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.