Patients frequently present to the Emergency Department complaining of a “toothache.” There are multiple common causes of toothache pain and similarly multiple etiologies for a dental abscess (Table 210-1).1 Distinguishing the type of dental abscess can have an impact on the treatment decisions, prognosis, and patient morbidity.2-5 Accurate diagnosis and proper treatment of these maladies requires that the Emergency Physician have a basic understanding of dental anatomy, pathophysiology, and simple dental treatment protocols. There are many complications of odontogenic infections (Table 210-2).6-8 Many of these conditions can be managed initially though the Emergency Department. The prudent Emergency Physician must have a clear understanding that these infections can rapidly become complicated requiring timely consultation or referral.
TABLE 210-1Common Etiologies for a Dental Abscess |Favorite Table|Download (.pdf) TABLE 210-1Common Etiologies for a Dental Abscess
Cysts that become infected
Mixed periodontal/periapical infections
Root fracture that becomes infected
TABLE 210-2Complications of Odontogenic Infections6-8 |Favorite Table|Download (.pdf) TABLE 210-2Complications of Odontogenic Infections6-8
Acute respiratory distress syndrome
Carotid sheath involvement
Cavernous sinus thrombosis
Cervical spine osteomyelitis
Disseminated intravascular coagulation
Internal jugular thrombophlebitis
Systemic immune response syndrome
ANATOMY AND PATHOPHYSIOLOGY
Teeth are essentially composed of three layers: the outermost enamel, underlying dentin, and the pulp which is the deepest layer (Figure 210-1). 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-sensitive and pressure-sensitive fibers.9 Anatomic structures in the body limit and direct the spread of infection in a predictable way. These structures include fascial layers, ligaments, tendons, muscles, and bone.10
Dental abscesses arise when bacteria penetrate the normal anatomic and physiologic barriers of the tooth and surrounding structures. This can lead to a localized collection of purulence contained within the tooth (i.e., a pulp abscess) or around the apex of the tooth (i.e., a periapical abscess) (Figure 210-2). Alternatively, a dental abscess may localize to the supporting structures of the tooth (i.e., a periodontal abscess) or strictly to the adjacent soft tissues (i.e., a ...