What is a Palatal Abscess?

front tooth abscess

This is an abscess – but it’s not on the palate.

Many patients will come to a dental office stating something to the effect of “I have an abscess” or “I have this bump here so it must be an abscess.” But what is an abscess? And more specifically, what is a palatal abscess? In this post, we will not only describe it to you, but we will show you incredibly detailed photos!

An Abscess Defined

Before we talk about a specific type of dental abscess – a palatal – let’s first define what an abscess is:

A circumscribed collection of purulent exudate appearing in an acute or chronic localized infection frequently associated with swelling and other signs of inflammation.

A more simplified definition would be:

A localized collection of pus associated with an infection.

We can further define an abscess based upon the location, consistency of the pus, and other variables. For this post, we are focusing on abscesses located on the palate (the roof of your mouth).

So a Palatal Abscess is Associated with the Palate?

A drawing of a palatal abscess

Diagram of a palatal abscess.

Yes!

A palatal abscess is a collection of pus associated with an infected tooth that drains onto the palate (a.k.a. roof of the mouth).

When an infection with a tooth develops, it most often begins at the tip of the root deep inside the bone. The infection expands within the bone, with pressure building. Ultimately, the infection perforates the bone, and enters the soft tissue, which creates a swelling.

In a palatal abscess, the infection spreads from the tip of the root towards the palate, resulting in swelling on the roof of the mouth near the offending tooth.

Palatal Abscess Photo #1

The photo below was taken in my dental office in Orange, CT. She developed a LARGE swelling on the roof of her mouth on the right hand side:

Upper right molar palatal abscess

Palatal Abscess associated with a fractured upper right molar. Clicking on the photo will show you all the gory details! Photo courtesy Dr. Nicholas Calcaterra.

In the above case, this 70 year old female split her upper right molar in half. This lead to an infection which culminated in a large palatal swelling. The solution was to remove the tooth and drain the abscess – which I did! Within a week, she was back to normal (except she no longer had the tooth).

Palatal Abscess Photo #2

This photo was taken on a mid 20s female. You are looking up at her palate. The infected tooth was #7 – her right maxilary lateral incisor. You notice a LARGE swelling.

Palatal Abscess with a maxillary lateral incisor

Abscess on the palate associated with an infected upper lateral incisor. Clicking on the photo will show you incredible detail. Photo and subsequent treatment by Dr. Nicholas Calcaterra.

Treatment for this patient involved draining the abscess and then performing a root canal. I am pleased to report that the treatment succeeded and that she still has the tooth!

Palatal Abscess Photo #3

This patient in her mid 70s developed swelling in the upper left. She called us but was not able to arrange transportation to see us for approximately 48 hours. In the interim, we prescribed antibiotics for her, which she began taking. When she arrived, she reported that there had been a swelling, but it had suddenty went down rapidly, accompanied by a metallic taste.

Palatal abscess that perforated and drained

Palatal Abscess that grew very large – and then ulcerated and drained. Photo and treatment performed by Dr. Nicholas Calcaterra.

In the above photo, the tissue is only slightly swollen now, but there is now a large ulceration. Treatment involved extracting the offending tooth. She was much happier after the tooth was gone!

I hope you enjoyed this post and the photos. I have dozens more photos. Want to see more? Leave a comment and I’ll post more.

Can You Do a Root Canal Through a Crown?

As a busy dentist in private practice, I get some variation of the “can I get a root canal on a tooth with a crown” question quite frequently. The question comes in various forms, but the general summary is something like this:

“I got a crown done about three years ago. Everything was fine until a week ago, and now it feels like it is on fire. I think I need a root canal. Can you do a root canal through a crown?”

The answer to this question is yes (most of the time).

Why Teeth Need Root Canals

Before we describe why/how a root canal is done through a crown, it is important to know why teeth sometimes need root canals.

tooth with cavity needing a root canal

This tooth had a large cavity. The brown spot visible in the photo is the decay. On subsequent removal of the decay, the nerve became inflamed, and the tooth needed a root canal.

A tooth needs a root canal when the nerve inside the tooth becomes inflamed or infected. This can be due to several reasons, including:

  1. Dental decay (a.k.a. cavity) that either comes close to or enters the nerve of the tooth.
  2. A crack or fracture of the tooth where the nerve become exposed.
  3. A large restoration (filling) placed very close to the nerve. The filling is done due to the presence of decay and/or cracks (as talked about in points 1 and 2 above). Note it is not the filling that causes the need for the root canal, but rather the decay and/or fracture.
  4. Trauma to a tooth in which the nerve is injured.
  5. Other more infrequent causes (internal resorption, external resorption, jaw cysts, metastatic malignancies which enter the jawbone, etc.)

Generally speaking, reasons 1, 2, and 3 are the causes for 99% of all root canals.

What is a Root Canal?

Describing a root canal is not the point of this post. But a general summary can be presented.

Root canal access cavity

View of a cleaned out nerve chamber of a lower tooth as seen from directly above the chewing surface. The 3 holes are entry points to 3 separate canls.

In a root canal, the infected and/or inflamed nerve tissue inside the tooth is cleaned out and then filled with a special filling material. We do this by drilling a hole from the top of the chewing surface of the tooth into the nerve chamber. In the photo above, you can see the large hole in the tooth which leads down and exposes 3 smaller openings or orifices. These are the openings to the canals of the tooth.

In a root canal, the roots of the tooth remain. They are not removed. By having a root canal done, you are able to keep a tooth that might otherwise have to be extracted.

How a Root Canal is Done Through a Crown

A crown, often called a cap, is a custom fabricated restoration comprised of metal and/or ceramic that covers the top of portion of the tooth. Crowns are done for many reasons, but they are mostly done to protect a tooth that has been compromised by decay and/or fractures.

When a tooth with a crown needs a root canal, you can expect the following sequence:

  1. You will be given local anesthetic so that your tooth is totally numb (and other parts of your mouth too).
  2. A rubber dam will be placed over the tooth.
  3. A small hole will be drilled through the crown into the tooth and into the nerve chamber.
  4. Then the dentist is ready to begin cleaning out the infected and/or inflammed nerve.

Before and after photos showing a root canal through a crown. In the left photo, you see the procedure in process with the rubber dam and access into the nerve chamber. The right photo shows the completed procedure with a filling sealing the access hole. The crown is saved! Photos and dentistry Dr. Nicholas Calcaterra.

In nearly all cases, the root canal is done through the crown, the access is sealed, and then everything goes back to normal.

When Saving the Crown is not Possible

In some cases, doing a root canal through a crown and keeping that crown is not possible. This can happen for a variety of reasons. Some of them include:

  • The decay – which caused the need for a root canal – is so advanced that a new crown is needed.
  • A large piece of porcelain broke off during the procedure so that the crown is no longer functional.
  • A root fracture of the tooth was discovered during the procedure and the tooth must be extracted.

The above list is not comprehensive but covers many of these situations.

In all cases, your dentist or endodontist should discuss with you the likelihood of you keeping the same crown after the root canal procedure.

90 Second Wisdom Tooth Extraction Video

This post, featuring an HD video of a wisdom tooth extraction, is different from many previous posts. Instead of tackling a topic and answering questions via the written word, this post uses a YouTube video to answer questions regarding one of the more feared and dreaded procedures in all of dentistry: wisdom teeth removal.

This video was shot in my office and features a young, early 20s patient having a lower right impacted wisdom tooth removed under IV sedation. The third molar and sedation procedures are performed by me along with two assistants. Check it out here:

Having participated in the filming of dental procedures before, I will tell you that capturing high quality video footage is not easy. Camera angle, proper lighting, patient participation, etc. are all difficult to control. I can confidently say that this is very high quality video footage of a third molar extraction (click here to go directly to the video on YouTube).

This video does answer many questions and resolve many myths that I’ve seen in blog comments and in questions I’ve received over years of private practice. Let’s review them.

Does getting a wisdom tooth extracted hurt?
  • No. In the YouTube video, the patient was given local anesthesia (a.k.a. novocaine) beforehand. She does not flinch nor respond during the procedure. That is because she is numb and is also under twilight sedation.
Does the dentist have to put a knee on my chest to pull the tooth?
  • No. That is a popular myth that I debunked in this post. Extraction of a tooth requires the controlled, precise application of force. It rarely requires a pulling force. The tooth literally slides up and out of the socket – as you can see at the 2:00 mark of the video.
Will I be in pain for days after getting my wisdom tooth out?
  • Not necessarily. Each and every case is different. In this video, the extraction itself only took 90 seconds. So she had very little pain afterwards. Other third molars require more time and are more invasive. Those will likely be more painful afterwards.
What is an impacted tooth?
  • An impacted tooth is when bone, gums, and/or other structures prevent the tooth from coming into the mouth properly. Wisdom teeth are frequently impacted. In the YouTubevideo, we see a soft tissue impacted tooth, meaning that there was a flap of gum tissue preventing the tooth from coming in properly. Other teeth are considered bony impactions in which there is bone preventing the tooth from coming in completely. Bony impaction extractions are typically more invasive.

I hope you enjoyed the video and it helped to answer questions and dispel some myths. Comments are welcome.

The Palatal Injection: Dentistry’s Most Painful Shot

Probably the most frequently commented upon topic on this blog involves what the majority of patients dread the most: the shot. As a result, I’ve posted many articles related to dental injections, including articles on novocaine (no, we don’t use it anymore), epinephrine (the racing heart does not mean you are allergic to it), why some people/teeth are hard to get numb (over ten different reasons), etc.

I’ve also done a two part series on what factors cause some dental injections to hurt more than others (located here and here). However, given the number of comments and questions about palatal injections, it was warranted to create an individual post on what can be considered dentistry’s most painful injection.

What is a Palatal Injection?

This may seem somewhat obvious but it is worth explaining. We’ll start with a photo.

palatal injection photo - most painful dental shot

Injection into the palate on the right side. If it looks painful, it’s because it is painful.

In a palatal injection, local anesthetic is injected into the soft tissue covering the hard palate, just adjacent to the tooth/teeth to be worked upon. It is not an injection into the soft palate nor the uvula. And it is only done for top teeth.

These types of injections are performed when you need the gum tissue on the roof of the mouth to be numb and/or when the procedure requires the tooth to be super numb (like an extraction or root canal). In my experience, for most fillings of upper teeth, palatal injections are NOT needed.

Why Palatal Injections Hurt so Darn Much!

There are two major reasons to explain why these hurt so much:

Tightness/Density – the tissue lining the hard palate is very dense and tight. There’s no “give” to it. The needle initially goes in and is accompanied by a pinch. That pinch is actually not the worst part. The worst part is when the local anesthetic fluid is forced in. There’s literally no room for it because the tissue is so dense. That forcible entry of fluid into this tissue is what causes the pain.

Topical anesthetic does not help with palatal injections

Traditional topical anesthetic does little to help with palatal injections.

Want an analogy? Imagine you have a turkey baster injector. Plunge the injector deep into the breast or thigh. Then try to inject. It will take GREAT force to get even a little fluid into this dense muscle. This is like a palatal injection. Next, move the tip of baster until it is just at the border of the thigh and skin. Then try to inject. There is little to no resistance. Fluid goes in with great ease, taking advantage of the looseness at the skin/muscle junction. This is like most other dental injections.

Traditional Topical Anesthetic Doesn’t Work Well – traditional topical anesthetic, a.k.a numbing jelly, doesn’t penetrate the tissue very easily, regardless of how long you wait. As a result, it exerts little to no effect, thus offering little to no pain relief.

How Palatal Injection Pain Can be Reduced

Fortunately, there are ways to reduce the pain associated with palatal injections. Note, however, that these are all done by the dentist himself/herself (except the last one which involves both dentist and patient).

  1. cotton applicator applying pressure can reduce pain of injection on the palate

    Application of pressure can reduce the pain.

    Waiting – in nearly all cases, if you are going to get an injection on the palate, you will also receive an injection on the cheek side. In many cases, if the dentist waits 10 minutes or so after the “cheek side” injection, some of that local anesthetic will work its way over and partially anesthetize the palate. This will make it so that the palatal injection is less painful.

  2. Pressure – placing firm pressure with a cotton applicator for at 30 seconds can slightly numb or obtund the pain sensation. The pressure is applied on the roof of the mouth right where the injection is going to go.
  3. Super Topical Anesthesia – some dentists will use a pharmacy compounded topical anesthetic that is several times more powerful than traditional topical. Using this correctly can also reduced the pain.
  4. Cold – application of a cold cotton applicator with pressure right before the injection can also reduce the sensation.
  5. Sedation – if you are sedated, you are unlikely to even feel the painful injection, let alone remember it. Sedation dentistry is very effective – I do it routinely in my office.

Not all dentists employ the above techniques. But all dentists are aware of the painful nature of this injection and do their best to only do it when necessary.