ACUTE APICAL ABSCESS

SYNONYMS: Acute dental abscess
Acute alveolar abscess
Acute dentoalveolar abscess
Acute periapical abscess
Acute radicular abscess

DEFINITION: Acute apical abscess ( A.A.A) is a painful localized collection of pus in the alveolar bone at the apex of the tooth( root) AFTER THE DEATH OF THE PULP with extension of infection through periapical foramen into the periapical tissue.
• It is a common dental emergency faced by dentists.
• It depends upon the death of the pulp for its origin.


WHY DOES A.A.A OCCUR..??..??..??
" It usually occurs due to the BACTERIAL INVASION from the pulp tissue."
Various conditions causing such invasion……
• DENTAL CARIES: It most commonly occurs as a sequelae to dental caries. Plaque bacteria attack the tooth causing destruction of enamel and dentin leading to dental caries. Acids and other toxic substances penetrate the dental tubules and reach the pulp leading to pulpitis. Bacteria continue to infect the pulp until it reaches the bone that surrounds and supports the tooth (alveolar bone) where the periapical abscess forms.
• ACUTE APICAL PERIODONTITIS: An already existing acute apical periodontitis with a necrotic pulp can advance to an extensive suppurative inflammatory stage like A.A.A.
• PERIODONTAL DISEASE
• PERICORONITIS
• INFECTION OF CYST OF JAWS.
AGE: It is more common in children than adults. Poor oral hygiene, thin enamel, primary dentition having more blood supply may be the factors for increased inflammatory response.
ONSET & COURSE OF INFECTION: Rapid.
FEATURES:
• Most commonly the tooth is carious on examination.
• Pulp is NON-VITAL.
• Extreme sensitivity / pain which is throbbing, pulsating type.
• Tooth is extremely painful to PERCUSSION.
• Offending tooth is easily identifiable and pain is localized to a particular area.
• Tooth demonstrates slight increase in mobility and protrudes from the socket.
• Abscess may penetrate the cortical plate at the thinnest and closest point to apex leading to space infection in adjacent soft tissue resulting in SWELLING in the adjacent tissue close to the affected tooth. Swelling is painful on palpation.
• Facial appearance changes due to the extensive swelling.
• The pressure from the accumulated PUS causes rupture of the surface tissue. Pus exudes from one or more opening . Pain gets relieved to some extent after pus discharge.
• Regional lymphnodes are enlarged and painful.
• Foul breath, foul taste present.
• SYSTEMIC SYMPTOMS: Fever, tiredness, headache, loss of sleep, irritation are present.
• Application of ice to some extent relieves pain in contrast to heat which aggravates pain.

DIAGNOSIS: The following help in diagnosis:
• History.
• Clinical examination.
• Percussion test: Positive, tooth is extremely sensitive to percussion.
• Vitality tests: Electric pulp testing and thermal tests yield negative results. Pulp is necrotic hence do not respond to electric or cold tests.
• Radiographs: Radiographs show deep faulty restorations / caries. Pulp is non-vital hence the pulp chambers / canals appear narrowed. Acuteness of the condition may not give it enough time to erode sufficient amount of bone to reveal a greater radioluscency. Widening of periodontal ligament space is noticed.

DIFFERENTIAL DIAGNOSIS: AAA should be differentiated from Irreversible pulpitis and acute periodontal abscess.
• Irreversible pulpitis: Pain is diffused. No pus formation, no sign of mobility or extrusion from the socket. Tooth may give positive response to electric pulp test except in severe cases.
• Acute periodontal abscess: Little pus discharge, but through the sulcus. Tooth is vital.
Hence, pulp vitality tests aid in diagnosis.

BACTERIOLOGY: Various strains of Staphylococcus and Streptococcus are the frequent causative organisms. Frequently encountered anaerobic organisms are Bacteroides, Peptostreptococcus, Actinomyces, Fusobacterium.

TREATMENT:
• Symptomatic treatment.
• Immediate establishment of pus drainage through Root canal ( access opening).
• Root canal treatment.
• In more severe cases, penicillin ( drug of choice) should be instituted immediately and Extraction done under antibiotic cover.

PROGNOSIS: Good. Tooth can be preserved using root canal treatment along with Periodontal treatment when required.

Cracked Tooth Syndrome

“CRACKED TOOTH SYNDROME is a painful condition caused by incomplete fracture of the tooth ,a fracture which is too small to be seen on a X-ray, which occasionally extends into the pulp.”

COMMON SITE: - Lower 2nd molar
Lower 1st molar
Upper bicuspids



SUSCEPTIBILITY: It is mostly seen in
* Persons with habit of BRUXISM
* Persons who apply more pressure while chewing/ Chew hard
substances like nuts, hand candies, pencils, ice sticks….
* Teeth with large fillings/ those which are rootcanal treated. Such teeth have just 30% of
strength… so everytime we grind/chew/ clench the tooth will flex slightly and in such
cases a hairline fracture develops at the bottom of the filling.


SYMPTOMS:

1. Severe pain / sharp uncomfortable sensation only while biting or chewing.(not all the time)
2. Pain might be felt only when the person bites in a specific direction due to difference in the direction, extent and location of the crack.
3. Pain more often experienced to cold stimulus
4. There is no constant pain like in cavity or abscess
5. Pain is severe particularly during the initiation and release of biting pressure
6. Patient is unable to identify offending tooth or the quadrant involved


WHY IT HURTS…?????

On biting tooth flexes which stimulates nerves in the tooth….. the hairline crack opens and closes applying pressure on tubules that run down the nerve causing the movement of the fluid in tubules. When the biting force/ pressure is taken off the tooth…. The crack closes and the fluid pressure stimulates the nerve which causes the pain.


DIAGNOSIS:

Cracked tooth syndrome is one of the most difficult diagnosis in dentistry…..

1. Based on thorough dental history : Bruxism
Clenching
Trauma
Masticatory habits such as chewing ice
2. Clinical / visual examination: check for craze lines on enamel with a sharp explorer check for a cracked restoration using transillumination
3. Diagnostic tests: - 1)a cotton roll is placed and the patient is asked to chew isolating each tooth.
Pain indicates a chance for a crack a rubber wheel or a bite stick can be
used for this purpose. “Tooth sleuth “ is used to check each individual
tooth cusp for a crack.
2)fiber-optic light is used for the detection of a crack
3)tooth staining using a special dye is also useful.
4. Radiographs: these cracks are too small to be seen on a X-ray, hence not very useful.



TREATMENT:

a) if the crack is simple involving - small cusps: restoration with a composite
- larger tooth surface: crown is indicated
b) if the crack is complex involving pulp: RCT is indicated.
c) if the crack extends far down the middle of tooth / root fracture : extraction indicated.



PREVENTION:

Bruxism and other abnormal chewing habits can increase risk to cracked tooth syndrome. Proper habit control methods have to be followed by consulting a dentist.

Pulpitis

PULPITIS

DEFINITION: “Pulpitis is the inflammation of the dental pulp within the tooth”. It is commonly manifested as toothache.

· Initially it presents itself as a dull to moderate pain, fairly well localized

· later it increases with time and becomes more severe and diffuse

· finally when the pulpal necrosis occurs pain ceases.

This can be attributed to the pulpal anatomy, wherein the soft pulpal tissue is surrounded by very hard dentin. the pressure created in the pulp has very little chance of dissipation to the neighbouring tissues where the lymph can reach unlike other parts of the body. This confinement mostly leads to pulpal necrosis.

CAUSES OF PULPITIS;

a) Dental caries is the most common cause.

b) Fractured restoration / fractured tooth

c) Physical agents such as –

i) pressure involved during cutting procedures

ii) high filling

iii) galvanic current produced by occluding amalgam restoration with gold one

d) Thermal agents such as heat from- cavity preparation, polishing restorations,inadequate thermal insulation(bases & liners)

e) Chemical agents- such as disinfecting chemicals such as alcohol / chloroform applied to exposed dentin, acid liquid components of cements, eugenol from zinc oxide eugenol etc..,

f) Exposure of dentin as a result of gingival recession, abrasion, attrition, erosion.

g) Advanced periodontal diseases.


CLASSIFICATION;

Based on the extent of pulpal damage pulpitis can be classified into:

a) Reversible pulpitis – Symptomatic (acute)

Asymptomatic (chronic)

b) Irreversible pulpitis- Symptomatic(acute)

Asymptomatic with exposure (chronic)

Pulp degeneration

Pulp necrosis


A) REVERSIBLE PULPITIS:

“ Mild to moderate inflammatory condition of the pulp caused by noxious stimuli, in which the pulp is capable of returning to the normal (uninflamed) state after the removal of the stimulus. “

SYMPTOMS:

· It is characterized by sharp pain lasting for a moment only

· Pain does not occur spontaneously

· It requires an external stimulus(cold, sugar, trauma, bacteria, chloroform, etc.,) and stops after the removal of irritant factor(stimulus)

· Pain can be localized.

· Pain is more often brought about by cold stimuli.

DIAGNOSIS:

· Based on symptoms

· Visual examination: caries, cervical erosion , abrasion.

· History regarding recent dental treatments, fractures or trauma.

· Radiography: depth of caries or cavity preparation can be judged.

Periapex negative - PDL and lamina dura are normal.

· Percussion: Negative response unless occlusal stress is present.

· Vitality test: Response is more to cold stimuli.

PREVENTION: Awareness of the causative agent

Control of the operative procedures

TREATMENT: A good restoration with adequate and effective insulation.

Iontophoresis with 1%NaF.

PROGNOSIS: Favourable if irritant is removed early… if delayed irreversible pulpitis can occur.

COMPLICATION: If neglected it can transform into Irreversible pulpitis.


B) IRREVERSIBLE PULPITIS:

“Persistent inflammatory condition of the pulp which is symptomatic or asymptomatic caused by a noxious stimulus”

SYMPTOMS:

a) Severe pain of sharp, piercing / shooting type.

b) Pain occurs spontaneously without an external stimulus

c) Pain is continuous/ intermittent in nature that lasts for several minutes to hours.

d) Pain may also be aggravated by sudden change in temp, pressure / by lying downi.e change in posture, on exertion, etc.,

e) Pain is more severe during nights while sleeping because of the increased cephalic blood pressure which increases the already excessive intra pulpal pressure.

f) Referred pain is common finding( to the temple or sinus if upper posteriors are involved., to the ears if the lower posteriors are involved)

g) At later stages Throbbing type of pain is present due to arterial pulsation in the area of increased pulpal pressure.

h) After pulpal necrosis pain is no more felt.

i) Difficulty in mastication

DIAGNOSIS:

· Based on symptoms

· History: patient may give history of pulp capping, deep caries, trauma, extensive restorations

· Visual examination: inspection discloses a deep cavity extending to the pulp or a decay under a filling.

· Radiographs: they show the extent and depth of caries and restorations involving the pulp. Widening of lamina dura is noticed in advanced stages.

· Percussion: tooth is sensitive to percussion as the periapical pressure increases due to hyperactive, exudative, inflammatory tissue.

· Vitality tests: thermal test is positive and persists after stimulus is removed. Electric testing: at early stages-response to less current is evoked and at advanced stages- more current is required to elicit a response.

TREATMENT: Root canal treatment.

COMPLICATIONS: If this condition is neglected it can lead to-

- apical periodontitis

- periapical abscess

- cellulitis …….