A dental abscess (also termed a dentoalveolar abscess, tooth abscess or root abscess), is a

localized collection of pusassociated with a tooth. The most common type of dental abscess is a
periapical abscess, and the second most common is aperiodontal 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.
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.[1]

Periodontal abscess: begin in a periodontal pocket (see: periodontal abscess)

Gingival abscess: involving only the gum tissue, without affecting either the tooth or the
periodontal ligament (see: periodontal abscess)

Pericoronal abscess: involving the soft tissues surrounding the crown of a tooth
(see: Pericoronitis)

Combined periodontic-endodontic abscess: a situation in which a periapical abscess and a

periodontal abscess have combined (see: Combined periodontic-endodontic lesions).

Symptoms from a dental abscess may range from light discomfort in the localized area to
severe pain. 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.

In order to diagnose a dental abscess thorough medical and dental histories must be taken,
extraoral and intraoral examinations performed and radiographic images obtained. A periodontal
abscess may be difficult to distinguish from a periapical abscess. Indeed sometimes they can occur
together.[2] 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.[2]

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.

In periodontal abscesses, the swelling usually precedes the pain, and in periapical
abscesses, the pain usually precedes the swelling.[2]

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. [2]

Differential Diagnosis On radiographs, cemento-osseous dysplasia and periapical dental

abscesses have a similar manifestation. This is a condition where fibrous, cementum-like connective
tissue replaces the bone in the maxilla or mandible in areas surrounding the tooth or in areas that
previously contained teeth. A way to differentiate periapical abscesses from cemento-osseous
dysplasia is to use percussion and/or a vitality test to determine the presence of an abscess. Also, if
caries or previous restorations are present, this also is an indicator of possible dental abscess in
comparison to cemento-osseous dysplasia.
Non-Hodgkin Lymphoma can occur in the oral cavity and can present clinically as a dental
abscess. If patients fail to respond to conventional therapies, such as endodontic procedures, then
the clinician needs to be on alert for a differential diagnosis. Not taking a biopsy could result in a
delay in treatment of a neoplastic condition. This in turn could influence the overall prognosis and
outcome.(9)
Plasmacytomas exhibit bucco-palatal swelling, expansion, well-defined margins and a smooth
surface; the swelling can cause nasal obstruction and epistaxis. Radiographs show a hazy
radiolucent area. Once blood work is done and no abnormalities are found a histological analysis
has to be performed. The analysis shows sheet-like proliferations at different levels of maturity with
atypic cells that mimic cartwheels. The blood work, atypic histopathology, and radiographs all need
to be utilized to accurately differentiate between a plasmacytoma and a dental abscess.(10)

Treatment[edit]
Successful treatment of a dental abscess centers on the reduction and elimination of the offending
organisms. This can include treatment with antibiotics[3] and drainage. If the tooth can be
restored, root canal therapy can be performed. Non-restorable teeth must be extracted, followed
by curettage of all apical soft tissue.
Unless they are symptomatic, teeth treated with root canal therapy should be evaluated at 1- and 2year intervals after the root canal therapy to rule out possible lesional enlargement and to ensure
appropriate healing.
Abscesses may fail to heal for several reasons:

Cyst formation

Inadequate root canal therapy

Vertical root fractures

Foreign material in the lesion

Associated periodontal disease

Penetration of the maxillary sinus

Following conventional, adequate root canal therapy, abscesses that do not heal or enlarge are often
treated with surgery and filling the root tips; and will require a biopsy to evaluate the diagnosis. [4]