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Clinical Summary

Acute pain, swelling, and mild tooth elevation are characteristics of a periapical or dentoalveolar abscess. Exquisite sensitivity to percussion or chewing on the involved tooth is a common sign. The involved tooth may have had dental caries, a filling, or a root canal. Periapical abscesses can enlarge over time and “point,” either internally on the lingual or buccal mucosal surfaces, or extraorally with swelling and redness of the overlying skin. Occasionally, these lesions may track up to the alveolar periosteum and gingival surface to form a parulis. Radiographically, these abscesses appear as well-circumscribed areas of radiolucency at the dental apex or along the lateral aspect of the root. Early acute periapical abscesses may not demonstrate any radiographic changes. Both deep periodontal and periapical abscesses may have sinuses draining purulent material onto the gingival surface. If the infection is allowed to progress, it can erode through cortical bone, manifesting itself in a variety of locations. Panorex films, dental radiographs, or a CT scan may aid in the diagnosis.

Management and Disposition

Analgesics, tetanus prophylaxis, and antibiotic therapy are indicated. A regional nerve block provides immediate temporary relief. Incision and drainage along with saline irrigation and prompt referral are indicated for parulis management. Dental follow-up in 1 to 2 days is recommended for endodontic evaluation or possible extraction of the involved tooth.

FIGURE 6.27

Periapical Abscess. This periapical abscess points externally to the overlying skin. (Photo contributor: Robin Cotton, MD.)

Pearls

  1. More than one tooth may be involved.

  2. Exquisite tenderness and pain on tooth percussion are key features on physical examination and identify the involved tooth.

FIGURE 6.28

“Gumboil” (Parulis). This lesion is a sinus tract extension of a periapical abscess. It is differentiated from a periodontal abscess by tenderness to tooth percussion. (Photo contributor: Alan B. Storrow, MD.)

FIGURE 6.29

Periapical Abscess. (A) Note the well-defined radiolucent area at the apex and lateral root of the tooth in this radiograph. (Photo contributor: James L. Kretzschmar, DDS, MBS.) (B) This Panorex film shows lucencies consistent with periapical abscesses, most notably of the right inferior posterior molar tooth (see arrows). (Photo contributor: David P. Kretzschmar, DDS, MS.)

FIGURE 6.30

Odontogenic Abscesses. As infection progresses from the pulp at the tooth apex, it erodes through the bone and can express itself in a variety of places. This illustration notes several possible locations or spaces. (Adapted with permission from Cummings C, Schuller D, eds. Otolaryngology Head and Neck Surgery. Chicago, IL: Mosby-Year Book; 1986.)

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