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Acute apical abscess

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Brief description of the condition

Progression of apical periodontitis (acute inflammation of the soft tissues immediately surrounding the tip of the root of a tooth; see Symptomatic apical periodontitis), where the infection forms a pus-filled swelling. Common synonyms for acute apical abscess include acute periradicular abscess, acute dentoalveolar abscess and acute periapical abscess.

Key signs and symptoms

  • Pain (usually localised to a single tooth; often quick onset with varying severity; source easy to ascertain as tooth becomes progressively more sensitive to chewing and touch)
  • Swelling of the gingiva (gum), face or neck (swelling caused by abscess often pushes affected tooth against other teeth, creating discomfort in the lower-upper teeth contact and may sometimes cause the tooth to become mobile; indicates spreading infection)
  • Fever
  • Listlessness, lethargy, loss of appetite for children younger than 16 years old

Initial management

Determine if the airway is compromised. Symptoms include: difficulty breathing; high pitched breathing sound (stridor); difficulty swallowing (dysphagia); hoarse or muffled sounding voice (dysphonia).

If the airway is compromised, send the patient immediately to emergency medical care at the nearest emergency department or call 999.

If the airway is not compromised:

  • Recommend optimal analgesia (see Analgesia).
  • Do not prescribe antibiotics unless there are signs of spreading infection (e.g. facial or neck swelling), symptoms of systemic infection, or judged appropriate for an immunocompromised patient.24,25,27
  • Advise the patient to seek urgent dental care.

Subsequent care

Consider:

  • Initiating drainage of the abscess through the affected tooth if possible. If there is an associated fluctuant soft tissue swelling attempt incisional drainage as soon as possible.
    • If able to drain through the tooth, irrigate the canal preferably with sodium hypochlorite solution (0.5–5.25%) or alternatively with 2% chlorhexidine gluconate solution (0.2% chlorhexidine solution, commonly sold as mouthwash, is not an effective antibacterial agent).28 Rubber dam should be used.28
    • Dry and seal in non-setting calcium hydroxide using a temporary dressing material.
    • Note that drainage is not normally carried out for a primary tooth. If drainage of the abscess through endodontic access is persistent, early recall and repeated cleaning of the canal may be necessary. The tooth should not be left on open drainage.
  • Prescribing appropriate analgesia if attempts to drain the infection are inadequate or if patient or clinician factors preclude immediate initiation of drainage (see SDCEP Drug Prescribing for Dentistry guidance).
  • Relieving occlusion on the affected tooth, if appropriate, following access and drainage of the root canal system.
  • Extracting the tooth, if appropriate (for a primary tooth this is usually considered as the first option;33 consider referral to secondary care for adjunctive sedation if the child is unable to cope with the procedure).
  • Prescribing appropriate analgesia to control post-operative pain following initial endodontic therapy (see SDCEP Drug Prescribing for Dentistry guidance).