Endodontic Diagnosis -- acute periapical periodontitis or acute apical abscess?

[SugarNaCl]

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So we had this Endo lecture the other day talking about how a patient responded to percussion and palpation and had swollen gums with an exudate. There was no radiograph, so you couldn't evaluate if gutta percha was tracing a sinus tract. You could not see any radiolucencies etc. We were asked to take a stab at a diagnosis. For me, there was not enough information. I have my MS concentration in neuroimmunology and I was fairly certain that both a general external infection or periodontitis if bad enough, could have exudate and swelling, as well as an abscess could have these features.

From this information, can one really tell that the correct answer was acute apical abscess? Am I overlooking something?

 

[djeffreyt]

I'll poke at it with a stick.

No diagnosis is for sure since all the diagnostic tools are not available. We get this all the time from our professors too...they show us a couple slides and ask to hypothesize a diagnosis only to tell us the final answer lies in getting a couple more diagnostic tools first...

 

[dentheartthrob]

So we had this Endo lecture the other day talking about how a patient responded to percussion and palpation and had swollen gums with an exudate. There was no radiograph, so you couldn't evaluate if gutta percha was tracing a sinus tract. You could not see any radiolucencies etc. We were asked to take a stab at a diagnosis. For me, there was not enough information. I have my MS concentration in neuroimmunology and I was fairly certain that both a general external infection or periodontitis if bad enough, could have exudate and swelling, as well as an abscess could have these features.

From this information, can one really tell that the correct answer was acute apical abscess? Am I overlooking something?[/QUOTE

yeah it seems like it would be inconclusive with out a radiograph

 

[SuperC]

I the real world I would agree with you, however I have seen an exam question like this a few tests ago. If I recall correctly, in the class room setting the idea here is to see that swelling is usually only related with the abscess. Here are some notes that I typed up some time ago.


D. Acute Apical Periodontitis (with irreversible pulpitis or pulp necrosis)
1. Signs/Symptoms: Intense pain made worse with mastication or percussion. Radiographic changes vary from none, thickened PDL at apex or periapical radiolucency.
2. Test Results: EPT and thermal responses range from hyper-responsiveness (irreversible pulpitis) to no response (necrotic pulp). Extreme sensitivity to percussion with or without palpation sensitivity.


E. Acute apical Abscess:
1. Signs/Symptoms: Spontaneous moderate to severe pain. Radiating throb. Prolonged duration, but may be episodic. Swelling ranges from barely perceptible to extensive. Later stages will manifest an elevated temperature. Radiographic changes vary from none, thickened apical PDL or periapical radiolucency. Thickened PDL at apex or periapical radiolucency.
2. Test Results: EPT and thermal tests yield no response. Marked sensitivity to percussion and apical palpation; increased mobility.

-C

 

[ElDienteLoco]

I think you can really tell the answer from the given info. I think the key to the question was "exudate." Exudate is seen in an abscess. In the absence of a periodontal cause for the exudate, I would assume that the abscess has perforated the cortical plate and is draining through the soft tissue.

IMHO - whenever I see pus around an endo-only lesion I'm thinking APA (acute periapical abscess).

 

[endoking]

I the real world I would agree with you, however I have seen an exam question like this a few tests ago. If I recall correctly, in the class room setting the idea here is to see that swelling is usually only related with the abscess. Here are some notes that I typed up some time ago.


D. Acute Apical Periodontitis (with irreversible pulpitis or pulp necrosis)
1. Signs/Symptoms: Intense pain made worse with mastication or percussion. Radiographic changes vary from none, thickened PDL at apex or periapical radiolucency.
2. Test Results: EPT and thermal responses range from hyper-responsiveness (irreversible pulpitis) to no response (necrotic pulp). Extreme sensitivity to percussion with or without palpation sensitivity.


E. Acute apical Abscess:
1. Signs/Symptoms: Spontaneous moderate to severe pain. Radiating throb. Prolonged duration, but may be episodic. Swelling ranges from barely perceptible to extensive. Later stages will manifest an elevated temperature. Radiographic changes vary from none, thickened apical PDL or periapical radiolucency. Thickened PDL at apex or periapical radiolucency.
2. Test Results: EPT and thermal tests yield no response. Marked sensitivity to percussion and apical palpation; increased mobility.

-C

I'm with SuperC, if you have swelling, its an abscess (be it perio or endo).

 

[MSDMD]

I'm with ElDienteLoco - the difference is the exudate. exudate in this case along with percussion sensitivity, etc. would make me think acute apical abscess. Certainly a gutta percha point headed right for the apex would make the diagnosis more certain though.
Acute apical periodontitis would be when there was percussion sensitivity, cold/hot sensitivity, etc, but no signs on the radiograph, and no sinus tract or exudate. As the lesion becomes more chronic, the lesion becomes visible on the radiograph, this is chronic apical periodontitis. If a tooth suddenly flares up with pain and you can see an abscess, then it is an acute exacerbation of chronic apical periodontitis, as it has to be chronic for you to be able to see the lesion on the radiograph.

Hope this helps, this is how I understand it.

 

[dentheartthrob]

I don't want to sound like a smart donkey but one of the cardinal signs of acute inflammation is swelling, and swelling is caused by an accumulation of exudates.

 

[ElDienteLoco]

I don't want to sound like a smart donkey but one of the cardinal signs of acute inflammation is swelling, and swelling is caused by an accumulation of exudates.

I think the original question referred to exudate meaning pus.

Do you always have an accumulation of exudate (pus) when you have swelling?

What about post-op extraction sites that are swollen but without any signs of acute infection? Or swollen tissue in gingivitis? I think there is a big difference between acute inflammation (with rubor, calor, tumor, etc.) and acute infection (with a big reservior of PMN's that presents as exudate).

 

[dentheartthrob]

I think the original question referred to exudate meaning pus.

Do you always have an accumulation of exudate (pus) when you have swelling?

What about post-op extraction sites that are swollen but without any signs of acute infection? Or swollen tissue in gingivitis? I think there is a big difference between acute inflammation (with rubor, calor, tumor, etc.) and acute infection (with a big reservior of PMN's that presents as exudate).

exudation isnt always pus, its the accumulation of plasma proteins and leukocytes in a tissue in response to an inflammatory reaction. Pus is just the eventual outcome of it...I would tend to lean on the abcess as well, but with out all the diagnostic tools, it would be premature to make a conclusion on what it is.

 

[SugarNaCl]

exudation isnt always pus, its the accumulation of plasma proteins and leukocytes in a tissue in response to an inflammatory reaction. Pus is just the eventual outcome of it...I would tend to lean on the abcess as well, but with out all the diagnostic tools, it would be premature to make a conclusion on what it is.

This was my point exactly and there was no radiograph at all to view. Exudate is due to inflammation in general. Both of these involve inflammation. I would be uncomfortable at this point making a firm diagnosis with the information given but I guess they want us to.

Anyhow, I do appreciate all of the responses. They have definitely given me a lot more to think about and consider. I like getting different perspectives. Thank you.

 

[DrJeff]

exudation isnt always pus, its the accumulation of plasma proteins and leukocytes in a tissue in response to an inflammatory reaction. Pus is just the eventual outcome of it...I would tend to lean on the abcess as well, but with out all the diagnostic tools, it would be premature to make a conclusion on what it is.

Isn't just dissapointing when you only get that clear exudate that more resembles crevicular fluid over some good 'ol fashioned yellow puss that is laced with the odor of anaerobes!😉😀

Personally, if I see some swelling, it's an abcess and deep down I hope that I'll get to drain some puss!

Bottomline in this scenario, you'll be talking endo or extraction with this patient no matter WHICH diagnosis further info gives you. The semantics of the exact diagnosis in a case like this is much more of an academic exercise than a determinant of what the clinical treatment will be.

 

[OhioOralOnc]

Isn't just dissapointing when you only get that clear exudate that more resembles crevicular fluid over some good 'ol fashioned yellow puss that is laced with the odor of anaerobes!😉😀

Personally, if I see some swelling, it's an abcess and deep down I hope that I'll get to drain some puss!

Bottomline in this scenario, you'll be talking endo or extraction with this patient no matter WHICH diagnosis further info gives you. The semantics of the exact diagnosis in a case like this is much more of an academic exercise than a determinant of what the clinical treatment will be.

kh