Tooth Abscess - A Highly Painful and Rapidly Spreading Oral Condition

What Is an Abscess?

The collection of pus is found routinely in all our body parts. The common term used for the collection of pus is an abscess.

What Is a Tooth Abscess?

Abscess, like in our whole body, is also found in the oral cavity. It can be either localized or generalized. The collection of pus in a localized manner is a common phenomenon in the oral cavity. A tooth abscess results from progressive oral diseases and can also be caused by trauma. It can be single or multiple and can be both acute or chronic. A tooth abscess is not gender-specific and affects both males and females in an equal manner. In addition, it is associated with severe pain, bone loss, high fever, and swollen lymph nodes. They can be broadly classified into four forms according to their location:

1. Periapical - A periapical abscess results from pulpal infections.

2. Periodontal - A periodontal abscess is due to a periodontal pocket.

3. Pericoronal - Abscess in the gums surrounding a partially erupted or impacted tooth.

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4. Gingival - A gingival abscess is due to trauma, while a pericoronal abscess is due to inflammation around the erupting tooth (preferably 3rd molar).

All these abscesses are usually acute in nature but can also become chronic if left untreated. A lot of complications are associated with abscesses like Ludwig’s angina and space infections. Hence, this condition needs to be sorted out in a systemic manner. They have to be appropriately examined and treated accordingly.

What is the Microbiology of Tooth Abscess?

Dental pus contains a variety of organisms. They are both anaerobic and aerobic. The reason behind the variable microbial community is the different available routes of oral infections. They range from Streptococcus mutans to Treponema pallidum in acute infections. Porphyromonas gingivalis, Bacteroides melaninogenicus, and Fusobacterium can be found later (chronic) in dental pus. Various techniques like simple culturing, PCR (polymerase chain reaction) are employed to determine the presence of microbes, and darkfield microscopy is the best choice for anaerobes.

What is the Pathogenesis of Tooth Abscess?

A tooth abscess is chiefly associated with microbial infection. Like in regular host-microbial interaction, there is a robust inflammatory response of bacterial endotoxin (Gram –ve bacteria) and exotoxins (Gram +ve) with polymorph neutrophils and macrophages of the host. A huge swelling and pain follow this. This pain is sometimes excruciating in nature and unbearable for individuals. Fever increases the severity of infection. Even lymph nodes are swollen and exhibit tenderness on palpation. Malaise can be observed, and sour taste may be associated in cases where pus is drained automatically. Relief is felt only after the pus is drained through the development of an orifice (small opening). Sometimes the process is aided by antibiotics and analgesics, but that is always secondary. The best treatment is the discharge of pus through the orifice.

How is Tooth Abscess Diagnosed?

The diagnosis of a tooth abscess depends upon both clinical and microbiological methods. Periapical pus is seen mostly below the tooth near the apical foramen. It usually is not clinically visible and shows tenderness on vertical percussion. The etiology is progressive caries, reversible or irreversible pulpitis, or postoperative RCT infection.

Periodontal Abscess is associated with a periodontal pocket. It shows tenderness on lateral percussion. Both these abscesses are confirmed by radiographic examination. Both show radiolucency, but bone loss is not always found in pulpal abscess, but chronic periodontal abscess always shows bone loss.

A gingival abscess is related to trauma (preferably toothbrush) or a foreign object. This abscess has no relation with bone loss and is always acute in nature with a strong orifice. It is clinically easily visible due to its transparency and fluctuating nature.

Pericoronal abscess occurs as an extension of pericoronitis. It happens at a later stage and is usually subsided after the arrest of pericoronal infection.

Sometimes the abscess is so large that it is extra orally visible due to high tender swelling. It occurs in space infections or Ludwig’s angina. There can be high-grade fever and reduced mouth opening (pericoronal abscess). Pain is not so severe in all these abscesses; however, spreading into spaces creates discomfort for the patient. A periapical abscess is usually associated with a non-vital tooth, but all other abscesses are related to vital teeth.

What are the Differential Diagnoses of Tooth Abscesses?

Differential diagnosis needs to be done in similar conditions like a cyst, mucocele, and sinus. While sinus is usually self-treated, cyst involves exposure of tooth or extractions. Mucocele is excised surgically and shows a rare occurrence inside the oral cavity.

How is Tooth Abscess Treated?

Treatment options include incision and drainage of the involved abscess. However, the role of antibiotics is also vital. Basically, the approach is according to the symptoms and involves toxicity.

Gingival and pericoronal abscesses are drained by discharging the pus from the orifice. But periodontal and periapical abscesses become chronic with the passage of time. Sometimes it is not feasible for the patient to get the treatment done immediately. Although it is controversial to prescribe antibiotics in every case, during emergency times, they provide immediate relief. Usually, narrow-spectrum antibiotics and Imidazoles are highly effective in controlling abscesses, but long-standing abscesses may also require broad-spectrum antibiotics. They are primarily supplied in both topical and systemic forms as either gels, lozenges, or tablets. They, along with analgesics, provide greater efficacy. In case of rapidly spreading abscess, there can be a need for raising flap.

Bone loss can require grafting (both soft and hard tissue), while in periapical abscesses, apicectomy can also be needed. The flap is accompanied by debridement and frequent povidone irrigation. Mobility may require splinting and apexification. Re-RCT may be necessary for periapical infections, but it has a poor prognosis.

What are the Complications of Tooth Abscess?

A tooth abscess is an excruciating condition, especially in the acute form. They cause a lot of discomfort along with tender lymph nodes (submandibular) and high-grade fever. Sometimes they cause vertical bone loss and grade 3 tooth mobility. One of the most severe complications is Ludwig’s angina which can be life-threatening. It occurs due to the spread of pericoronal abscess. Diabetic individuals are prone to develop a lot of periodontal abscesses due to decreased immunity and septicemia. Hence a lot of precautions are required in handling the abscesses.

Conclusion:

A tooth abscess is very painful, rapidly progressing, and sudden in onset. The presence of microbial infection helps in the spreading of diseases and makes it sometimes difficult to manage. Complications make the treatment unmanageable and cause mortality also. Hence, both clinicians and patients should be aware of its complications, and problems must be treated systemically.