Acute Apical Abscess Treatment

Symptomatic Apical Periodontitis –  Acute Apical Periodontitis

Symptomatic apical periodontitis is defined as painful inflammation of the periodontium as a result of trauma, irritation, or infection through the root canal, regardless of whether the pulp is vital or nonvital. It is an inflammation around the apex of a tooth.

Symptomatic apical periodontitis Etiology:

• In vital tooth, it is associated with occlusal trauma, high points in restoration, wedging or forcing objects between teeth.
• In nonvital tooth, it is associated with sequelae to pulpal diseases.
• Iatrogenic causes can be over instrumentation of a root canal, pushing debris and microorganisms beyond the apex, overextended obturation, and root perforations.

Read And Learn More: Endodontics Notes

Apical periodontitis Signs and Symptoms:

Apical periodontitis serves as a protective function, confining the microorganisms extruded from root canal space and preventing them from spreading in adjacent bone marrow areas. But it can’t eradicate the source of infection because the defense mechanism of pulp can’t come into play due to lack of vascular supply, once the pulp is nonvital.

This mechanism occurs at the apical area but can’t penetrate in fully matured tooth, so lack of proper treatment can result in chronic lesions.

• The tooth is tender on percussion
• The tooth may present mild-to-severe soreness
• Dull, throbbing, and constant pain
• Pain occurs over a short period of time
• Pain on mastication

Apical periodontitis Histopathology:

Pulp and periradicular tissue may be sterile if periodontitis is due to occlusal trauma or chemical or mechanical irritation during root canal treatment. In some cases, bacteria or their toxic products extrude through the periapex and irritate the periradicular area.

Apical periodontitis Diagnosis:

• The tooth is tender on percussion
• A radiographic picture of the vital tooth may show no change, whereas in the case of the nonvital tooth, it may show a widening of apical periodontal ligament space and loss of lamina dura.

Apical periodontitis Diffrential Diagnosis:

It should be diffrentiated from an acute apical abscess on the basis of history, symptoms, and clinical tests.

Apical periodontitis Treatment:

• If the cause is irreversible pulpitis or necrotic pulp, initiate endodontic treatment.
• If the cause is hyper occlusion, adjust the occlusion for immediate relief.
• To control postoperative pain following initial endodontic therapy, analgesics are prescribed.
• The use of antibiotics, either alone or in conjunction with root canal therapy is not recommended.
• For nonrestorable teeth, extraction is indicated

Acute Apical Abscess

Acute Apical Abscess Synonyms:

Acute Abscess, Acute Dentoalveolar, Abscess, Acute Periapical Abscess, and Acute Radicular Abscess. It is an inflammatory reaction to pulp infection and necrosis characterized by rapid onset, pus formation, spontaneous pain, tenderness on percussion, and eventual swelling of associated tissues.

Etiology:

• The most common cause is an invasion of bacteria from necrotic pulp tissue.
• Trauma, chemical, or any mechanical injury resulting in pulp necrosis.
• Irritation of periapical tissue by chemical or mechanical treatment during root canal treatment.

Tissue at surface of swelling appears taut and inflmed and pus starts to form underneath it. Surface tissue may become inflamed from the pressure of underlying pus and finally rupture from this pressure.

Initially, the pus comes out in the form of a small opening but later it may increase in size or number depending upon the amount of pressure of pus and the softness of the tissue overlying it. This process is the beginning of chronic abscess.

Acute Apical Abscess Symptoms:

• In the early stage, there is the tenderness of the tooth which is relieved by continued slight pressure on the extruded tooth to push it back into the alveolus.
• Later on, throbbing pain develops with diffuse swelling
  of overlying tissue.
• Tooth becomes more painful, elongated, and mobile as infection increases in later stages.
•  The patient may have systemic symptoms like fever and increased WBC count.

Spread of lesion toward a surface may take place causing erosion of cortical bone or it may diffuse and spread widely leading to the formation of cellulitis. The location of swelling is determined by the relation of the apex of the involved tooth to the adjacent muscle attachment.

Spread of apical abscess to surrounding tissues, if it isnot treated:

1. Vestibular abscess,
2. Periapical abscess,
3. Palatal abscess, and
4. Maxillary sinus.

Acute Apical Abscess Histopathology:

Acute Apical Abscess Diagnosis:

• Clinical examination
• In the initial stages, locating a tooth is difficult due to diffuse pain. The location of the offending tooth becomes easier when a tooth gets slightly extruded from the socket.
• A negative response to pulp vitality tests
• Tenderness on percussion and palpation
• The tooth may be slightly mobile and extruded from its socket
• Radiography was helpful in determining the affected tooth as it may show caries or evidence of bone destruction at the root apex.

 

Acute Apical Abscess vManagement:

•  Drainage of the abscess should be initiated as early as possible. This may include
  • Nonsurgical endodontic treatment
  • Incision and drainage
  • Extraction

Considerations regarding the treatment of a tooth with periapical abscess depend on the following factors:

• • Prognosis of the tooth
  • Patient preference
  • The strategic value of the tooth
  • The economic status of the patient
• In the case of localized infections, systemic antibiotics provide no additional benefit over drainage of abscesses.
• n the case of systemic complications such as fever, lymphadenopathy, cellulitis, or a patient who is immunocompromised, antibiotics should be given in addition to drainage of the tooth.
• Relieve the tooth out of occlusion in hyper occlusion cases.
• To control postoperative pain following endodontic therapy, nonsteroidal anti-inflammatory drugs should be given.
  

Phoenix Abscess Or Recrudescent Abscess Or Acute Exacerbation of Asymptomatic Apical Periodontitis

Phoenix abscess is defined as an acute inflammatory reaction superimposed on an existing asymptomatic apical periodontitis.

Etiology:

Chronic periradicular lesions such as granulomas are in a state of equilibrium during which they can be completely asymptomatic. But sometimes, inflx of necrotic products from diseased pulp or bacteria and their toxins can cause the dormant lesion to react. This leads to the initiation of acute inflammatory response. Lowered body defenses also trigger an acute inflammatory response.

Phoenix abscess Symptoms:

• Clinically, often indistinguishable from the acute apical abscess.
• At the onset, tenderness of the tooth and extrusion of the tooth from the socket.
• Tenderness on palpating the apical soft tissue.

Phoenix abscess Diagnosis:

• Most commonly associated with the initiation of root canal treatment.
• History from patient
• Pulp tests show a negative response
• Radiographs show a large area of radiolucency in the apex created by inflammatory connective tissue which has replaced the alveolar bone at the root apex
• Histopathology of Phoenix abscess shows areas of liquefaction necrosis with disintegrated polymorphonuclear leukocytes and cellular debris surrounded by macrophages, lymphocytes, and plasma cells in periradicular tissues.
• Phoenix abscesses should be differentiated from acute alveolar abscesses by the patient’s history, symptoms, and clinical test results.

Phoenix abscess Treatment:

• Establishment of drainage
• Once symptoms subside—complete root canal treatment

Asymptomatic Apical Periodontitis Or Chronic Apical Periodontitis

It is the sequelae of symptomatic apical periodontitis resulting in inflammation and destruction of periradicular area due to the extension of pulpal infection, characterized by asymptomatic periradicular radiolucency. It is seen as a chronic low-grade defensive response of periradicular area to pulpal infection.

Etiology:

Necrosis of pulp causing continued irritation and stimulation of periradicular area resulting in the formation of granulation tissue.

Apical Periodontitis Clinical features:

• Tooth is nonvital
• Usually asymptomatic but in the acute phase, dull, throbbing pain may be present

Possible complications of chronic apical periodontitis

• Formation of periapical granuloma, radicular cyst, sinus tract, and acute exacerbation of the disease.

Apical Periodontitis Diffrential Diagnosis:

A main characteristic feature is a nonvital pulp with a periapical lesion. If the pulp is vital:

• Rule out lateral periodontal abscess, central giant cell granuloma, and cemental dysplasia.
• Check medical history to rule out hyperparathyroidism or the presence of malignant lesions.
  

Apical Periodontitis Treatment:

• Endodontic therapy of affected tooth.
• In the acute phase, treatment is the same as acute apical abscess, i.e. cleaning and shaping of canals followed by analgesics if required.
• Extraction of nonrestorable teeth.

Chronic Alveolar Abscess

A chronic alveolar abscess is a long-standing low-grade infection of periarticular bone characterized by the presence of an abscess draining through a sinus tract.

Chronic Alveolar Abscess Synonyms:

Chronic suppurative apical periodontitis, Chronic apical abscess, Suppurative periradicular periodontitis, Chronic periradicular/periapical abscess.

Etiology:

It is similar to an acute alveolar abscess. It also results from pulpal necrosis and is associated with chronic apical periodontitis that has formed an abscess.

Chronic Alveolar Abscess Symptoms:

• Generally asymptomatic
• Detected either by the presence of a sinus tract or on the routine radiograph.
• In the case of an open carious cavity, the drainage through the root canal sinus tract prevents swelling or exacerbation of the lesion.

Chronic Alveolar Abscess Diagnosis:

• A chronic apical abscess is associated with an asymptomatic or slightly symptomatic tooth.
• The patient may give a history of sudden sharp pain which subsided and has not reoccurred.
• The clinical examination may show a large carious exposure, discoloration of the crown, or restoration.
• The presence of a sinus tract prevents exacerbation or swelling so usually asymptomatic but may show symptoms if the sinus tract gets blocked.
• Vitality tests show a negative response because of the presence of necrotic pulps.
• The site of origin is diagnosed by radiograph after insertion of gutta-percha in the sinus tract.
• Radiographic examination shows diffuse areas of rarefaction. The rarefied area is so diffuse that fades indistinctly into normal bone.

Chronic Alveolar Abscess Diffrential Diagnosis:

The chronic alveolar abscess must be differentially diagnosed from a granuloma or cyst by carrying histopathological examination. It should also be diffrentiated from cementoma which is associated with the vital tooth.

Chronic Alveolar Abscess Treatment:

Removal of irritants from a root canal and establishment of drainage is the main objective of the treatment. Sinus tract resolves following the endodontic treatment.

The draining sinus is active with pus discharge surrounded by reddish-pink color mucosa. It can be detected by inserting gutta-percha. Healed sinus shows the absence of pus discharge and normal-colored mucosa.