VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

Periapical Abscess: Approach and Management in Children and Adults Josephine Bolin, OMS IV 1 , Caitlin Gann, OMS IV 1 , Hanna S. Sahhar, MD, FAAP, FACOP 1,2 Edward Via College of Osteopathic Medicine-Carolinas Campus, Spartanburg, SC 1 Spartanburg Medical Center, Department of Pediatrics, Spartanburg, SC 2

Abstract # CBR-10




Dental disease has negatively affected patients for centuries with reports as early as the 1600s listing “teeth” as the 5th or 6th leading cause of death, but discussion concerning management and prevention did not pick up until the late 1900s. From 1999 to 2004, the Hull Royal Infirmary showed an increasing number of patients requiring oral and maxillofacial surgery secondary to dental sepsis. Despite increasing modernization and understanding, dental disease, its treatment, and its causes remain an important topic of discussion. Acute periapical abscesses are of particular concern for the medical field as well as the dental field because they account for 60% of non traumatic dental emergencies. These abscesses are infectious pus accumulations within the wall of the alveolar socket secondary to various events. Common inciting events include periodontitis, cary formation, pulp necrosis, periapical infection, dental trauma, or foreign body impaction with foreign body impaction being particularly common in children. Additionally, they may be caused iatrogenically during dental procedures, such as implant placement. Many studies have sought a bacterial species that initiates abscess development. Most of these studies isolate a wide variety of anaerobes, primarily Gram-positive anaerobes, when studying the oral flora. If not properly identified and appropriately treated, the disease may progress to mediastinitis, sepsis, multiorgan failure, and death. Considering this significant morbidity and mortality, it is vital to patient care to better understand disease prevention, especially during dental procedures, commonly associated bacterial communities, and appropriate surgical and pharmacological treatment. For this reason, we seek to address these topics through the review of disease development and treatment in two acute cases of periapical abscess. Periapical abscesses have plagued humans of all ages for centuries. While thought to be a dental problem, it is not uncommon for physicians to treat periapical abscesses, especially in the emergency setting. We investigated two cases of periapical abscesses that presented to the emergency room and resulted in subsequent tooth extractions. The first case is that of a man with progressive lucency of the left lower second bicuspid (tooth #20) on dental radiographs over a matter of months. He was evaluated and had a tooth extraction and implant of the left lower first molar (tooth #19), but the progressive lucency noted of the left lower second bicuspid (tooth #20) was not addressed because he had no complaints at the time. The tooth in question had previously been treated with a root canal for asymptomatic apical periodontitis. Following his implant of the left lower first molar (tooth #19), he was prescribed clindamycin, but presented to the emergency room with symptoms concerning for an acute Phoenix abscess in the left lower second bicuspid (tooth #20). A Phoenix abscess is a painful inflammation of the apical portion of a tooth root. At this time he had an extraction of the left lower second bicuspid (tooth #20) and incision and drainage of the abscess. Cultures performed from the abscess identified Prevotella melaninogenica and Gemella spp . Similarly, the second case is of a child who had been given a course of penicillin by his dentist for dental pain and then presented to the emergency room with diffuse facial swelling and worsening pain. He had signs of systemic infection, such as fever and neutrophilia, at the time of presentation. A diagnosis of pulpal necrosis and acute suppurative periapical abscess was made and he was admitted, started on intravenous antibiotics and dexamethasone, and scheduled for extraction of the right lower first molar (tooth #30). Following tooth extraction, he had improvement in his pain and swelling. Our goal in this paper is to evaluate and critique the initial management and treatment of two cases of periapical abscesses based on current guidelines. Introduction

Case 1 A 50- year-old male presented for routine dental maintenance in early 2021 without complaints. A panoramic view of the dentition showed some lucency at the periapical area of the left lower second bicuspid (tooth #20), but this lucency was considered asymptomatic apical periodontitis, a precursor to abscess, instead of an abscess due to the patient’s lack of complaints. Four months later, the patient was undergoing inspection of a 5mm deep pocket of his left lower first molar (tooth #19) with plans to surgically inspect the tooth. Additional imaging was obtained at that time showing increased lucency compared to prior imaging. During surgical inspection 2 days later, the surgeons decided to extract the left lower first molar (tooth #19) and planned to place an implant 5 months later. CT imaging obtained on the same day of implant placement showed lesion progression at the left lower second

Complete blood count with differential showed neutrophilia. CT imaging findings as in figure 6. Findings were likely related to the periapical erosions around the anterior right mandibular molar, Figure 6: Coronal (A) and sagittal (B) views of the CT scan with contrast of the soft tissue of the neck for the patient in Case 2. It reveals diffuse edema and inflammatory stranding throughout the superficial soft tissues over the right mandible and lucency at tooth #30 consistent with periapical abscess.

Figure 2: Periapical formation and progression in an adult male. From left to right: (A) Incidental lucency seen at tooth #20 during evaluation of crown placement at tooth #19. Patient asymptomatic. (B) At 9 months, implant screw placed at tooth #19 with lucency progression seen at tooth #20. The patient became symptomatic with swelling and pain. (C) At 11 months, follow-up imaging after extraction and bone graft at tooth #20 without signs of recurrent infection. (D) Final imaging at 16 months shows new implant body at tooth #20 without signs of recurrent infection.

but they were otherwise normal. The emergency physician ordered IV ampicillin-sulbactam. An oral and Maxillofacial specialist was consulted and recommended adding dexamethasone. The patient was admitted to the pediatric hospitalist service. On day two of admission, the patient was taken to the operating room for extraction of his right lower first molar (tooth #30) under anesthesia. In the postoperative period, he had significantly less pain and swelling. Notable physical exam findings at discharge are seen in figure 7.

bicuspid (tooth #20) compared to previous images. The implant was placed, and the patient started a 7-day course of clindamycin. Seven days after implant placement and his antibiotic course, he was diagnosed with an acute periapical abscess at his left lower second bicuspid (tooth #20). He subsequently underwent tooth extraction. The abscess was drained, and microbiological specimens were collected for culture. Day two anaerobic cultures from sample one saw growth of gray and aerobic organisms on the CDC anaerobic blood agar, aerobic organisms and pinpoint growths on the Columbia CNA agar, and clear growths on the anaerobic agar with kanamycin and vancomycin (See Figure 4). The clear and pinpoint anaerobic organisms were identified as Prevotella melaninogenica and Gemella species respectively. Sample two produced rare growths of Capnocytophaga sputigena . The patient’s clindamycin regimen was extended for a total of ten days. Follow -up imaging showed healing in the area of the extracted left lower second bicuspid (tooth #20) and a stable implant of left lower first molar (tooth #19) and no signs of abscess recurrence.

Figure 7: Physical exam findings showing complete resolution of edema and tenderness to palpation after surgical extraction of tooth #30 and drainage of periapical abscess


References The cases presented and discussed above are merely two examples of a very common dental problem that is managed in a variety of ways by dental and medical professionals. In this paper, we have demonstrated ways that periapical abscesses should be approached and managed based on our findings in the literature. Going forward, there needs to be more consensus on the management of periapical abscesses among both dental and medical professionals.


Figure 4: Clear growths on CDC anaerobic blood agar treated with kanamycin and vancomycin from samples obtained from the patient in Case 1. They were identified as Prevotella melaninogenica by Bruker MALDI (matrix-assisted laser desorption/ionization)- identification.

Figure 3: Gram stain showing anaerobic gram-negative rods, consistent with Prevotella melaninogenica. Specimens were grown from samples obtained from the patient in Case 1.

Special thanks to Dr. David W. Jones, DMD, MHS at Piedmont Periodontics & Implant Dentistry, Spartanburg, South Carolina for his excellent care of our adult patient and to Dr. James W. Howell, DMD at Carolinas Center for Oral & Facial Surgery, Greenville, South Carolina for taking care of our pediatric patient. Thanks to Amanda Blackwell, M (ASCP), microbiology manager at SRHS for preparing and providing the microbiology plates and to Dr. Amy Baruch, MD, MHCDS, medical director of Cytopathology at SRHS for preparing and providing the gram stain slides. We truly appreciated the expertise of our consultant Dr. Basem L. Abu Qube, DMD at Al-Quds University-School of Dentistry, Abu Dis, Palestine for his expert opinion and scientific critique and guidance on the research part of the project. We obtained written and informed consent from the legal guardian of the minor. Acknowledgements 5.De Sousa ELR, Ferraz CCRF, de Almeida Gomes BPF, Pinheiro ET, Teixeira FB, and de Souza-Filho FJ. Bacteriological study of root canals associated with periapical abscesses. Oral Surg Oral Med Pathol Oral Radiol Endod. 2003: 96(3):332-339. Doi: 10.1016/s1079-2104(03)00261-0. 6.Rabah H, Gharib KE, Assaad M, Kassem A, and Mobarakai N. Gemella endocarditis. IDCases. 2022: 8(29). doi:10.1016/j.idcr.2022.e01597. 7.Ramanathan A, Gordon SM, and Shrestha NK. A case series of patients with Gemella endocarditis. Diagn Microbiol Infect Dis. 2020: 97(1). doi:10.1016/j.diagmicrobio.2020.115009. 1.American Academy of Pediatric Dentistry. Classification of periodontal diseases in infants, children, adolescents, and individuals with special health care needs. The Reference Manual of Pediatric Dentistry ; 2021:435-49. 2.Zhang W, Chen Y, Shi Q, Hou B, Yang Q. Identification of bacteria associated with periapical abscesses of primary teeth by sequence analysis of 16S rDNA clone libraries. Microbial Pathogenesis. 2020: 141. Doi: 10.1016/j.micpath.2019.103954 3.Lockhart P, Tampi M, Abt E, et. al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical related dental pain and intraoral swelling: A report from the American Dental Association. Journal of American Dental Association. 2019: 150(11): 906 921. Doi: 10.1016/j.adaj.2019.08.020 4.Sanz M, Herrera D, Kebschull M, et. al. Treatment of stage I-III periodontitis - The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology. 2020: 47(22): 4-60. Doi: 10.1111/jcpe.13290

Case 2 A 7-year-old male presented to the emergency department with fever, diffuse facial swelling and severe dental pain. His mother stated he had pain in his right lower first molar (tooth #30) since the previous night. He was seen by his dentist and given a course of penicillin for it. At the time he arrived in the emergency department, he had received two doses of penicillin and ibuprofen without any pain relief.

He subsequently developed facial swelling in the area of the painful tooth. His review of systems was notable for diffuse facial swelling and dental pain, but otherwise negative. Concerning his dental history, the patient had a metallic crown placed but no other known dental history. Physical exam findings were as seen in Figure 5 with tenderness to palpation and fluctuation adjacent to the right first molar of the lower jaw (tooth #30).

Figure 5: Physical exam findings for periapical abscess in a pediatric patient upon admission to the hospital showing marked edema in the right submandibular region that extends posteriorly to the neck in sagittal (A) and coronal views (B).

Figure 1: Diagram of teeth number of the upper and lower jaw as used in this presentation


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