening the Mouth
  • Other symptoms can include: tenderness of your tooth and surrounding area sensitivity to very hot or cold food and drink an unpleasant taste in your mouth bad breath (halitosis) a general feeling of being unwell difficulty opening your mouth difficulty[nidirect.gov.uk]
  • The right side of his face was severely swollen, to the point he couldn’t open his right eye, and he had difficulty opening his mouth enough for us even to take a look and identify the problem tooth.[smilesbypayet.com]
  • Having difficulty opening your mouth, swallowing or breathing. Having swelling of the floor of your mouth, face or jaw. Being in severe pain despite taking painkillers at maximum dose. Having a spreading infection of your face.[patient.info]
  • Signs and symptoms of a dental abscess include: pain in the affected area when biting or when touching the affected area sensitivity to cold or hot food and liquids a foul taste in the mouth fever a generally unwell feeling difficulties opening the mouth[medicalnewstoday.com]
Halitosis
  • Other symptoms can include: tenderness of your tooth and surrounding area sensitivity to very hot or cold food and drink an unpleasant taste in your mouth bad breath (halitosis) a general feeling of being unwell difficulty opening your mouth difficulty[nidirect.gov.uk]
  • Bad breath (halitosis) : factors that affect the mouth and cause bad breath. Toothache : how can toothache be avoided? Last updated 29.01.2016 Nigel Carter Chief executive British Dental Health Foundation[netdoctor.co.uk]
  • Bad breath (halitosis) : factors that affect the mouth and cause bad breath. Toothache : how can toothache be avoided? Last updated 29.01.2016[netdoctor.co.uk]
  • Symptoms include a rapid onset of: Inflammation Pus formation Sour or metallic taste Halitosis (bad breath) Spontaneous pain Sensitivity to percussion Discomfort when biting or chewing Swelling of associated tissues Questions the dentist will often ask[dentagama.com]
  • […] labialis) Dental abscess Dental plaque Denture Irritations and Infections Denture stomatitis (prosthetic stomatitis) Dry socket Erosion Fluorosis (dental) Gingival hyperplasia Gingival pocket Gingivitis Gum Disease (Periodontal Disease) Gum recession Halitosis[studiodentaire.com]
Yellow Teeth
  • Cosmetic Dentistry Do you have a smile that has chips, cracks, missing, or yellow teeth? No matter the problem, Premier Dental Care has the cosmetic dentist solutions for you. We will give you a smile you can’t wait to share with the world.[drandersonpremierdental.com]
Myalgia
  • Abstract A 9-year-old girl presented with arthralgia and myalgia which progressed to developing renal failure and overwhelming septic shock. The underlying cause was assumed to be a periodontal abscess from an upper right deciduous canine tooth.[ncbi.nlm.nih.gov]
Neck Weakness
  • Call 911 Call 911 if any of these occur: Swelling spreads to the upper half of your face or neck You eyelids begin to swell shut Unusual drowsiness Headache or a stiff neck Weakness or fainting Difficulty swallowing or breathing When to seek medical advice[fairview.org]
Facial Swelling
  • This article describes the case of a 5-year-old girl who presented at an evening clinic with tooth pain, fever, and facial swelling.[ncbi.nlm.nih.gov]
  • In this present case, a 51-year-old woman arrived at the public health department with high fever and facial swelling. The findings suggested a dental origin and the patient was directed to dentistry.[ncbi.nlm.nih.gov]
  • The patient later developed unilateral facial swelling and pain, and a dentoalveolar abscess was found. He was started on antibiotics, underwent pulpectomy and eventually, extraction, prior to improvement in symptoms.[ncbi.nlm.nih.gov]
  • The symptoms of a tooth abscess are sensitivity to hot or cold, severe toothache, sensitivity to pressure, fever, facial swelling, swollen lymph nodes in the jaw and neck area.[lafayettedentalexcellence.com]
Facial Pain
  • Author information 1 Department of Oral & Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA 02114, USA. cresnick@partners.org Abstract In the imaging evaluation of Emergency Department patients presenting with facial pain, there is a condition[ncbi.nlm.nih.gov]
  • METHODS: A retrospective review of ED records of adult patients with atraumatic facial pain, swelling, and toothache who received a panorex x-ray and bedside US was performed. Medical records were reviewed for ED evaluation and disposition.[ncbi.nlm.nih.gov]
  • Symptoms of sinusitis include: a blocked or runny nose facial pain and tenderness a high temperature (fever) of 38 C (100.4 F) or above Sinusitis often clears up without treatment but, if necessary, antibiotics can be prescribed.[everestpharmacy.co.uk]
  • Symptoms of sinusitis include: a blocked or runny nose facial pain and tenderness a high temperature (fever) of 38 C (100.4 F) or above Sinusitis often clears up without treatment but, if necessary, antibiotics may be prescribed.[your.md]
Facial Edema
  • If treatment is delayed, the infection may spread through adjacent tissues, causing cellulitis, varying degrees of facial edema, and fever. The infection may spread to osseous (bony) tissues or into the soft tissues of the floor of the mouth.[healthcentral.com]
Neck Mass
  • The purpose of this report is to present a tularemia case accompanied by a neck mass that easily may be confounded with dental abscess. Francisella tularensis is a potential agent of biologic terrorism.[ncbi.nlm.nih.gov]
Headache
  • Call 911 Call 911 if any of these occur: Swelling spreads to the upper half of your face or neck You eyelids begin to swell shut Unusual drowsiness Headache or a stiff neck Weakness or fainting Difficulty swallowing or breathing When to seek medical advice[fairview.org]
  • Headache, fever and general fatigue. A significant amount of green and foul-smelling pus that eventually drifts out and the pain stops right after.[studiodentaire.com]
  • Findings of particular concern are Headache Fever Swelling or tenderness of floor of the mouth Cranial nerve abnormalities Red flag finding of headache suggests sinusitis, particularly if multiple upper molar and premolar (back) teeth are painful.[merckmanuals.com]
Insomnia
  • There is however, one particular painful episode that can unravel even the toughest of people: a stomach churning, insomnia inducing, mind altering toothache that never seems to go away not matter what you do.[drbautista.ca]
  • […] dental abscess include: pain in the affected area when biting or when touching the affected area sensitivity to cold or hot food and liquids a foul taste in the mouth fever a generally unwell feeling difficulties opening the mouth swallowing difficulties insomnia[medicalnewstoday.com]
Agitation
  • There are likely to be fever like symptoms; dizziness, hot and cold flushes, agitation, sweating, and swelling all around the face and neck. This occurs because there is an infected part of the mouth and bacteria has accumulated there.[carefreedental.com]
  • Did I do something to agitate it? This abscess was visible on pano that was taken in Febr. 2.Is there any home remedies for swelling? Thank YOU! Sometimes with a root canal and abscess, it can be treated and leave a radiolucency in the area.[medhelp.org]
Trigeminal Neuralgia

Workup

DA diagnosis is based on radiographic imaging. In most cases, plain radiography yields reliable results [2]:

  • The most common form of DA is the apical abscess, which is related to an endodontic infection. It may only affect teeth devoid of a vital pulp, either due to caries, trauma, or root canal treatment. Radiographs may thus depict anomalies consistent with the disease’ etiology, e.g. radiolucency in the crown in case of caries [8]. The infection may spread to adjacent bones and osseous tissue may be destructed. This development corresponds to the appearance of periapical radiolucent foci in radiographic images. Of note, local bone resorption is primarily an indicator of chronic DA, and affected individuals are usually asymptomatic. Radiographic findings may be absent in patients suffering from acute DA unless the latter has been preceded by chronic infection.
  • An accumulation of pus in periodontal tissues is referred to as a periodontal abscess. This type of DA is less common. If a periodontal abscess is located close to the gingival surface, a bulge may be noted during early stages of the disease. Bone resorption is to be expected in patients suffering from chronic disease. Here, osseous lesions are observed periodontally [9]. Otherwise, clinical and radiographic features largely resemble those observed in cases of apical DA.

Additional techniques, namely sonography, computed tomography and magnetic resonance imaging may be employed to assess a possible route of spread of the infection [4] [10].

Laboratory analyses of blood samples may be carried out. Leukocytosis and anomalies consistent with dehydration may indicate a spreading infection [4]. Concentrations of inflammatory parameters like C-reactive protein are usually enhanced.

An aspiration through the intact disinfected mucosa is best suited for bacterial culture and sensitivity testing [4]. However, the determination of pathogens causing DA poses a major challenge. Multiple species are involved in this process, and culture conditions should be chosen to facilitate the growth of anaerobic and aerobic bacteria [2] [11]. Alternatively, causative pathogens may be identified using molecular biological techniques.

X-Ray Abnormal
  • In 1 of the 2 cases where US disagreed with panorex x-rays, x-ray abnormalities were reported on the nonsymptomatic side. The other patient was given antibiotics and recommended outpatient follow-up.[ncbi.nlm.nih.gov]
Gram-Positive Rods
  • Abstract A previously undescribed filamentous, beaded, Gram-positive, rod-shaped bacterium was isolated from pus of a human dental abscess.[ncbi.nlm.nih.gov]
  • The use of non-culture techniques has expanded our insight into the microbial diversity of the causative agents, identifying such organisms as Treponema species and anaerobic Gram-positive rods such as Bulleidia extructa, Cryptobacterium curtum and Mogibacterium[ncbi.nlm.nih.gov]
  • Other anaerobic Gram-positive rods include Bulleidia extructa, Cryptobacterium curtum, Eubacterium sulci, Mogibacterium timidum and Mogibacterium vescum,[ 30 ] Pseudoramibacter alactolyticus, and Slakia exigua.[ 31 ] While unfamiliar anaerobic Gram-negative[ncbi.nlm.nih.gov]
Actinomyces Bovis
  • Comparative 16S rRNA gene sequencing studies showed the bacterium represents a hitherto unknown subline within the genus Actinomyces, clustering within a group of species, which includes Actinomyces bovis, the type species of the genus.[ncbi.nlm.nih.gov]
  • Comparative 16S rRNA gene sequencing studies showed the bacterium represents a distinct subline within the genus Actinomyces, clustering within a group of species that includes Actinomyces bovis, the type species of the genus.[ncbi.nlm.nih.gov]
Staphylococcus Aureus
  • The pus from the abscess grew a toxic shock syndrome toxin 1-producing Staphylococcus aureus.[ncbi.nlm.nih.gov]
  • Staphylococcus aureus has been frequently reported from acute dental abscess, ranging from 0.7% to 15%.[ 17 , 19 , 27 , 38 ] Recovery rates of coagulase-negative strains of staphylococci (usually reported as Staphylococcus epidermidis) are generally higher[ncbi.nlm.nih.gov]
Francisella Tularensis
  • Serologic tests showed that the patient had a Francisella tularensis infection.[ncbi.nlm.nih.gov]

Treatment

  • Three treatment choices are discussed: (1) 400 mg of amoxicillin (Augmentin), by mouth, with comfort measures, and return to the clinic in the morning; (2) 2 g of ceftriaxone by injection, with comfort measures, and return to the clinic in the morning[ncbi.nlm.nih.gov]
  • The microbiology and treatment of the acute localized abscess and severe spreading odontogenic infections are reviewed.[ncbi.nlm.nih.gov]
  • CKS found no evidence that specifically looked at antibiotics in the treatment of dental abscess by general medical practitioners.[web.archive.org]
  • It is suggested that initially establishing drainage after dental treatment would have prevented the sequela that ensued.[ncbi.nlm.nih.gov]
  • This is particularly important medicolegally in case the tooth develops symptoms shortly after the prophylactic treatment.[ncbi.nlm.nih.gov]

Prognosis

  • Plain radiograph / OPG and CT well-defined lucency at or distal to the root apex, usually 2-4 the tooth or teeth involved often show signs of caries an empty socket may indicate recent extraction for infection Treatment and prognosis Some dental abscesses[radiopaedia.org]
  • What Is the Prognosis for Dental Abscesses? The prognosis is good for resolution of a small dental abscess once it has ruptured or been drained. If the symptoms are improving, it is unlikely that the infection is getting worse.[emedicinehealth.com]
  • The prognosis for a periapical abscess is similar, if it is treated quickly and appropriately with the elimination of the infection that is causing the abscess.[encyclopedia.com]

Etiology

  • Radiographs may thus depict anomalies consistent with the disease’ etiology, e.g. radiolucency in the crown in case of caries. The infection may spread to adjacent bones and osseous tissue may be destructed.[symptoma.com]
  • 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.[en.wikipedia.org]
  • As soon as the etiologic factors have been eliminated the swelling is reduced. The healing process is usually uneventful and regeneration frequently occurs.[encyclopedia.com]

Epidemiology

  • OBJECTIVES: The objective of this epidemiologic study was to estimate the healing time of acute dental abscesses and to evaluate the main variables involved in the healing process itself.[ncbi.nlm.nih.gov]
  • EPIDEMIOLOGY AND RISK FACTORS In the early 1600s, the London Bills of Mortality began listing the causes of death with teeth being continually listed as the fifth or sixth leading cause of death.[ 3 ] By 20 th century, the potential of dental abscesses[ncbi.nlm.nih.gov]
  • The use of antibiotics in dental practice is characterised by empirical prescription based on clinical and bacteriological epidemiological factors, resulting in the use of a very narrow range of broad‐spectrum antibiotics for short periods of time.[doi.org]
Sex distribution
Age distribution

Pathophysiology

  • Conclusion Practitioners who are likely to treat patients with dental infections should understand the pathophysiology, management and complications of such infections.[racgp.org.au]

Prevention

  • This will prevent the infection from spreading further into the jaw and bone tissue. Tooth Abscess Prevention The good news about a dental abscess is that it’s easily preventable![growingsmilessa.com]
  • A model for the progression of dental caries in low-income groups with recommendations for prevention is also presented.[ncbi.nlm.nih.gov]
  • How can I prevent abscesses? Because of how dangerous an abscess can be, it’s important to practice good oral hygiene in order to prevent an abscess from developing.[lafayettedentalexcellence.com]

References

Article

  1. Azodo CC, Chukwumah NM, Ezeja EB. Dentoalveolar abscess among children attending a dental clinic in Nigeria. Odontostomatol Trop. 2012; 35(139):41-46.
  2. Siqueira JF, Jr., Rocas IN. Microbiology and treatment of acute apical abscesses. Clin Microbiol Rev. 2013; 26(2):255-273.
  3. Campanelli CA, Walton RE, Williamson AE, Drake DR, Qian F. Vital signs of the emergency patient with pulpal necrosis and localized acute apical abscess. J Endod. 2008; 34(3):264-267.
  4. Robertson DP, Keys W, Rautemaa-Richardson R, Burns R, Smith AJ. Management of severe acute dental infections. Bmj. 2015; 350:h1300.
  5. Fardy CH, Findlay G, Owen G, Shortland G. Toxic shock syndrome secondary to a dental abscess. Int J Oral Maxillofac Surg. 1999; 28(1):60-61.
  6. Green AW, Flower EA, New NE. Mortality associated with odontogenic infection! Br Dent J. 2001; 190(10):529-530.
  7. Lee WI, Lee J, Bassed R, O'Donnell C. Post-mortem CT findings in a case of necrotizing cellulitis of the floor of the mouth (Ludwig angina). Forensic Sci Med Pathol. 2014; 10(1):109-113.
  8. Schwendicke F, Tzschoppe M, Paris S. Radiographic caries detection: A systematic review and meta-analysis. J Dent. 2015; 43(8):924-933.
  9. Marquez IC. How do I manage a patient with periodontal abscess? J Can Dent Assoc. 2013; 79:d8.
  10. Shuaib W, Hashmi M, Vijayasarathi A, Arunkumar J, Tiwana S, Khosa F. The Use of Facial CT for the Evaluation of a Suspected Simple Dentoalveolar Abscess in the Emergency Department. Clin Med Res. 2015; 13(3-4):112-116.
  11. Shweta, Prakash SK. Dental abscess: A microbiological review. Dent Res J (Isfahan). 2013; 10(5):585-591.

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Last updated: 2019-07-11 21:58