Dental abscess

A dental abscess is a localized collection of pus associated with a tooth.

The abscess typically comes from a bacterial infection, often one that has accumulated in the soft pulp of the tooth.
Bacteria exist in plaque, a by-product of food, saliva, and bacteria in the mouth, which sticks to the teeth and damages them and the gums. If the plaque is not removed by regular and proper brushing and flossing, the bacteria may spread inside the soft tissue of the tooth or gums. This can eventually result in an abscess.
Abscesses are the result of an infection, generally bacterial, localized in the area where the abscess forms. They are almost always accompanied by swelling and inflammation. Dental abscesses are abscesses affecting the teeth and adjacent jaw tissue.
Each tooth is made up of several layers. The outermost layer is the enamel, which covers a softer layer, the dentin. The dentin and enamel are the tooth’s protective layers. Underneath the dentin is the pulp, where the tooth’s nerves and blood vessels are situated. The pulp runs down the center of the root of the tooth, which connects the tooth to the underlying bone of the upper or lower jaw. Infections in the pulp can therefore easily spread into the bone of the jaw. Likewise, if the gum around the tooth becomes infected, the tooth is at risk of damage as well. Some abscesses affect the pulp first and spread to the bone, while others affect the surrounding tissues of the gum and do not start in the pulp.
The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth.
This can be caused by tooth decay, broken teeth or extensive periodontal disease (or combinations of these factors). A failed root canal treatment may also create a similar abscess.
A dental abscess is a type of odontogenic infection, although commonly the latter term is applied to an infection which has spread outside the local region around the causative tooth.

·      Classification :

1-Periapical abscess:The result of a chronic, localized infection located at the tip, or apex, of the root of a tooth.

2-Periodontal abscess: begins in a periodontal pocket.

3-Gingival abscess:  involving only the gum tissue, without affecting either the tooth or the periodontal ligament.

4-Pericoronal abscess: involving the soft tissues surrounding the crown of a tooth .

5-Combined periodontic-endodontic abscess: a situation in which a periapical abscess and a periodontal abscess have combined.

·      Signs and symptoms :

The main symptom of an abscessed tooth is throbbing pain near a tooth or in your gums. The pain usually comes on suddenly and gets worse over time.

Pain in the affected area when biting or when touching the affected area, sensitivity to cold or hot food and liquids, a foul taste in the mouth, fever, a generally unwell feeling, difficulties opening the mouth, swallowing difficulties, insomnia.

The main symptom of a dental abscess is pain. This may be a throbbing pain and is often intense. The pain usually starts suddenly and becomes more intense over the following hours or days. In some cases, the pain may radiate to the ear, jawbone, and neck.

The pain is continuous and may be described as extreme, growing, sharp, shooting, or throbbing. Putting pressure or warmth on the tooth may induce extreme pain. The area may be sensitive to touch and possibly swollen as well. This swelling may be present at either the base of the tooth, the gum, and/or the cheek, and sometimes can be reduced by applying ice packs.

An acute abscess may be painless but still have a swelling present on the gum. It is important to get anything that presents like this checked by a dental professional as it may become chronic later.

In some cases, a tooth abscess may perforate bone and start draining into the surrounding tissues creating local facial swelling. In some cases, the lymph glands in the neck will become swollen and tender in response to the infection. It may even feel like a migraine as the pain can transfer from the infected area. The pain does not normally transfer across the face, only upwards or downwards as the nerves that serve each side of the face are separate.

Severe aching and discomfort on the side of the face where the tooth is infected is also fairly common, with the tooth itself becoming unbearable to touch due to extreme amounts of pain.

·      Diagnostic approach :

A periodontal abscess may be difficult to distinguish from a periapical abscess. Indeed, sometimes they can occur together.  Since the management of a periodontal abscess is different from that of a periapical abscess, this differentiation is important to make.

-If the swelling is over the area of the root apex, it is more likely to be a periapical abscess; if it is closer to the gingival margin, it is more likely to be a periodontal abscess.

-Similarly, in a periodontal abscess pus most likely discharges via the periodontal pocket, whereas a periapical abscess generally drains via a parulis nearer to the apex of the involved tooth.

-If the tooth has pre-existing periodontal disease, with pockets and loss of alveolar bone height, it is more likely to be a periodontal abscess; whereas if the tooth has relatively healthy periodontal condition, it is more likely to be a periapical abscess.

-In periodontal abscesses, the swelling usually precedes the pain, and in periapical abscesses, the pain usually precedes the swelling

-A history of toothache with sensitivity to hot and cold suggests previous pulpitis, and indicates that a periapical abscess is more likely.

-If the tooth which gives normal results on pulp sensibility testing, is free of dental caries and has no large restorations; it is more likely to be a periodontal abscess.

-A dental radiograph is of little help in the early stages of a dental abscess, but later usually the position of the abscess, and hence indication of endodontal/periodontal etiology can be determined. If there is a sinus, a gutta percha point is sometimes inserted before the x-ray in the hope that it will point to the origin of the infection.

-Generally, periodontal abscesses will be more tender to lateral percussion than to vertical, and periapical abscesses will be more tender to apical percussion.

·      Treatment :

Depending on the type and severity of your abscess, treatment options include:

-Draining the abscess. Your dentist will make a small cut in the abscess to drain the pus. They’ll follow up by cleaning the area with a saline solution.

-A root canal procedure. A root canal involves drilling into the affected tooth to drain the abscess and remove any infected pulp. Next, your dentist will fill and seal the pulp chamber, which holds pulp, and the root canal. They may also cap your tooth with a crown to strengthen it. A crown procedure is usually done during a separate appointment.

-Tooth extraction. If your tooth is too damaged, your dentist might remove it before draining the abscess. Your dentist may pull the tooth if it can’t be saved and then drain the abscess.

-Antibiotics. If the infection has spread beyond the abscessed area or you have a weakened immune system, your dentist might prescribe oral antibiotics to help clear the infection.

-Removal of foreign object. If your abscess is caused by a foreign object in your gums, your dentist will remove it. They’ll finish up by cleaning the area with a saline solution.

If you can’t get in to see your dentist right away, you can take an over-the-counter anti-inflammatory drug, such as ibuprofen (Advil, Motrin) to help with the pain. Rinsing your mouth with warm salt water may also help.

·      Complications :

If left untreated, a severe tooth abscess may become large enough to perforate bone and extend into the soft tissue eventually becoming osteomyelitis and cellulitis respectively. From there it follows the path of least resistance and may spread either internally or externally. The path of the infection is influenced by such things as the location of the infected tooth and the thickness of the bone, muscle and fascia attachments.

External drainage may begin as a boil which bursts allowing pus drainage from the abscess, intraorally (usually through the gum) or extraorally. Chronic drainage will allow an epithelial lining to form in this communication to form a pus draining canal (fistula). Sometimes this type of drainage will immediately relieve some of the painful symptoms associated with the pressure.

Internal drainage is of more concern as growing infection makes space within the tissues surrounding the infection. Severe complications, which is a combination of growing infection and cellulitis which closes the airway space causing suffocation in extreme cases. Also infection can spread down the tissue spaces to the mediastinum which has significant consequences on the vital organs such as the heart. Another complication, usually from upper teeth, is a risk of septicaemia (infection of the blood) from connecting into blood vessels, brain abscess (extremely rare), or meningitis (also rare).

Depending on the severity of the infection, the sufferer may feel only mildly ill, or may in extreme cases require hospital care.