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 also named by our Houston dentists 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
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
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
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 he 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
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 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 recommeded 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 our Houston dentist may prescribe erythromycin or clindamycin.
It is 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