eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Dental Abscess: Follow-up

Author: Jane M Gould, MD, FAAP, Assistant Professor of Pediatrics, Drexel University College of Medicine; Hospital Epidemiologist, Attending Physician, Section of Infectious Diseases, St Christopher's Hospital for Children
Coauthor(s): Jeffrey J Cies, PharmD, BCPS, Pharmacy Clinical Coordinator, Critical Care Clinical Pharmacist, St Christopher's Hospital for Children
Contributor Information and Disclosures

Updated: Feb 5, 2010

Follow-up

Further Inpatient Care

• Criteria for hospital admission in patients with dental abscesses include the following:
  • Unable to handle secretions
  • Airway compromise
  • Involvement of facial spaces of head and neck
  • Systemic involvement
  • Failure of outpatient therapy
  • Need for intravenous (IV) hydration

Further Outpatient Care

• Follow-up care should be obtained as recommended by a physician.

Deterrence/Prevention

• The most effective preventive measure against dental caries and, thus, dentoalveolar abscess is fluoridation of communal drinking water.
• In fluoride-deficient areas, prevention can be obtained with dietary fluoride supplements. The AAP and the American Dental Association recommend administration of fluoride if the concentration of fluoride in the drinking water is less than 0.30 parts per million (ppm) or 0.30-0.60 ppm for individuals aged 3-16 years. Administer fluoride according to the following age-appropriate schedule (all doses are per day):¹⁰
  • Age 0-6 months - None
  • Age 6 months to 3 years - 0.25 mg if fluoride in drinking water is less than 0.30 ppm, none if fluoride in drinking water is more than 0.3 ppm
  • Age 3-6 years - 0.50 mg if fluoride in drinking water is less than 0.30 ppm, 0.25 mg if fluoride in drinking water is 0.30-0.60 ppm
  • Age 6-16 years - 1 mg if fluoride in drinking water is less than 0.30 ppm, 0.50 mg if fluoride in drinking water is 0.3-0.6 ppm
• The other effective preventive measure against dental caries and dentoalveolar abscess is proper dental hygiene. This includes brushing teeth after meals and regular dental check-ups.

Complications

• Dentocutaneous fistulae arise from chronic dental infections. The fistulous pathway develops as the chronic inflammation erodes through the alveolar bone, perforates the periosteum, and spreads into the surrounding soft tissues. The diagnosis is often missed because a chronic asymptomatic dental infection is usually present and the skin lesion is mistakenly thought to arise locally.
• Acute suppurative osteomyelitis was common before the era of antibiotic therapy. Osteomyelitis is an inflammation of the medullary cavity and adjacent cortex of bone. The mandible is more commonly involved than the maxilla because the maxilla has a better blood supply. Garr é osteomyelitis is a chronic nonsuppurative sclerosing osteomyelitis that is characterized by a localized, hard, nontender swelling of the mandible and is usually associated with dental caries of the lower first molar. Radiography may reveal a focal area of bone proliferation with a periosteal reaction that has an onion-peel or laminated appearance.
• Cavernous sinus thrombosis (CST) may be a complication. Approximately 10% of patients with CST have an odontogenic focus. Spread of infection from dental abscesses to the cavernous sinus is believed to occur via the valveless pterygoid venous plexus by way of the retromandibular vein. Patients often present with headache, unilateral retro-orbital pain, periorbital edema, fever, proptosis, chemosis, and ptosis. Treatment consists of antibiotics, anticoagulants, and, occasionally, surgery.
• Ludwig angina is rapidly spreading cellulitis of the bilateral sublingual, submandibular, and submental spaces. Abscesses of the second and third mandibular molars account for 75% of cases. Ludwig angina manifests as swelling of the floor of the mouth with elevation and posterior displacement of the tongue. A rapidly spreading gangrenous cellulitis produces a brawny edema of the suprahyoid region of the neck. The infection begins unilaterally but quickly spreads to include the entire neck. The most common presenting symptoms include oral, neck, and dental pain; neck swelling; odynophagia; drooling; dysphagia; dysphonia; trismus; and tongue swelling. The patient may lean forward in order to maintain airway patency. The infection can extend into the retropharyngeal space and the mediastinum. This is a life-threatening infection. Ludwig angina is unusual in children.
• Maxillary sinusitis may occur from direct extension of an odontogenic infection or from perforation of the floor of the sinus during extraction.
• Facial-space swelling secondary to spread of the infection most often involves the following areas:
  • Submandibular swelling is caused by dental abscesses from the second or third molars whose roots lie below the attachment of the mylohyoid bone. This space contains the submandibular gland, Wharton duct (the opening of the submandibular salivary gland), lingual and hypoglossal nerves, facial artery, and vein. A firm, ill-defined, and often significant-sized swelling is present below the mandible. The inferior border and angle of the mandible are difficult to palpate. The patient may have mild trismus.
  • Sublingual swelling is caused by any lower tooth whose apex is above the mylohyoid muscle attachment (ie, incisors, canines, premolars, mesial roots of the first molar). Infections produce a unilateral elevation of the floor of the mouth near the offending tooth but can spread across the midline, causing pain, dysphagia, and an elevation of the base of the tongue, leading to potential airway compromise.
  • Buccal swelling originates from infected maxillary or mandibular molars. Clinically, infection produces a large tender swelling of the cheek without trismus. Boundaries for this type of infection may extend from the philtrum of the lip, to the border of the parotid, and up to the eye.
  • Less frequently involved facial-space swellings include submental, masticator, canine, lateral pharyngeal, and retropharyngeal. Retropharyngeal space infections are serious infections with the potential to cause airway obstruction and infection of the organs in the mediastinum.
• Necrotizing fasciitis of the face or neck that results from an odontogenic abscess is very rare.

Prognosis

• The prognosis is excellent with proper incision, drainage, antibiotic therapy, tooth extraction, root canal therapy and follow-up care.

Patient Education

• Most dentoalveolar abscesses are preventable.
  • Inquire if drinking water is fluorinated. If not, counsel parents about fluoride supplementation (see Deterrence/Prevention).
  • Instruct patients about proper dental hygiene, including brushing teeth after meals, flossing, and regular dental check-ups.
• For excellent patient education resources, visit eMedicine's Teeth and Mouth Center and Infections Center. Also, see eMedicine's patient education articles Dental Abscess, Toothache, When to Visit the Dentist, and Antibiotics.

Miscellaneous

Medicolegal Pitfalls

• Failure to consult a dentist if the patient has an uncomplicated abscess
• Failure to consult a maxillofacial oral surgeon if the patient has a complicated abscess

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Karen Schneider, MD, to the original writing and development of this article.

• Search for CME/CE on This Topic »

• Urticaria (Pediatrics: General Medicine)
• Hypophosphatemic Rickets (Pediatrics: General Medicine)
• Lymphadenopathy (Pediatrics: General Medicine)

• Dental Abscess Causes
• Toothache Overview
• Infections Center
• Teeth and Mouth Center
• Dental Abscess Overview
• Dental Abscess Symptoms
• Dental Abscess Treatment
• Antibiotics Introduction
• When to Visit the Dentist - Introduction

• Infectious Complications of Biological Therapy
• Examining the Ears, Nose, and Oral Cavity in the Older Patient