What is dental abcess?
• Dental abscess: An lesion characterized by localization of pus in the
structures that
surround
the teeth, can be either acute or chronic.
• Sometimes the abscess develops some distance away from the
teeth (like cervical region)
but
if is of dental origin then still is called dental or odontogenic abscess.
• When dental caries is not treated by restoration will
results into pulpitis.
• If pulpitis is not treated by root canal or extraction ends
up with periapical abscess.
• The periapical abscess and its counterpart periodontal
abscess (due to periodontal
diseases)
when extend out of the tooth boundaries may extend through the bone and
muscles
causing pus collection in soft tissues which is called abscess.
Aetiology of Dental Abscess
• Odontogenic (dental) infections are polymicrobial.
• On average 4-6 different bacteria species are involved.
• The normal flora bacteria are involved but the dominant
isolates are anaerobes.
• Generally the Anaerobic Gram negative rods followed by
Anaerobic Gram positive cocci
are
of significant concern.
• The predominant species include; Bacteroides, Fusobacterium,
Peptococcus,
Peptostreptococcus
and Streptococcus viridians.
• The abscess formation depends on loss of balance between the
resistance of the host
tissues
and virulence of bacteria.
• When there is high resistance of host tissues with normal or
low virulence of microbes
inflammation
is usually confined, and resolve, otherwise abscess develops.
• Common causes of entry of microbes and abscess formation
include.
o
Infected teeth e.g. deep caries, trauma
involving the pulp.
o
Periodontal infections.
o
Pericoronitis is a common condition,
and is an infection of the gingiva surrounding a
partially
erupted third molar.
o
Post-extraction infection – (especially
in septic procedures).
o
Introducing infection by a needle
during administration of local anaesthesia especially
mandibular
block.
o Mandibular and maxillary fractures.
Clinical Features of Dental
Abscess
• Patient looks moderately ill sometimes severely ill and
toxic.
• High body temperature.
• Painful swelling.
• The skin is tense, shiny, warm and red or purple unless the
abscess is very deep.
• Muscle trismus (the patient is unable to open his/her mouth
fully).
• Gingival fistulas (drainage of pus into the mouth).
• Cellulitis (inflammation of the soft tissues).
Extension of Dental Abscess
• The dental abscess usually extend to the following
regions/spaces; buccal space,
sublingual,
submental, submandibular and generally around the mandible and maxilla.
• Sometimes the infection can extend to distant areas like
cervical, pharynx and
mediastenum
on the inferior aspect, infraorbital, parotid and temporal superioly.
• Life threatening infections due to complications of dental
abscess include:
o
Ludwing’s angina(bilateral swelling of
the submandibular and submental spaces
includind
floor of the mouth causing rising of the tongue and airway obstruction).
o
Mediastinitis; infection descending
from orofacial region to cervical and eventually to
the
chest.
o
Carvenous sinus thrombosis:- infection
ascends to the carvenous sinus and can cause
thrombosis
with the sinus and and meningitis.
Treatment of Dental Abscess
Antibiotics
• Combination of broad spectrum antibiotics of penicillin
family or its alternative with
metronidazole
(highly active against anaerobic gram-negative bacilli).
Analgesics and Antipyretics
• Non-streroidal ant-inflammatory drugs (NSAIDs) like
ibuprofen and diclofenac are
useful
to relieve pain and reduce fever.
Incision and Drainage and Removal
of the Cause
• This is the ideal treatment of abscess once pus has been
localized.
• The dental personnel around can be of help to the patient,
if there is none patient shoud be
referred
immediately after providing basic care like antibiotics and analgesics.
• Removal of the cause may mean extraction of an offendind
tooth which is done during
incision
and drainage where feasible if not then few day later. Note: Always Make Sure
You Assess the Airway
• Some forms of dental abscess cause life threatening airway
obstruction ( e.g. Ludwig’s
agina). • In such case endotracheal intubation or trachestomy may be
required.
Ludwig’s Angina
• A bacterial infection of the floor of the mouth
• Swelling of the tissues occurs rapdily and may block the
airway or prevent swallowing of
saliva.
• Symptoms include
o
Breathing difficulty
o
Confusion or other mental changes
o
Fever
o
Neck pain
o
Neck swelling
o
Redness of the neck
o
Weakness, fatigue, excessive tiredness
o
Drooling
o
Earache
• Signs include
o
An examination of the neck and head
shows redness and swelling of the upper neck,
and
under the chin.
o
The swelling may reach to the floor of
the mouth.
o
The tongue may be swollen or out of
place
Complications of Dental Abscess
• Osteomyelitis of the jaws
• Maxillary sinusitis
• Cavernous sinus thrombosis
• Necrotizing fasciitis
• Others:
o
Mediastinitis
o
Meningitis
o
Brain abscess
General Pre-referral Care for
Dental Patients
• Patient with pain due to pulpitis or any other cause are
given analgesics
• Patient with acute infections are given antibiotics and
analgesics
• Patient with acute infections are assessed for danger of
airway obstruction and toxaemia
• Patients with traumatic dental injuries are given analgesics
and antibiotics
• Patients with bleeding effort is made first to control
bleeding by packing with a gauze
(preferably
soaked with adrenaline) and if persist suturing is attempted. • If bleeding persists then pack the site, stabilize the
patient with intravenous fluids (and
blood
if patient has bled a lot) and refer
• Always insist on abiding to the referral plan
