Dental abscess

Dr. Gabor Gelencser

Oral and maxillofacial surgeon
Pathogens in odontogenic infections

 Anaerobic only - 50%

 Mixed anaerobic and aerobic - 44%
 Aerobic only - 6%
 Anaerobic pathogens
 Peptostreptococcus species
 Other anaerobic streptococci
 Prevotella
 Porphyromonas
 Fusobacterium species
 Aerobic pathogens
 Streptococcus milleri group
 Streptococcus viridans
 Staphylococci
 Neisseria
 Corynebacterium
 Haemophilus
Pathogens in odontogenic infections
 Almost all odontogenic infections are
caused by multiple bacteria

 In most odontogenic infections an average

of five species of bacteria can be identified
by laboratory
 Major origins of odontogenic
infections

 Periapical

 Periodontal
 Major origins of odontogenic
infections

 Periapical – result of pulpal necrosis and

subsequent bacterial invasion into the
periapical tissue
 Major origins of odontogenic
infections

 Periodontal – as a result of periodontal

pocket that allows inoculation of bacteria
into the underlying soft tissues
 Progression of odontogenic
infections

 Pulpitis, gangraena pulpae

 Periapical periodontitis
 Osteomyelitis, periostitis
 Abscess, cellulitis
 Pulpitis, pulpal gangraene
 Initially, the infection is localized to the pulp
or to the root canal (pulpitis)

 Necrosis of dental pulp (gangraena pulpae)

 Periapical periodontitis
 The infection spreads via the apical foramen
to the periapical area
 Osteomyelitis, periostitis
 From the periapical area, the infection
spreads in the bone – osteomyelitis
 If the infection erodes through the cortical
plate – periostitis
 Abscess, cellulitis
 The infection breaks through the periosteum
and abscess forms under the mucosa
 The infection spreads in the soft tissue and
facial spaces
(cellulitis)
 Location of the infection (abscess)
 The thickness of the bone overlying the
apex of the tooth
 The relationship of the site of perforation of
bone to muscle attachments of the maxilla
or the mandible
 Location of the infection (abscess)
 The thickness of the bone overlying the apex of
the tooth
 When infection perforates through bone, it will
enter soft tissue through thinnest bone
 Labial abscess
 The labial bone
overlying the apex of
the tooth is thin
compared with the
palatal bone
 Therefore, as the
infectious process
spreads, it goes into
the labial soft tissues
 Palatal abscess
 If tooth is severely
inclined (lateral incisor)
 Apex is near palatal
aspect (palatal root of
maxillary first molar or
premolar
 Palatal bone will be
perforated
 Location of the abscess (infection)
 Relationship of point of bone perforation to
muscle attachment determines fascial space
involved
 Vestibular abscess
 When tooth apex is
lower than muscle
attachement
 Vestibular abscess
develops
 Fascial space infection
 If infection erodes
through the bone
superior to the
attachment of muscle
 Adjacent fascial space
is involved
 Infections from maxillary teeth
 Generally erode through the
facial cortical plate below the
muscle attachment
 Most maxillary dental
abscesses appear as a
vestibular abscess
 Infections from maxillary teeth
 Lateral incisor (the root apex often bends in a
disto-palatinal direction)
 Palatal root of first molar an premolar
 Palatal abscess
 Infections from maxillary teeth
 Maxillary molars
 Infections erode
through the bone
superior to the
insertion of the
buccinator muscle
 Buccal space infection
 Infections from maxillary teeth
 Long maxillary canine root
 Infection erodes through
the bone superior to the
insertion of the levator
anguli oris muscle
 Infraorbital space infection
 Infections from lower teeth
 Incisors, canines and premolars usually
erode through the fascial cortical plate
superior to the attachment of the muscles of
the lower lip
 Vestibular abscess
 Infections from lower teeth
 Infections from molar teeth may drain
buccally or lingually
 First molar – buccally or lingually
 Second molar – usually lingually
 Wisdom – almost always lingually
 Infections from lower teeth
 In case of lingually
spreading
 Mylohyoid muscle
determines whether
infections go superior into
sublingual space or below
into the submandibular
space
 Diagnosis
 Clinical signs
 Radiological picture
 Vestibular abscess
Clinical signs
 Vestibular swelling with fluctuation
 Gingiva and mucosa are red, inflamed,
sensitive
 General symptoms (temperature, enlarged
regional lymph nodes, leukocytosis)
Vestibular abscess
 Vestibular abscess
Radiographic picture

 Periapical lesion
 Radiolucency
 Vestibular abscess
Therapy

 Extraction – pus can be discharged via the

alveolus
 Intraoral incision, drain
 Antibiotic
Vestibular abscess
Incision, drainage
 Palatal abscess
Clinical signs

 Pain
 Palatal swelling
 Tooth is sensitive
to percussion
 Palatal abscess
Radiographic picture

 Periapical lesion
 Radiolucency
 Palatal abscess
Therapy

 Incision (in the sagittal direction)

 Antibiotic
 Conservative : root canal treatment
 Conservative - surgical : root canal
treatment + apicectomy (lateral incisor)
 Surgical: removal of the tooth
 Pericoronitis
 In association with impacted lower third
molar
 A sac forms between the gingiva and the
wisdom tooth – periodontal origin
 Bacteria accumulate in this sac
 Starting as acute inflammation, as the
infection progresses, abscess may develop
 Pericoronitis
Clinical signs

 Pain (mild-strong, constant, radiates into the

ear)
 Gingiva is red and swollen
 Exsudate/ pus discharge from the sac
 Limited mouth opening (trismus)
 General symptoms (temperature,
submandibular lymphadenitis)
 Pericoronitis
Clinical signs
 Difficulties in swallowing
 Pterygomandibular space is
affected
 Pericoronitis
Therapy

 Antibiotics
 Local treatment
 Irrigation of the sac
 Incision, drainage (in case of abscess)
 After recovery period, circumcision or
surgical removal of the wisdom tooth to be
carried out