ACUTE APICAL ABSCESS [AAA]

“Evil Being the root of mystery, PAIN is the root of KNOWLEDGE.”

Simone Weil

(Philospher)

ACUTE: 1. Sharp, severe.

2. Denoting the swift onset and course of a disease.

Glossary of Periodontal Terms — The American Academy of Periodontology 2001

Apical : apex of a tooth.

Glossary of Periodontal Terms — The American Academy of Periodontology 2001

ABSCESS: Localized collection of purulent exudates (pus) in a cavity

formed by the disintegration of tissues

Glossary of Periodontal Terms — The American Academy of Periodontology 2001

ACUTE APICAL ABSCESS [AAA]

• A severe localized Inflammatory condition

characterized by formation of purulent exudates(

PUS) involving the dental pulp or pulpal remnants

and the tissues surrounding the apex of a tooth.

• An abscess is a natural defense mechanism in

which the body attempts to localize an infection

and wall off the microorganisms so that they

cannot spread throughout the body.

• So as a dentist we are part of QUICK

REACTION TEAM which makes sure that the

problem is timely diagnosed and prevented from

spreading.

Also Known As :

• # Periradicular abscess ( along the root)

• Periapical abscess( around the root tip)

• Apical Abscess ( at the root tip)

• DentoAlveolar abscess

• Tooth root abscess

ETIOLOGY

• Most common factor is Bacterial Invasion of the pulp from a carious lesion.

•

• Toxins from necrotic pulp

• Tooth trauma (infective, mechanical, thermal, chemical) resulting in pulpitis and necrosis.

• Acute exacerbation of a chronic situation, eg-may originate from a pre-existing apical granuloma or cyst.

• Iatrogenic / Procedural Mishaps during

endodontic treatment.

• Partially or previously endodontically treated (if

continued bacterial contamination and/or leakage

occurs)

Abscess can be seated inMultirooted tooth

• Inflammation of the periapical part of the

periodontal tissue being confined to a minute

space between the apex and its surrounding

bone may lead to resorption of :

–Adjacent Bone and

–Root Apex

CLINICAL SIGNS & SYMPTOMS

• Acutely painful to biting pressure, percussion &

Palpation

• No Response to Electric Pulp Testing (However

need not be Non Vital all the time.)

• Varying degrees of Mobility

• Tooth may be elevated in alveolar socket

(pressure from inflamed tissue around the tooth).

• Patient may exhibit raised temperature and

malaise.

• Fractured and/or discolored tooth

crowns/fillings.

• The cervical & submandibular lymph nodes

tender to palpation.

Sequalae Of Periapical Abscess

• Localized swelling( Intra & Extra Oral)

1. LOCALIZED- confined within oral cavity.

2. DIFFUSED- extensive, spreads through adjacent

soft tissues , dissecting tissue spaces along

fascial planes ( Cellulitis)

3. FLUCTUANT- Lying Superficially

4. FIRM-

Radiographically

• Thickening of apical PDL

• Ill defined apical radiolucent lesion. *

DIAGNOSIS

• Ask pointed subjective questions about the patients – pain, history, location, severity, duration, character, & eliciting stimuli if any .

• Meticulous oral examination to identify tooth (teeth) with pulpal pathology (caries, fractured teeth with pulpal exposure, discolored teeth, drainage tracts)

• X-ray to assess periapical status of affected tooth (teeth). Acute abscess may show varying appearances.

• The patient's pain is typically relieved to some

extent by application of cold substances to the

affected tooth.

The following criteria support this diagnosis:

• Acute pain, arising out of a long-standing

infection. Although the patient may not be aware

of a long-standing infection, the tooth now hurts

when biting, chewing, or tapping on it.

• Swelling may or may not be present

• Response to Pulp testing may or may not be there.

• Presence of fever and general malaise (feeling

poorly)

DIFFERENTIAL DIAGNOSISAbscesses generally result in the classic "toothache",

• But other things can make teeth ache as well:

1. Sinus infections may cause the upper back teeth to ache;

2. Heart pain (angina) can radiate into the jaws, producing the symptoms of a toothache.

3. Lymphoma has also been reported to cause repeated toothache pain.

4. Other types of cysts or tumors may also cause the jaws to ache and/or swell.

• It's important that any abnormal conditions in the mouth be identified and properly diagnosed, so that appropriate treatment can be prescribed, and ideal long term oral health maintained.

EMERGENCY MANAGEMENT

• The principle of treating all endodontic periapicallesions is same –

“TO ERADICATE IRRITANTS IN THE ROOT CANAL SYSTEM”

“START by doing what is NECESSARY, then what is POSSIBLE, and suddenly you are doing the IMPOSSIBLE”

(Francis of Assisi)

• FOREMOST Establish drainage to relieve pain

• Once acute phase subsides RCT should be

performed .

• DRAINAGE ACHIEVED BY :-

– Surgical Drainage

• Immediate relieve from Pain

– Access Opening and Drainage

first visit accomplishes two things

• Relief from pain and pressure

• Removal of potent irritants [pus]

ROOT CANAL TREATMENT

• Since abscess is localized ideal drainage can be

done through root canals.

• THUMB rule for managing all these infections is

to ACHIEVE DRAINAGE AND TO

REMOVE THE SOURCE OF INFECTION

• Although leaving these teeth open for a day has

been a COMMON PRACTICE however Current

Trend is NOT leaving open for Drainage.

Thorough Cleaning Of The

Canal

• CLEAN, CLEAN and CLEAN !!!

• Extremely important to remove the ROOT

CAUSE ( bacterial toxins) from within the ROOT

CANAL.

• PROGNOSIS depends on it.

• Avoid pushing of debris into periapex

• IRRIGANT, use Copious amount.

Over Instrumentation

• Establishes drainage & widens the apical constriction.

• Case selection very important

• Only done after thorough cleaning & shaping of canals.

• Reamers & K files instruments of choice.

• Viscous Pus is drained.

• Over instrumentation to be 1-1.5 mm beyond apex

CALCIUM HYDROXIDE

• Proven AntiMicrobial activity

• Due to High pH has the ability to alter acidic

environment of Inflamed Periapical Lesions.

• Can absorb exudate in root canal.

• Even if it goes beyond apex ,its good.

• SINGLE VISIT -VS- MULTIPLE

VISITS

Single Visit Endodontics

• Definitely NOT prefferred in Acute Apical Abscess.

• Patients body language to be OBSERVED CAREFULLY !! ( pt with pain/swelling)

• A green signal if :

1. Dry canals

2. Tooth Asymptomatic

3. Complete cleaning, shaping & filling of canals be achieved in single sitting.

– To be avoided incase of evidence of Pain, Swelling or Exudation

Multiple Visit Endodontics

• Provides shorter initial visit , thus considered

comfortable.

• Intervisit microbial dressing can be provided.

• In either cases the Elimination of BACTERIA is

of PRIME IMPORTANCE.

SURGICAL DRAINAGE

• Surgical management is needed in case :

- when drainage cannot be achieved through the canals

- Rapidly progressing infection

Apart from IMMEDIATE relief from swelling it ALSO reduces the total treatment time.

• Depending upon Location choose b/w Incision & Drainage and Aspiration.

INCISION & DRAINAGE (I&D) :

• Topical anesthesia usually sufficient.

• Else nerve block / infiltration (anterior and

posterior to the area) can be used.

• The area should be cleaned with a disinfecting

solution such as beta dine.

• Use no.11 blade to make the incision

• INCISION given at the site of GREATEST

FLUCTUANT swelling to encourage draining.

• Usually stab incision is made.

• Cut through the mucosa and sub-mucosa into the

abscess cavity eventually extending towards the

offending roots.

• Rinsing with LUKE warm SALT water keeps

wound CLEAN thus promotes drainage.

• This is a modification of technique described by Hoen

et al

• For this method patient should be scheduled for

appointments twice a week & done for 3-4 weeks.

• Topical anesthesia is applied on the mucosa over the

most fluctuant part

• Two 17 gauge needle are inserted side by side about 1

cm apart into the mucosa for a depth of 5-8 mm and

direction perpendicular to the mucosal surface.

• Into one of the needles an empty 10ml syringe is

attached

SIMPLE SYRINGE TECHNIQUE :

• The contents of the lesion is aspirated slowly

• If the patient experiences pain L.A can be injected in the periphery, without withdrawing the needle

• Then the syringe is replaced with another syringe containing normal saline

• Amount of saline must be equal to the amount of

fluid aspirated

• Then the saline is injected very slowly into the

lesion

• This procedure may be repeated three times

• This method is very effective and has

successfully given good results

• It also reduces the treatment time within 3-4

weeks .

TREPHINATION

• Done in absence of swelling.

• NOT in much TREND nowadays.

• Involves making a window through the mucosa and bone to the abscess at the root tip.

• Uses engine driven perforator to enter through the cortical bone.

• Often No Incision required.

• Provides immediate pain relief.

• High chances of causing irreversible injury to the tooth root or surrounding structures (BLIND APPROACH)

ANTIBIOTICS ??

• Antibiotics may be prescribed in conjunction

with Drainage of the tooth.

• In the event of patient with fever, or for an

immuno compromised patient, antibiotics may

be prescribed.

• Clinically when the tooth is tender , usually

antibiotics are prescribed.

• In the management of localized( EARLY) acute

apical abscess in the permanent dentition, the

abscess should be drained through a pulpectomy

or incision and drainage. This analysis indicated

that antibiotics are of no additional benefit.

– Debora C. Matthews, DDS, Dip Perio, MSc •

– • Susan Sutherland, DDS, MSc •

– • Bettina Basrani, DDS, Dip Endo, PhD •

– (© J Can Dent Assoc 2003; 69(10):660)

ANALGESICS

• Only to control/prevent the post operative pain.

• Ibuprofen 400mg is the drug of choice.

• Acetaminophen (max 4gm/24 hrs) is given to

ptnts contraindicated with NSAID’s & aspirin.

Tracing the sinus tract :

• Any sinus opening present has to be traced – this will direct the clinician to which tooth sometimes more specifically which root is the source of the infection

• A size#25 G.P cone is threaded into the opening of the sinus tract

• The cone should be inserted until a resistance is felt

• This may be slightly uncomfortable for the ptnt

• A periapical radiograph is taken

• The termination of the G.P cone shows the path taken

by the sinus tract from the opening to the source.

Advanced Pathway OF AAA or

SEQUELAE

Steven R. Singer, DDS

OSTEOMYELITIS

• Inflammation of the bone

• May spread to involve:

– Marrow

– Cortex Periosteum

– Cancellous portion

• Caused by pyogenic organisms from abscessed

teeth, trauma, or surgery

• Source of infection can not always be identified

• Paraesthesia of the lip may be present, suggesting

a malignancy

• Bacteria and by-products stimulate an

inflammatory reaction in bone

• Presence of sequestra is a hallmark of

osteomyelitis. These can be seen in both plain

films and CT

• SEQUESTRA : a portion of dead bone which

becomes seperated from the sound portion

Radiagraphic Features

• Location

– The most common location of osteomyelitis of

the jaws is the posterior body of the mandible

– Involvement of the maxilla is rare, perhaps due

to its excellent vascularity

• Borders

– The borders of these lesions are illdefined,

gradually blending into the normal trabecular

pattern

• Effects on adjacent structures

– Surrounding bone may be resorbed or laid down

– May cause resorption of the cortex

Treatment

• Acute Osteomyelitis :– Antibiotics Penicillin, clindamycin, cephalexin,

gentamycin

– Drainage

– Extraction Of the Tooth

– Sequestra should be removed.

• Chronic Ostemyelitis :– Intravenous antibiotics

– Removal of necrotic bone

– Immobilization of jaws

– Hyperbaric oxygen

CELLULITIS▪An edematous inflammation

▪Associated with diffuse spreading invasive micro-organism

throughout connective tissue and facial planes.

▪S/S: Diffuse swelling of facial or cervical tissues.

▪Sequelae of apical abscess that penetrates bone, allowing

the spread of pus along the path of least resistance

between the facial structures.

▪Implies usually the facial planes between muscles of face

and neck.

▪ It may or may not be associated with fever and malaise.

(ingle 6th edition)

• Fortunately these rarely occurs

• Rapidly progressive , painful . Severe discomfort

• Swelling not localized

• Regional lymphadenopathy with tenderness [ sub-

mandibular – cervical ]

Treatment

• Incision & Drainage

• Antibiotics

• Endodontic T/t after drainage

• If NO significant Improvement :

(Life Threatening)

– REVIEW diagnosis & t/t

– Referral for persistent infections

– Referral EVEN for Extra Oral Drainage

Ludwig's angina :

• Rapidly spreads to sublingual and submandibular spaces, bilaterally and almost simultaneously

• The characteristic features are diffuse swelling , pain, fever and malaise

• Swelling is tense and tender with characteristic board like firmness

• Overlying skin is tight and shiny

• Pain and edema limit the mouth opening and cause dysphagia

• Regional lymph nodes are swollen and tender

• Tongue becomes hard and pushed against the soft palate

• Systemic condition gets severe soon

• Airway obstruction can quickly result in asphyxia

Any abscessed tooth has the potential to become a life

threatening situation. Infection of a tooth in the lower jaw

can cause swelling of the cheek and under the jaw bone. If

the swelling under the jaw becomes too advanced,

swallowing and breathing can become critically impaired

(Ludwig's Angina).

Treatment

• REFER immediately…!!