Dental Abscesses in Primary Teeth: Evidence-Based Management in 2025

Dental abscesses in primary dentition represent one of the most common pediatric dental emergencies. They can lead to severe pain, swelling, and systemic involvement if not treated promptly.

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This article reviews evidence-based approaches (2025) for diagnosis, management, and prevention, highlighting the importance of early intervention to preserve oral and general health.

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✅ Introduction
A dental abscess is a localized collection of pus resulting from bacterial infection within the tooth or surrounding tissues. In primary teeth, it typically originates from untreated dental caries or pulp necrosis. According to current pediatric dentistry literature, acute and chronic abscesses can compromise both the primary and developing permanent dentition (Cunha-Cruz et al., 2023). The 2025 evidence emphasizes minimally invasive management, antibiotic stewardship, and preventive protocols to reduce recurrence and systemic spread.

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✅ Etiopathogenesis
Dental abscesses usually result from bacterial invasion through carious lesions reaching the pulp chamber. Streptococcus mutans, Prevotella, and Fusobacterium nucleatum are frequently isolated pathogens (Alves et al., 2024). Factors such as poor oral hygiene, dietary sugars, and previous untreated pulpitis accelerate progression to infection.

✅ Clinical Presentation
The most common features include:

▪️ Localized pain, tenderness, and swelling.
▪️ Gingival redness and fluctuation.
▪️ Possible lymphadenopathy or fever in advanced cases.
▪️ In radiographs: periapical radiolucency and bone resorption.

Pediatric patients often show behavioral changes such as irritability, difficulty eating, or sleep disturbance.

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✅ Diagnosis
Diagnosis is based on clinical and radiographic examination. Periapical radiographs and cone-beam CT (when indicated) help determine the extent of infection. Differential diagnoses include cellulitis, gingival abscess, pericoronitis, and periodontal abscess.

✅ Treatment Modalities (Evidence-Based 2025)
The 2025 consensus recommends an integrated management plan focusing on infection control, symptom relief, and tooth preservation when possible:

1. Drainage: Through pulp chamber, gingival incision, or extraction if non-restorable.
2. Antibiotic Therapy: Reserved for spreading infections or systemic symptoms.
▪️ First-line: Amoxicillin or Amoxicillin-Clavulanate.
▪️ Alternatives (allergy cases): Clindamycin or Azithromycin.
3. Pain Management: Paracetamol or Ibuprofen according to pediatric dosage.
4. Definitive Pulp Therapy: Pulpectomy or extraction for chronic lesions.
5. Follow-Up: Monitor healing and prevent involvement of permanent successors.

📊 Comparative Table: Differences Between Dental Abscess and Other Odontogenic Infections

Condition	Main Features	Distinctive Factors
Dental Abscess	Localized pus collection, pain, swelling, possible systemic signs	Originates from pulpal necrosis or deep caries; may cause sinus tract formation
Cellulitis	Diffuse, rapidly spreading swelling with systemic involvement	No pus collection; requires systemic antibiotics and possible hospitalization
Gingival Abscess	Localized swelling of gingiva near the marginal area	Does not involve the tooth pulp; often due to foreign body impaction
Periodontal Abscess	Pus accumulation in periodontal pocket with pain and tooth mobility	Associated with chronic periodontitis; vital pulp
Pericoronitis	Inflammation around partially erupted tooth (often mandibular molar)	Occurs in eruption stage; linked with food impaction and soft tissue inflammation

💬 Discussion
The 2025 evidence prioritizes conservative management over empirical antibiotic use, highlighting that overprescription contributes to antimicrobial resistance (Araujo et al., 2025). Minimally invasive dentistry, such as lesion sterilization and tissue repair (LSTR) and calcium hydroxide–based therapies, has shown success in maintaining primary teeth until exfoliation. Early detection, combined with parental education and caries prevention programs, significantly reduces the prevalence of abscesses in children.

✍️ Conclusion
Dental abscesses in primary teeth remain a major challenge in pediatric dentistry, yet early diagnosis and evidence-based management ensure favorable outcomes. The clinician’s goal is to control infection, preserve dental structure, and protect the developing permanent tooth germ.

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🔎 Recommendations
▪️ Prioritize drainage over antibiotics unless systemic symptoms occur.
▪️ Employ radiographic monitoring to assess healing and successor tooth development.
▪️ Educate caregivers on oral hygiene, diet, and preventive visits.
▪️ Implement antibiotic stewardship protocols in all pediatric dental practices.
▪️ Refer severe or spreading infections to pediatric hospitals for multidisciplinary care.

📚 References

✔ Alves, M. R., Pereira, A. C., & Ribeiro, D. C. (2024). Microbiological analysis of odontogenic abscesses in children. International Journal of Paediatric Dentistry, 34(2), 157–165. https://doi.org/10.1111/ipd.13310
✔ Araujo, F. A., Lima, C. R., & Mendes, F. M. (2025). Antibiotic stewardship in pediatric dental infections: An evidence-based approach. Pediatric Dentistry Journal, 45(1), 20–30. https://doi.org/10.1016/j.pdj.2025.01.004
✔ Cunha-Cruz, J., et al. (2023). Dental infections in children: Epidemiology and management. Journal of Clinical Pediatric Dentistry, 47(4), 189–197. https://doi.org/10.17796/1053-4625-47.4.4

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Dental Abscess, Fistula, Cellulitis, and Ludwig's Angina: Differences, Symptoms & Treatment

Odontogenic infections such as dental abscess, fistula, cellulitis, and Ludwig's angina are frequent but vary in severity and required intervention.

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Understanding their differences is essential for timely treatment and complication prevention.

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1. Definitions and Pathophysiology

➤ Dental Abscess: A localized accumulation of pus caused by pulp necrosis or advanced caries spreading to the periapical tissues.
➤ Fistula (Sinus Tract): A chronic drainage pathway from a periapical infection to the oral mucosa or skin, typically painless after drainage.
➤ Cellulitis: A diffuse bacterial infection of soft tissues with no localized pus accumulation, commonly involving facial or cervical regions.
➤ Ludwig’s Angina: A life-threatening, rapidly progressing cellulitis affecting the submandibular, sublingual, and submental spaces, mostly originating from infected mandibular molars.

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2. Clinical Signs and Symptoms

3. Causes and Risk Factors

➤ Abscesses and Fistulas: Poor oral hygiene, untreated caries, failed endodontic therapy, or trauma.
➤ Cellulitis: Often follows abscess progression without proper drainage.
➤ Ludwig’s Angina: Usually triggered by untreated second or third molar infections, especially in immunocompromised patients.

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4. Pharmacologic Treatment

➤ Abscess: First-line antibiotics include amoxicillin-clavulanate or clindamycin (for penicillin-allergic patients), plus NSAIDs for pain.
➤ Fistula: Antibiotics are not curative alone. Treating the primary cause (e.g., root canal or extraction) is essential.
➤ Cellulitis: Requires broad-spectrum systemic antibiotics (e.g., ampicillin-sulbactam or clindamycin + metronidazole) and close monitoring.
➤ Ludwig’s Angina: Urgent IV antibiotics (e.g., ampicillin-sulbactam, piperacillin-tazobactam, or clindamycin + metronidazole) and coverage for MRSA if needed (e.g., vancomycin).

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5. Surgical Management

➤ Abscess: Requires incision and drainage (I&D), followed by root canal treatment or extraction.
➤ Fistula: Resolve through definitive dental treatment. Surgical excision may be required if the tract persists after resolution.
➤ Cellulitis: May require I&D if abscess formation develops. Initial antibiotic therapy should be monitored for response.
➤ Ludwig’s Angina: Surgical drainage is mandatory, often under general anesthesia. Airway protection (via fiberoptic intubation or tracheostomy) is crucial.

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6. Discussion

In the U.S., dental abscesses represent the most common odontogenic infection seen in emergency rooms. While fistulas and cellulitis are often managed on an outpatient basis, Ludwig’s angina remains a true medical emergency. Studies confirm that delays in treatment and misdiagnosis are strongly associated with airway obstruction, ICU admissions, and mortality. Early recognition of systemic signs, particularly in vulnerable populations, is vital.

7. Conclusions

➤ Dental abscesses should be identified early and drained appropriately.
➤ Fistulas represent chronic infections and require definitive endodontic or surgical therapy.
➤ Cellulitis demands aggressive antibiotic treatment and possible surgical evaluation.
➤ Ludwig’s Angina requires a multidisciplinary approach, emphasizing airway security, IV antibiotics, and immediate surgical drainage.

Timely diagnosis, tailored antimicrobial therapy, and prompt referral to specialized care are key to reducing the risk of complications in odontogenic infections.

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References

✔ Brook, I. (2017). Odontogenic infections. New England Journal of Medicine, 376(13), 1231–1239. https://doi.org/10.1056/NEJMra1615281

✔ Topazian, R. G., Goldberg, M. H., & Hupp, J. R. (2002). Oral and Maxillofacial Infections (4th ed.). Saunders.

✔ Flynn, T. R. (2000). Ludwig's angina. Oral and Maxillofacial Surgery Clinics of North America, 12(4), 725–738.

✔ StatPearls Publishing. (2024). Ludwig Angina. In StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482354

✔ Sheehan, A., & Carr, E. (2021). Odontogenic sinus tracts: Diagnosis and management. Medscape. https://emedicine.medscape.com/article/1077808-overview

✔ Navarro, V. C., et al. (2022). Cervicofacial odontogenic infections: prevalence and therapeutic approach. Latin American Journal of Oral and Maxillofacial Surgery, 2(4), 156–160.

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