Alveolar Abscess 
E. HERBERT ADAMS/M.D., D.D.S., 
Toronto. 
Reprinted from THE CANADIAN PRACTITIONER. ALVEOLAR ABSCESS* 
E. Herbert Adams, M.D., D.D.S. 
ALVEOLAR abscess is a term applied to any abscess having its origin 
in the alveolar process of either of the maxillae. It is generally due 
to a pericementitis occurring at the apex of the root of the tooth, and 
caused by the death of the dental pulp. The first pus is pent up in the 
apical space by bony walls, and the pressure being very great results in the 
rapid destruction of the surrounding osseous tissue. The pus burrows 
where there is least resistance, and on account of the cancellous nature 
of the bone surrounding the root, and the denser nature of the bone nearer 
the surface, a larger pus cavity is formed. 
The pericemental membrane surrounding the apex of the tooth is even 
yet not perhaps destroyed ; but its fibres become elongated and their 
meshes filled with pus; the swollen tissue forming the shreddy bag-like 
mass so often seen attached to the end of a root of an abscessed tooth after 
extraction. 
Should the outer lamina of bone be perforated, the pus has then ready 
exit through the soft tissues. The pain now lessens, and the symptoms 
abate somewhat. This may, however, be only a temporary cessation. The 
whole side of the face may swell up, the eye be distorted, or the jaws be so 
stiffened or swollen that they cannot be separated sufficiently for feeding 
purposes. 
An examination will show a large swelling over the affected root. The 
swelling will usually show signs of fluctuation, and if left to itself will gener- 
ally open just above the root. It is better, however, to anticipate nature 
by opening with a bistoury. After the discharge of pus, the swelling and 
pain usually subside. 
Unless the affected tooth is removed, or the diseased pulp removed 
from the interior of the tooth by a dentist and the pulp cavity rendered 
aseptic a chronic source of irritation is kept up, and the abscess assumes 
the chronic type. 
In acute alveolar abscess there may be seen, occasionally, a consider- 
able elevation of temperature, even as high as 1030 or 1040. During 
abscess formation, and before the pus has found exit, a peculiar dull, throb- 
bing pain is often present, and the lymphatics at the angle of the jaw are 
sometimes sore and swollen. 
*Read before the Toronto Medical Society. 4 
ADAMS: ALVEOLAR ABSCESS. 
An abscess, if left to itself, usually assumes the chronic form, the pus 
continuing to be discharged, but in lessened volume. In the chronic form 
of alveolar abscess the burrowing of pus may cause a fistulous opening in the 
cheek, chin, or neck, though the most usual place for the abscess to dis- 
charge is on the gum over the roof of the affected tooth. 
Abscesses associated with the wisdom teeth, or third molars, sometimes 
pass in the direction of the parotid region. In these cases it is not 
uncommon to find the orifice of the fistula as low down as the clavicle. 
This is due to the unyielding character of the parotid fascia, which is a 
continuation of the deep cervical. 
On account of the close relation of the roots of the teeth of the upper 
jaw to the antrum abscesses may open in the maxillary sinus, and thence 
be discharged through the nares. These cases are frequently mistaken for 
a diseased condition of the nasal passages, and treated accordingly, and, 
of course, invariably without success. The relation of the roots of teeth 
to the antrum is variable. In some cases the floor of the antrum is 
perforated by the first and second molars, so you can readily see how an 
abscess can open in this way. 
The habit of applying hot fomentations, poultices, and counter-irritants 
to the cheek and face is often to blame for abscesses pointing on the face 
and neck. 
One of the most common places for abscessed teeth of the upper jaw 
to open on the face is just beneath the malar bone, and just in front of the 
anterior border of the of the masseter muscle. A disfiguring scar often 
results if the abscess is allowed to open in this or any other facial region. 
Such abscesses may discharge anywhere below the region of the eye. 
Occasionally, abscesses of the superior incisors discharge directly into 
the nasal cavity, and an abscess of an anterior tooth has been known to 
pass back beneath the mucous membrane of the hard palate, and discharge 
at the junction of the hard and soft palate. 
The greater number of abscesses discharging on the face are in the 
lower jaw. This is probably due to gravitation. Frequently these 
abscesses open first on the gum, but during the healing process this open- 
ing becomes closed. Little pus perhaps remains as the abscess becomes 
chronic, but the slow burrowing of this, according to the law of gravitation, 
causes it finally to find exit through the lower jaw. There may be no pain 
nor other symptoms until this opening has occurred, much to the surprise 
and annoyance of the patient; the pus in some cases passing directly down- 
ward through the bone, but more frequently passing outward into the soft 
tissues, and then following these downward to point at the lower margin 
of the jaw. 
Blind abscesses may occur, the pus being small in quantity, and being ADAMS : ALVEOLAR ABSCESS. 
5 
apparently absorbed without any external opening being formed for its exit. 
Occasionally, alveolar abscesses have been known to cause extensive 
necrosis of the bones of the face. This is more especially the case in 
strumous or syphilitic patients. 
Abscesses may also form osseous cysts on the side of the jaw. The 
pus, instead of being absorbed, is provided for by the expansion of the outer 
plate of the bone. These cysts form some what rapidly, and are sometimes 
half the size of a hazelnut. The rapid growth of these cysts is an impor- 
tant point in diagnosis. 
In persons with an abnormally small jaw, the eruption of the wisdom 
teeth often causes severe inflammation and abscess, the jaw being too small 
to accommodate the new tooth. These abscesses generally discharge at 
the margin of the gum, but the swelling is often so severe as to cause 
almost complete immobility of the jaw. In a recent case where it was 
impossible to open the jaw sufficiently to extract the offending wisdom 
tooth, the second molar was removed, and of course the third molar had 
now a chance to come forward and the inflammation soon subsided. 
Imprisoned teeth may be a cause of alveolar abscess. The diagnosis 
of these forms is rather obscure. A probe passed into the sinus, if one has 
been formed-if not, a bistoury passed through the softer parts and bone- 
will often assist in the diagnosis of such cases. Abscesses of temporary 
teeth require especial care, and if they are not readily amenable to treat- 
ment the diseased tooth should be extracted. 
The diagnosis in most cases is comparatively simple; but from what has 
been said it will be seen that the diagnosis, of some forms at least, of 
alveolar abscess is not an easy matter for the general practitioner. And 
it is these unusual and anomalous cases that most frequently come under 
the observation of the physician and surgeon, and the ignorance displayed 
in treatment renders matters often uncomfortable for the patient, and not 
infrequently so for the surgeon. 
A simple means of testing whether a tooth is abscessed is by rapping 
the tooth with an instrument. If it should prove tender on pressure, the 
apical pericemental membrane is inflamed, and the root of the tooth 
probably abscessed. 
Abscesses most frequently occur on teeth with dead pulps. In such 
teeth the natural translucence of the tooth is gone, the dentinal tubuli 
being filled up with dead matter, due to the disintegration of the pulp. 
The dark color and opacity is often very marked, but is occasionally so 
slight as to escape notice. If, however, the patient is placed in the sun- 
light and the rays of light reflected on the teeth by means of a mirror, 
a slight opacity, will be noticed. 
The patient's notice is often directed to a painful tooth as a possible 6 
ADAMS : ALVEOLAR ABSCESS. 
cause of the trouble, but it must be remembered that neither a decayed 
tooth nor pain need necessarily be present. The pulp may have died 
from some other cause, and the diagnosis can be made by the opacity of a 
tooth and its tenderness on pressure. 
The following are some of the cases which have been recorded in dental 
and medical literature as cases of mistaken diagnosis : 
Dr. Otto Arnold {Dental Review} mentions a case where a patient was 
confined to her bed by what her physician supposed to be diphtheria. After 
being treated for about a week, she began to suspect that her teeth were in 
some way implicated. The pharynx and tonsils were severely inflamed, 
but after some difficulty the diagnosis of an impacted wisdom tooth was 
made, and on its extraction she got well. 
Dr. C. R. Butler {Items of Interest, 1891) mentions a case, diagnosed by 
the patient's physicians as carbuncles,but which proved to be due to alveolar 
abscesses from three dead teeth. On their extraction a cure was effected. 
J. P. Wilson {Items of Interest, 1888) mentions a case of alveolar 
abscess of eight years' standing, where there was a fistulous opening over 
the clavicle, near the place of origin of the platysma myoides muscle. The 
disease had been pronounced by a council of physicians to be of a strumous 
character. He removed the roots of a diseased first molar and the dis- 
charge soon ceased, and the abscess healed without further treatment. 
Dr. Tees {Items of Interest, 1886) mentions a case where death occurred 
from a surgeon performing a surgical operation on a case of alveolar 
abscess with much facial swelling, the patient sinking gradually after 
the operation. He states that the abscess differed in no way from an 
ordinary alveolar abscess, the three roots of the first left superior molar 
being diseased, and the swelling of a sudden and recent nature. 
A case recently occurred which had the following history: A boy 
had a swelling of the face. His family physician applied poultices 
and hot fomentations to the side of .the face, and afterwards opened 
into the pus cavity with a lancet. A running ulcer formed, which 
lasted for about a year and three months. The school authorities 
refused to admit the boy to school during this time on account of the 
disease. The boy was examined by a couple of physicians from the civic 
health department, who also recommended his detention from school. 
He would probably be absent from school still and the abscess still dis- 
charging had not another physician made the diagnosis of an abscessed 
tooth. On the extraction of this tooth, the abscess healed readily, and the 
sinus closed of its own accord. 
The treatment is comparatively simple in most cases, and consists in 
the evacuation of the contents of the pus cavity, and in injections of anti- 
septics until it is rendered thoroughly aseptic. ADAMS : ALVEOLAR ABSCESS. 
7 
In the more simple cases this is readily accomplished by a dentist drill- 
ing through the root canal and thus allowing an exit for the pus, and an 
opening through which antiseptics can be injected. It is rare, indeed, that 
a skilled dentist cannot successfully treat even the worst cases by this 
means. Of course, if the offending tooth is for any reason considered of 
no value, the simplest method of cure is its removal, when the abscess will, 
as a rule, heal without any medication. 
In some cases a simple way is to drill through the alveolus, just above 
the root of the tooth, and thus give an exit for the pus, and an opening for 
antiseptic medication. If it is desirable to keep this sinus open, a simple 
method is to place a pledget of cotton, soaked in a strong solution of car- 
bolic acid, in the sinus. 
In acute alveolar abscess where there is much swelling of the face, it is 
often well to endeavor to cause the abscess to point on the buccal surface 
of the gum over the root of the abscessed tooth. This can often be 
accomplished by the application of a counter-irrit ant, such as capsicum or 
cantharidine, to the gum overlying the root of the affected tooth. A roasted 
fig or raisin is said also to accomplish the same result. 
All applications of hot fomentations, or poultices, or counter-irritants 
to the external surface of the face should be religiously avoided, and if the 
abscess seems to have a tendency to point externally a free incision for the 
pus should be made in the mouth, and the counter-irritants or other medica- 
ments applied in the mouth. This will prevent many an opening on the 
face, and its consequent scar. 
Constitutional treatment should not be neglected where indicated. A 
saline cathartic will often assist in hastening the removal of an acute 
abscess. 
In those cases where there is a fistulous opening on the face, it is 
always well to direct, if possible, the discharge into the mouth. If this is 
done the sinus will heal of its own accord, and the abscess can then be 
treated in the usual manner. As a rule, the sinus needs little attention 
after the abscess has healed. 
Often considerable disfigurement results from the scar due to a fis- 
tulous opening on the face. If under the chin the scar does not show 
much, and in a male can be covered by a beard. If on the neck it may be 
hidden by the clothing; but on the cheek, especially in a female, little can 
be done to hide the disfigurement. 
And here let me give a note of warning. A great many cases have 
come under my observation where surgeons have made external facial 
incisions simply because the abscess showed a tendency to point on the 
face. In one case where the simple extraction of the tooth would have been 
all that was required to heal the abscess (though even that was not neces- 8 
ADAMS: ALVEOLAR ABSCESS. 
sary), a prominent surgeon made a crucial incision in the cheek, thrust in 
a couple of his fingers as an exploratory procedure, and then ordered a 
lotion of ac. carbol., i in 20, to be applied externally. 
It is needless to state that such treatment is very reprehensible. There 
are cases where an external incision is indicated, but these are the excep- 
tion and not the rule. In such cases, if the knife is used in a conservative 
manner, the healing process is speedy on account of the vascularity of the 
facial tissues, and often no perceptible scar remains. 
From an aesthetic point of view, the surgeon should always endeavor to 
give vent to the pus by an incision inside the mouth, and not by an incision 
on the surface of the face. 
One of the hardest tests to which my powers of argument were ever put 
was in persuading a fellow practitioner from making a great gash in the 
cheek of a lady who had an alveolar abscess, which any good dentist 
could successfully treat by drilling through the root canal, and giving vent 
to the pus in that manner. 
In regard to antiseptic medication any reliable antiseptic will do. Car- 
bolic acid, peroxide of hydrogen, listerine, and campho-phenique are per- 
haps the favorites with dentists. Thymol, creasote, oil of cloves, oil of 
cinnamon, sanitas, salicylic acid, iodine, and various other antiseptics, all 
have their advocates. 
In this paper I have purposely omitted going into the detail of treat- 
ment of the simpler forms of alveolar abscesses, as they belong to the 
domain of the dentist and not of the surgeon. I would also strongly 
recommend that in all cases of doubtful diagnosis a competent dentist 
or oral specialist be called into consultation. These abscesses respond 
speedily to proper treatment, and the diagnosis, too, is, as a rule, simple to 
the dentist or oral specialist; and yet there are innumerable cases where 
the patient has been disfigured or inconvenienced for years by this disease 
simply through the ignorance of their family physician, who has failed to 
make a correct diagnosis. Later on, perhaps, a correct diagnosis is made by 
a dentist, or some one who is familiar with the disease, and the patient is 
cured in a few days or a week. Naturally, the patient is much embittered 
against the medical man whose ignorance allowed such a foul ulcer to 
remain on their face for such a long time. 
Prophylaxis is of importance in the prevention of alveolar abscesses, 
but this belongs largely to the domain of the dentist. It should, however, 
be the duty of every physician, whenever he finds decayed or offensive 
teeth present in any patient, to impress on them the importance of visiting 
their dentist and having their teeth attended to.