An acute apical abscess (AAA), also known as acute periapical abscess, acute
dentoalveolar abscess or acute periradicular abscess, is a highly symptomatic inflammatory
response of the periapical connective tissues (3). It originates when the pulpal tissues initiate
an inflammatory response to trauma or caries, eventually leading to pulpal necrosis.
There are usually clear clinical and radiographic signs in a patient with AAA, although
there is a continuum. Pain often occurs rapidly, the severity ranging from slight tenderness to
intense, throbbing pain. The source of the pain is easy to determine, as the affected tooth
becomes increasingly tender to percussion and chewing. The tooth may be in hyperocclusion, again interfering with normal function. In some cases, the tooth may be mobile. In
the late stages of abscess formation, the patient can usually tolerate the discomfort if the
tooth is not touched. Resorption of the overlying cortical bone and localization of the
suppurative mass beneath the alveolar mucosa produces a palpable, fluctuant swelling.
2Frequently, a localized sense of fullness accompanies the pain. Radiographically, the
appearance of the periodontal ligament space ranges from within normal limits, to slightly
thickened, (4) to a large periapical radiolucency.
As AAA is due to pulpal necrosis and localized infection, the recommended treatment
is to remove the necrotic tissue. This is generally accomplished by allowing drainage of the
infection via trephination through the tooth and extripation of the necrotic pulp (i.e.
pulpectomy), incision of the soft tissue swelling (as short term relief), or extraction of the
offending tooth (4). Other therapies have been used on their own or in conjunction with a
pulpectomy to relieve the patient’s symptoms. These include the use of systemic or local
medicaments, such as corticosteroids, analgesics, and antibiotics. If untreated, AAA may
progress to a more wide spread infection and even cellulitis. There is a risk of dissemination
of organisms from a periapical abscess to the bloodstream, resulting in systemic
complications. The signs of systemic involvement are pyrexia, lymphadenopathy and malaise
(5). This risk is reduced in periapical infections that can drain freely.
If adequate drainage cannot be established through pulpectomy, incision and drainage
or extraction, antibiotics are commonly prescribed to prevent systemic complications.
Although incidence of the latter is unreported, it would seem logical to use them as an adjunct
in patients who are immunocompromised (6). Although the pain from AAA is the result of an
infectious process, this infection is usually localized; thus, the use of antibiotics as a sole or
concomitant therapy for most patients is questionable. Despite this, up to 75% patients with
painful abscesses, and no systemic symptoms may be treated with antibiotic therapy (7-9).
The prevalence of AAA has been reported to range from 5% to 46% (10, 11). The
condition can have significant social impact (12), in terms of days of work missed and
diminished quality of life. In terms of cost, emergency dental treatment comprises from 2-6%
of the costs of all dental therapy, an amount similar to all periodontal treatment costs (13, 14).
In view of the prevalence of this condition in everyday practice and the evidence of practice
variation, a systematic review is warranted. The objective of this review is to determine the
effectiveness of the various interventions used in the management of acute apical abscess in
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