Kingdom of Saudi Arabia

King Khalid University

College of Dentistry

Dr. Sultan Mohammed Kaleem

Bacterial Infection Affecting Teeth

Dental Abscess

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Faisal Moteq Al-Qhtani 431803127 Bacterial Infections:

A bacterial oral infection is when bacteria invade the oral cavity (mouth) and cause infection (the harmful growth of microorganisms).

Most bacteria in the body are harmless or even helpful. However, some do cause disease and produce pathogens in the body that make you sick.

The most common bacterial oral infections are gingivitis and periodontitis. Dental plaque, also called plaque biofilm, is teeming with bacteria. Some of the bacteria is good and necessary for health. Others are associated with gum disease. The type and the virulence of the bacteria change and multiple the longer they are in the mouth. When the bad bacteria outnumber the good, disease begins - gingivitis and periodontitis. Because of the biofilm nature of the plaque, systemic antibiotics are not a good choice for treating gingivitis and/or periodontitis.

In many cases, a deep cleaning followed by good daily oral hygiene helps clear up the infection and restore gum health. A visit with your dental professional can help determine the right treatment.

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If untreated, a bacterial infection can spread to the bloodstream. This condition is called bacteremia.

Definition :

A dental abscess, or tooth abscess, is an accumulation of pus that

forms inside the teeth or gums. The abscess typically originates 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, as well as

the gums. If the plaque is not removed by regular and proper tooth

brushing and flossing the bacteria may spread within the soft tissue

inside the tooth or gums, eventually resulting in an abscess.

Classification :

The main types of dental abscess are:

Periapical abscess: The result of a chronic, localized infection

located at the tip, or apex, of the root of a tooth .

Periodontal abscess: begin in a periodontal pocket .

Gingival abscess: involving only the gum tissue, without affecting

either the tooth or the periodontal ligament .

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Pericoronal abscess: involving the soft tissues surrounding the

crown of a tooth.

Combined periodontic-endodontic abscess: a situation in which a

Periapical abscess and a periodontal abscess have combined .

o Periapical abscess : Bacteria enter the tooth through tiny holes caused by tooth decay (caries) that form in the tooth enamel (hard outer layer of the tooth). The caries eventually break down the softer layer of tissue under the enamel, called dentine. If the decay continues, the hole will eventually penetrate the soft inner pulp of the tooth - infection of the pulp is called pulpitis. As the pulpitis progresses the bacteria make their way to the bone that surrounds and supports the tooth, called the alveolar bone, and a Periapical abscess is formed.

o Periodontal abscess : When bacteria which are present in plaque infect the gums the patient has periodontitis. The gums become inflamed, which can make the periodontal ligament separate from the base of the tooth. A periodontal pocket, a tiny gap, is formed when the periodontal ligament separates from the root. The pocket gets dirty easily and is very hard to keep clean. As bacteria build up in the periodontal pocket, periodontal abscess is formed.

Epidemiology : Mortality/Morbidity :Mortality is rare and is usually due to airway compromise. Morbidity relates to pain, probable tooth loss, and dehydration . Race & Sex :No race or sex predilection is observed. Age :

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- 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.

- In adults, periodontal abscess is more common than Periapical abscess.

Clinical Presentation : 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 due to dental abscess.

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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) .

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

Decreased intake of fluid, food, or both .

Physical Examination : Gingiva : o Swelling .o Warmth .o Erythema .o Fluctuant mass that usually extends toward the buccal side of the

gum and to the gingival-buccal reflection.o 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) .

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.

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CT scan showing a large tooth abscess (right in the image) with significant inflammation of fatty tissue under the skin

the maxillary right second premolar (upper right 2nd bicuspid), after extraction.

o Increased mobility (mostly Periapical abscess).o Pressure or percussion tenderness (mostly Periapical abscess).o Extrusion.

Regional lymph node involvement . More severe infection :

o Trismus, indicating involvement of the masticator space .o Difficulty swallowing (dysphagia) .o Respiratory difficulty.o Necrotizing fasciitis .

Neck or facial swelling . Signs of dehydration .

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 a Periapical abscess, this differentiation is important to make. The following factors may help to this:

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 with relatively healthy periodontal condition, it is more likely to be a Periapical abscess.

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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 an dental abscess, but later usually the position of the abscess, and hence indication of endodontal/periodontal etiology 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.

Work up : Laboratory Studies : Uncomplicated (ie, simple) dental abscess : No laboratory studies are

required. Complicated abscess (accompanying cellulitis) :

The CBC count may reveal leukocytosis with neutrophil predominance.

Obtain a blood culture (aerobic and anaerobic) before initiating parenteral antibiotics.

Needle aspirate is indicated for Gram stain and aerobic and anaerobic cultures.

Imaging Studies : Depending on severity of abscess based on clinical presentation the

following is recommended:

Periapical radiography is the first level of investigation. It provides a localized view of the tooth and its supporting structures. Widening of

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the periodontal ligament space or a poorly defined radiolucency may be noted.

Panoramic radiography (pantomography) is most helpful in emergency situations because it provides the most information for all teeth and supporting structures.

If cellulitis swelling extends beyond local area then the following is indicated:

Lateral and anteroposterior neck views to rule out a soft tissue neck mass that impinges on the airway.

CT scanning with intravenous contrast is the most accurate method to determine the location, size, extent, and relationship of the inflammatory process to the surrounding vital structures.

Procedures :

Confirm presence of the abscess via needle aspiration.

If pus is obtained, do not aspirate more than 1-2 drops. Leave the abscess as large as possible to make the area easier to find for further management.

If pus cannot be aspirated, manage medically until a more localized infection develops.

Incision and drainage may be performed only if pus can be aspirated.

Packing a periapical abscess is generally not necessary.

Histologic Findings :

The flora at different oral sites varies. The surface of the carious tooth usually contains acid producing aerobic and anaerobic bacteria including

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Streptococcus mutans, Lactobacillus acidophilus, and Actinomyces viscosus. S mutans is the only organism recovered from decaying dental fissures. Obligate anaerobes such as Propionibacterium, Eubacteria, Arachnia, Lactobacillus, Bifidobacterium, and Actinomyces constitute most organisms isolated from carious dentin. The bacteria isolated from inflamed pulp and root canals are aerobic, facultative anaerobic and strict anaerobic organisms, in addition to yeast.

Anaerobes usually outnumber aerobes and facultative anaerobes.

Most odontogenic infections involve plaque organisms.

Supragingival plaque mainly consists of gram-positive facultative anaerobes or microaerophilic cocci and rods.

Subgingival plaque consists of anaerobic gram-negative rods with motile form, including spirochetes.

Treatment & Management : Medical Care : In patients with dental abscess, assess the airway upon respiratory distress, oropharyngeal tissue swelling, or inability to handle secretions; then, secure the airway via endotracheal intubation or tracheostomy.

Properly collect specimen for Gram stain and aerobic and anaerobic cultures.

Administer empiric antibiotic therapy if necessary. Administer analgesia. Hydrate the patient.

Surgical Care : The primary therapeutic modality is surgical drainage of any pus collection. A pulpectomy or incision and drainage is the recommended management of a localized acute apical abscess in the permanent

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dentition. Incision and drainage or spontaneous rupture of the abscess quickly accelerates resolution of the infection. The addition of antibiotics is not recommended for a localized dental abscess. Emergent surgery is indicated in the operating room if the airway is threatened or if the patient's condition is rapidly deteriorating.Third molar removal is a common surgical procedure. Consultations : Consult a dentist if the patient has an uncomplicated abscess.Consult a maxillofacial oral surgeon if the patient has a complicated abscess. Diet : Diet is as tolerated. However, a soft bland diet is usually preferred. Activity : Activity is as tolerated.Medication :

Penicillin (Pfizerpen, Pen-Vee K) Traditionally been considered the DOC for the treatment of a dental abscess. Antibiotic therapy alone, without surgical drainage, may not be effective because of poor antibiotic penetration into the abscess cavity, ineffectiveness at low pH levels, and the inoculum effect.

Azithromycin (Zithromax) May be an option for the treatment of a dental abscess in patients who are allergic to penicillin or beta-lactam.

Metronidazole (Flagyl)

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Effective against obligate anaerobic organisms. It can be combined with penicillin if anaerobic organisms that produce beta-lactamase enzymes are a concern.

Clindamycin (Cleocin)Can be used in patients who are penicillin or beta-lactam allergic.

Amoxicillin and clavulanate (Augmentin) Amoxicillin works by binding to one or more of the penicillin-binding proteins, which interferes with bacterial cell wall synthesis during active bacterial replication.

Cefoxitin (Mefoxin) Binds to one or more of the penicillin binding proteins, which interferes with bacterial cell wall synthesis during active replication.

Follow-up :

Further Inpatient Care :

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.

Systemic involvement.

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Failure of outpatient therapy.

Need for intravenous (IV) hydration.

Further Outpatient Care :

Follow-up care should be obtained as recommended by a physician.

Deterrence/Prevention : The most effective preventive measure against dental caries and,

thus, dentoalveolar abscess is fluoridation of communal drinking water. In fluoride-deficient areas, prevention can be obtained with dietary fluoride supplements.

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 : Complications include the following:

Dentocutaneous fistulae arise from chronic dental infections Acute suppurative osteomyelitis was common before the era of antibiotic

therapy. The mandible is more commonly involved than the maxilla because the maxilla has a better blood supply.

Cavernous sinus thrombosis (CST) may be a complication. Approximately 10% of patients with CST have an odontogenic focus.

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.

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Maxillary sinusitis may occur from direct extension of an odontogenic infection or from perforation of the floor of the sinus during extraction.

Facial-space swelling secondary to spread of the infection , most often involves the following areas:

o Submandibular swelling. o Sublingual swelling .o Buccal swelling o Less frequently involved facial-space swellings include submental,

masticator, canine, lateral pharyngeal, and retropharyngeal. Necrotizing fasciitis of the face or neck that results from an odontogenic

abscess is very rare. Prognosis : The prognosis is excellent with proper incision, drainage, antibiotic . therapy, tooth extraction, root canal therapy and follow-up care . Patient Education : Most dentoalveolar abscesses are preventable.

Inquire if drinking water is fluorinated. If not, counsel parents about fluoride supplementation .

Instruct patients about proper dental hygiene, including brushing teeth after meals, flossing, and regular dental check-ups.

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