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Acute periapical abscess

and spread of
inflammation
Dr. Fahed S.Habash.
2
nd
Semester, 2004
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Acute Periapical Abscess
and Spread of Inflammation
Aetiology and microbiology: -
An acute periapical abscess may develop
directly from acute periapical periodontitis
or more usually from a chronic periapical
periodontitis (granuloma).
Mixed bacterial infection.
Synergistic interaction between organisms
will increase the severity of the infection.
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Routes of Spread
If the cause of the abscess is not removed,
suppuration will continue and the abscess
continues to enlarge.
In some cases, a balance may eventually be
established between the irritant and the host
defenses and the abscess becomes chronic and
remain localized.
More frequently, the increase in hydrostatic
pressure within the abscess associated with
progressive suppuration causes the pus to track
in one of a number of directions.
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Possible Routes of Spread
It may drain through the root canal into the
mouth.
It may track through the periodontal
ligament to discharge into the gingival sulcus.
It may track through the cancellous bone and
perforates the cortex.
Once the cortical plate is perforated the pus
strips up the periostium and may result in the
formation of subperiosteal abscess.

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It may penetrates the periosteum &
may track in various direction
(affected by anatomical factors).
The relationship of the cortical
perforation (which related to the apex
of the abscessed root) to the origins
of muscles, for example buccinator and
Mylohyoid, and the strength of the
overlying periosteum are important
factors.
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Possible outcomes of
infection spread
1. The pus may discharge directly into the oral cavity
through a sinus following local penetration of the
overlying periosteum & mucosa.
On other occasions the pus may accumulate beneath
the mucosa and the patient may complain of a gumboil
before a sinus develops.
A nodule of granulation tissue often forms in
response to the irritation by pus and marks the
opening of the sinus.
2. The dense palatel mucoperiosteum is resistance to
penetration by pus. Pus tracking palatally may spread
under the mucoperiostium and present as a palatal
abscess.

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3. Abscess in the molar region of either Jaw
may penetrate the buccal cortical plate
above (in the maxilla) or below (in the
mandible) the attachments of the
buccinator muscle spreading of the
infection in the soft tissue of the face or
neck (cellulitis). Or less frequently as a
localized soft tissue abscess.
4. Abscess developing of the root apices of
maxillary molars and premolars are very
close to the floor of the maxillary sinus
and consequently may discharge into the
sinus.
5. Abscess related to ant. maxillary teeth
may pass into the upper lip.


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6. An abscess related to mandibular premolar
or molar tooth may perforate the lingual
plate of the mandible below the attachment
of mylohyoid muscle to involve the
submandibular space. This cause a marked
swelling at the lower border of the mandible
spreading toward the neck (submandibular
space has communications with the sublingual
and lateral pharyngeal spaces).
7. Pus from an abscess associated with a
mandibular incisor or canine may track
labially and perforate the bone below the
insertion of the mentalis muscle and pass
downwards to present as a subcutaneous
abscess. (most often at the mid line).
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Cellulitis
o Potentially life-threatening infections due to spread of
bacteria into perioral fascial spaces.
o Associated with steptococcal infections and the rapid spread
due to the release of large amounts of steptokinase and
hyaluronidase.
o Its not localized and affected tissues swollen.
o Infection usually arises from lower second or third molars.
Cellulitis may associated with maxillary teeth involves the
upper half of the face.
o Severe systematic upset associated.
o Ludwigs angina comprises bilateral involvement of sublingual
and submandibular spaces usually as a result of initial
involvement of submandibular space. This diffuse infection
may tracks backwards to involve the pharynx and larynx with
risk of death by suffocation.
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