Periapical and Dentoaveolar Abscesses

Abscess make up of about 2% of all dental problems around the root tips of the teeth.  This oral infection is divided into two forms.  The primary (neoteric) form involves the inflammation of the pulp and has little no significant change that can be seen on the dental x-rays.  They are also named as an acute apical periodontitis or acute periapical abscess.  The secondary (recrudescent) form comes from a previously existed, asymptomatic lesions such as granuloma, cyst, scar, and cholesteatoma. 

The causes and the course of the disease

The primary abscess always appears suddenly.  It is associated with the root tip of the tooth and a dead pulp.  The inside of the root canal contains large numbers of live bacteria that spread quickly into the surrounding tissue.  This rapid spread of the infection causes the dental ligament to become inflamed (acute periodontitis) and results in an extremely painful toothache.  Sometimes, the inflammation is so sudden and severe that it pushes the tooth slightly out of the tooth socket and brings even more pain when chewing.

The secondary abscess may be either acute or chronic, depending several factors such as the number and the aggressiveness of the offending bacteria, the immune system of the patient, and the type and timing of the treatment provided. Often various strains of staphylococci and streptococci are causative microorganism; however, a wide variety of other anarobes microorganisms such as  Baccteroides, Peptococcus, Pepr­tostreptococcus, Actinomyces, Eubacterium, and Fusohacterium, are sometimes found. These frequently en­countered anaerobes are resistant to penicillin.

The clinical features

On clinical examination the tooth with an acute abscess is painful to percussion, and if it is in occlusion, the patient complains that it seems "high" when it touches with the opposing tooth. As a rule it does not respond to electrical pulp tests. The application of ice, however, relieves the pain somewhat, in contrast to heat, which intensifies the pain. The tooth may display increased mobility.

If let to progress without treatment, the abscess may penetrate the jawbone at the thinnest and closest point to the root tip and form a space infection in the bordering soft tissues. The abscess area is painful, and the surface of the skin over the abscess feels warm and rubbery to palpation and shows fluild-like feel. The body temperature may be lifted. Aspiration usually produces yellowish pus. Regional lymph nodes may become enlarged and painful.

If circumstances are unfavorable, such as lowered host resistance combined with virulent multiplying organisms and inadequate early treatment, serious complications may occur.  Complications like osteomyelitis, septicemia, septic emboli, asphyxia from a Ludwig's angina or other space infection can compromise the airway and could be fatal.

A chronic infection happens when the virulence and number of the organisms are low and the host resistance is high If left untreated, the chronic abscess often forms a sinus tract, allowing the pus to drain to the surface. A small growth of inflammatory tissue forms on the surface and is called a parulis. When drainage is established, the tooth and associated swelling are no longer painful because the pressure of the abscess is lessened.

The differential diagnosis

When a painful fluctuant swelling is present, the diagnosis of an abscess is suspected. Whether the abscess is the primary or secondary type, however, is more difficult to decide.  This is because the original periapical lesion may not be easy to identify. Sometimes, this identification is often impossible because the tissue makeup has been destroyed by the infection.

If the abscess comes from a progression of pulpitis, cyst, granuloma, scar, or cholesteatoma is not of practical concern.  However, it is critical when the abscess comes from either a secondarily infected primary tumor or secondary malignant tumor.

It is also necessary to consider that not all abscesses involving teeth are of pulpal origin. The periodontal (gum) abscess, originating in a deep periodontal pocket, is a common lesion and can be distinguished from the periapical abscess by proper radiographic and clinical examination.  If the x-ray shows the absence of a periapical involvement, it usually is a periodontal abscess.  In addition, the pulps of teeth with such periodontal abscesses are almost always, vital.

The recommended treatment

The acute abscess should be treated aggressively to alleviate the patients pain and to ensure that untoward sequelae do not occur. It is better to establish drainage immediately if possible, since this speeds the resolution of the abscess.  Drainage may be set up by opening the pulp chamber and passing a file through the canal into the periapical region. When drainage cannot be established in this manner, a trephination procedure is suggested. This procedure involves making a window through the mucosa and bone to the abscess at the root tip.  When the abscess spreads to the spaces around the chin, cheek, tongue and roof of the mouth, a through-and-through drain may need to be placed and frequently irrigated.

In more severe cases penicillin therapy should be began immediately, not less than 500 mg 4 times a day for at least 5 days. If the patient is allergic to penicillin, then Dr Antonious may prescribe erythromycin or clindamycin.

It is sometimes viewed unwise to extract a severely abscessed tooth (especially if much surgical manipulation is needed).  Unless the patient has been adequately treated with antibiotics to ensure an effective blood level, the patient is at risk of the bacterial shower in the circulation produced by surgical manipulation in an abscessed area.  Nevertheless, it is advantageous to keep the offending tooth once the acute phase of the infection has been controlled. Routine root canal treatment may be performed with or without a root resection to save the tooth.

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