Acute apical dental abscess

Acute apical dental abscess 

Updated 2012 Mar 05 01:32:00 PM: Japanese Society of Chemotherapy Committee/Japanese Association for Anaerobic Infection Research guideline on anaerobic infections (individual fields): dental and oral infections (J Infect Chemother 2011 Jul) view updateShow more updates

Related Summaries:  

Dental caries Periodontitis

General Information Description: 

bacterial infection in periodontal tissue around apical foramen of tooth (1, 2, 3) o localized, purulent form of apical periodontitis o complication of pulpitis, secondary to bacterial invasion of pulp from dental caries

Also called:          

acute dental abscess acute dentoalveolar abscess apical abscess apical periodontitis acute periradicular abscess dental abscess odontogenic infection periapical abscess periapical infection tooth abscess

Organs involved: 

teeth, soft tissue and bony structures of oral cavity

Who is most affected: 

adults and children with untreated dental caries(1, 2)

Incidence/Prevalence: 

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most common self-reported reasons for dental visit resulting in endodontic treatment were toothache (40%) and abscess (30%) in prospective cohort study of 873 adults followed for 48 months (J Endod 2003 Dec;29(12):806) estimated 1 per 2,600 persons admitted to hospital for acute dental infection in 5year retrospective study of adults admitted with maxillofacial infections in United States (Int J Oral Maxillofac Surg 2005 Sep;34(6):646 as referenced in(3)) periapical abscess was diagnosis in 47% outpatients in chart review of pediatric emergency room visits for nontraumatic preventable dental disease (Pediatr Dent 2000 Mar-Apr;22(2):134)

Causes and Risk Factors Causes: 

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bacteria from dental caries(3) o no single causative pathogen has been identified o most infections caused by complex mix of  strict anaerobes - most commonly streptococci, Fusobacterium species, Prevotella and Porphyromonas, less frequently Staphylococcus species  facultative anaerobes - most commonly viridans group streptococci and anginosus group streptococci, infrequently Clostridia (3) trauma failed root canal treatment(3)

Pathogenesis: 

periapical abscess is a complication of pulpitis arising from dental caries (2, 3) o decay of untreated carious lesion causes  colonization of root canal  inflammation of pulp (pulpitis) o abscess forms when bacteria and toxic products enter periapical tissues through apical foramen

Likely risk factors: 

dental caries in permanent teeth (less frequent in primary teeth)(2)

Complications and Associated Conditions Complications:  

gingival and facial cellulitis - an emergency(2) maxillary infection may spread to periorbital area with risk of (2)

o o o

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vision loss cavernous sinus thrombosis central nervous system involvement sepsis syndrome(3) deep neck space infection(3) o rare, potentially life-threatening complication o potential for spread of infection to interpleural space and mediastinal tissue o airway occlusion a significant risk - early tracheostomy required o high mortality, death usually due to sepsis and multiple organ failure o diabetic and elderly patients at greater risk o occurs in males more than females Ludwig's angina in case reports o N Engl J Med 2008 Oct 2;359(14):1501 o Emerg Med J 2004 Mar;21(2):242 PDF o Infect Dis Obstet Gynecol 2010;2010:158264

History and Physical History: Chief concern (CC):   

severe, spontaneous, and persistent pain localized to affected tooth (2) fever if cellulitis present(1, 2) systemic effects of infection may be more pronounced in children including(2) o rapid rise in temperature o greater risk of dehydration

History of present illness (HPI): 



pain may occur(2, 4) o with chewing o triggered by hot, cold, and sweet stimuli o less severe if pus is draining stiffness or pain in neck may suggest complications of deep neck space infection or meningitis

Physical: General physical: 

assess for presence and extent of cellulitis to determine if outpatient treatment appropriate(2)

HEENT: 

tenderness elicited by tapping affected tooth(1)

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

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fluctuant buccal or palatal swelling with or without(2, 4) o erythema o draining fistula if cellulitis findings may include (2) o erythema of gingiva and possibly face (1) o diffuse, tense and painful swelling of surrounding tissues (1) o trismus (inability to open jaw) be systematic about oral exam o external o internal (gums, teeth, palate, pharynx, tongue) o jaw o neck o ears

Neck: 

regional lymphadenopathy may occur(1, 2)

Diagnosis Making the diagnosis: 

diagnosis based on clinical presentation

Rule out:  



abscess arising from periodontitis nondental sources of oral pain(2) o myofascial inflammation o migraine o maxillary sinusitis o temporomandibular joint (TMJ) dysfunction o neuralgia additional nondental sources of oral pain o acute otitis media (AOM) o otitis externa o gingival ulcers o pericoronitis (inflamed or infected gingival overgrowth of molar) o parotitis

Testing overview: 

computed tomography if concern for spread of infection to deep spaces of head and neck(2)

Imaging studies:



computed tomography findings of periapical abscess o widening or breech of periodontal ligament o erosion of lamina dura o Reference - Infect Dis Clin North Am 2007 Jun;21(2):305

Other diagnostic testing: 

culture of aspirate from abscess(3) o obtain sample by aspirating through intact mucosa after disinfecting with antiseptic mouth wash or swab (such as chlorhexidine) to reduce contamination by normal oral flora o complex mix of strict anaerobes and facultative anaerobes may be challenging for non-specialist microbial labs, may limit usefulness of test

Treatment Treatment overview: 

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definitive treatment is root canal or extraction(2) o refer patient for evaluation by dentist within 1-2 days o prescribe pain medication to cover period until dental visit o incision and drainage of a fluctuant area by physician may be appropriate antibiotic therapy not required before referral to dentist unless cellulitis present treat localized cellulitis with antibiotics o penicillin 500 mg 3 times daily in adults or 50 mg/kg/day in 3 divided doses in children o if penicillin allergy, erythromycin or clindamycin consider emergency if severe cellulitis involving deeper orofacial spaces requires hospitalization(1, 2) o immediate IV antibiotic therapy including coverage of anaerobes o computed tomographic imaging to detect abscess o surgical drainage no evidence to recommend one antibiotic regimen over another for management of systemic complications of acute apical abscess

Medications: 

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antibiotic therapy not required before referral to dentist unless (1, 2, 3, 4) o cellulitis present (4) o patient is immunocompromised treat localized cellulitis with antibiotics(2) o penicillin 500 mg 3 times daily in adults or 50 mg/kg/day in 3 divided doses in children o if penicillin allergy, erythromycin or clindamycin no consensus about preferred antibiotic regimen to prevent or treat systemic complications, but antibiotics widely used (3, 4)

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no evidence to recommend one antibiotic regimen over another for management of systemic complications of acute apical abscess o based on systematic review of low quality trials o systematic review and meta-analysis of 8 trials evaluating antibiotics for relief of pain and swelling, and reduction in systemic symptoms in 531 patients  2 trials with 71 patients compared antibiotic with placebo or no antibiotic treatment  4 trials with 460 patients compared 2 antibiotics o antibiotics included  azithromycin  amoxicillin  amoxicillin-clavulanate  clindamycin  metronidazole  penicillin V  penicillin G o quality limitations reported in all trials  intention-to-treat analysis reported in no trials  method of randomization described in only 3 trials  withdrawals and dropout rates described in only 4 trials  blinding in only 2 trials o no significant differences between treatment and control groups observed in 7 trials o statistically significant result favoring azithromycin over amoxicillinclavulanate in 1 low-quality open-label trial o Reference - J Can Dent Assoc 2003 Nov;69(10):660 PDF bacteria associated with endodontic abscesses reported to be susceptible to several antibiotics (level 3 [lacking direct] evidence) o based on cultures of 98 species of bacteria aseptically aspirated by needle from endodontic abscesses o percentages of susceptibility  amoxicillin 91%  amoxicillin-clavulanate 100%  clindamycin 96%  penicillin V 85%  metronidazole 45%  metronidazole with penicillin V 93%  metronidazole with amoxicillin 99% o Reference - J Endod 2003 Jan;29(1):44

Surgery and procedures: 

removal of necrotic pulp tissue by one of following(4) o incision of soft-tissue swelling and drainage (short-term relief) o drainage by trephination and pulpectomy o extraction of affected tooth

Consultation and referral:   

refer for dental evaluation within 1-2 days(1, 2) advise patient to return for evaluation if swelling or pain worsens before dental visit(2) surgical and infectious disease consults for patients hospitalized with regional cellulitis(2)

Prognosis 

most dental abscesses respond to surgical treatment (incision and drainage, root canal or extraction) and elimination of source of infection(2, 3)

Prevention and Screening Prevention: 



apply principles of dental caries prevention(1, 2) o ingest limited sugar-containing foods at planned snack and meal times o regular toothbrushing with fluoridated toothpaste o regular flossing o appropriate supplementary fluoride use o screen all patients for caries and other oral health issues at well visits o help all patients to have regular checkups at dental home see Dental caries for detailed prevention information

Guidelines and Resources Guidelines: United States guidelines:   

consensus statement on diagnostic terms for periapical/periradicular health and disease states can be found in J Endod 2009 Dec;35(12):1658 consensus statement on diagnostic terms for pulpal health and disease states can be found in J Endod 2009 Dec;35(12):1645 consensus statement on metrics, hierarchy, and predictive value for parameters and/or methods used during endodontic diagnosis can be found in J Endod 2009 Dec;35(12):1635

Canadian guidelines: 

Canadian Collaboration on Clinical Practice Guidelines in Dentistry (CCCD) practice guideline on treatment of acute apical abscess (AAA) in adults can be found in Evid Based Dent 2004;5(1):8 or at CCCD 2003 Oct PDF, editorial can be found in Evid Based Dent 2004;5(1):9

European guidelines: 

Spanish consensus statement on antimicrobial treatment of odontogenic bacterial infections can be found in Med Oral Patol Oral Cir Bucal 2004 Nov-Dec;9(5):36976; 363 PDF [Spanish, English]

Asian guidelines: 

Japanese Society of Chemotherapy Committee/Japanese Association for Anaerobic Infection Research guideline on anaerobic infections (individual fields): dental and oral infections can be found in J Infect Chemother 2011 Jul;17 Suppl 1:112

Review articles:  

review of antibiotics for acute dentoalveolar abscesses can be found in Br Dent J 2009 Apr 11;206(7):357 review of antibiotic use in dental practice can be found in Med Oral Patol Oral Cir Bucal 2007 May 1;12(3):E186 PDF