Skip to Main Content


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

Table Graphic Jump Location
Table 155-1. Common Etiologies for a Dental Abscess

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).

Figure 155-2
Graphic Jump Location

Locations of common dental abscesses.


Pulpal Abscesses


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 ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessEmergency Medicine Full Site: One-Year Subscription

Connect to the full suite of AccessEmergency Medicine content and resources including advanced 8th edition chapters of Tintinalli’s, high-quality procedural videos and images, interactive board review, an integrated drug database, and more.

$595 USD
Buy Now

Pay Per View: Timed Access to all of AccessEmergency Medicine

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.