Pulpal Necrosis (and Previously Treated Teeth) with Acute

Periradicular Abscess
NoSwelling
The treatment of pulpal necrosis with periapical symptoms should involve
thorough removal of necrotic pulp tissue from the root canal system.
Complete cleaning and shaping of the root canals and placement of a
calcium hydroxide dressing are the goals of emergency treatment. Some
clinicians believe that if necrotic debris is not pushed beyond the apex, the
patient will have less postoperative discomfort.[24][47][97][113] If possible and
time permits, then complete instrumentation of the canal or canals is
appropriate, at the emergency visit, to remove as much of the canal
contents as possible. This is facilitated by improvements in technology,
such as electronic apex locators that can quickly and predictably determine
an accurate working length.[39] Taking it a step further, one school of
thought proposes introducing a file slightly beyond the apex to ensure
patency of the canal. This may also establish drainage from the periapical
tissues and is especially useful when the clinician has diagnosed pulpal
necrosis with acute periradicular abscess but no drainage has

been achieved by access into the root canals. Because of the possibility of
iatrogenic damage (i.e., apical transportation), care must be taken to
prevent aggressive extension with large files past the apical foramen.

Emergency treatment of previously root-treated teeth that are symptomatic

and have extensive restorations (including posts and cores, crowns, and
bridgework) can be difficult and time consuming. However, the goal
remains the same: removing contaminants from the root canal system and
establishing patency to achieve drainage.[55][96] Gaining access to the
periapical tissues through the root canals may require removal of posts
and failing root canal fillings, as well as negotiation of blocked or ledged
canals. On occasion the canal may be obstructed with blockages or ledges
that prevent canal negotiation. Failure to complete root canal debridement
and achieve periapical drainage may result in continued painful symptoms.

Historically, trephination, the surgical perforation of the alveolar cortical

plate to release accumulated tissue exudate causing pain, was advocated
to provide pain relief in patients with severe and recalcitrant periradicular
pain. The technique involved an engine-driven perforator entering the
medullary bone without the need for an incision[30] and thus providing a
 pathway for drainage from the periradicular tissues. However, recent
studies have failed to show a benefit of trephination not only in patients
with irreversible pulpitis with acute periapical periodontitis[80] but also in
patients with symptomatic necrotic teeth with radiolucencies.[89] Trauma of
the surgical procedure may add to the pain process and also to inadvertent
and possible irreversible injury to the tooth or surrounding structures.
However, one very real use for trephination is with an acute alveolar
abscess when the area is large and almost perforating the buccal bone,
such as usually occurs with maxillary teeth. A sterile root canal instrument
can be manipulated into the area, and an artificial sinus tract will be
created.

Although single-visit endodontic treatment for teeth diagnosed with

irreversible pulpitis is not contraindicated, [1][95][96][105][123] treatment of
necrotic and previously treated teeth is not so cut and dried. Research[40]
has indicated that postoperative pain differs little in cases of pulpal
necrosis filled at the time of the emergency versus at a later date. Whereas
some recent studies[41][66] show no difference between the outcome of
one- visit versus two-visit treatment, other recent studies[114][119] have
questioned the long-term prognosis of such treatment, especially in cases
of acute periodontitis. Appropriate treatment in multiple visits will permit
elimination of bacteria in the root canal system.

WithSwelling
Tissue swelling associated with an acute periradicular abscess may be
seen at the initial emergency visit, as an interappointment flare-up, or as a
postendodontic complication. Swellings may be localized or diffuse,
fluctuant or firm. Localized swellings are confined within the oral cavity. A
diffuse swelling or cellulitis is characterized by its spread through adjacent
soft tissues, dissecting tissue spaces along fascial planes.[61]

Three avenues can address swelling and infection:

1. Establish drainage through the root canal

2. Establish drainage by incising a fluctuant swelling

3. Antibiotic treatment

The cardinal rule for managing all these infections is to achieve drainage
and remove the source of the infection.[50][61] When the swelling is
localized the preferred avenue is drainage through the root canal. Cleaning
and shaping are paramount to success regardless of drainage, because
bacteria remaining within the root canal system compromise resolution of
the acute condition.[78] Copious irrigation is performed throughout the
cleaning and shaping of the canal.[52][121]

The drainage should be allowed to stop; then the root canals should be
dried, medicated with calcium hydroxide, and closed.[31][47][54] Gentle
finger pressure to the mucosa overlying the swelling may aid drainage. On
very rare occasions, drainage may continue and the clinician may opt to
step away from the patient for some time.[62] As a rule, teeth should not be
left open between appointments.[7][125] If good drainage is achieved by
access and instrumentation of the root canal system, then no incision and
drainage procedure is needed.

The prescription of antibiotics should be adjunctive to appropriate clinical

treatment (see Chapter 13 for details). Antibiotics are not indicated for
localized swelling[42][51][56][122]; rather, they are indicated when signs and
symptoms are associated with systemic involvement, for patients with
progressive infections, or for patients who are immunocompromised.[10]
The objective is to aid the elimination of pus from the tissue spaces.
Generally the use of antibiotics alone (without concurrent cleaning and
shaping) is not considered appropriate treatment.[50][61]

With localized swelling the practitioner is dealing with an abscess that is

confined within the oral cavity. A diffuse swelling indicates an advanced
infection that is potentially dangerous for the patient (see Chapter 13 for
further information on how these infections are managed). More
aggressive treatment is necessary to minimize the possibility of the
infection spreading.

Incisionfordrainage
Management of a localized soft tissue swelling can be facilitated through
incision for drainage of the area.[87] Incision for drainage is indicated
whether the cellulitis is indurated or fluctuant.[61] A pathway for drainage is

needed to prevent further spread of the abscess or cellulitis. An incision for

drainage allows decompression of the increased tissue pressure
associated with edema and provides significant pain relief for the patient.
The incision also provides a pathway not only for bacteria and bacterial
byproducts but also for the inflammatory mediators associated with the
 spread of cellulitis.

The basic principles of incision for drainage are as follows:

1. Make the incision at the site of greatest fluctuance.

2. Dissect gently, through the deeper tissues, and thoroughly explore all parts
of the abscess cavity, eventually extending to the roots of the teeth
responsible for the pathosis. This will allow compartmentalized areas of
pus to be disrupted and evacuated.

3. To promote drainage, the wound should be kept clean with hot saltwater
mouth rinses. Intraoral heat application to infected tissues results in a
dilation of small vessels, intensifying host defenses through increased
vascular flow.[50][61]

A diffuse swelling can turn into a medical emergency with potentially life-
threatening complications. One determining factor that directs the spread
of the infection is the muscle attachments. A patient under the care of a
dentist should be contacted every 8 to 12 hours until the swelling starts to
resolve. In addition, the patient should be able to contact the dentist at any
time for additional instructions or an alternative course of action if the
situation worsens. Analgesics should be prescribed, and the patient should
be monitored closely for the next several days until there is improvement.
Individuals who show signs of toxicity, elevation of body temperature,
lethargy, central nervous system (CNS) changes, or airway compromise
should be referred to an oral surgeon for immediate hospitalization, with
aggressive medical and surgical intervention. This team will no doubt
include members of a department for infectious disease.