What Is a Dental Abscess?

It's a potentially serious tooth infection -- and if you don't know the signs, it can spiral out of control quickly. Learn about the symptoms, causes, and ways to prevent it.

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Just after 8 P.M. on a Monday in June, my daughters and I were hurrying through the library when my 5-year-old told me her tooth hurt "just a little." Charlotte seemed fine. I didn't see anything strange inside her mouth, but her left cheek did feel a bit firm to the touch.

Although I tend to rush my kids to the doctor for anything that can't be fixed with ibuprofen and a bandage, the slightly puffy cheek did not rattle me. But it should have.

Unbeknownst to me, Charlotte had a severe dental abscess, an infection that began in her tooth and spread to the jaw and into the soft tissues of her face. This condition usually starts as a cavity and frequently pops out of the gum like a pimple, often without causing pain or facial swelling at first. An abscess like Charlotte's is rare. The inflammation advances inside the gum and into other parts of the body. Inflammation from an abscess near lower teeth can eventually affect a child's airway, making it difficult to breathe. An abscess near upper teeth can travel to the brain. If untreated or treated too late, an abscess can be life threatening.

"If you're not looking for them, they can get out of hand pretty quickly. But the number of kids with dental abscesses, particularly young kids, is very, very low," says Paul Casamassimo, D.D.S., director of the American Academy of Pediatric Dentistry's Pediatric Oral Health Research and Policy Center. Fortunately, the warning signs -- including dental pain and facial swelling -- are clear indications that you should contact your child's dentist.

However uncommon, dental abscesses among children are a critical issue, says Gerald Ferretti, D.D.S., who chairs the Pediatric Dentistry Department at Case Western Reserve University's School of Dental Medicine in Cleveland. Between 5 and 10 children under the age of 5 are admitted for facial swelling -- including dental abscesses -- every month at Rainbow Babies and Children's Hospital in Cleveland, where Dr. Ferretti is the chief of dentistry. A 2013 study in the Journal of Endodontics revealed that hospitalizations for tooth abscesses are increasing overall.

I didn't take Charlotte to the emergency room immediately because I didn't know how serious her condition was, and I knew her dentist would see her in the morning. I also thought we had already been through the worst with Charlotte's teeth.

The previous fall, she had undergone general anesthesia to have several cavities filled, one extraction and two pulpotomies. Dentists opt to do a pulpotomy when the tooth decay in a baby-tooth molar is too advanced for a filling but does not require an extraction. Only the top part of the tooth pulp is infected. With a pulpotomy, the dentist can remove that part and save the tooth, though a crown must be placed on top.

Our family dentist had said Charlotte's tooth decay had developed quickly. When she finally had tooth pain, he sent us to a pediatric dentist because he didn't have the equipment necessary to do X-rays on 4-year-olds. More than seven months had passed since a board-certified pediatric dentist had treated Charlotte, and though he warned me that pulpotomies can sometimes fail, I thought we were past the period of having to worry that something went wrong. Unfortunately, children who have had pulpotomies must be followed carefully for years. Even though the decayed part of the tooth has been removed and the remaining tissue treated, inflammation can remain.

When Charlotte awoke the next morning, her cheek was noticeably swollen. I drove her to the dentist, who looked grave as he tried to get her to open her mouth wide. He told us she had an abscess, and he needed to pull one and possibly two teeth as soon as possible. Because Charlotte's mouth was too swollen at the time for him to do so, he prescribed oral antibiotics to manage the infection and bring the swelling down, which would allow him to extract the teeth in a day or so.

But even with the antibiotics, Charlotte's face continued to swell over the next 24 hours, and she spiked a fever. She was admitted to Akron Children's Hospital the following day, where she had surgery to extract two of her teeth and drain the infection. Then she began to get better.

    Red flags

    Charlotte had all of the classic signs of an abscess:

    • tooth pain, often spontaneous or at night
    • facial swelling
    • fever

    Other signs may include:

    • bitter taste in the mouth
    • pain when chewing
    • sensitivity of the teeth to hot or cold
    • gum swelling that may resemble a pimple
    • swollen neck glands
    • swollen upper or lower jaw

      Who is at risk?

      Kids who don't have access to a dentist for regular preventive care are at higher risk. Others who are more likely to develop tooth decay that might lead to abscesses are:

      • Children with medical or behavioral conditions that make proper teeth-cleaning difficult
      • Kids on certain modified diets, such as a high-carbohydrate one
      • Children who have suffered trauma to the teeth, such as taking a baseball to the mouth or hitting themselves on a coffee table. "They have to be followed very carefully because they may not have any dental decay, but the trauma to the tooth itself could cause the nerve or the dental pulp to abscess," Dr. Ferretti says.
      • Those who have had a pulpotomy. "Even with the best techniques in pulpotomies, there is only a 80 to 90 percent success rate," Dr. Ferretti says. I didn't realize that, and I wish I'd asked.

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          How to prevent an abscess

          Even though some children are more at risk, the condition that sets the stage for abscesses -- tooth decay -- is occurring more frequently in young children across the country. Twenty-eight percent of children between the ages of 2 and 5 have cavities, according to the Centers of Disease Control and Prevention.

          Anything that protects children from cavities will protect them from abscesses. In addition to having their children drink fluoridated water, brush with fluoride toothpaste, and floss twice a day, parents can do the following:

            1. Limit sweets and snacking between meals. I have always brushed and flossed my kids' teeth and taken them to the dentist every six months, but Charlotte was a big snacker, and we think this contributed to her dental problems. Sugar, the starch found in white bread and crackers (often a go-to snack for kids) creates a good breeding ground for the bacteria that cause tooth decay. "The prevailing wisdom is that if you have sugar more than three times a day, you're probably more prone to tooth decay," Dr. Casamassimo says. Processed foods, such as soda and candy, are particularly detrimental. Eating a dessert with a meal is better than eating a candy bar in the middle of the day, because the child is more likely to be drinking something with the meal that'll clear the sugar.
            2. Take children to a pediatric dentist. "Sometimes general dentists don't have the skills, patience, or time to be able to do the kinds of things a pediatric dentist can do," says Dr. Casamassimo, who is also chief of pediatric dentistry at Nationwide Children's Hospital in Columbus. Pediatric dentists go through advanced training to help them treat children who don't want to sit in a dentist's chair or those who have complicated medical problems.
            3. Never accept a wait-and-see attitude. Some dentists do not want to fix baby teeth when a cavity is small, but Dr. Ferretti says parents should make sure any kind of tooth decay is treated; it will never get better on its own.
            4. Ask how a new medication will affect your child's oral hygiene. Some drugs decrease saliva production, making the teeth more vulnerable to decay. Saliva helps break down acids from sugars and carbohydrates and helps maintain a healthy mouth.

              As I learned the hard way, preventive dental care is not just brushing, flossing, and having twice-a-year dental checkups. When your child has an injury or an unsuccessful dental procedure, decay can set in quickly and with serious repercussions. But pediatric dentists are trying to improve education and access to care. In Cleveland, for instance, Rainbow Babies and Children's Hospital is training pediatricians to do oral exams, and Nationwide Children's Hospital is treating children with abscesses within 24 hours, fixing all their dental problems while they're under general anesthesia.

              But no one can identify a child's serious dental condition more quickly than her parents. You just have to know what to look for.

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