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Every Stage of a Tooth Abscess With Pictures

Updated: Jul 18

So you have a tooth abscess and you're wondering which stage of the infection you're in but you don't know what it looks like. Worry not because we're going to describe in detail what each stage of the tooth infection entails as well as pictures for examples.



Stages of a tooth abscess:



Stage Zero - Tooth Decay

A tooth abscess does not miraculously appear out of thin air because there is a legitimate cause with the most common being tooth decay. It always starts off as a small cavity but when left untreated, it can progress into an abscess.


Due to the fact that tooth decay precedes a tooth abscess, we will have to call cavities stage zero of the progression. Before we go into abscesses, we'll go over every step of how a cavities form and develop.


Stages of tooth decay

Cavities are caused by bacteria in your mouth that consume all of the sugars you eat. Therefore, tooth decay starts on the outside layer of the tooth called enamel but then it slowly works its way through the dentin and eventually the pulp.

  1. Enamel

  2. Dentin

  3. Pulp


Here is a diagram of each layer of the tooth:



Enamel decay

The first stage of tooth decay starts in the enamel, which is the outermost layer of your tooth. It is also the hardest layer because it contains the highest concentration of hydroxyapatite, which is a hard mineral that your teeth and bones are made out of.


Here is a picture of what decay in the enamel looks like and consequently the first stage of tooth decay:

small enamel decay on side of molar

Appearance: It looks like a small brown or black spot on your tooth. It can appear on any surface of your tooth, whether it be on the top or the sides. It will feel soft and sticky if you try to probe it with an instrument.


Symptoms: At this stage, the decay is usually painless and not sensitive at all so it may be difficult for you to even realize that you have a cavity. The only way you'd be able to tell is if you looked in a mirror or went for your dental check up.


Treatment: A small tooth filling is sufficient to treat this decay. If it is shallow enough, you may not even need any local anesthesia.



Dentin decay

The second stage of tooth decay begins when an untreated cavity in the enamel is allowed to progress into dentin. The dentin is the second layer of your tooth and is also the middle layer as well. It is much softer than the enamel because it contains less hydroxyapatite so once the cavity reaches the dentin, it will start to grow faster.


Here is a picture of what decay in the dentin looks like:

decay in dentin

Appearance: What it looks like is a bigger brown spot or black spot. Sometimes an actual hole might form if it gets big enough.


Symptoms: Since the dentin is close to where the nerve is, it may feel sensitive whenever you eat something sweet. That is a sign that you may have a cavity but unfortunately, not everyone will experience sensitivity to sweet even if they have a cavity in the dentin. Therefore a lack of sweet sensitivity is not an indication that you are cavity-free.


The texture of the cavity will also feel soft and mushy if you poke it with a dental instrument.


Treatment: A small to medium sized cavity filling should be sufficient for removing the decay. If it happens to be larger than expected and is in close proximity to the nerve but not touching it, a medicinal liner may be used prior to placing the filling material.



Pulp decay

The third stage of tooth decay starts when an untreated cavity in the dentin progresses into the pulp. The pulp is the innermost layer of your tooth and literally located in the middle of it. It is the softest layer and also filled with blood vessels and nerve tissue.


Here is what pulp decay looks like:

pulp decay

Appearance: What it looks like is usually a very big brown or black hole in the tooth. For a cavity to get into the nerve, it has to have grown very large. The size of the decay is proportional to the size of the brown spot.


Symptoms: Since the pulp of the tooth is where the nerve resides, once the cavity reaches here it may cause you an unbearable toothache. It could also be a throbbing toothache that comes and goes. The worse is when it causes you extreme tooth pain that you can't even sleep.


Treatment: Once the decay reaches the nerve, the nerve will need to be treated and that can only be done with a root canal. That procedure involves separating the nerve from the tooth but the tooth remains in the mouth.




First Stage - Periapical Pathology (PAP)

The first stage of a tooth abscess happens once the infection travels through the pulp and down to the tip of the root. The infection will then proceed to eat through the bone around the root tip and eventually form a dark circle which can be seen on a dental x-ray. Once we can see this dark circle, it is officially a tooth abscess.


Here is an x-ray of the dark circle which is consequently a dental abscess:

dental abscess in bone

Appearance: You can't actually see a dental abscess at this stage because it is hidden within the bone. The only way you would be able to see it is if you drilled through the bone to expose it. Aside from that, the primary way that your dentist is able to see it is with a dental x-ray.


Symptoms: An abscess within the bone can be extremely painful because it can start swelling up with pus. The pain that you feel is from the increase in swelling pressure.


Treatment: If you catch this tooth abscess early, you may be able to treat it with just a root canal. If you don't catch it in time, your dentist may need to place antibacterial medication within your tooth for a few weeks prior to finishing the root canal. It just adds more time to the total treatment.


Here is a picture of a completed root canal:

completed root canal



Second Stage - Parulis (Abscess on the gum)

The second stage of a tooth abscess happens when the infection in the bone eats through the bone completely and then forms a pimple on the gums. This pimple is full of pus and is what we call a parulis or more commonly a gum boil. It is basically an abscess on the gums but please do not mistakenly call it a gum abscess because that is a different condition with a different etiology.


Here is a picture of what an abscess on the gums look like:

parulis

Appearance: This is the first stage that you can finally see what a dental abscess looks like and its similar to a pimple by the side of your tooth that is either pink or red in color. If you squeeze it and pop it, you will see pus flow out of it because that is what infections are composed of. This gum boil is usually located on the gums around the tooth.


Symptoms: This stage of the abscess is usually not painful because most of the pain is derived from the swelling pressure that has no where to go. Once the parulis forms, it can be popped and that actually relieves the pressure. Therefore you should not feel much pain once this pimple forms. If you do feel pain, it is typically less than what you were experiencing before it formed.


Treatment: You will definitely need a root canal by your dentist and they will have to place medication inside of the tooth. If the gum boil is big enough, it may also need to be drained in addition to the root canal treatment.




Third Stage - Facial Swelling

The third stage of a dental abscess is when your face starts to swell up from the untreated infection. The face swells up because the abscess continually produces more pus and since it has nowhere to go, your face is forced to continually expand like a balloon.


Here is a picture of what an abscess with facial swelling looks like:

abscess with swelling
Credit: Wiki

Appearance: The abscess is usually located on one side of the face so only the affected side will swell up. The swelling will continue to expand and grow larger day by day if left untreated. Therefore the size of the swelling is indicative of how many days it has been. The swelling can look very disfiguring, almost as if you have a golf sized ball in your cheeks.


Symptoms: As you can imagine, it hurts when your face swells up to this size. It will feel tender and warm to the touch. It could be soft or it could be hard depending on how mature the swelling is.


Treatment: The swelling itself will need to be drained by your dentist and that is the only way to get pain relief. You will need to take the full course of antibiotics and you must finish it. Once the swelling has started to come down, your dentist can then finally treat the source of the infection, which is the infection coming from the offending tooth. That tooth will either need a root canal or will need to be extracted depending on the condition of it.


Here is a video showing a dental abscess being drained in the mouth. Yes, it is drained from within the mouth and not outside of it when it is at this stage.




Fourth Stage - Airway Compromise

The fourth stage of a tooth abscess begins when the swelling from the face spreads lower towards the throat and causes throat swelling. Since your airway runs through the throat, swelling around this area can compress it and make it difficult to breath. In the worst case scenario, the swelling can be so bad that it could completely cut off your ability to breath.


That makes this stage of the infection potentially life threatening because if you lose your ability to breath, it would be fatal. This condition should not be ignored and you should seek medical help immediately.


Here is a picture of what swelling that can compromise the airway looks like:

severe facial abscess in the throat

Appearance: This swelling is located near the throat and lower jaw, which is where the airway begins. Therefore what it looks like is a massive expansion of soft tissue of the throat and lower jaw. The swelling can look like you have a large baseball stuck down there. That is how big it can get.


Symptoms: With the size of this type of swelling, it will be excruciatingly painful. You may find it hard to talk and eat. Last but not least, you'll definitely find difficulty breathing.


Treatment: When the tooth infection has gotten to this stage, you are better off getting treatment at a hospital because private dental clinics will not be equipped to handle it.

  • Requires hospitalization until the condition stabilizes.

  • Abscess will need to be drained.

  • Physical drains will need to be placed and sutured into the abscess to let it drain for the next few days.

  • Be prepared to be pumped full of antibiotics for the entire duration of your hospital stay.

The difference between drainage at this stage vs the previous one is that it requires extra-oral drainage. The previous stage was intra-oral, meaning you drain it from inside the mouth. At this stage you drain it from outside the mouth in addition to inside the mouth.


Here is a picture of what drains placed in a severe abscess looks like:

abscess with drains in place
  • There is literally a piece of plastic that is stitched into the abscess in order to keep it open. The plastic is to allow the infection to continue to drain. If you close it up without the plastic tube, the patient may swell back up again.




Fifth Stage - The Afterlife

The fifth and last stage of a tooth abscess is the afterlife because the previous fourth stage was life threatening. It was dangerous and potentially fatal because it can compromise your airway and ability to breath. If you did not get it treated at the previous stage, there is no second chances. Hopefully you were able to find medical help.


In case you were wondering, yes a tooth infection can kill you and how long it takes really depends on which stage of the infection you are at. If you're at the earlier stages you have more time but if you're at the later ones, you don't have much time at all.



Prevention

Rather than letting a mild cavity grow into an abscess, the best thing that you can do is actually prevent it from happening in the first palace. You should follow these tips by our dentists on how to not get to the point of requiring treatment for a dental infection.

  • Routine dental check ups every six months.

  • Brush twice a day for at least 2 minutes each time.

  • Floss before you go to bed.

  • Use a mouthwash periodically to keep bacteria in check.

  • Minimize or eliminate sugar from your diet.

  • Treat small dental problems immediately.



Treatment

To sum it all up, here is a review of what treatments are required for each stage of the abscess.

  • Stage Zero - Dental filling

  • Stage One - Root canal and crown

  • Stage Two - Root canal with medication and crown

  • Stage Three - Abscess drainage along with either root canal or extraction

  • Stage Four - Hospitalization

  • Stage Five - The current extent of science cannot help you



Takeaway

Hopefully that clarifies what each stage of a tooth abscess consists of. This guide was full of details as well as pictures so you should know what each particular stage looks like. You should also know what to expect when you get treatment as well.



Author: Written by Dr David Chen, a dentist in long island city.

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About the author: Dr David Chen, DDS

Hello, I'm Dr Chen and I'm an actively practicing dentist in Long Island City, NY. I graduated from Columbia University College of Dental Medicine in 2016 but prior to going to dental school I was already working in the dental field. It's been more than a decade since I first got to know dentistry and let me tell you, time flies by quickly. Since then I've developed a fondness for writing, which is how this all got started!

Association Memberships:

Medical Disclaimer:

This blog is purely meant for information purposes and should not be used as medical advice. Each situation in your mouth is unique and complex. It is not possible to give advice nor diagnose any oral conditions based on text nor virtual consultations. The best thing to do is to go in person to see your dentist for an examination and consultation so that you can receive the best care possible.

The purpose of all of this oral health information is to encourage you to see your dentist and to inform you of what you may expect during your visit. Due to the unfortunate nature of dentistry, there isn't really any true home remedies that will get rid of dental problems. Roughly 99.99% of them require in-person intervention by a healthcare professional.

Hint: That is the reason why you can't eliminate seeing dentists in your life!