Types of dental abscess
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Types of Dental Abscess
A dental abscess is a localized collection of pus resulting from bacterial infection of the teeth or supporting structures. There are three primary types, distinguished by anatomical location and origin.
1. Periapical Abscess (= Dentoalveolar Abscess)
Most common type.
| Feature | Detail |
|---|---|
| Origin | Pulpal infection (dental caries → pulpitis → pulpal necrosis) |
| Location | Apex (tip) of the tooth root, within the periapical area of the periodontal ligament |
| Pathogenesis | Caries breaches enamel → infects pulp → irreversible pulpitis → pulpal necrosis → infection travels down root canals into periapical tissues |
Pathological forms at the periapex:
- Acute periapical abscess — acute suppurative inflammation with pus
- Periapical granuloma — chronic non-suppurating inflammation (chronic form)
- Radicular (periapical) cyst — formed when epithelial rests in the periodontal ligament are stimulated within the chronic granuloma
Clinical features:
- Tooth tender to percussion
- Swelling of adjacent gingiva; may develop a parulis (gum boil) — a small swelling with a draining fistula adjacent to the affected tooth
- If pus erodes through cortical bone without draining spontaneously → subperiosteal extension with intraoral or facial swelling/fluctuance
Radiology:
- Periapical radiograph shows periapical radiolucency (widening of periodontal ligament space, thinning of lamina dura, radiolucent area at root apex)
Treatment:
- Root canal therapy or dental extraction (definitive)
- Incision and drainage if fluctuant
- Antibiotics (amoxicillin first-line)
- NSAIDs ± acetaminophen for pain
2. Periodontal Abscess
Second most common type.
| Feature | Detail |
|---|---|
| Origin | Pre-existing periodontal (gum) disease — plaque/debris entrapped in a periodontal pocket |
| Location | In the supporting tissues (periodontal pocket, alveolar bone, periodontal ligament) — lateral to the root, not at the apex |
| Pathogenesis | Chronic periodontal disease → organisms trapped in the periodontal pocket → purulent material may escape via gingival sulcus or invade supporting alveolar bone and periodontal ligament |
Clinical features:
- Localized, painful, fluctuant swelling along the lateral surface of the root
- May have pus draining from the gingival sulcus
- Deep periodontal pocketing on probing
- Tooth may be vital (pulp not primarily involved)
Radiology:
- Vertical or horizontal alveolar bone loss visible on periapical X-ray
- Radiolucency lateral to the root rather than at the apex
Treatment:
- Drainage via the periodontal pocket
- Root planing and scaling
- Antibiotics if systemic involvement
3. Gingival Abscess
| Feature | Detail |
|---|---|
| Origin | Superficial infection confined to the gingival soft tissue only — no involvement of deeper periodontal structures |
| Location | Marginal or interdental gingiva |
| Cause | Foreign body embedded in the gingiva (e.g., toothbrush bristle, food particle), trauma, or poor oral hygiene |
Clinical features:
- Localized, tender, fluctuant swelling of the gingiva
- No involvement of the periodontal ligament or alveolar bone
- Resolves quickly once the cause is removed
Treatment:
- Identify and remove the embedded foreign body
- Irrigation with normal saline
- Continued home irrigation; symptoms resolve rapidly
4. Pericoronal Abscess (Pericoronitis with Suppuration)
Sometimes listed as a fourth type — infection around the crown of a partially erupted tooth (most commonly the mandibular third molar/wisdom tooth).
| Feature | Detail |
|---|---|
| Origin | Food/debris impacted beneath the operculum (gingival flap overlying erupting tooth) |
| Location | Pericoronal tissues |
| Risk | Close proximity to the masticator space → trismus; spread to parapharyngeal spaces → life-threatening airway compromise |
Treatment:
- Local irrigation beneath the operculum
- Oral antibiotics (amoxicillin or metronidazole)
- Saline rinses and analgesics
- Definitive: extraction of the offending tooth
Complications of All Types (if untreated)
Dental abscesses — particularly periapical ones — can spread progressively:
- Osteomyelitis — spread into alveolar bone
- Cellulitis — spread into fascial planes of the head and neck
- Ludwig's angina — bilateral submandibular/sublingual space infection with tongue elevation, trismus, and potential airway obstruction
- Septic thrombophlebitis — ascending spread via venous channels
- Cavernous sinus thrombosis, brain abscess, mediastinitis — rare but life-threatening
The causative organisms are typically a mixed anaerobic infection (Prevotella spp., Fusobacterium spp., peptostreptococci, microaerophilic streptococci), reflecting the normal oral microbiota.
Sources: Tintinalli's Emergency Medicine, p. 1622–1624 | Harrison's Principles of Internal Medicine 22E, p. 1376 | Sherris & Ryan's Medical Microbiology, p. 6211 | Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 2062
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