Dentoalveolar Abscess

Question 1

What is an abscess?

Answer 1

Pathological cavity filled with pus and lined by pyogenic membrane

Question 2

What is a dentoalveolar abscess?

Answer 2

An acute lesion characterised by a localised collection of pus in the structures which surround the teeth

Question 3

Name 4 common conditions which may lead to a dentoalveolar abscess forming

Answer 3

1. Periapical periodontitis
2. Periodontal disease
3. Acute pericoronitis
4. Infection of a cyst

Question 4

Describe the pathogenesis of dentoalveolar abscesses

Answer 4

• Due bacterial infection resulting from necrotic pulp and periapical pathology
• Arises as a result of failure to eradicate source of infection
• Membrane classically consists of granulation tissue but may be a rim of inflammatory cells
• Soft tissue may become swollen
• Localised reaction to bacterial products

Question 5

What causes soft tissue swelling in dentoalveolar abscesses?

Answer 5

Inflammatory exudate

Question 6

Describe the causative microorganisms of dentoalveolar abscess

Answer 6

Facultative Anaerobes
     - Strep viridans
     - Strep anginosus
Strict Anaerobes
     - Anaerobic cocci
     - Prevotella
     - Fusobacterium

Question 7

Describe the classic clinical presentation of a dentoalveolar abscess

Answer 7

• Severe pain, often poorly localised
• Affected tooth TTP
• Carious tooth / history of trauma
• Soft fluctuant swelling

Question 8

Describe 2 major differences between dentoalveolar abscess caused by periapical periodontitis and periodontal disease

Answer 8

• Periapical periodontitis will have -ve vitality tests where periodontal disease will have +ve vitality tests
• Swelling often overlying tooth in periapical periodontitis whereas usually nearer gingival margin in periodontal disease

Question 9

Describe 3 possible radiographical features of dentoalveolar abscess

Answer 9

1. Loss of periapical lamina dura
2. Periapical radiolucency, well defined
3. Infection causes loss of definition of margin

Question 10

Describe the management of dentoalveolar abscess

Answer 10

• Establish drainage of push via root canal (RCT), extraction or incision
• No antibiotics unless evidence of systemic spread

Question 11

Name 2 clinical presentations of localised spread of infection from dentoalveolar abscess

Answer 11

1. Trismus

2. Cervical lymphadenopathy

Question 12

Name 2 clinical presentations of systemic spread of dentoalveolar abscess

Answer 12

1. Pyrexia

2. Tachycardia

Question 13

Name 5 factors which promote progression of dentoalveolar abscess to acute spreading infection

Answer 13

1. Physiological factors (age, pregnancy)
2. Poor nutrition
3. Immunosuppression
4. Virulence of organism
5. Antibiotic resistant organism

Question 14

Describe the acute spreading of dental infections

Answer 14

• Tracks along lines of least resistance (fascial and muscle planes)
• Potential tissue spaces contain loose CT so allow infection to expand easily
• Path of spread dependent on where apex of root of infected tooth lies

Question 15

What is a clinical presentation of acute spread of dental infection to submasseteric tissue spaces?

Answer 15

Profound trismus but very little extra oral swelling

Question 16

What is a clinical presentation of acute spread of dental infection to pharyngeal areas?

Answer 16

Airways issues as infection can cause patients to become unwell

Question 17

What is a clinical presentation of acute spread of dental infection to submandibular tissue spaces?

Answer 17

Marked swelling underneath the chin

Question 18

What is a clinical presentation of acute spread of dental infection to sublingual tissue spaces?

Answer 18

Tongue may be elevated within the oral cavity

Question 19

Describe cellulitis and its relationship to a dentoalveolar abscess

Answer 19

• Spreading infection of CT typical of streptococcal organisms through tissue spaces
• Usually results from virulent organisms
• Painful swelling with overlying tense, red skin
• Associated trismus, malaise, pyrexia and cervical lymphadenopathy
• Oedema rather than pus
• Can arise from inadequately managed dental infection

Question 20

Describe Ludwig’s Angina and its relationship to a dentoalveolar abscess

Answer 20

• Spreading cellulitis involving submandibular, sublingual and submental spaces bilaterally
• Gross oedema, elevation of tongue, airway compromise
• Emergency with 5% death rate

Question 21

Describe Cavernous Sinus Thrombosis and its relationship to a dentoalveolar abscess

Answer 21

• Can arise from maxillary dentoalveolar infection
• Blood clot within the cavernous sinus
• Thrombophlebitis of facial vein
• Intracranial spread of infection via venous system
• Rare but life threatening

Question 22

Name 4 clinical features of cavernous sinus thrombosis

Answer 22

1. Severe headache around eye
2. Periorbital swelling and redness
3. Inability to move eye / loss of vision / proptosis
4. Eye pain

Question 23

Describe 6 special investigations when dentoalveolar abscess is suspected

Answer 23

1. Vitality testing
2. Radiographic examination
3. Checking patient’s temperature
4. Haematological investigations
5. Blood cultures
6. Pus samples for appropriate antibiotic prescription

Question 24

Name 3 things the management of dentoalveolar abscesses depend on

Answer 24

1. Severity and site of infection
2. Rate of progression of infection
3. General health of patient

Question 25

Name 3 situations where prescription of antibiotics is inappropriate

Answer 25

1. Chronic infection
2. Post surgery
3. Where diagnosis is not clear

Question 26

Name 4 possible causes of facial pain where there is no definitive diagnosis

Answer 26

1. Chronic pulpitis / periodontitis
2. Pericoronitis of wisdom teeth
3. TMD
4. Sinusitis