Dental Abscess Follow-up

Follow-up care should be obtained as recommended by a physician. Most dentists would see the patient after 1-2 days of antibiotics if it is a primary tooth involved for dental extraction and then continue antibiotics for 2-3 more days for a total antibiotic course of 5 days. For a dental abscess in a secondary tooth the patient is typically seen back after 5 days of antibiotics for a root canal procedure followed by an additional 5-10 days of antibiotics. Pain control is typically achieved with acetaminophen or non-steroidal anti-inflammatory medications for outpatients. For inpatients whose pain is not adequately controlled with these medications morphine sulfate can be utilized.

A cross-sectional study found that periodontal abscess can be considered as possible oral clinical diagnostic criteria for the diagnosis of diabetes mellitus in the elderly. ^[13]

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 such as Ludwig’s angina

• Systemic involvement

• Failure of outpatient therapy

• Need for intravenous (IV) hydration

The most effective preventive measure against dental caries and, thus, dentoalveolar abscess in addition to homecare with brushing and flossing is fluoridation of communal drinking water. ^[26]

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): ^[14]

• 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 include the following:

• 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. ^[15]

• 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. Case reports exist of odontogenic orbital abscess secondary to spread of infection to the maxillary sinus. These patients can present with facial edema, ocular pain, ophthalmoplegia and proptosis. ^[16]

• 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.

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

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 eMedicineHealth's Teeth and Mouth Center and Infections Center. Also, see eMedicineHealth's patient education articles Dental Abscess, Toothache, When to Visit the Dentist, and Antibiotics.