Bacterial Infections

 Bacterial Infections: A bacterial oral infection is when bacteria invade the oral cavity

(mouth) and cause infection (the harmful growth of microorganisms).

 The most common bacterial oral infections are gingivitis and periodontitis.

 When the bad bacteria outnumber the good, disease begins - gingivitis and periodontitis.

 Because of the biofilm nature of the plaque, systemic antibiotics are not a good choice for

treating gingivitis and/or periodontitis.

 Oral Abscess

 Definition : A dental abscess, or tooth abscess, is an accumulation of pus that forms inside the teeth or gums.

 The abscess typically originates from a bacterial infection, often one that has accumulated in the soft pulp of
the tooth.

 Bacteria exist in plaque, a by-product of food, saliva and bacteria in the mouth which sticks to the teeth and
damages them, as well as the gums.
 Classification

 Classification : The main types of dental abscess are:

 Periapical abscess: The result of a chronic, localized infection located at the tip, or apex, of the root of a
tooth .
 Periodontal abscess: begin in a periodontal pocket .
 Gingival abscess: involving only the gum tissue, without affecting either the tooth or the periodontal
ligament .
 Pericoronal abscess: involving the soft tissues surrounding the crown of a tooth.
 Combined periodontics-endodontic abscess: a situation in which a Periapical abscess and a periodontal
abscess have combined .
 Periapical abscess

 Periapical abscess : Bacteria enter the tooth through tiny holes caused by tooth decay (caries) that form in
the tooth enamel (hard outer layer of the tooth).

 The caries eventually break down the softer layer of tissue under the enamel, called dentine.

 If the decay continues, the hole will eventually penetrate the soft inner pulp of the tooth - infection of the
pulp is called pulpitis.

 As the pulpitis progresses the bacteria make their way to the bone that surrounds and supports the tooth,
called the alveolar bone, and a Periapical abscess is formed.
 Periodontal abscess

 Periodontal abscess : When bacteria which are present in plaque infect the gums the patient has

periodontitis.

 The gums become inflamed, which can make the periodontal ligament separate from the base of the tooth.

 A periodontal pocket, a tiny gap, is formed when the periodontal ligament separates from the root.

 The pocket gets dirty easily and is very hard to keep clean.
 Clinical Presentation

 History : The following may be reported in patients with dental abscess:

1. Localized pain and swelling ( may progress over a few hours to days).
2. Thermal sensitivity (Periapical abscess) : This is thought to occur secondary to
exposure of the dentine to the external environment as a result of enamel loss or
gingival recession.
3. Fever .

4. Gingival bleeding (on occasion with periodontal abscess) .

5. Decreased intake of fluid, food, or both .

 : Physical Examination

Gingiva :

Swelling .

Warmth .

Erythema .

Fluctuant mass that usually extends toward the buccal side of the gum and to the gingival-buccal reflection.

 Parulis or "gum boil" (a soft, solitary, reddish papule located facial and apical to a chronically abscessed tooth that occurs at the

endpoint of a draining dental sinus tract) .

 Teeth : The tooth that is most frequently involved is the lower third molar, followed by other lower posterior teeth; upper

posterior teeth are involved much less frequently, and anterior teeth are rarely involved.

Increased mobility (mostly Periapical abscess).

 Pressure or percussion tenderness (mostly Periapical abscess).

 Physical Examination : ( cont.)

 Regional lymph node involvement .

 More severe infection :

 Trismus, indicating involvement of the masticator space .

 Difficulty swallowing (dysphagia) .

 Respiratory difficulty.

 Necrotizing fasciitis .

 Neck or facial swelling .

 Signs of dehydration
 :Diagnostic test

 Laboratory Studies :

 Uncomplicated (i.e., simple) dental abscess : No laboratory studies are required.

 Complicated abscess (accompanying cellulitis) :

 The CBC count may reveal leukocytosis with neutrophil predominance.

 Obtain a blood culture (aerobic and anaerobic) before initiating parenteral antibiotics.

 Needle aspirate is indicated for Gram stain and aerobic and anaerobic cultures.
 Diagnostic test: ( cont.)

 Imaging Studies :

 Depending on severity of abscess based on clinical presentation the following is recommended:

 Periapical radiography is the first level of investigation. It provides a localized view of the tooth

and its supporting structures. Widening of the periodontal ligament space or a poorly defined

radiolucency may be noted.

 Panoramic radiography (pantomography) is most helpful in emergency situations because it

provides the most information for all teeth and supporting structures.
 : Procedures

 Confirm presence of the abscess via needle aspiration.

 If pus is obtained, do not aspirate more than 1-2 drops. Leave the abscess as large
as possible to make the area easier to find for further management.

 If pus cannot be aspirated, manage medically until a more localized infection

develops.

 Incision and drainage may be performed only if pus can be aspirated.

 Packing a periapical abscess is generally not necessary.

 : Treatment & Management
 Medical Care :

 In patients with dental abscess, assess the airway upon respiratory distress, oropharyngeal tissue

swelling, or inability to handle secretions; then, secure the airway via endotracheal intubation or

tracheostomy.

 Properly collect specimen for Gram stain and aerobic and anaerobic cultures.

 Administer empiric antibiotic therapy if necessary.

 Administer analgesia.

 Hydrate the patient.

 Treatment & Management : ( cont.)

 Surgical Care : The primary therapeutic modality is surgical drainage of any pus collection.

 A pulpectomy or incision and drainage is the recommended management of a localized acute apical abscess

in the permanent dentition.

 Incision and drainage or spontaneous rupture of the abscess quickly accelerates resolution of the infection.

The addition of antibiotics is not recommended for a localized dental abscess.

 Emergent surgery is indicated in the operating room if the airway is threatened or if the patient's condition is

rapidly deteriorating.

 Third molar removal is a common surgical procedure.

 : Consultations

 Consult a dentist if the patient has an uncomplicated abscess.

 Consult a maxillofacial oral surgeon if the patient has a complicated

abscess.

 Diet : Diet is as tolerated. However, a soft bland diet is usually preferred.

 Activity : Activity is as tolerated

 : Medication

  Medication :

 Penicillin (Pfizerpen, Pen-Vee K).

 Azithromycin (Zithromax).

 Metronidazole (Flagyl).

 Clindamycin (Cleocin).

 Amoxicillin and clavulanate (Augmentin)

 Cefoxitin (Mefoxin).
 : Patient Education

 Most dentoalveolar abscesses are preventable.

 Inquire if drinking water is fluorinated. If not, counsel parents about fluoride

supplementation .

 Instruct patients about proper dental hygiene, including brushing teeth after meals,

flossing, and regular dental check-ups.