Overview
Dental Abscess
Quick Reference
Critical Alerts
- Ludwig angina is a surgical emergency: Rapidly progressive floor of mouth infection
- Airway compromise can develop quickly: Monitor for stridor, dysphagia, trismus
- Immunocompromised patients need IV antibiotics: Higher risk of spread
- Incision and drainage is definitive: Antibiotics alone may be insufficient
- Dental referral essential: Definitive treatment is extraction or root canal
- Deep space infections require CT and surgical consultation
Red Flags for Deep Space Infection
| Finding | Concern |
|---|---|
| Trismus (difficulty opening mouth) | Masticator space involvement |
| Dysphagia, drooling | Airway compromise |
| Neck swelling | Deep space spread |
| Bilateral submandibular swelling | Ludwig angina |
| Fever, toxic appearance | Severe infection |
| Stridor, respiratory distress | Impending airway obstruction |
Emergency Treatments
| Condition | Treatment |
|---|---|
| Localized dental abscess | I&D + Oral antibiotics + Dental referral |
| Deep space infection | IV antibiotics + CT + Surgical consultation |
| Ludwig angina | Secure airway + IV antibiotics + Emergent surgical drainage |
| Pain management | NSAIDs + Opioids PRN |
Definition
Overview
A dental abscess is a localized collection of pus arising from bacterial infection of the tooth or surrounding tissues. Most originate from dental caries, periodontal disease, or trauma. While many are manageable with antibiotics and dental referral, deep space extension (Ludwig angina, parapharyngeal abscess) can be life-threatening and requires emergent intervention.
Classification
By Location:
| Type | Origin | Location |
|---|---|---|
| Periapical abscess | Tooth pulp necrosis | At root apex |
| Periodontal abscess | Gingival/periodontal pocket | Along tooth root laterally |
| Pericoronal abscess | Impacted/erupting tooth | Around crown (e.g., wisdom tooth) |
| Vestibular abscess | Spread to buccal mucosa | Oral vestibule |
Deep Space Infections (Extensions):
| Space | Risk |
|---|---|
| Submandibular | Ludwig angina if bilateral |
| Sublingual | Airway compromise |
| Parapharyngeal | Airway, carotid involvement |
| Retropharyngeal | Mediastinitis |
| Masticator | Trismus |
Epidemiology
- Very common: Dental caries affect >90% of adults
- ED visits: ~1% of all ED visits are for dental complaints
- Deep space infections: Less common but life-threatening
- Ludwig angina mortality: 5-10% with treatment; higher if delayed
Etiology
Pathogens (Polymicrobial):
| Category | Organisms |
|---|---|
| Aerobic | Streptococcus viridans, Streptococcus anginosus group |
| Anaerobic | Prevotella, Peptostreptococcus, Fusobacterium, Bacteroides |
| Mixed | Most dental infections are polymicrobial |
Risk Factors:
- Poor dental hygiene
- Dental caries
- Immunocompromise (diabetes, HIV)
- Recent dental procedure
- Trauma
Pathophysiology
Mechanism
- Dental caries or periodontal disease: Bacteria enter pulp or periodontal space
- Pulp necrosis: Dead pulp tissue becomes infected
- Periapical abscess: Pus collects at root apex
- Spread through bone: Path of least resistance to vestibule
- Deep space extension: If crosses mylohyoid or periosteum
Ludwig Angina Mechanism
- Submandibular and sublingual space infection
- Rapidly progressive cellulitis/phlegmon
- Tongue elevation → Airway obstruction
- Often originates from mandibular molars (>90%)
Clinical Presentation
Symptoms
| Symptom | Description |
|---|---|
| Tooth pain | Localized, severe, throbbing |
| Swelling | Intraoral or facial |
| Fever | Variable |
| Sensitivity to heat/cold | Early pulpitis |
| Sensitivity to percussion | Periapical abscess |
| Trismus | Masticator space involvement |
| Dysphagia | Deep space spread |
| Foul taste | Pus drainage |
History
Key Questions:
Physical Examination
Oral Exam:
| Finding | Significance |
|---|---|
| Fluctuant swelling at gingiva/vestibule | Periapical or periodontal abscess |
| Carious tooth | Source |
| Percussion tenderness | Periapical involvement |
| Mobile tooth | Severe infection |
| Purulent drainage | Abscess rupture |
| Floor of mouth elevation | Ludwig angina |
Extraoral Exam:
| Finding | Significance |
|---|---|
| Facial swelling | Vestibular or deep space extension |
| Submandibular swelling | Submandibular space involvement |
| Trismus | Masticator space |
| Cervical lymphadenopathy | Reactive |
| Stridor | Airway compromise |
| Fever | Systemic spread |
Which tooth? Duration of pain?
Common presentation.
Swelling location and progression
Common presentation.
Fever, chills
Common presentation.
Difficulty opening mouth (trismus)
Common presentation.
Difficulty swallowing or breathing
Common presentation.
Prior dental work
Common presentation.
Medical history (diabetes, immunocompromise)
Common presentation.
Allergies (penicillin)
Common presentation.
Red Flags
Deep Space Infection / Ludwig Angina
| Finding | Concern | Action |
|---|---|---|
| Bilateral submandibular swelling | Ludwig angina | Emergent airway evaluation, IV abx, surgery |
| Floor of mouth elevation | Airway compromise | Secure airway |
| Drooling, dysphagia | Oral secretions not controlled | Anticipate airway intervention |
| Stridor, voice change | Impending obstruction | Emergent airway |
| Trismus (can't open mouth) | Masticator/parapharyngeal space | CT, surgery |
| Fever + toxic appearance | Severe infection | IV abx, imaging |
Differential Diagnosis
Other Causes of Facial Swelling / Oral Pain
| Diagnosis | Features |
|---|---|
| Peritonsillar abscess | Sore throat, "hot potato" voice, uvular deviation |
| Ludwig angina | Bilateral submandibular, floor of mouth elevation |
| Parapharyngeal abscess | Neck swelling, trismus, systemic illness |
| Parotitis | Parotid swelling, pus from Stensen's duct |
| Angioedema | Diffuse swelling, no fever, may have urticaria |
| TMJ dysfunction | Pain at TMJ, clicking, no swelling |
| Tumor | Chronic, progressive mass |
Diagnostic Approach
Clinical Diagnosis
- Most dental abscesses are diagnosed clinically
- Imaging for deep space concerns
Imaging
Panoramic Dental X-Ray (Panorex):
- Visualizes teeth, periapical pathology
- Often unavailable in ED
CT Neck with Contrast (Gold standard for deep spaces):
| Finding | Significance |
|---|---|
| Rim-enhancing fluid collection | Abscess |
| Soft tissue gas | Necrotizing infection |
| Extent of involvement | Surgical planning |
Laboratory Studies
| Test | Indication |
|---|---|
| CBC | Leukocytosis, severe infection |
| BMP | Dehydration, diabetes assessment |
| Blood cultures | Sepsis, toxic patient |
| Glucose | Diabetic assessment |
Treatment
Principles
- Assess for deep space infection: If present → Emergent management
- Pain control: NSAIDs, opioids PRN
- Antibiotics: Cover oral flora (aerobes + anaerobes)
- Incision and drainage: If fluctuant abscess
- Dental referral: Definitive treatment (extraction, root canal)
Pain Management
| Agent | Dose |
|---|---|
| Ibuprofen | 400-600 mg PO q6-8h |
| Acetaminophen | 650-1000 mg PO q6h |
| Opioids (if severe) | Hydrocodone, oxycodone short course |
Antibiotics
Outpatient (Localized Abscess):
| Agent | Dose | Duration |
|---|---|---|
| Amoxicillin | 500 mg TID | 7 days |
| Amoxicillin-Clavulanate | 875/125 mg BID | 7 days |
| Clindamycin (if PCN allergy) | 300 mg QID | 7 days |
| Metronidazole + Penicillin | 500 mg TID + 500 mg QID | 7 days |
Inpatient (Severe/Deep Space):
| Agent | Dose |
|---|---|
| Ampicillin-Sulbactam | 3 g IV q6h |
| Clindamycin | 600-900 mg IV q8h |
| Piperacillin-Tazobactam | 4.5 g IV q6h (if severe) |
| + Metronidazole | 500 mg IV q8h (if anaerobic coverage needed) |
Incision and Drainage
Intraoral I&D:
- Fluctuant vestibular abscess
- Local anesthesia (can be difficult with infection)
- Incision at most fluctuant point
- Blunt dissection to break loculations
- Consider packing or drain
Deep Space I&D:
- Performed by oral maxillofacial surgery or ENT
- May require OR under general anesthesia
- If airway compromised, consider awake fiberoptic intubation or tracheostomy
Ludwig Angina Management
| Step | Intervention |
|---|---|
| Airway | Early intubation (fiberoptic preferred) or surgical airway |
| Antibiotics | Ampicillin-Sulbactam or Clindamycin IV |
| Surgery | Emergent surgical drainage and debridement |
| ICU | Close monitoring |
Disposition
Discharge Criteria (Localized Abscess)
- No signs of deep space infection
- No airway compromise
- Pain controlled
- Able to tolerate oral antibiotics
- Dental follow-up arranged
Admission Criteria
- Deep space infection (submandibular, parapharyngeal)
- Ludwig angina
- Airway concern
- Immunocompromised with severe infection
- Unable to tolerate oral intake
- Need for IV antibiotics or surgical drainage
Dental Referral
- All dental abscesses need definitive dental care
- Extraction or root canal therapy
- Within 24-48 hours for localized abscess
- Urgent for severe or recurrent infections
Patient Education
Condition Explanation
- "You have an infection around your tooth that has formed a pocket of pus."
- "We can drain it and give you antibiotics, but you will need to see a dentist for definitive treatment."
- "If left untreated, this can spread and become very serious."
Home Care
- Complete full course of antibiotics
- Take pain medications as directed
- Warm salt water rinses
- Soft diet
- Follow up with dentist promptly
Warning Signs to Return
- Worsening swelling, especially under the jaw or in the neck
- Difficulty breathing or swallowing
- Fever not improving
- Inability to open mouth
- Worsening pain despite medication
Special Populations
Diabetics
- Higher risk of severe infection and spread
- Lower threshold for admission and IV antibiotics
- Poor glycemic control worsens outcomes
- Close follow-up essential
Immunocompromised
- HIV, chemotherapy, transplant patients
- Atypical organisms possible
- Broader antibiotic coverage
- Early imaging and surgical consultation
Pregnancy
- Use penicillins and cephalosporins (safe)
- Avoid fluoroquinolones, tetracyclines
- Pain control with acetaminophen; limit NSAIDs in 3rd trimester
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| CT for suspected deep space infection | 100% | Identify abscess, plan surgery |
| Antibiotics covering anaerobes | >5% | Polymicrobial infection |
| Dental referral documented | 100% | Definitive care |
| Airway assessment in Ludwig angina | 100% | Life-threatening |
Documentation Requirements
- Source tooth identified
- Swelling location and extent
- Airway assessment
- I&D performed (if applicable)
- Antibiotics prescribed
- Dental referral arranged
Key Clinical Pearls
Diagnostic Pearls
- Percussion tenderness = periapical abscess: With decayed tooth
- Trismus = deep space involvement: Not just localized abscess
- Floor of mouth elevation = Ludwig angina: Emergent
- CT for any concern of deep space infection: Don't delay
- Most dental abscesses are polymicrobial: Aerobes + anaerobes
- Diabetics and immunocompromised spread faster: Low threshold for admission
Treatment Pearls
- Antibiotics alone may not be enough: I&D often needed
- NSAIDs are excellent for dental pain: Ibuprofen 400-600 mg
- Amoxicillin-clavulanate or clindamycin: Good outpatient choices
- Ludwig angina needs early airway management: Before it's too late
- Definitive treatment is dental: Extraction or root canal
- Deep space = surgery: Oral maxillofacial or ENT
Disposition Pearls
- Localized abscess can go home: With antibiotics and dental referral
- Deep space infection = admit: IV antibiotics, possible OR
- Ludwig angina = ICU: Airway and surgical management
- All patients need dental follow-up: Prevention and definitive care
References
- Flynn TR, et al. Severe odontogenic infections. Dent Clin North Am. 2006;50(2):265-289.
- Bali RK, et al. A review of complications of odontogenic infections. Natl J Maxillofac Surg. 2015;6(2):136-143.
- Seppänen L, et al. Deep neck space infections: an upward trend. Int J Oral Maxillofac Surg. 2020;49(8):1037-1042.
- Vieira F, et al. Deep neck infection. Otolaryngol Clin North Am. 2008;41(3):459-483.
- Patterson HC, et al. Ludwig's angina: an update. Br J Oral Maxillofac Surg. 1982;20(2):83-91.
- Shemesh A, et al. Antibiotics in dentistry. Quintessence Int. 2018;49(1):80-92.
- American Dental Association. Dental Emergency Guidelines. 2019.
- UpToDate. Dental infections and deep neck space infections. 2024.