Periodontal Abscess, Emergency Medicine

Basics

Description

Collection of pus in supporting structures of teeth:
- Periodontal ligament
- Alveolar bone
Periodontal pockets result from progression of periodontal disease and resultant bone loss:
- Food and debris accumulate in periodontal pockets
- Coronal epithelial tissues can reattach to tooth while bacteria and food debris remain trapped in pocket, impairing drainage
- Food and debris become secondarily infected in the setting of impaired drainage
Complications:
- Osteomyelitis
- Dentocutaneous fistula
- Cavernous sinus thrombosis
- Ludwig angina
- Maxillary sinusitis
- Mediastinitis
- Tooth loss
- Sepsis

Periodontal abscess is rare in children
Periapical abscess is more common:
- Originates in pulp
- Associated with caries

Etiology

Anaerobic gram-negative rods
Peptostreptococci
Viridans group streptococci
Neisseria species
Usually polymicrobial

Diagnosis

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

Periapical abscess
Maxillary sinusitis
Aphthous ulcers
Oral herpes
Salivary gland tumors
Mumps
Blocked salivary gland due to sialadenitis or dehydration
Localized adenopathy due to oral infections
Facial cellulitis
Acute otitis media
Peritonsillar abscess
Pediatric consideration: Periapical abscess
For asymptomatic parulis:
- Fibroma
- Pyogenic or peripheral ossifying granuloma
- Kaposi sarcoma

Treatment

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)

Follow-Up

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

Followup 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)

Pearls and Pitfalls

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

Additional Reading

Beaudreau RW. Chapter 240. Oral and dental emergencies. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinallis 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.

Codes

ICD9

522.5 Periapical abscess without sinus
522.7 Periapical abscess with sinus
523.31 Aggressive periodontitis, localized

ICD10

K04.6 Periapical abscess with sinus
K04.7 Periapical abscess without sinus
K05.21 Aggressive periodontitis, localized

SNOMED

83412009 Periodontal abscess (disorder)
109602002 Acute apical abscess (disorder)

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