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Periodontal Abscess, Emergency Medicine

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Periodontal Abscess, Emergency Medicine

Basics

Description

This is a clinical diagnosis:

Maxillary sinusitis may be incorrectly diagnosed without adequate oral exam:

  • Collection of pus in supporting structures of teeth:Periodontal ligamentAlveolar bone
  • Periodontal pockets result from progression of periodontal disease and resultant bone loss:Food and debris accumulate in periodontal pocketsCoronal epithelial tissues can reattach to tooth while bacteria and food debris remain trapped in pocket, impairing drainageFood and debris become secondarily infected in the setting of impaired drainage
  • Complications:OsteomyelitisDentocutaneous fistulaCavernous sinus thrombosisLudwig anginaMaxillary sinusitisMediastinitisTooth lossSepsis
  • Periodontal ligament
  • Alveolar bone
  • 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
  • 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 pulpAssociated with caries
  • Originates in pulp
  • Associated with caries

Etiology

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

Diagnosis

Signs and Symptoms

  • Dental pain
  • Malaise
  • Fever
  • Facial swelling
  • 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 tractMay 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
  • Pimple-like lesion on gingiva, representing terminal aspect of a sinus tract
  • May be seen in chronic abscess

Essential Workup

  • Imaging and lab data are not essential for diagnosis

Diagnosis Tests & Interpretation

  • Complicated abscess
  • Immunocompromised patients
  • 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
  • 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:FibromaPyogenic or peripheral ossifying granulomaKaposi sarcoma
  • Fibroma
  • Pyogenic or peripheral ossifying granuloma
  • Kaposi sarcoma

Treatment

Pre-Hospital

  • 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 distressInability to handle secretionsOropharyngeal tissue swelling that impairs or threatens airway
  • 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 occursMake a 1 cm stab incision using a scalpel blade toward alveolar boneBlunt dissection using mosquito hemostatIrrigate cavity with salineIf 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 presentPenicillin considered first-line empiric therapyErythromycin, azithromycin, clindamycin for penicillin-allergic patientsClindamycin for penicillin-allergic patients or patients not responding to penicillinAmpicillin/sulbactam for severe infections
  • Warm salt water rinses hourly while awake for 24 " “48 hr
  • 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
  • To prevent its aspiration, secure gauze or drain with silk suture
  • 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

Medication

  • 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 ƒ — 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)
  • 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

  • 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:NeutropeniaUncontrolled diabetesAdvanced HIVCancer 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
  • Neutropenia
  • Uncontrolled diabetes
  • Advanced HIV
  • Cancer patients undergoing chemotherapy
  • Uncomplicated cases
  • Dental follow-up available in 24 " “48 hr
  • Viability of affected tooth
  • Dental extraction
  • Root canal therapy
  • Removal of Penrose drain or wic

Followup Recommendations

  • 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

  • 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.

See Also (Topic, Algorithm, Electronic Media Element)

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)