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Patients frequently present to the Emergency Department complaining of a “toothache.” The common causes of toothache pain are multiple.1 Several of these conditions present with clinical evidence of inflammation or intraoral swelling. Similarly, there are multiple etiologies for a dental abscess (Table 155-1). Distinguishing a pulpal abscess from a periodontal abscess and simple pericoronitis can impact treatment, prognosis, and morbidity.2–5 The Emergency Physician must have a basic understanding of dental anatomy, pathophysiology, and treatment protocols in order to accurately diagnose and treat these conditions. Many of these conditions can initially be managed through the Emergency Department. The Emergency Physician must also know when dental infections require consultation or referral to a higher level of care.3,5,6

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Table 155-1. Common Etiologies for a Dental Abscess
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Teeth are essentially composed of three layers (Figure 155-1). These layers, from the outside and working inward, are the enamel, the dentin, and the pulp. The dentin and pulp are living tissues that are sensitive to noxious stimuli. The crown is covered with enamel, while the root is covered with a substance known as cementum. Cementum helps attach the tooth to the surrounding alveolar bone via the periodontal ligament (PDL). The neurovascular supply enters the pulp through the apical foramen at the root apex. The pulp contains only pain-transmitting neuronal fibers, while the PDL contains both pain- and pressure-sensitive fibers.7 Dental abscesses arise when bacteria penetrate the normal anatomic and physiologic barriers of the tooth and surrounding structures. This can lead to a pulpal abscess, periodontal abscess, or a pericoronitis (Figure 155-2).

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Figure 155-2
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Locations of common dental abscesses.

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Pulpal Abscesses

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Dental abscesses often arise from pulpal necrosis secondary to dental caries or a defective dental restoration.1,3,4,6,7 Dental caries is commonly known as dental decay or “cavities.” This is the direct destruction of the tooth substance by the acidic bacterial products of normal oral flora. A carious tooth may not initially be painful. The products of inflammation eventually reach the dental pulp as the disease process progresses and the tooth will become sensitive.1–3,7–9 This is known as pulpitis. Patients will report non-localizable and intermittent symptoms. This process may initially be reversible by routine dental treatment (e.g., a filling). The pulp will rapidly necrose and die once the pulp tissues actually become infected. Products from the necrotic pulp ...

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