Abscessed Teeth – Where will they lead?

Earlier today I was thinking about my patients who refuse to visit a dentist, for whatever reason.  Now and then they see or call me about a toothache, requesting an antibiotic until they can get to a dentist.  Amoxicillin usually fixes them up for awhile . . . long enough for them to decide, once again, not to see a dentist.  The majority of these patients seem to do OK, though their teeth crumble and fall out.  But then there was that 25-year-old who nearly died, when the infection spread to his heart. 

I asked our friendly tooth doctor how he saw things playing out at the end of the world as we know it.  Here is his reply.  Thanks, WH2THDR.

* * *

Doc Cindy asked me to give my thoughts regarding the consequences of untreated abscessed teeth, both in this world and the possible dark days ahead. Let me say in summary that we just do not know exactly how this disease process will progress in each circumstance. Let me explain.

Teeth have a unique place in our bodies. God in his infinite wisdom and creation gave us tools to, among many other things, begin the process of consuming and processing food. In this role, our teeth are solidly imbedded in the jaw bone (mesoderm, internal body tissue); from there they leave the body through the gingival (ectoderm, external body tissue). This top portion, or crown of each tooth, is subject to external trauma, either physical through fracture, or bacterial through decay.  If this traumatic destruction progresses to the point where the pulp (mesoderm) is involved, oral flora is introduced into this tissue that is rarely able to defend itself and therefore dies. Once dead, it no longer can keep its space free of bacteria; the pulp chamber is turned from a sterile space into a wonderful, warm , dark, and wet culture medium that grows some real nasty bugs.

At the tip of the root, there is a foramen that in health allows the passage of a neurovascular bundle. After pulpal necrosis, that opening becomes an inoculation point for bacteria and toxins to be injected directly into the central core of the body.  One principal that I use in my clinical practice is the realization that the mix of bacteria within the infected pulp chamber is not static. In general, the immune system acts to kill off all of the bacteria that it is deft at destroying. What is left? Bacteria that the body is not well-suited to destroy immunologically. This process continues until a real nasty mix of flora lives in the pulp chamber, and since the body’s defenses are not deft to defend this mix, an acute infection results. Antibiotics at this point can help knock the abscess back, but remember that there is no blood supply within the tooth, and as soon as the antibiotic regimen is finished, the process begins again. This time the mix of flora has been changed by the killing of those bugs that are susceptible to the medication but leaving the resistant ones.

All that being said, what are the sequelae of dental abscesses?

  • 1.  Apical pressure from infection yields an elevated tooth and severe pain on biting.
  • 2.  Pressure is enhanced by arterial pulse, and throbbing is the symptom.
  • 3.  Products of pulpal breakdown and infection lead to granuloma formation at the apex
  • 4.  Breakdown of the pulp leads to cystic formation at the apex
  • 5.  Granuloma/cyst growth and expansion of alveolus
  • 6.  Growth of granuloma/cyst punches through bone and into tissue causing cellulitis/swelling, pus accumulation
  • 7.  Extension of infection along lines of facial and cervical fascial planes (life threatening if extension into neck and mediastinum)
  • 8.  Extension along facial veins into the venous plexus in the skull (life threatening due to intracranial abscess
  • 9.  Septicemia
  • 10.  Sub-acute Bacterial Endocarditis
  • 11.  Venting of the infection into the mouth on the facial or lingual surfaces.
  • 12.  Venting of the infection onto the face (possibility of permanent scar and fistula)
  • 13.  Venting of the infection through the periodontal ligament leading to a periodontal problem
  • 14.  Boney breakdown leads to loosening and possible spontaneous exfoliation.
  • 15.  Acute sensitivity to hot/cold during the process of pulpal death
  • 16.  All of the above.
  • 17.  None of the above.

Notice that in no case have I mentioned extension to neighboring teeth. I do not believe that I have ever seen that happen. But then even after 35 years, I still see new stuff all the time. My experience in third world on mission trips is that there is a whole class of chronic conditions possible for long-standing untreated abscesses that dentistry has not been exposed to in the memory of the textbook writers. There may be a paper on this subject, but I am not aware of it.

Bottom line is that there are some rare but serious consequences of untreated abscessed teeth that will not heal on their own.  If at all possible removal of the tooth or endodontic treatment is needed to relieve the focus of infection and allow healing.

Copyright ©2011 WH2THDR

(Featured image: This is a case of suspected meth mouth. This patient, who will remain anonymous, was treated at the University of Tennessee Health Science Center: College of Dentistry in Memphis, Tennessee.  Source: Photo taken by Dozenist}

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About Cynthia J. Koelker, MD

CYNTHIA J KOELKER , MD is a board-certified family physician with over twenty years of clinical experience. A member of American Mensa, Dr. Koelker holds degrees in biology, humanities, medicine, and music from M.I.T., Case Western Reserve University School of Medicine, and the University of Akron. She served in the National Health Service Corps to finance her medical education.
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3 Responses to Abscessed Teeth – Where will they lead?

  1. Dr. Facefixer says:

    As an oral surgeon and the specialist that usually gets called into the ER in the middle of the night because of these infections, I will say you are right on the money with all above with the exception of “none of the above”. The only reason dental infections sit dormant and don’t seem to be causing worsening problems is when they set up a chronic and draining infection (usually into the mouth).

    Biotene is a rinse marketed mainly to those people with salivary difficulties which predispose them to caries from the lack of saliva remineralizing their teeth ie. Post radiation patients or those that have had salivary gland removal because of pathology. It WILL NOT treat a dental infection. Reducing normal oral bacterial populations long term is usually not a good thing – that’s when we see opportunistic fungal infections. Even Peridex one of the more solid oral antibiotic rinses loses its benefit after a few weeks of use.

  2. Gil J says:

    There is a new mouth rinse “BIOTENE’ that utilizes four (4) milk enzymes to knock out bacteria very efficiently. Also comes with plaque remover. This rinse will prove to be a new miracle for tooth decay. I have used it for four years and believe me it will knock out dental infections very well. I think everyone should have this mouth rinse stocked up for emergency.

    • Doc Cindy says:

      I’ve never used this product, but according to http://www.biotene.com the product is intended for relief of oral dryness and chronic dry mouth.
      I have not heard of this Glaxo product elsewhere, but wish it were (and doubt it is) the answer to tooth decay. Any of our dental experts care to comment?

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