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Patients frequently present to the Emergency Department complaining of a “toothache”. The common causes of toothache pain are multiple.1 Similarly, there are multiple etiologies for a dental abscess (Table 177-1). Distinguishing the type of dental abscess can have an impact upon treatment decisions, prognosis, and patient morbidity.2–5 The accurate diagnosis and proper treatment of these maladies require that the Emergency Physician has a basic understanding of dental anatomy, pathophysiology, and simple dental treatment protocols. Many of these conditions can be managed initially through the Emergency Department. The prudent Emergency Physician must have a clear understanding that these infections can rapidly become complicated and may require timely consultation or referral.
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Teeth are essentially composed of three layers (Figure 177-1). These layers, from the outside 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-sensitive 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 localized collection of purulence contained within the tooth (pulpal abscess), or around the apex of the tooth (periapical abscess) (Figure 177-2). Alternatively a dental abscess may localize to the supporting structures of the tooth (periodontal abscess) or strictly to the adjacent soft tissues (pericoronitis) (Figure 177-2).
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Pulpal or Periapical Abscesses
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Dental abscesses often arise from pulpal necrosis secondary to dental caries or a defective 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 nonlocalizable and intermittent ...