Dental abscess

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Periapical vs Periodontal Abscess

Category Periapical Periodontal
Other Names Tooth abscess, dentoalveolar abscess, apical abscess, endodontic abscess, and lesion of endodontic origin Gingival, pericoronal, lateral (periodontal) abscess
Epidemiology More common Less common
Area Associated with a nonviable dead tooth (e.g. pulpitis) Associated with a vital (living) tooth
Cause Tooth infection Gum infection

Dental Numbering

Classic dental numbering.
  • Adult (permanent) teeth identified by numbers
    • From the midline to the back of the mouth on each side, there is a central incisor, a lateral incisor, a canine, two premolars (bicuspids), and three molars
  • Children (non-permanent) teeth identified by letters
  • Common landmarks:
    • 1: Right upper wisdom
    • 8 & 9: Upper incisors
    • 16: Left upper wisdom
    • 17: Left lower wisdom
    • 24 & 25: Lower incisors
    • 32: Right lower wisdom
Anatomy of the periodontium. The crown of the tooth is covered by enamel (A). Dentin (B). The root of the tooth is covered by cementum. C, alveolar bone. D, subepithelial connective tissue. E, oral epithelium. F, free gingival margin. G, gingival sulcus. H, principal gingival fibers. I, alveolar crest fibers of the periodontal ligament (PDL). J, horizontal fibers of the PDL. K, oblique fibers of the PDL.

Clinical Features

Chronic apical periodontitis (with arrows).jpg
Abscess originating from a tooth that has spread to the buccal space. Above: deformation of the cheek on the second day. Below: deformation on the third day.
A decayed, broken down tooth, which has undergone pulpal necrosis. A periapical abscess has then formed and pus is draining into the mouth via an intraoral sinus (gumboil).
Periodontal abscess between the lower left canine and first premolar.
  • Acute pain, swelling, and mild tooth elevation
  • Exquisite sensitivity to percussion or chewing on the involved tooth
  • Swelling in surrounding gingiva, buccal, lingual or palatal regions
  • May see small white pustule (parulis) in gingival surface characteristic for abscesses

Differential Diagnosis

Dentoalveolar Injuries

Odontogenic Infections



CT scan showing a large left tooth abscess with significant inflammation of fatty tissue under the skin.


  • Consider CT if concern for a larger or deeper abscess


  • Typically clinical
  • Differentiation between periapical and periodontal abscess is not of key importance in the ED, as the initial treatment is the same


  • Analgesia with NSAIDs, opioids and/or local anesthetics
  • Dental follow-up within 48 hrs
  • Emergent oral surgeon follow-up if complicated (Ludwig's angina, Lemierre's syndrome)


Treatment is broad and focused on polymicrobial infection


  • Can be performed in ED depending on provider comfort or by a dental consultant


  • 11 or 12 blade stab incision
  • Hemostat blunt dissection +/- packing


  • Outpatient management
    • Follow up with a dentist

See Also

External Links