Acute Periapical Abscess

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Introduction

  • A localized collection of pus in the periapical region of a tooth contained within the alveolar bone

Aetiology

  • May develop either directly from acute periapical periodontitis or more usually from a chronic periapical granuloma
  • Generally the result of a mixed bacterial infection
  • Culture of the pus yields a wide range of different organisms
  • Strict anaerobes (e.g. prevotella, porphyromonas) usually predominante, but facultative anaerobes may be found

Clinical features

  • Painful swelling at the root of tooth
  • Sinus (may be present)
  • Tooth is tender to biting or percussion
  • Tooth may be mobile

Differential diagnoses

  • Infected radicular cyst
  • Periodontal abscess

Investigations

  • Radiographs (periapical)

Treatment objectives

  • Relieve symptoms
  • Eliminate the infection

Non-drug treatment

  • Drain abscess using local anaesthesia by root canal extirpation if tooth is to be retained
  • Otherwise extract the involved tooth
  • Treat residual infection

Drug treatment

  • Amoxicillin
    • Adult: 250 mg orally every 8 hours for 5 to 7 days
    • Child up to 10 years: 125 mg every 8 hours for 5-7 days, doubled in severe infections
  • Metronidazole
    • Adult: 200 mg orally every 8 hours for 3 - 7 days
    • Child:
      • 1 - 3 years: 50 mg orally 8 hourly for 3 - 7 days
      • 3-7 years: 100 mg 8 hourly
      • 7-10 years: 100 mg 8 hourly for 3-7 days

In dento-alveolar abscess that has not responded to penicillins or metronidazole

  • Clindamycin
    • Adult: 150 - 300 mg every 6 hours; up to 450 mg every 6 hours in severe infections
    • Child:
      • 1 month – 18 years 3 - 6 mg/kg (max. 450 mg) every 6 hours
      • Neonate:
        • Under 14 days 3-6 mg/kg 3 times daily
        • 14-28 days 3-6 mg/kg (max. 450 mg) 4 times daily

By deep intramuscular injection or by intravenous infusion, 0.6-2.7 g daily (in 2-4 divided doses) life threatening infection, up to 4.8 g daily; single doses above 600 mg by intravenous infusion only; single doses by intravenous infusion not to exceed 1.2g.

Notable adverse drug reactions, contraindications and caution

  • Discontinue immediately if diarrhoea or colitis develops; monitor liver and renal function if treatment exceeds 10 days, and in neonates and infants; avoid rapid intravenous administration; avoid in acute porphyria