PERIAPICAL ABCESS

OVERVIEW OF DISEASE

Dental abscess is a broad term used to describe an abscess in the tooth and

structures around it. A periapical abscess is an inflammatory reaction with the

accumulation of pus at the root of an infected tooth. It can lead to death of the central

region of the tooth known as the dental pulp. Generally a periapical abscess is an acute

dental infection requiring immediate dental intervention. The condition is associated with

significant discomfort and extreme pain. If left untreated it can lead to various

complication and permanent loss of the affected tooth. A periapical abscess is the most

common type of dental abscess among children. Another type, a periodontal abscess, is

where the abscess is located in the tissue around the tooth, including the alveolar bone. A

periodontal abscess is more commonly seen among adults. (Bickley, L. S., & Hoekelman, R. A.

2013).

ASSESSMENT

 Swelling

 Warmth

 Erythema

 Fluctuant mass that usually extends toward the buccal side of the gum and to the

gingival-buccal reflection

 Parulis or "gum boil" (a soft, solitary, reddish papule located facial and apical to a

chronically abscessed tooth that occurs at the endpoint of a draining dental sinus tract)

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Teeth: The tooth that is most frequently involved is the lower third molar, followed by

other lower posterior teeth; upper posterior teeth are involved much less frequently, and

anterior teeth are rarely involved.

 Increased mobility (mostly periapical abscess)

 Pressure or percussion tenderness (mostly periapical abscess)

 Extrusion

Regional lymph node involvement

More severe infection

 Trismus, indicating involvement of the masticator space

 Difficulty swallowing (dysphagia)

 Respiratory difficulty

 Necrotizing fasciitis

Neck or facial swelling

(Brandt, L.J. Ed.2010)

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PATHOPHYSIOLOGY

The term dentoalveolar abscess comprises 3 distinct processes, as follows:

 A periapical abscess that originates in the dental pulp and is usually secondary to dental

caries is the most common dental abscess in children. Dental caries erode the protective

layers of the tooth (ie, enamel, dentin) and allow bacteria to invade the pulp, producing

a pulpitis. Pulpitis can progress to necrosis, with bacterial invasion of the alveolar bone,

causing an abscess.

 A periodontal abscess involves the supporting structures of the teeth (periodontal

ligaments, alveolar bone). This is the most common dental abscess in adults, but may

occur in children with impaction of a foreign body in the gingiva.

 Pericoronitis describes the infection of the gum flap (operculum) that overlies a

partially erupted or impacted third molar.

Developmental and acquired conditions are associated with dental abscesses in

childhood. Developmental conditions include abnormal morphology of the crown (eg,

dens invaginatus, dens evaginatus) and abnormal structure of the dentine (eg, dentine

dysplasia, dentinogenesis imperfecta, osteogenesis imperfecta, familial

hypophosphatemia). Acquired conditions include pre-eruptive intracoronal resorption and

mandibular infected buccal cyst.

Odontogenic infections are polymicrobial, with an average of 4-6 different causative

bacteria. The dominant isolates are strictly anaerobic gram-negative rods and gram-

positive cocci, in addition to facultative and microaerophilic streptococci. Anaerobic

bacteria outnumber aerobes 2-3:1.In general, strictly anaerobic gram-negative rods are

more pathogenic than facultative or strictly anaerobic gram-positive cocci.

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Generally, a nonpathologic resident bacterium gains entry when the host's defenses are

breached, rather than when a nontypical microorganism is introduced. The predominant

species associated with dental abscess include Bacteroides, Fusobacterium, Actinomyces,

Peptococcus,Peptostreptococcus, andPorphyromonas as well as Prevotella

oralis, Prevotella melaninogenica, andStreptococcus viridans. Beta-lactamase producing

organisms occur in approximately one third of dental abscesses.

The use of molecular techniques such as 16S rRNA gene sequencing and polymerase

chain reaction (PCR) have identified difficult-to-culture organisms and expanded

knowledge of the microflora associated with dental abscess. Examples

include Treponema, Atopobium, Bulleidia extructa, and Mogibacterium species, as well

as Cryptobacterium curtum. (Castell, D. O., & Richter, J. E. (2012).

MEDICAL MANAGEMENT

Complicated abscess (accompanying cellulitis)

 The CBC count may reveal leukocytosis with neutrophil predominance.

 Obtain a blood culture (aerobic and anaerobic) before initiating parenteral antibiotics.

 Needle aspirate is indicated for Gram stain and aerobic and anaerobic cultures.

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PHARMACOLOGIC THERAPY

 Penicillin (Pfizerpen, Pen-Vee K)

Traditionally been considered the DOC for the treatment of a dental abscess.

Antibiotic therapy alone, without surgical drainage, may not be effective because of poor

antibiotic penetration into the abscess cavity, ineffectiveness at low pH levels, and the

inoculum effect. Bactericidal against sensitive organisms when adequate concentrations

are reached and is most effective during the stage of active multiplication. Inadequate

concentrations may produce only bacteriostatic effects. Binds to one or more penicillin

binding proteins, which interferes with bacterial cell wall synthesis during active

multiplication. Final transpeptidation step of peptidoglycan synthesis is inhibited leading

to death.

 Azithromycin (Zithromax)

May be an option for the treatment of a dental abscess in patients who are allergic to

penicillin or beta-lactam. Binds to the 50S ribosomal subunit of susceptible

microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, inhibiting

bacterial RNA-dependent protein synthesis. Concentrates in phagocytes and fibroblasts,

as demonstrated by in vitro incubation techniques. In vivo studies suggest that

concentration in phagocytes may contribute to drug distribution to inflamed tissues.

Indicated for mild-to-moderate microbial infections.

Emergence of beta-lactamase producing bacteria may decreased efficacy, although it

remains the antibiotic of choice for mild-to-moderate infections.

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 Metronidazole (Flagyl)

Effective against obligate anaerobic organisms. It can be combined with penicillin if

anaerobic organisms that produce beta-lactamase enzymes are a concern. Compliance

must be considered with a 2-drug regimen. It inhibits DNA synthesis by affecting the

helical DNA structure leading to DNA strand breakage causing cell death.

 Clindamycin (Cleocin)

Can be used in patients who are penicillin or beta-lactam allergic. Inhibits bacterial

protein synthesis by binding to the 50S ribosomal subunit preventing peptide bond

formation. Excellent activity against PO aerobes and anaerobes; penetrates bone and

abscess cavities.

 Amoxicillin and clavulanate (Augmentin)

Amoxicillin works by binding to one or more of the penicillin-binding proteins,

which interferes with bacterial cell wall synthesis during active bacterial replication. The

final transpeptidation step of peptidoglycan synthesis is inhibited leading to cell death.

Clavulanic acid binds and inhibits beta-lactamase enzymes that inactivate amoxicillin

resulting in an expanded spectrum of activity for Augmentin. For children, the dosing

should be based on the amoxicillin component.

 Cefoxitin (Mefoxin)

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Binds to one or more of the penicillin binding proteins, which interferes with bacterial

cell wall synthesis during active replication. The final transpeptidation step of

peptidoglycan synthesis is inhibited leading to cell death. It is a second-generation

cephalosporin with activity against some gram-positive cocci, gram-negative rods, and

anaerobic bacteria. Infections caused by cephalosporin-resistant or penicillin-resistant

gram-negative bacteria may respond to cefoxitin.

(De Vita, V. T., Hellman, S., & Rosenberg, S. A. Eds 2011).

SURGICAL MANAGEMENT

Surgical procedure

 The primary therapeutic modality is surgical drainage of any pus collection. A

pulpectomy or incision and drainage is the recommended management of a

localized acute apical abscess in the permanent dentition. Incision and drainage or

spontaneous rupture of the abscess quickly accelerates resolution of the infection.

The addition of antibiotics is not recommended for a localized dental abscess.

 Emergent surgery is indicated in the operating room if the airway is threatened or

if the patient's condition is rapidly deteriorating.

 Third molar removal is a common surgical procedure.

 A retrospective analysis of all patients affected by an odontogenic infection that

received surgical therapy from 2004 to 2011 under stationary conditions reported

that two patients per week affected by an odontogenic infection required

stationary surgical treatment and about two patients per year were likely to require

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additional intensive medical care. The study also reported that if well-known risk

factors are present in patients affected by odontogenic infection, appropriate

interdisciplinary management should be considered as early as possible.

NURSING RESPONSIBILITIES

In patients with dental abscess, assess the airway upon respiratory distress, oropharyngeal

tissue swelling, or inability to handle secretions; then, secure the airway via endotracheal

intubation or tracheostomy.

 Properly collect specimen for Gram stain and aerobic and anaerobic cultures.

 Administer empiric antibiotic therapy if necessary.

 Administer analgesia.

 Hydrate the patient.

DIAGNOSTIC TEST

In addition to examining your tooth and the surrounding area, your dentist may:

 Tap on your teeth. A tooth that has an abscess at its root is generally sensitive to

touch or pressure.

 Recommend an X-ray. An X-ray of the aching tooth can help identify an abscess.

Your dentist may also use X-rays to determine whether the infection has spread,

causing abscesses in other areas. (Fonseca, R. J. Ed. 2010)

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