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Periapical Abscess: Things To Know

Updated: Nov 22

This is a guide for the dental condition known as a periapical abscess. It happens to be one of the stages of a tooth abscess with a pulp infection preceding before it. What comes after it is usually facial swelling.


We will explain everything that you need to know about it which includes how you can tell if you have it and also how to treat it. So, do you think you have one?


Overview

The definition of a periapical abscess is an abscess around the apex of a tooth and it is a type of dental abscess. It describes a particular stage or point in time of a tooth abscess. It is an endodontic condition and thus will require endodontic treatment.


tooth abscess
tooth abscess

Let's breakdown the semantics of the term:

  • Periapical consists of two words, "peri" (around) and "apical" (apex of tooth root). Essentially periapical means around the tip of the tooth root.

  • Periapical abscess as its name implies, means an abscess around the tip of the root.


Therefore the term carries a slightly different meaning from a "tooth abscess" which merely implies that the infection originates from the tooth. Yes, a tooth abscess can be used to describe a periapical abscess but the latter describes a very specific stage of the disease.


Tooth Abscess Stages

Note: A lot of online sources use the two terms interchangeably but there is a nuance to their meaning. For clarity, we do believe it is important for you to understand the semantic differences between the two terms. Also, in case you were wondering, yes it is different from a periodontal abscess as well.


 

Symptoms

Signs and symptoms for how you can tell if you have a periapical abscess.

  • Toothache. Tooth pain that may be be constant or it comes and goes. The pain can feel sharp, shooting or dull. It can also throb and radiate across your entire face.

  • Swelling. Gums or area around the tooth are swollen.

  • Purulence. A tell-tale sign of an abscess is if you see pus, which is a white fluid that is filled with dead bacteria and white blood cells.

  • Sensitivity. Lingering sensitivity when you eat/drink hot or cold foods.

  • Gum boil. Do you see a pimple on the gums next to your tooth?

  • Chewing pain. It hurts whenever you chew or bite down.

  • Fever. You can potentially develop a fever.

  • Foul odor. Bad taste or bad smell in your mouth.

  • Loose tooth. Abscessed teeth will often be mobile and loose. You can wiggle it.


Diagnosis

A periapical abscess can be diagnosed with a periapical x-ray in conjunction with a clinical exam. The periapical x-ray (PA) will show a radiolucent lesion around the tip of the tooth root. That radiolucency around the apex is what an abscess looks like on an x-ray.


Periapical abscess outlined on x-ray
Periapical abscess outlined on x-ray

The clinical exam is used to confirm the results of the PA x-ray.

  • Percussion test. Tapping on the tooth with the back end of a mirror. An infected tooth will be symptomatic.

  • Cold test. A cold test can be performed with endo ice to check the vitality of the tooth nerve. An unhealthy nerve will have a lingering, delayed, or no response to the cold.

  • Visual exam. Most notably a pimple on the gum or otherwise known as a gum boil, is a tell-tale sign of a periapical abscess.


gum boil
gum boil

Sinus tract vs No sinus tract

A gum boil is actually the opening of a sinus tract which leads to a periapical abscess. Essentially the infection starts from the apex of the tooth root and eats its way through the jaw bone. It can destroy enough bone and even puncture through the gums thus forming a pimple.


Therefore the pimple on the gums will actually lead straight to the periapical abscess if you trace it with gutta percha (GP). A technique called gutta percha tracing involves inserting the GP into the gum boil and along the sinus tract to identify the source of the infection.


x-ray of gutta percha tracing a sinus tract
x-ray of gutta percha tracing a sinus tract

However, not all of these abscesses present with a sinus tract. The less mature periapical abscess will often not have a pimple on the gums.


gutta percha tracing
gutta percha tracing

Therefore you can think of the periapical abscesses with a sinus as a more chronic condition as opposed to ones without it. In fact, the acute variations often don't even show up on the x-rays.


Causes

Most commonly, a periapical abscess is the result of untreated tooth decay. It begins with demineralization which progresses to enamel decay. From there the decay will travel to the dentin and ultimately to the pulp. Shortly after infecting the tooth nerve, an abscess will develop at the root tip.


However there can be other sources for the infection:

  • Perio-endo lesion. Severe periodontal disease can lead to the tooth dying and developing an abscess. This condition requires both endo and perio treatment.

  • Trauma. Blunt force trauma to the teeth from sports injuries or accidents can kill the tooth. When they die it can develop an infection.

  • Tooth fracture. A tooth that has split in half is an open house for bacteria to enter.


Treatment

Treatment for a periapical abscess will depend on how severe the infection is. You can save the tooth with a root canal if the prognosis is good. However if the prognosis is poor or questionable, it may need to be extracted. Last but not least, you may need it drained if there is swelling present.


Types of treatment:

  • Incision and drainage. Any type of diffuse swelling will need to be drained.

  • Root canal. The source of the infection usually stems from the infected pulp. Until you remove the source with a root canal, the infection will continue to proliferate.

  • Extraction. If the infection is too severe, the only option left may be to have the entire tooth removed. If that is the case you would need an implant afterwards to replace it.

  • Antibiotics. Severe and diffuse swelling will need antibiotics for successful treatment. Draining it will treat it locally but you may need help systemically by taking antibiotics.


 

Aftercare

After you get rid of the infection you must deal with the aftermath of having a root canal or extraction.


If you received a root canal, you'll need to get a crown on the tooth to protect it. When the nerve gets removed, the blood supply comes out with it. That means the tooth will no longer receive nutrients and become brittle over time. By placing a crown over it, you can extend its longevity.


If you received an extraction, you'll have a missing tooth but you can replace it with a dental implant. This process involves placing a titanium screw into your jaw bone and then putting an implant crown over that. This treatment can take 6-12 months to complete.


After all of that, you just need to brush and floss the new crowns like any other teeth in the mouth. You don't need to do anything special or additional to take care of it. Hopefully you maintain good oral hygiene habits so you don't end up with another infection.

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About the author: Dr David Chen, DDS

Hello, I'm Dr Chen and I'm an actively practicing dentist in Long Island City, NY. I graduated from Columbia University College of Dental Medicine in 2016 but prior to going to dental school I was already working in the dental field. It's been more than a decade since I first got to know dentistry and let me tell you, time flies by quickly. Since then I've developed a fondness for writing, which is how this all got started!

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Medical Disclaimer:

This blog is purely meant for information purposes and should not be used as medical advice. Each situation in your mouth is unique and complex. It is not possible to give advice nor diagnose any oral conditions based on text nor virtual consultations. The best thing to do is to go in person to see your dentist for an examination and consultation so that you can receive the best care possible.

The purpose of all of this oral health information is to encourage you to see your dentist and to inform you of what you may expect during your visit. Due to the unfortunate nature of dentistry, there isn't really any true home remedies that will get rid of dental problems. Roughly 99.99% of them require in-person intervention by a healthcare professional.

Hint: That is the reason why you can't eliminate seeing dentists in your life!

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