Friday, March 5, 2010

A) PERIAPICAL ABSCESS

def:
it is defined as “ the localized, acute or chronic suppurative (associated with the discharge of purulent exudate- “the pus”) infection in the periapical region of the tooth.

It is also k/a dentoalveolar abscess





etiopathogenesis
Progression of pulpal infection into the periapical tissue.
Accidental perforation of the apical foremen during endo- rx , leading to the entry of pulpal microorganisms into the periapical area
Spread of periodontal infection into the periapical tissues
Fracture of tooth with pulp exposure
Secondary bacterial invasion into the pre-existing periapical granuloma or cyst or scar
Anachoretic infection of periapical tissues


Due to strict anaerobes like
prevotella,
porphyromonas etc.
Also , anaerobic streptococci,
staphylococci.

It is a common odontogenic infection (2% of all apical radiolucencies)





Clinical features
Severe pain
localized swelling and erythematous overlying mucosa
Extreme tenderness to persussion and to pressure on
chewing
Slight extrusion of the tooth
non- vital , mobile tooth
fever and localized lymphadenitis
Pain – aggravated by heat,
relieved by cold
In chronic periapical abscess –
dull, mild pain with
intraoral/extraoral pus discharging sinuses.




Sequelae of acute periapical abscess
If untreated, invades cortical plates of bone (mostly buccal) and invades adjacent soft tissues , leading to space infection and finally cellulitis
pus discharging sinus-
either intraorally (on alveolar mucosa over the apex of root)
or extraorally (on skin over the jaw)
Chronic periapical abscess
(if host defense is high, or
virulence of microorganisms is low)
Osteomyelitis
(I f the abscess invades the medullary spaces of the bone)
Infection of fascial spaces
(further complicated by ludwig’s angina, septicaemia, cavernous sinus thrombosis etc.)





Radiographic finding
Acute periapical abscess
as it develops rapidly, no time for bone resorption to occur; hence the only r/f that is seen is-
the thickening (slight) of PDL spaces in the apex region of the tooth involved.

Chronic periapical abscess
small radiolucent areas at the apex of the root with poorly defined margins.




Histological features
Lesion consists of “ZONE OF LIQUEFACTION NECROSIS” , which consists of
Protein exudates
necrotic tissues , and
a large no. of viable or dead neutrophils (pus).
Dilated blood vessels and
neutrophilic infiltration, adj. to the lesion
PDL and adj bone marrow also shows inflammatory changes
bony trabeculae in the periapical region may show empty lacunae (due to the death of osteocytes)
In chronic periapical abscess
- chronic inflammatory cells (like lymphocytes)
- area of bone destruction accompanied by
area of bone regeneration and fibrosis
- pus discharging sinus lined by
either granulation tissue
or squamous epithelium.




treatment
Drainage established
either through an opening in the tooth
or by incision over soft tissue swelling at apex

Antibiotic administration (START WITH PENICILLIN; IF ALLERGIC TO PENICILLIN, DO ERYTHROMYCIN OR CLINDAMYCIN)

Rct or
extraction of the tooth (after the acute phase of the disease is controlled)

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