Periapical abscess

Background

Maxillary right second premolar after extraction. The two single-headed arrows point to line separating the crown (in this case, heavily decayed) and the roots. The double headed arrow (bottom right) shows the extent of the abscess that surrounds the apex of the palatal root.

• Associated with dental caries or nonviable teeth
• Significant erosion of the pulp with bacterial overgrowth

Clinical Features

Abscess originating from a tooth that has spread to the buccal space. Above: deformation of the cheek on the second day. Below: deformation on the third day.

A decayed, broken down tooth, which has undergone pulpal necrosis. A periapical abscess (i.e. around the apex of the tooth root) has then formed and pus is draining into the mouth via an intraoral sinus (gumboil)

• Acute pain, swelling, and mild tooth elevation
• Exquisite sensitivity to percussion or chewing on the involved tooth
• Swelling in surrounding gingiva, buccal, lingual or palatal regions
• May see small white pustule (parulis) in gingival surface characteristic for abscesses

Differential Diagnosis

Dentoalveolar Injuries

• Dental fracture
• Dental subluxation
• Dental avulsion
• Bleeding dental socket

Odontogenic Infections

• Acute alveolar osteitis
• Acute necrotizing ulcerative gingivitis (trench mouth)
• Dental caries (pulpitis)
• Ludwig's angina
• Periapical abscess
• Pericoronitis
• Periodontal abscess
• Peritonsillar abscess (PTA)
• Retropharyngeal abscess
• Vincent's angina - tonsillitis and pharyngitis

Other

• Scurvy
• Gingival hyperplasia
  • Phenytoin
  • Cyclosporine
  • Nifedipine, Amlodipine
  • Leukemia

Evaluation

CT scan showing a large left tooth abscess with significant inflammation of fatty tissue under the skin.

• Clinical evaluation
• Radiographs

Management

• Analgesia with NSAIDs, opioids and/or local anesthetics
• Dental follow-up within 48 hrs.
• Emergent oral surgeon follow-up if complicated (Ludwig's angina, Lemierre's syndrome)

Antibiotics

Treatment is broad and focused on polymicrobial infection

• Amoxicillin-clavulanate 875 mg PO q12 hours x 7 days
• Clindamycin 300 mg PO q8 hours x 7 days
• Penicillin VK 500 mg PO q6 hours x 7 days (frequently prescribed but no longer recommended as monotherapy)
• Ampicillin/Sulbactam 3g IV q6 hours x 7 days

I&D

• Can be performed in ED depending on provider comfort or by a dental consultant

Procedure

• 11 or 12 blade stab incision
• Hemostat blunt dissection +/- packing

See Also

• Dental Problems

References

• ER Atlas