23. Dental Abscesses Flashcards
Define ‘abscess’
- collection of pus
- walled off by a barrier of inflammatory reaction
Abscesses are … meaning …-producing
- pyogenic
- pus
Pathogenesis of abscesses
- can develop in any confined space
- to which bacteria can gain access and multiply
Did dental abscesses used to be serious?
- leading cause of death
- London Bills of Mortality said ‘teeth’ were the 5th or 6th leading cause of death
How is a periodontal abscess defined?
- differentiated from dentoalveolar ones as tooth associated with it has vital pulp
- infection in periodontal pocket - foreign body/obstruction
Symptoms of periodontal abscess
- swelling and erythema
- pus likely to discharge from gingival margin
Microbiology of periodontal abscess
- associated with Prophyromonas species
- Provotella
- Fusobacterium species
- haemolytic streptococci
- actinomyces species
- spirochetes
Management of periodontal abscess
- treated by local measures
- drainage, subgingival instrumentation, irrigation
- extraction?
- antibiotic prescription only if spreading infection and systemic involvement
Routes of infection in dentoalveolar/periapical abscess
- dental caries
- exposed dentinal tubules
- direct pulp exposure
- lateral/apical foramen
- blood-borne bacteraemia
- root fracture
What is endodontic infections?
- infected pulp
Periodontal disease causes … while dental caries causes …, both lead to …
- lateral periodontal abscess
- endodontic infection
- dentoalveolar abscess (through a periapical granuloma/cyst for endodontic disease first)
Dentoalveolar abscess causes what?
- dry socket
- osteomyelitis
- facial space infection
What, other than dentoalveolar abscess, can cause facial space infections?
pericoronitis
What do facial space infections lead to?
- Ludwig’s angina
- cavernous sinus thrombosis
- then death after both
How to treat endodontic infections?
- root canal treatment cleans out canals and seals to prevent bacterial access
- sodium hypochlorite, chlorhexidine, calcium hydroxide and iodine are commonly used to kill residual bacteria
What causes a flare-up in endodontic infection?
- survival of species such as Enterococcus faecalis
What type of bacteria cause dental abscesses?
- gram positive coccus
- gram negative rods
Most abscesses are mixed infections of … and … but difficult to sample. why?
- facultative and strict anaerobes
- because the sample is gained and hard to not contaminate
Give some facultative anaerobes in abscess formation?
- oral streptococci
- strep anginosus
- staphylococcus spp.
Give some obligate anaerobes in abscess formation
- fusobacterium species
- prevotella species
- prophyromonas
- tannerella forsythia
- treponema denticola
- clostridium
- actinomyces
Factors that affect bacterial population in abscess
- oxygen tension (select for anaerobes)
- availability of nutrients (selects for proteolytic bacteria)
- bacterial interactions (selects for mutual co-operation)
- immune response
Explanations for selecting a population of 3-4 species
- multiple infectiom but only certain species survive
- one species infects and prepares the way for appropriate others
Coaggregation between diff bacteria in periodontal and endodontic infection leads to …
- coinvasion of epithelial cells (e.g F. nucleatum can carry strep cristatus into cells)
- coinvasion of dentine tubules
Localised spread of infection is through …
into …
- soft tissue abscess
- sinus linking main abscess cavity with mouth/skin
- through soft tissue (cellulitis)
INTO - adjacent facial space
- deeper layers like osteomyelitis
- maxillary sinus
- indirectly to lymphatic and haematogenous routes
Define ‘osteomyelitis’
- inflammation of medullary bone within maxilla or mandible with posterior extension #
- into the adjacent cortical bone and overlying periosteum
How is osteomyelitis treated?
- difficult to treat effectively
- more common in reduced vascularity
- local debridement, topical antiseptic on exposed areas, antibiotics as required
When osteomyelitis presents, typical isolates include …
- obligate anaerobes
- Actinomyces species
List tissue spaces
- pterygomandibular
- lateral pharyngeal
- retropharyngeal
- submasseteric
- buccal
- vestibular
- sublingual
- submandibular
- submental
Management scheme of dental abscess
- signs and symptoms
- assess patient - in detail and medical history
- define location, nature and swelling
- systemic symptoms?
- identify cause of infection
- diagnosis
- treatment
Treatment of dental abscess process
- local measures
- drain pus if present
- tooth extraction
- access and drain through root canal
- soft tissue pus drain by incision
- debride infected periodontal pockets
- irrigate/debride infected operculum
When do we provide antibiotics?
- evidence of spreading infection
- lymph node involvement
- swelling
- persistant swelling despite local treatment
- trismus
- failure to respond to local measures
- uncooperative patient
- floor of mouth swelling
- breathing risk
Warning signs with abscesses
- swelling, pain and raising of tongue
- elevated floor of mouth
- malaise
- fever
- swelling of neck or tissues in submandibular/sublingual space
Explain Ludwig’s angina with abscesses
- progression of dentoalveolar infection to cause widespread swelling of tissue spaces (submental/lingual/mandibular)
- swelling of neck and difficulty breathing
- spread of infection through fascial spaces to mediastinum
Microbiology of Ludwig’s angina
- Prevotella species
- Porphyromonas species
- Fusobacterium species
- anaerobic strep
3 antibiotics we prescribe for this
- amoxicillin
- phenoxymethylpenicillin
- metronidazole
What’s a major problem for prescribing antibiotics for abscesses?
- antibiotic resistance
- increase in antibiotic resistance to dentoalveolar infection
What is pericoronitis?
- superficial infection of operculum, occasional local spread of infection
- infection in space between tooth and overlying soft tissue
What bacteria are involved with pericoronitis?
- P.intermedia
- anaerobic strep
- fusobacterium species
- T. forsythia
- A. actinomycetemcomitans
Management of pericoronitis
- local measures
- irrigation
- extraction?
- if spreading infection and systemic involvement, prescription of antibiotics and metronidazole drug of choice
What is cervicofacial actinomycosis?
- opportunistic infection caused by members of Actinomyces genus (A. israelii in 90% of cases, A.bovis or A. naeslundii)
- most commonly a submandibular swelling, at the angle of mandible. Can be local or diffused
- tooth extraction or trauma likely to precipitate infection with bacterial species reaching deeper tissues
How does cervicofacial actinomycosis progress?
- swelling progresses and multiple sinuses develop
- thick and yellow pus expressed from sinus
- pus contains visible granules called sulphur granules (consist of calcified aggregates of Actinomyces filaments)
Causes of necrotising gingivitis
- poor oral hygeine/poor plaque control
- immunocompromised
- poor diet/poor general health
- smokers
What is necrotising gingivitis? What bacteria?
- superficial infection of gingival margins
- associated with fuso-spirochaetal bacteria (treponema species and prevotella intermedia)
Treatment of necrotising gingivitis
- OHI and improvement in oral hygeine
- removal of supra and subgingival deposits, periodontal instrumentation/ultrasonic debridement
- risk factor identification/management
- prescribe only in more severe cases - metronidazole if doing so
Oral soft tissue infections are …
bacterial, viral or fungal
