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Periapical Abscess

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Periapical Abscess, Periapical Tooth Infection, Apical Periodontitis, Apical Abscess, Periapical Periodontitis, Suppurative Periapical Periodontitis, Odontogenic Infection, Tooth Infection

  • See Also
  1. Dental Caries
  2. Periodontal Disease (Gingivitis, Periodontitis)
  • Definitions
  1. Odontogenic Infection
    1. Tooth Infections due to Dental Caries (periapical infection) and Periodontal Infections (Gingivitis, periodonitis)
  • Pathophysiology
  1. Complication of Irreversible Pulpitis (Dental Caries)
  2. Tooth cavity or injury allows infection to pass through the enamel and dentin into the pulp
  3. Infection spreads via the apical foramen at tooth base into the bone
  4. Ultimately infection expands into a Periapical Abscess, most commonly at the tooth's buccal aspect
  • Symptoms
  1. Severe, persistent pain localized to affected tooth
  2. Focal swelling at the involved tooth or cheek
  3. Drainage may be present
  • Signs
  1. Apical Abscess may be present
    1. Fluctuant swelling at Buccal mucosa or Palate
    2. Drainage may be present
  2. Localized swelling of the cheek
  3. Percussion with metal object elicits pain
  4. Regional Lymphadenopathy of the Head and Neck
  • Differential Diagnosis
  1. See Tooth Pain
  2. See Pulpitis
  • Management
  1. See Dental Incision and Drainage (if abscess present)
  2. See Ludwig's Angina (surgical emergency!)
  3. Root canal or Tooth Extraction by dentist
  4. Antibiotics not required in most cases after Incision and Drainage
    1. Start if Periodontal Cellulitis suspected
    2. Infections are polymicrobial, both aerobic and anaerobic
    3. Options
      1. Clindamycin (preferred)
      2. Augmentin
      3. Penicillin and Metronidazole
        1. Even with Penicillin alone, 95% of patients improve
        2. Warnke (2008) Surg 36(8): 462-7 +PMID:18760616 [PubMed]
  • Complications
  1. Periodontal Cellulitis
  2. Regional spread (e.g. Acute Sinusitis)
  3. Ludwig's Angina
  • References
  1. Delaney (2017) EM:Rap 17(10): 4
  2. Amsterdam in Marx (2002) Rosen's Emergency Med, p. 897
  3. Douglass (2003) Am Fam Physician 67(3):511-16 [PubMed]