How to identify oral abscess

1. Introduction

Treatment of symptomatic apical periodontitis and acute apical abscess requires achieving adequate drainage by opening the pulp chamber. When the purulent discharge has destroyed the periosteum and the abscess is already in the submucosal phase, causing swelling of the intraoral soft tissues, it must be incised with a scalpel blade to establish drainage [5]. If the patient is immunocompetent, this intervention resolves the clinical picture. However, in immunocompromised patients, or when there are systemic symptoms or the purulent discharge progresses and expands, the prescription of systemic antibiotics is indicated [6]. On the contrary, asymptomatic apical periodontitis and chronic apical abscesses do not require antibiotic treatment [6,7].

Antibiotic Over-Prescription by Dentists in the Treatment of Apical Periodontitis: A Systematic Review and Meta-Analysis. © 2024 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Gingival and Periodontal Abscesses

For the diagnosis of periodontal abscess, inspection and examination by periodontal probe (to identify edema/gingival erythema, periodontal pockets and bone defects) and a radiographic image confirming the decrease in bone height, are usually sufficient. However, when the clinical features are not accompanied by periodontal disease and there is a history of trauma or impaction, gingival abscess is usually diagnosed [3]. Pericoronitis is an infection that is associated with an erupting tooth, especially the third molar. The mucosa covering the tooth becomes inflamed, with a traumatism caused by the opposing teeth and infection caused by food remnants under the mucosal layer. The pain is intense, and is usually associated with submandibular adenitis, sore throat, trismus and fever [7]. The treatment of gingival/periodontal abscess aims to achieve drainage of the purulent collection, either through an incision in the fluctuant area or through the periodontal pocket. In cases of periodontal abscess, root debridement is usually required, along with antibiotic and analgesic treatment [3, 7].

The Periodontium as a Potential Cause of Orofacial Pain: A Comprehensive Review. © 2018 Miranda-Rius et al. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Review

Acute gingival abscesses Abscesses in the periodontium are odontogenic infections that can result from trauma, surgery, pericoronitis, periodontal infections, or pulp necrosis [37]. A gingival abscess is a small, acute inflammatory lesion. Only the marginal and interdental gingiva are affected by a gingival abscess, which is a painful localized swelling that is typically linked to foreign objects that have subgingivally impacted the gingiva. A periodontal abscess develops in a periodontal pocket connected to a periodontitis lesion, whereas a gingival abscess solely affects the marginal soft tissues of previously healthy locations. Both disorders can occur in gingiva that was previously healthy. “A localised, painful, rapidly expanding lesion involving the marginal gingiva or interdental papilla, sometimes in an area previously free of disease" is the definition of a gingival abscess by the International Workshop on a Classification of Conditions and Diseases of the Periodontal System (1999). Etiology Conditions can develop from trauma, microbial plaque infection, or impaction of a foreign object. Clinical Features

Clinical Features, Etiopathogenesis, and Therapeutic Approaches of Acute Gingival Lesions: A Narrative Review. Copyright © 2024, Bhagat et al. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

1. Introduction

A localized, pus-forming infection of the surrounding tissues of a periodontal pocket is called a periodontal abscess [1]. The periodontal tissues appear edematous accompanied by bleeding on probing (BOP), suppuration and periodontal pocket formation [2]. Pre-existing chronic periodontitis has been identified as one of the main risk factors for periodontal abscess [2]. Trauma to periodontal tissues is another major predisposing factor in patients without chronic periodontal disease [3]. Presence and recurrence of periodontal abscess has been associated with tooth loss in chronic periodontitis patients [4] which highlights the importance of early treatment of acute periodontal abscess.

Characterization and Antimicrobial Susceptibility of Pathogens Associated with Periodontal Abscess. © 2020 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

1. Introduction

A critical decision point in managing acute pediatric odontogenic infections is the differentiation between cellulitis—a diffuse inflammation of soft tissues typically responsive to antibiotic therapy—and a loculated abscess, which generally necessitates surgical incision and drainage (I&D) for resolution. This distinction can be particularly challenging in pediatric patients due to their often-limited ability to precisely describe symptoms, cooperate with physical examinations, or tolerate discomfort, thereby complicating clinical assessment [5,6]. While experienced oral and maxillofacial surgeons (OMFSs) or pediatric dental specialists may possess heightened clinical acumen for detecting abscesses, general pediatricians, emergency physicians, and junior clinicians—who are often the first point of contact—may find this differentiation difficult [7]. This diagnostic uncertainty can contribute to delays in appropriate treatment, increased ED utilization, potentially avoidable hospital admissions, prolonged patient suffering, and, consequently, increased healthcare expenditures [8].

Diagnostic Accuracy and Clinical Impact of Handheld Point-of-Care Ultrasound in Pediatric Odontogenic Infections: A Prospective Cohort Study. © 2025 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Clinical examination

Starting with an extra-oral examination, the clinician can assess for the presence of facial swelling or asymmetry, being mindful of the potential for systemic spread of dental infection (eg cellulitis); although, such cases are thankfully uncommon. Critical indicators of systemic involvement include pyrexia and difficulty swallowing or breathing, which may signify airway restriction that requires urgent hospital referral. Additionally, palpation of the temporomandibular joint (TMJ) and lymph nodes is essential. TMJ dysfunction should be ruled out in cases of pain, which may mimic endodontic issues. The intra-oral examination aims to identify the potential causes of the patient's symptoms. It begins with assessing the patient's general dental hygiene status and examining the oral soft tissues. It is the responsibility of any clinician who examines the patient to be able to identify and report abnormalities. Dental professionals should be vigilant in recognising soft tissue irregularities and arrange for further investigation or referral when needed.

Endodontic assessment, complexity, diagnosis and treatment planning. © The Author(s) 2025. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Diagnostic accuracy of MRI

The study consisted of 106 patients (67 male, 39 female) with a clinically confirmed acute odontogenic infection who underwent MRI imaging in the emergency department (Table 1). Imaging showed evidence of one or more abscesses in 81 patients (76%), of whom 73 (90%) underwent surgery (Table 2). This surgically managed group had four false positives and 69 true positives. In addition, 14 (56%) patients out of the 25 with no MRI evidence of an abscess underwent a surgical operation, and pus was found in four cases (false negatives). These results led to sensitivity, specificity, and accuracy of 0.95, 0.84, and 0.92, respectively, for MRI diagnosis of an abscess. The positive and negative predictive values were 0.95 and 0.84, respectively. The most common abscess location was submandibular (49%), followed by the sublingual space (18%) (Figs. 1 and 2). Of the 87 total surgical interventions, 52 (60%) were performed intraorally, and 35 (40%) required extraoral surgery. Patients with multi-space abscesses, parapharyngeal extension, and no previous dental procedure had the most severe course of illness (details provided in Supplementary Data Table 6).

MRI of odontogenic maxillofacial infections: diagnostic accuracy and reliability. © The Author(s) 2022. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Gingival and Periodontal Abscesses

Both gingival and periodontal abscesses present localized reddening of the gingivae, which may include the alveolar mucosa. Injuries are fluctuant, violaceous, cyanotic or erythematous and may be accompanied by a fistula [3]. It is important to carry out differential diagnosis of the case of pulpal pain. Table 1 summarizes the main clinical features of irreversible pulpitis and periodontal abscesses. Abscesses are caused by the localized proliferation of periodontal bacterial flora in an affected area, but can also be caused by traumatic impaction of food or a foreign body. The microflora of the abscess predominantly contains periodontal pathogens including Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Peptostreptococcus micros and Bacteroides forsythus [6]. Areas with periodontal disease (periodontitis) present destruction of the connective tissue and alveolar bone around the tooth. Periodontitis is caused by the activation of host inflammatory mediators in response to bacterial microorganisms. The gingival or periodontal abscess is a focus of purulent exudate with granulation tissue, surrounded by infiltrating leukocytes [3].

The Periodontium as a Potential Cause of Orofacial Pain: A Comprehensive Review. © 2018 Miranda-Rius et al. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Gingival and Periodontal Abscesses

Gingival abscesses, which appear in the gingival sulcus, are comparatively rare. Periodontal abscesses usually occur in areas with periodontal pockets, in which deep spaces are generated around the teeth. They cause a dull, gnawing, localized pain but are not painful to percussion. The discomfort ranges from low intensity aches to severe acute pain. Periodontal abscesses may be tender to lateral periodontal pressure and the pain in the tooth adjacent to the injury usually worsens with chewing. Gingival abscesses are usually located in the marginal interdental tissue. Both gingival and periodontal abscesses present localized reddening of the gingivae, which may include the alveolar mucosa. Injuries are fluctuant, violaceous, cyanotic or erythematous and may be accompanied by a fistula [3].

The Periodontium as a Potential Cause of Orofacial Pain: A Comprehensive Review. © 2018 Miranda-Rius et al. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).