Dental abscess covers a clinical spectrum from minor well-localised infection to severe life-threatening complications involving multiple fascial spaces.
The vast majority of otherwise healthy patients presenting with a dental infection can be managed on an outpatient basis.
Common presenting symptoms include dental pain/toothache; intra-oral and/or extra-oral oedema, erythema, or discharge; and thermal hypersensitivity.
A major consideration is the potential for airway obstruction as a consequence of extension of the infection into fascial spaces surrounding the oropharynx.
Panoramic dental x-ray reveals the source of infection in most cases; however, a periapical x-ray may also be helpful. A computed tomography scan is recommended if there is suspicion of a fascial space infection or if panoramic or periapical x-rays are not available.
Prompt operative intervention to identify and eliminate the source of infection and provide a path for drainage, along with antibiotic therapy and supportive care, is required. Operative treatment is considered the cornerstone of successful management.
Immunocompromised patients must be treated in a timely fashion as tooth-related infections may spread rapidly.
A dental abscess is the final product of an inflammatory process, a suppurative collection associated with the structures surrounding the teeth. It is a type of odontogenic infection (i.e., an infection that originates within a tooth).
An abscess may remain localised (damaging only the adjacent tissues) or it may develop into a diffuse cellulitis, which can lead to the development of potentially life-threatening systemic complications.
The vast majority of otherwise healthy patients have localised infections which can be managed on an outpatient basis.
The most common types of dental abscess are periapical, periodontal, and pericoronal. Other less common types include gingival or combined periodontal-endodontic. This topic primarily deals with the most common types of dental abscess.
History and exam
Key diagnostic factors
- presence of risk factors
- dental pain/toothache
- thermal sensitivity of teeth
- intra-oral and/or extra-oral oedema
- intra-oral and/or extra-oral erythema
- intra-oral and/or extra-oral discharge
- tooth percussion sensitivity
- mobile teeth
- deep periodontal pockets, bleeding, gingival recession
- bone loss around teeth
- elevated/extruded tooth
- dyspnoea/respiratory stridor
- uvular deviation
- floor of mouth elevation
Other diagnostic factors
- halitosis/bad taste in mouth
- neurological signs
- poor oral hygiene
- dental caries
- periodontal disease
- partially erupted or impacted tooth
- dental trauma
- fractured teeth
- excessive occlusal wear
- alcohol or drug misuse
- low socioeconomic status
- age extremes
- prior radiotherapy
- certain medications
- immunosuppression or comorbidity (higher risk for complications)
- large dental restorations
- prior root canal treatment failure
1st investigations to order
- FBC with differential
- panoramic x-ray
Investigations to consider
- periapical x-ray
- CT head and neck (with contrast)
- infection site aspiration Gram stain/culture and sensitivity
- erythrocyte sedimentation rate (ESR)
- serum electrolytes
- plasma fibrinogen level
- MRI head and neck
- ultrasound of fascial spaces
- electric pulp testing
- thermal testing
- blood cultures
- C-terminal cross-linking telopeptide (CTX)
- Antimicrobial prescribing in dentistry: good practice guidelines
- Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: a report from the American Dental Association
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