Histology / Diagnosis and Treatment of Acute Apical Abscess

Acute Apical Abscess

§ It is a severe inflammation of pulp origin, in which the periodontal membrane and alveolar bone around the root tip are affected, and
localized pus collects!
§ Acute apical abscess or Dentoalveolar abscess, Periapical abscess, Periradicular abscess, Apical abscess, all describes the AAA.
Ñ At the onset of chronic abscess,
Ñ After chronic periapical periodontitis,
Ñ It may occur as a result of untreated acute apical periodontitis.
Histologically;
§ dead and live neutrophilic leukocytes,
§ disintegrated tissue cells,
§ degraded extracellular matrix,
§ bacterial toxins,
§ It is a local aggregation of suppurative / purulent exudate consisting of lysosomal enzymes released by dead neutrophilic leukocytes.
Etiology
§ The invasion of microorganisms into the pulp and their progression in the root canal
system.
Gradient

Apical region
§ Lower oxygen tension
§ Nutrients from the periradicular tissues: proteins and
glycoproteins
§ Lower bacterial counts
§ Bacteria less accessible to treatment measures

Coronal region
§ Higher oxygen tension
§ Nutrients from the oral cavity: carbohydrates
§ Higher bacterial counts
§ Microorganisms more accessible to treatment

Microorganisms
75% facultative and obligate anaerobes
Facultative anaerobes
§ Streptococcus Oralis
§ Streptococcus
Sanguinis
§ Staphylococcus
Aureus (in
children’s)
Obligate anaerobes
§ Peptostreptococcus
(micros, anaerobius)
§ Fusobacterium
(nuclearum)
§ Bacteriodes (black
pigmented bacteria)
o Prevotella
o Porphyromonas

Etiology
m Microorganisms
Those that give
damage to pulp
and
m periapical tissues
• Trauma
• Mechanical
and chemical
irritation
√ If there no
microorganism there
is no infection
 What happens in the acute apical abscess area?
§ Inflammatory reaction (exudation)
• Polymorphic core leukocytes
• lysosomal enzymes
§ The 'proteinase' enzyme of polymorph core leukocytes and the 'hydrolase' of macrophages cause enzyme connective tissue
destruction.
§ Gram-negative anaerobic lipopolysaccharides (endotoxins) trigger inflammatory bone resorption. Bone destruction occurs with defence
cells.
§ There is a pus that consists of dead defence cells, microorganisms, enzymes and remnants of the tissue they have disrupted, and
purulent exudate.
§ Disruption of the integrity of periodontal membrane results in elevation of the tooth within alveolar space. the the the
Pathogenesis
§ It has become evident that osteoblasts have a global role in orchestrating the bone remodelling process. Their function is not
restricted solely to bone formation but it is now firmly established that they are responsible for initiating bone resorption. Osteoblasts
provide the essential and sufficient stimuli that control the behavior of the osteoclasts, an event that occurs via cell-cell interaction.
Clinical Symptoms
§ The first symptom is a feeling of discomfort in the tooth.
§ The patient feels that the tooth is slightly elevated and slightly moves in the alveoli when the tooth is pressed.
§ As the abscess progresses, it spreads to the soft tissues around the root, and severe pain is seen in a pulsatile manner.
§ As the infection progresses, the tooth rises higher in the alveolar space with increasing pus in the periapical region. Severe and
continuous pain picture is observed.
§ As a result of the spread of the infection, the erosion and perforation of the adjacent cortical bone results in swelling in the area.
§ The swelling may spread and show a diffuse appearance of the infection is not treated. This picture is called 'cellulite'. The patient
has fever and malaise.
§ Acute apical abscess has a fast-growing picture.
§ In the first stage, the detection of the related tooth may be difficult. However, the elevation of the relevant tooth in the alveolar
cavity and the sensitivity during the contact of the teeth make the diagnosis easier.
§ The tooth has lost its vitality.
§ There is severe pain (at first pulsating, then severe and continuous).
§ The tooth is mobile and very sensitive to percussion.
§ There is swelling originating from the related tooth in the area.
§ Palpation is painful.
§ The swelling is fluctuant or plump (cellulite).
§ The radiograph may show either no change in the periapical tissues or a large periapical lesion.
§ There may be no changes in the periapical tissues on the radiograph or it may be seen in a large periapical lesion.
§ Antibiotics are not prescribed if drainage can be done.
§ If the patient has widespread swelling on the face (cellulitis), if the incision cannot be drained and if there is no pus from the canal,
if there is fever and lymphadenopathy, antibiotics are given.
§ The pus opens a path from the weakest part of the tissues through a fistula into or out of the mouth. Thus, the patient's pain is
relieved or completely stopped.
subperiosteal abscess
§ If the pus collected in the periapical region pierces the bone over time and collects under the periosteum, a 'subperiosteal abscess'
occurs.
submucous abscess
§ If it passes through the periosteum and collects under the mucosa, it becomes a 'submucous abscess'.
parulis
§ If the pus collects under the gingiva, it is called 'parulis'.
phoenix abscess
§ Phoenix abscess; It is the transformation of a chronic apical lesion into an acute inflammatory reaction.

The pus flows out in three ways:

1. Via root canal
2. Via the periodontal space
3. By piercing the mucosa or jawbone
Localization of swelling
§ The swelling is positioned according to the tooth and anatomic structure.
§ Usually, perforation occurs in the bone wall closest to the root apex.
§ Then the path of progression of the pus depends on the adjacent muscle and fascia.
§ The spread of the pus is seen in different regions in each tooth group.
maxillary central incisors
§ Root apex is close to the lip surface of the alveolar bone.
§ Swelling occurs at the base of the nose. The upper lip swells.
maxillary lateral incisors
§ The root apex of some of them is close to the lip surface of the alveolar bone, and in some it is close to the palatal surface.
§ There is an abscess of the nasal septum, the upper lip swells.
§ If the root is close to the palate, it opens to the palate.
maxillary canines
§ The maxillary canine tooth abscess usually opens to the surface of the lip.
§ There is swelling on the side of the upper lip, the part of the cheek close to the nose and extending to the eyelid.
§ This is also called 'fossa canina abscess'.
mandibular central, lateral and canine teeth
§ The exudate usually drains from the lip surface of the alveolar bone.
§ The relationship between the mentalis muscles and the tooth roots determines the spread of the pus.
§ In the lower canine, the pus usually punctures the buccal cortical bone and collects into the vestibule.
maxillary and mandibular premolars
In the maxillary premolars
§ If the infection originates from the vestibule root of the first premolar, in the vestibule; if it originates from the root of the palate,
there will be swelling in the palate.
§ If the tooth is single rooted, swelling often is seen in the vestibule.
§ The pus from the second premolar swells in the vestibule or open into the sinus.
In the mandibular premolars
§ There is swelling in the mouth towards the vestibule.
Maxillary molars
§ Periapical lesions usually puncture the bone from the buccal side of the alveolar bone and collect buccally.
§ The swelling is often on the cheek.
§ Rarely, the abscess originating from the palatal roots collects in the palatal and opens
into the mouth by puncturing the palate or into the sinus cavity by puncturing the sinus Maxillary central nasal floor,
incisors upper lip
floor.
Mandibular molars
§ It mostly affects the place where the buccinator muscle is attached.
§ If the tooth roots are above the attachment line of the muscle, the abscess collects in Maxillary lateral nasal septum,
the vestibule in the mouth. incsors palatal region
§ The root ends of the first molar are closer to the vestibule surface of the alveolar
bone.
§ In very few cases, the abscess can access to the lingual surface.
§ Ludwig's Angina Maxillary canine fossa canine
mandibular second molars
§ The root ends of the mandibular second molars, on the outside buccinator, inner side
mylohyoid muscle may be above or below the grip line.
Maxillary vestibule
Differential diagnosis premolar
It can be confused with periodontal abscess
§ Dull pain
§ The tooth is sometimes mobile Buccal roots of
§ Swelling in the coronal direction the maxillary vestibule
§ Palpation is sensitive in the coronal direction molars
§ Pulp is vital, positive response to heat tests
§ Vertical bone loss in alveolar bone
Palatal palatal
Acute apical abscess rootPalatal root
§ Severe, pulsating pain
§ The tooth is mobile
§ Swelling in the apical direction lower lip,
Mandibular chin tip,
§ Palpation sensitive in the apical direction incisors rarely neck
§ Pulp is non-vital area
§ Radiolucent image in the periapical region
Mandibular ear,
posterior group submaxillary
teeth region
Treatment
§ Shaping and disinfecting the root canal system
§ Drainage (incision)
§ Pressure reduction and removal of microorganisms
§ If there is cellulitis, fever, lymphadenopathy; antibiotic + anti-inflammatory; if not, only anti-inflammatory are prescribed
§ Completion of root canal treatment
§ Tooth extraction
o Prognosis of the tooth (restorability, periodontal condition)
o Strategic importance
o Patient's choice or
o Economic reasons...

Discharge of the pus:

§ Drainage through the root canal
§ Surgical drainage with incision
§ "trephination" by drilling the bone with the bur
drainage through the root canal
§ Anesthesia is not needed (the tooth has lost its vitality), but 'intramucosal' or 'regional anesthesia' can be used to relieve the pain
from pressure.
§ The tooth is painful on contact. If the endodontic access cavity can prepared without pressure on the tooth, the patient's pain will
be less.
§ If finger support is provided to the tooth from the opposite side of the bur pressure, tooth mobility is eliminated.
§ The pulp orifice is access, pulp residues are removed. It is helped to remove the pus by light palpation at the level of the root apex
with a finger.
§ The exudate from the root canal is first colored yellowish- whitish. Then it takes on a greenish color mixed with blood. Gradually the
color turns red, the purulence decreases, the blood comes. Finally, a bright yellow prulence comes, this is blood-stained serum
exudate.
Surgical drainage
§ Intramucosal anesthesia, regional anesthesia or cold sprays can also be used before incision.
§ If drainage through the root canal is not sufficient, an incision is made.
§ When the swelling is palpated, the soft and filled with purulent (fluctuant) area should be noticed.
§ The tip point of the abscess is white or yellowish.
§ This appearance indicates that the abscess has matured; In this case, an incision can be made.
§ Palpation is not performed in the cellulite case
trephination
§ Drilling the Bone "Trephination"
§ Sometimes, when pus collects around the root apex, the surrounding compact bone prevents it from spreading; The pus remains
inside the cancellous bone.
§ Although the incision is made, there is no discharge.
§ It is necessary to drill the compact bone from the outside.
§ After the root canals are shaped and irrigated, a horizontal incision is made at the level of the root apex.
§ The exposed bone is drilled with a 4 or 6 round bur.
Should the root canals be left open?
§ Many microorganisms enter the root canal through the mouth and the root canal flora can become more complex.
§ Nutrient residues can reach the periapical tissues through the root canal.
§ The inflammatory reaction may recur and recovery may be delayed or impossible.
"Sedare Dolorem Opis Divinum Artem" (Relieving pain is a divine art) - Hippocrates