Acute apical abscess
Brief description of the condition
Acute inflammation of the soft tissues immediately surrounding the tip of the root of a tooth, often caused by tooth decay and subsequent death of the pulp tissue. This can also follow trauma. Common synonyms for the condition 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: the patient is unable to swallow their own saliva or they are unable to push their tongue forward out of their mouth.
If the airway is compromised, send the patient immediately to emergency care via NHS 24 or call 999.
If the airway is not compromised:
- Recommend optimal analgesia (see Appendix 2).
- Do not prescribe antibiotics unless there are signs of spreading infection (e.g. facial or neck swelling), systemic infection, or for an immunocompromised patient.
- 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 with either sodium hypochlorite solution (1–5.25%) or 0.2% chlorhexidine gluconate solution before drying and sealing 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 (non-steroidal anti-inflammatory drugs) if attempts to drain the infection are inadequate or if patient or clinician factors preclude immediate initiation of drainage (see Appendix 2).
- Relieving occlusion on the affected tooth, if appropriate.
- Extracting the tooth, if appropriate (for a primary tooth this is usually considered as the first option; refer to secondary care for adjunctive sedation if the child is unable to tolerate pain).
- Prescribing non-steroidal anti-inflammatory drugs to control post-operative pain following initial endodontic therapy (see Appendix 2).