eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Dental Abscess

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

Introduction

Background

A dentoalveolar abscess is an acute lesion characterized by localization of pus in the structures that surround the teeth. Most patients are treated easily with analgesia, antibiotics, drainage, and/or referral to a dentist or oral-maxillofacial surgeon. However, the physician should be aware of potential complications of simple dentoalveolar abscess.

Pathophysiology

The term dentoalveolar abscess comprises 3 distinct processes, as follows:

• A periapical abscess that originates in the dental pulp and is usually secondary to dental caries is the most common dental abscess in children. Dental caries erode the protective layers of the tooth (ie, enamel, dentin) and allow bacteria to invade the pulp, producing a pulpitis. Pulpitis can progress to necrosis, with bacterial invasion of the alveolar bone, causing an abscess.
• A periodontal abscess involves the supporting structures of the teeth (periodontal ligaments, alveolar bone).¹ This is the most common dental abscess in adults, but may occur in children with impaction of a foreign body in the gingiva.
• Pericoronitis describes the infection of the gum flap (operculum) that overlies a partially erupted or impacted third molar.

Developmental and acquired conditions are associated with dental abscesses in childhood. Developmental conditions include abnormal morphology of the crown (eg, dens invaginatus, dens evaginatus) and abnormal structure of the dentine (eg, dentine dysplasia, dentinogenesis imperfecta, osteogenesis imperfecta, familial hypophosphatemia). Acquired conditions include pre-eruptive intracoronal resorption and mandibular infected buccal cyst.²

Odontogenic infections are polymicrobial, with an average of 4-6 different causative bacteria. The dominant isolates are strictly anaerobic gram-negative rods and gram-positive cocci, in addition to facultative and microaerophilic streptococci. Anaerobic bacteria outnumber aerobes 2-3:1.³ In general, strictly anaerobic gram-negative rods are more pathogenic than facultative or strictly anaerobic gram-positive cocci.

Generally, a nonpathologic resident bacterium gains entry when the host's defenses are breached, rather than when a nontypical microorganism is introduced. The predominant species associated with dental abscess include Bacteroides, Fusobacterium, Peptococcus, Peptostreptococcus, and Porphyromonas as well as Prevotella oralis, Prevotella melaninogenica,  and Streptococcus viridans. Beta-lactamase producing organisms occur in approximately one third of dental abscesses.⁴

The use of molecular techniques such as 16S rRNA gene sequencing and polymerase chain reaction (PCR) have identified difficult-to-culture organisms and expanded knowledge of the microflora associated with dental abscess. Examples include Treponema, Atopobium, Bulleidia extructa, and Mogibacterium species, as well as Cryptobacterium curtum.⁵

Mortality/Morbidity

Mortality is rare and is usually due to airway compromise. Morbidity relates to pain, probable tooth loss, and dehydration. See Complications.

Race

No race predilection is observed.

Sex

No sex predilection is noted.

Age

Dental abscess is rare in infants because abscesses do not form until teeth erupt. In children, periapical abscess is the most common type of dental abscess. This is because of the combination of poor hygiene, thinner enamel, and the primary dentition having more abundant blood supply, which allows for an increased inflammatory response. In adults, periodontal abscess is more common than periapical abscess.

Clinical

History

The following may be reported in patients with dental abscess:

• Localized pain and swelling (may progress over a few hours to days): Examples of swelling are shown in the following images.
  
  

  

  Obvious swelling of the right cheek.

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  Obvious swelling of the right cheek.

  
  

  

  Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection.

  [ CLOSE WINDOW ]

  

  Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection.

  
  

  

  Gingiva with swelling and erythema.

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  Gingiva with swelling and erythema.

• Thermal sensitivity (periapical abscess): This is thought to occur secondary to exposure of the dentine to the external environment as a result of enamel loss or gingival recession.
• Fever
• Gingival bleeding (on occasion with periodontal abscess)
• Decreased intake of fluid, food, or both

Physical

• Gingiva
  • Swelling
  • Warmth
  • Erythema
  • Fluctuant mass that usually extends toward the buccal side of the gum and to the gingival-buccal reflection
  • Parulis or "gum boil" (a soft, solitary, reddish papule located facial and apical to a chronically abscessed tooth that occurs at the endpoint of a draining dental sinus tract)⁶
• Teeth: The tooth that is most frequently involved is the lower third molar, followed by other lower posterior teeth; upper posterior teeth are involved much less frequently, and anterior teeth are rarely involved.
  • Increased mobility (mostly periapical abscess)
  • Pressure or percussion tenderness (mostly periapical abscess)
  • Extrusion
• Regional lymph node involvement
• More severe infection
  • Trismus, indicating involvement of the masticator space
  • Difficulty swallowing (dysphagia)
  • Respiratory difficulty
  • Necrotizing fasciitis⁷
• Neck or facial swelling (see Complications)
• Signs of dehydration

Causes

• Dental caries are caused by the following:
  • "Infant-bottle" tooth decay or "nursing" caries: The term "early childhood" caries is replacing these terms because the description also includes dental caries in breastfed babies. The American Academy of Pediatrics (AAP) along with the American Academy of Pediatric Dentistry issued a clinical report entitled "Oral and Dental Aspects of Child Abuse and Neglect," which states that the caregivers of children who present for dental care with severe early childhood caries must be carefully interviewed to differentiate caregivers with adequate knowledge and willful failure to seek dental care from caregivers without knowledge or awareness of a child's dental needs. Failure to seek dental care may result from many socioeconomic factors, and clinicians should determine if dental care is readily available and accessible when considering the possibility of negligence. Physicians and dentists are required by law to report suspected cases of child negligence and abuse.⁸
  • Plaque: This is a noncalcified precipitate of microorganisms and their byproducts that adheres to the enamel of teeth.
• In immunocompromised patients, bacteria may hematogenously spread to invade the pulp of the tooth.
• Gingivitis is an inflammation of the gingiva without attachment loss or with nonprogressing attachment loss.
• Posttraumatic infection or postsurgical infection may also cause dental abscess.

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