This condition develops from an acute periapical periodontitis. In the early stages, the difference between the two is not always clear. Radiographic changes range from a widening of the periodontal ligament space (Fig. 2),
to a welldefined area (Fig. 3). The typical symptoms of an acute periapical abscess are a pronounced soft-tissue swelling (Fig. 4) and an exquisitely tender tooth. Extrusion from the socket will often cause the tooth to be mobile. Differential diagnosis of a suspected periapical swelling is important in case the cause is a lateral periodontal abscess. The diagnosis can be made by testing the vitality of the tooth. If it is vital, then the cause may well be periodontal in origin.
The immediate task is to relieve pressure by establishing drainage, and in the majority of cases this can be achieved by first opening up the pulp chamber, as seen in Figure 5. Initially, gaining access can be difficult because the tooth is often extremely tender. Gently grip the tooth and use a small, round, diamond bur in a turbine to reduce the trauma of the operation. Regional analgesia may be necessary, and inhalation sedation can prove invaluable. If drainage is not immediate it is permissible to explore the apical foramen with a very fine (size 08 or 10) file. The foramen should not be instrumented or enlarged, and if drainage does not result the procedure should not be persevered. As discussed in Part 7, the use of ultrasonically activated endodontic files may be particularly helpful in this situation for effectively flushing infected debris from the root canal system.
If a soft-tissue swelling is present and pointing intra-orally, then it may be incised to establish drainage as well. The presence of a cellulitis may result in little or no drainage. If a cellulitis is present, medical advice should be sought before any treatment is carried out (Fig. 6).
The immediate task is to relieve pressure by establishing drainage, and in the majority of cases this can be achieved by first opening up the pulp chamber, as seen in Figure 5. Initially, gaining access can be difficult because the tooth is often extremely tender. Gently grip the tooth and use a small, round, diamond bur in a turbine to reduce the trauma of the operation. Regional analgesia may be necessary, and inhalation sedation can prove invaluable. If drainage is not immediate it is permissible to explore the apical foramen with a very fine (size 08 or 10) file. The foramen should not be instrumented or enlarged, and if drainage does not result the procedure should not be persevered. As discussed in Part 7, the use of ultrasonically activated endodontic files may be particularly helpful in this situation for effectively flushing infected debris from the root canal system.
If a soft-tissue swelling is present and pointing intra-orally, then it may be incised to establish drainage as well. The presence of a cellulitis may result in little or no drainage. If a cellulitis is present, medical advice should be sought before any treatment is carried out (Fig. 6).