Pathophysiology

The two most common conditions that effect teeth are caries and periodontitis. Caries results in what patients may describe as rotten teeth and results from acid producing bacteria causing breakdown of tooth substances. This alone can result in dentine hypersentivity, as this can expose dentinal tubules present within the tooth. When exposed, changes in temperature and osmolarity can cause movement of fluids within these tubules, ultimately resulting in a normally short lasting pain to stimulus.

The image above shows the Image taken from enchantedlearning.com

If the carious process continues, it can result in a pulpal exposure, whereby the blood vessels and nerves present within the tooth become exposed to the bacterial pathogens causing the dental decay. The bacteria eventually cause pulpal necrosis, and begin to infect the pulpal system. Eventually the toxins released by the bacteria will begin to seep out through the apical foramen, and result in a periapical abscess.

The image above demonstrates how when caries breaching the pulp chamber; the pulp undergoes necrosis, and the subsequent release of toxins and bacteria from the apical foramen results in abscess formation.

Abscesses in the oral cavity can spread via tissue spaces. This occurs because as the abscess grows, the abscess will follow the path of least resistance. In the maxilla, abscesses generally drain either buccally or palatally. In the mandible, abscesses often may penetrate though the alveolar bone buccally, to form a buccal abscess, or lingually to form a sublingual abscess. If the abscess expands below the mylohyoid, a submandibular abscess may develop. Abscesses can also tract posteriorly under the masseter forming a submasseteric abscess. Finally abscesses may spread via the pterygomandibular and parapharyngeal spaces.

Sub-masseteric abscesses can result in trismus, and this requires admission to hospital. Sublingual and submandibular abscesses can result in a raised floor of mouth, which is an airway risk. If the patient goes on to develop sublingual swelling bilaterally, then this is termed Ludwigs angina, and is a life threatening condition that requires urgent management.

Periodontitis, otherwise known as gum disease and historically termed pyorrhea, results from oral pathogens releasing toxins, ultimately damaging the tooth supporting structures via a chronic disease process. This results in the gums receding, exposing the tooth root surface which can cause sensitivity. Furthermore the damage caused to the tooth supporting structures results in tooth mobility, which can also cause pain.

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The image above shows advanced periodontitis, resulting in exposure root surface. The teeth will be less stable and may move. Furthermore, the exposed root surface may feel sensitive. This condition is not an emergency, and patient should be advised to seek treatment with a general dental practitioner.