SIGNS AND SYMPTOMS 
Periodontal abscess is a clinical diagnosis
History
- Dental pain
- Malaise
- Fever
- Facial swelling
Physical Exam
- Focal swelling or fluctuance of gums and or face
- Tenderness to palpation
- Increased tooth mobility
- Parulis:
- Pimple-like lesion on gingiva, representing terminal aspect of a sinus tract
- May be seen in chronic abscess
- Expression of pus from sinus tract
- Heat sensitivity
- Lymphadenopathy
- Trismus is generally absent, unless infection has spread to muscles of mastication
ESSENTIAL WORKUP
This is a clinical diagnosis:
- Imaging and lab data are not essential for diagnosis
DIAGNOSIS TESTS & INTERPRETATION
Lab
Anaerobic culture of pus:
- Complicated abscess
- Immunocompromised patients
Imaging
- Panoramic, periapical, or occlusal radiographs
- Bedside US may also aid in confirming diagnosis
- CT may help visualize extension of abscess into adjacent structures
- Imaging can confirm and help define extent of abscess but is not essential to make diagnosis
Diagnostic Procedures/Surgery
Electric pulp testing:
- Performed by dental consultant to verify viability of tooth
- Performed during follow-up visit with dentist
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
Rarely associated with airway emergencies, but if any signs of airway compromise are present:
- Intubation equipment at bedside
- Transport in sitting position
- Supplemental oxygen
- Suction secretions as needed
INITIAL STABILIZATION/THERAPY
- Assess for airway patency
- Establish definitive airway via endotracheal intubation or cricothyrotomy/tracheostomy in the presence of:
- Respiratory distress
- Inability to handle secretions
- Oropharyngeal tissue swelling that impairs or threatens airway
ED TREATMENT/PROCEDURES
- Analgesia with NSAIDs or opiates may be required
- Incision and drainage:
- Anesthetize gingiva superficially with 2% lidocaine with 1:100,000 epinephrine until blanching occurs
- Make a 1 cm stab incision using a scalpel blade toward alveolar bone
- Blunt dissection using mosquito hemostat
- Irrigate cavity with saline
- If abscess cavity sufficiently large, place 1/4 in iodoform gauze drain or fenestrated Penrose drain for 24–48 hr:
- To prevent its aspiration, secure gauze or drain with silk suture
- Antibiotics:
- Indicated if abscess extensive or if systemic signs present
- Penicillin considered first-line empiric therapy
- Erythromycin, azithromycin, clindamycin for penicillin-allergic patients
- Clindamycin for penicillin-allergic patients or patients not responding to penicillin
- Ampicillin/sulbactam for severe infections
- Warm salt water rinses hourly while awake for 24–48 hr
MEDICATION
First Line
- Penicillin VK: 250–500 mg PO q6h (peds: 25–50 mg/kg/d PO div. q6h)
- Azithromycin: 500 mg (peds: 10 mg/kg) PO 1st day, then 250 mg (peds: 5 mg/kg) PO per day × 4 days (for penicillin-allergic patients)
- Clindamycin: 150–450 mg PO q6h (peds: 10–25 mg/kg/d div. PO q6h)
- Clindamycin: 300–900 mg IV q8h (peds: 15–25 mg/kg/d IV div. q8h)
- Erythromycin: 250–500 mg PO q6–8h (peds: 30–50 mg/d PO div. q6h)
Second Line
- Ampicillin/sulbactam IV: 1.5–3 g IV q6h (peds > 1 yr, < 40 kg: 300 mg/kg/d IV div. q6h)
- Amoxicillin/clavulanate: 875 mg PO q12h (peds: 25–45 mg/kg/d div. q12h) (oral conversion)
- Moxifloxacin: 400 mg PO or IV QD (not routinely recommended for pediatric use)
[Outline]
DISPOSITION
Admission Criteria
- Severe infection or complication requiring parenteral antibiotics
- Necrosis or cellulitis involving areas with potential airway compromise
- Cavernous sinus thrombosis
- Osteomyelitis
- Outpatient therapy failure
- Immunocompromised patients:
- Neutropenia
- Uncontrolled diabetes
- Advanced HIV
- Cancer patients undergoing chemotherapy
- Ludwig angina
- Systemic involvement with significant dehydration
- Patients unable to handle secretions
- Patients unable to manage infection at home because of physical or mental disability or psychosocial factors
Discharge Criteria
- Uncomplicated cases
- Dental follow-up available in 24–48 hr
Issues for Referral
Dental follow-up useful for:
- Viability of affected tooth
- Dental extraction
- Root canal therapy
- Removal of Penrose drain or wic
FOLLOW-UP RECOMMENDATIONS
Dental follow-up in 24–48 hr:
- Lacking dental follow-up, patients should have alternative follow-up in 24–48 hr with provider familiar with disease process (oral surgeon, ED, urgent care, primary care)
[Outline]
Maxillary sinusitis may be incorrectly diagnosed without adequate oral exam:
- Dental follow-up is essential for short-term resolution of symptoms and long-term tooth viability and oral hygiene issues
- Beaudreau RW. Chapter 240. Oral and dental emergencies. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill;2011.
- Benko K Chapter 22. Dental emergencies. In: Adams JG, ed. Emergency Medicine. 1st ed. Philadelphia, PA: Saunders Elsevier; 2008.
- Capps EF, Kinsella JJ, Gupta M, et al. Emergency Imaging assessment of acute nontraumatic conditions of the head and neck. Radiographics. 2010;30:1335–1352.
- Gould J. Dental abscess. Medscape. Updated May 30, 2012.
- Levi ME, Eusterman VD. Oral infections and antibiotic therapy. Otolaryngol Clin North Am. 2011;44:57–78.
- Patel PV, Kumar S, Patel A. Periodontal abscess: A review. J Clin Diagn Res. 2011;5:404–409.
- Robertson D, Smith AJ. The microbiology of the acute dental abscess. J Med Microbiol. 2009;58(Pt 2):155–162.
- Schaad UB. Will fluoroquinolones ever be recommended for common infections in children? Pediatr Infect Dis J. 2007;26:865–857.
- Sobottka I, Wegscheider K, Balzer L, et al. Microbiological analysis of a prospective, randomized, double-blind trial comparing moxifloxacin and clindamycin in the treatment of odontogenic infiltrates and abscesses. Antimicrob Agents Chemother. 2012;56:2565–2569.
See Also (Topic, Algorithm, Electronic Media Element)
Toothache