Abscesso dentoalveolar crônico em paciente pediátrico com drenagem rara / Absceso dentoalveolar crónico en paciente pediátrico con drenaje raro / Chronic dentoalveolar abscess in a pediatric patient with rare drainage

RESUMO Introdução: As infecções do complexo maxillomandibular são corriqueiras na odontologia, podendo ser um quadro facilmente revertido, a depender da habilidade do profissional de diagnosticar e tratar precocemente, bem como da imunocompetência do paciente. Seu fator etiológico na grande maioria das vezes é de origem dentária, possuindo microbiota mista com presença de Streptococos e Peptostreptococos. Estas bactérias estão associadas ao processo de necrose pulpar e formação de abscesso dentoalveolar. Quando este quadro se desenvolve a partir dos molares inferiores, a disseminação ocorre normalmente pelo espaço vestíbulo bucal. No entanto, há casos que evadem o padrão, podendo um molar disseminar através dos espaços mastigador, mandibular, submandibular, sublingual e submentoniano. Objetivo: Relatar um caso de infecção odontogênica do dente 36, com disseminação atípica para o espaço submandibular em paciente pediátrico. Relato de caso clínico: Paciente do sexo feminino, 8 anos de idade, constou em seu histórico odonto-médico, junto a sua genitora, episódio de internamento para diagnóstico e tratamento da infecção em face. O diagnóstico de celulite foi determinado e a origem dentária descartada. Iniciou antibióticoterapia e após regressão teve alta. Após 9 meses apresentou reagudização do processo com disseminação para região submandibular. Através da história da doença atual, exame físico e radiográfico foi definido o diagnóstico de abscesso dentoalveolar crônico com disseminação e drenagem para o espaço submandibular, optando-se pela exodontia e antibióticoterapia. Conclusões: Faz-se importante o diagnóstico e tratamento precoce, afim de evitar a progressão para complicações mais severas, como a mediastinite e fasciíte necrosante(AU)

RESUMEN Introducción: Las infecciones del complejo maxilo-mandibular son comunes en la odontología, pudiendo ser un cuadro fácilmente revertido, que depende de la habilidad del profesional de diagnosticar y tratar precozmente, así como de la inmunocompetencia del paciente. Su factor etiológico en la gran mayoría de las veces es de origen dental, con microbiota mixta y presencia de Streptococos y Peptostreptococos. Estas bacterias están asociadas al proceso de necrosis pulpar y formación de absceso dentoalveolar. Cuando este cuadro se desarrolla a partir de los molares inferiores, la diseminación ocurre normalmente por el espacio vestíbulo bucal. Sin embargo, hay casos que evaden el estándar, pudiendo un molar diseminar a través de los espacios masticador, mandibular, submandibular, sublingual y submentoniano. Objetivo: Describir un caso de infección odontogénica proveniente de necrosis pulpar del diente 36, con diseminación atípica para el espacio submandibular en paciente pediátrico. Caso clínico: Paciente de sexo femenino, de 8 años, constó en su historia médica-dental, episodio de internamiento para diagnóstico y tratamiento de la infección en el rostro. Se determinó el diagnóstico de celulitis y tuvo el origen dental descartado. Se inició antibioticoterapia y se dio alta hospitalaria. Después de 9 meses presentó exacerbación del proceso con diseminación para región submandibular. A través de la historia de la enfermedad actual, examen físico y radiográfico se definió el diagnóstico de absceso dentoalveolar crónico con diseminación y drenaje para el espacio submandibular, y entonces fue posible optar por la exodoncia y antibioticoterapia. Conclusiones: Se hace importante el diagnóstico y tratamiento precoz, a fin de evitar la progresión para complicaciones más severas, como la mediastinitis y fasciitis necrosante(AU)

ABSTRACT Introduction: Infections of the maxillomandibular complex are common in dentistry and may be easily reversed, depending on the professional's ability to diagnose and treat promptly, as well as the patient's immunocompetence. In most cases their etiology is dental, i.e. a mixed microbiota with presence of Streptococci and Peptostreptococci. These bacteria are associated to the process of pulp necrosis and dentoalveolar abscess formation. When this condition develops from the lower molars, dissemination usually occurs through the buccal vestibular space. However, there are cases that do not follow this pattern, allowing a molar to spread through the buccal, mandibular, submandibular, sublingual and submental spaces. Objective: Report a case of odontogenic infection from pulp necrosis of the lower first molar (36) ​​with atypical dissemination to the submandibular space in a pediatric patient. Clinical case: Female 8-year-old patient with an episode of hospitalization for diagnosis and treatment of a facial infection, according to her medical / dental record. The infection was diagnosed as cellulitis and dental origin was discarded. Antibiotic therapy was started and the patient was discharged. After 9 months, the infection underwent a process of exacerbation with dissemination to the submandibular region. Analysis of the antecedents of the current condition, alongside physical and radiographic examination, led to the diagnosis of chronic dentoalveolar abscess with dissemination and drainage to the submandibular space, and the consequent indication of dental extraction and antibiotic therapy. Conclusions: Early diagnosis and treatment are vital to avoid progression to severer complications such as mediastinitis and necrotizing fasciitis(AU)

Mediastinitis as complication of odontogenic infection: A case report.

Odontogenic infections are one of the most common dental problems, which affect 80%-90% of the population. Untreated odontogenic infections can cause life-threatening complications such as necrotizing fasciitis, descending necrotizing mediastinitis, internal jugular vein thrombosis, cavernous sinus thrombosis, carotid artery pseudoaneurysm or rupture, and systemic inflammatory response syndrome. This report aims to present a mediastinitis case, in a 22-year-old healthy male patient, which originated from an odontogenic infection. The patient was hospitalized because of worsening general health status, despite the antibiotherapy. Computed tomography (CT) scan revealed that periapical abscess was spreading to the mediastinum through retropharyngeal space. The patient was successfully treated by IV antibiotherapy, transcervical drainage, and extraction of tooth.

Influencia de la tomografía computarizada de haz cónico en el plan de tratamiento endodóncico / No disponible

La evaluación radiográfica y las pruebas diagnósticas son de vital importancia para realizar un adecuado plan de tratamiento en endodoncia. En el campo de la endodoncia, tradicionalmente se han utilizado diferentes pruebas como la palpación, la percusión, las pruebas de sensibilidad pulpar y las radiografías periapicales (RP). Hasta la actualidad las RP (convencionales o digitales) han sido un complemento indispensable para realizar el tratamiento endodóntico, así como para determinar el éxito de dicho tratamiento. Sin embargo, está demostrado que las RP presentan ciertas limitaciones como superposiciones de estructuras anatómicas, la visión en dos dimensiones (2D) y la distorsión geométrica. Las imágenes obtenidas mediante RP ofrecen solamente datos de la dimensión mesio-distal, lo que dificulta la detección de cierta información como: la anatomía radicular, la presencia de alteraciones alrededor de las raíces, la pérdida ósea, los diferentes tipos de reabsorciones radiculares, las fracturas radiculares y otros aspectos importantes en la planificación de una cirugía apical. A través de la imágenes obtenidas a partir de la tomografía computarizada de haz cónico (TCHC), en inglés llamada cone-beam computed tomography (CBCT), se puede obtener una mayor información diagnóstica en comparación a las RP preoperatorias; información que influye directamente en el plan de tratamiento del clínico, especialmente en los casos de dificultad alta. Por todo a ello, en este artículo se presentan diferentes situaciones clínicas en las que la CBCT juega un papel fundamental en relación al plan de tratamiento endodóncico

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Correlation between crestal alveolar bone loss with intracanal bacteria and apical lesion area in necrotic teeth.

OBJECTIVE: This study aimed to analyze the correlation between crestal alveolar bone loss with the presence of some bacterial species in root canals and the apical lesion area of necrotic teeth. DESIGN: Data from 20 patients with diagnosis of pulp necrosis and acute apical abscesses, without active periodontal diseases, were evaluated. Patients with history of antibiotic usage three months prior to the study, with exposed pulp cavity, and with probing depth >3 mm were not included. The root size, the distance between the bone crest to the tooth apex in the mesial and distal surfaces, and the apical lesion area were measured from standard periapical radiographies by a calibrated examiner. Root canal samples were collected using sterilized paper points. In multirooted teeth, the largest root canal was sampled. Culture, microbial isolation and identification by phenotypic methods were performed. Spearman correlation and exact Fischer test were calculated between higher/lower existing bone crests, according to the median and the presence of specific bacteria. RESULTS: No statistically significant differences were found between occurrence of pathogenic bacteria, such as Porphyromonas gingivalis, Porphyromonas endodontalis, and Prevotella intermedia, and groups with higher/lower degree of bone loss (p > 0.05). A negative significant correlation was found between Parvimonas micra and periodontal bone loss (p = 0.02). Additionally, no statistically significant association was found between crestal bone loss and the apical lesion area. CONCLUSIONS: It was concluded that, in patients without active periodontitis, the presence of pathogenic bacteria in the root canal was not correlated with periodontal bone loss.

Cone-beam computed tomographic and histological investigation of regenerative endodontic procedure in an immature mandibular second premolar with chronic apical abscess.

AIM: The aim of the present study was to investigate the tissue generated after regenerative endodontic procedure (REP) in the root canal space of an immature mandibular second premolar with pulp necrosis and chronic apical abscess using cone-beam computed tomographic (CBCT) and histological methods. METHODS: REP was performed in an immature mandibular second premolar. At the 3-year follow up, CBCT scans were taken to evaluate the outcome of treatment. As the tooth was not restorable to function, it was extracted and processed for histological examination. RESULTS: CBCT showed a reduction in size of the periradicular radiolucency, with a marginal increase in root length. Apical closure and thickening of the root canal walls were apparent. Histologically, the root canal space was filled with minimally-inflamed fibrous connective tissue. Some cementum-like mineralized connective tissue was evident on the internal canal walls. The apical third showed cementum-like deposits at the apex and the outer canal walls, without dentin formation. CONCLUSIONS: The present study of a structurally-failed tooth with prior REP demonstrates that the tissue formed within the root canal space was fibrous connective tissue with cementum-like deposition in the canal space. No evidence of dentin- or pulp-like tissue was found.

A severe deep neck odontogenic infection not prioritised by the emergency department triage system and National Early Warning Score.

A 62-year-old man with a background of type 2 diabetes mellitus presented to the emergency department (ED) with a 5-day history of dental pain, progressive right facial swelling, trismus, dysphagia and voice changes. The oropharynx could not be directly examined completely due to trismus. The patient had a National Early Warning Score of 0 and so was triaged into the 'minors' section of ED. Following assessment by the on-call oral and maxillofacial surgeon, an urgent contrast-enhanced CT demonstrated a large parapharyngeal collection, which required urgent anaesthetic and surgical intervention. The patient developed pulmonary complications postoperatively, but eventually made a full recovery.

Complicated untreated apical periodontitis causing paraesthesia: A case report.

The purpose of this article was to report a case of untreated apical periodontitis resulting in severe late complications. A patient with an asymptomatic crowned root canal-treated mandibular molar revealing a radiographic substandard endodontic treatment and a slight periapical radiolucency was made aware of the treatment options and opted for no treatment. The lesion slightly increased in size after 6 years, but the tooth remained asymptomatic and endodontic retreatment was again refused. After 4 more years, the patient presented with an abscess and severe pain, complicated by paraesthesia of the left chin and lip. Radiographic examination revealed that the lesion had increased considerably to involve the mandibular canal. The treatment protocol included long-term intracanal medication with calcium hydroxide and follow-ups revealed complete resolution of the periapical radiolucency and the paraesthesia had completely subsided.

Chondroblastic osteosarcoma mimicking periapical abscess.

CASE REPORT: The present report describes a case of chondroblastic osteosarcoma in the periapical region of teeth #29, #30, and #31 of an 18-year-old male. Clinical history showed self-reported discomfort in the right posterior gingiva for over a month. Physical examination showed a small expansion and redness of the right mandibular buccal and lingual cortical plates, but no signs of pain or inflammation were observed. All the teeth responded positively to pulp sensibility. Periapical and panoramic radiographs showed slight periapical radiolucency in the roots of teeth #29 and #30, clear periodontal ligament space widening, and evident loss of lamina dura. Incisional biopsy was performed, and based on microscopic findings the diagnosis of chondroblastic osteosarcoma was confirmed. CONCLUSIONS: Non-endodontic diseases associated with tooth root apex, such as chondroblastic osteosarcoma, should be included in differential diagnosis of jaw lesions that resemble periapical abscess.

Chondroblastic osteosarcoma mimicking periapical abscess

Abstract Lesions of non-endodontic origin may mimic periapical abscess. Osteosarcoma is a rare malignant lesion. Case report The present report describes a case of chondroblastic osteosarcoma in the periapical region of teeth #29, #30, and #31 of an 18-year-old male. Clinical history showed self-reported discomfort in the right posterior gingiva for over a month. Physical examination showed a small expansion and redness of the right mandibular buccal and lingual cortical plates, but no signs of pain or inflammation were observed. All the teeth responded positively to pulp sensibility. Periapical and panoramic radiographs showed slight periapical radiolucency in the roots of teeth #29 and #30, clear periodontal ligament space widening, and evident loss of lamina dura. Incisional biopsy was performed, and based on microscopic findings the diagnosis of chondroblastic osteosarcoma was confirmed. Conclusions Non-endodontic diseases associated with tooth root apex, such as chondroblastic osteosarcoma, should be included in differential diagnosis of jaw lesions that resemble periapical abscess.

Diagnosis and Treatment of Odontogenic Cutaneous Sinus Tracts in an 11-Year-Old Boy: A Case Report.

Odontogenic cutaneous sinus tracts (OCSTs) are generally primarily misdiagnosed and inappropriately treated by virtue of their rarity and the absence of dental symptoms. Accurate diagnosis and treatment and the elimination of the source of infection can reduce the incidence of complications and relieve the pain of the patient.In this case report, we present the case of an 11-year-old patient with an apparent abscess but an unobvious draining sinus tract in his left cheek. Intraorally, a glass-ionomer-cement filling on the occlusal surface of the left mandibular first molar (tooth 36) was noted. Radiographic examination revealed a radiopaque mass inside the crown and pulp chamber and an irregular, radiolucent periapical lesion surrounding the distal root apex. He was diagnosed with an OCTS secondary to a periapical abscess of tooth 36. Precise root canal therapy (RCT) and chronic granuloma debridement was performed; 6 months later, the abscess and sinus had healed completely, and the periapical lesion had resolved.Odontogenic cutaneous sinus tracts are uncommon in the clinic. This case report reminds us of the significance of OCSTs and provides some implications for their diagnosis and treatment.

An unnoticed origin of fever: periapical tooth abscess. Three case reports and literature review.

Dental infections may lead to severe local or systemic infections such as endocarditis, brain abscesses and mediastinitis. Fever may be the only symptom. We aim to highlight dental/odontogenic abscesses as the occult source of unexplained fever by reporting on three cases and reviewing the relevant literature. Early dental evaluation and referral of patients with persistent fever (even without any oral symptoms) to a dentist plays a critical role in preventing unnecessary, time-consuming and high-cost further diagnostic tests and invasive procedures. A simple panoramic dental radiography may suffice to establish the diagnosis.

Prevalence of several herpesviruses and human papillomavirus in acute apical abscesses.

AIM: To investigate and compare the radiographic size of acute apical abscess lesions for the presence of Epstein-Barr virus (EBV), human cytomegalovirus (HCMV), human herpesvirus-6 (HHV-6) and human papillomaviruses (HPV) DNA by means of the real-time polymerase chain reaction (PCR) method. METHODOLOGY: According to the radiographic size of acute apical abscess lesions, 11 lesions were categorized as large (≥5 mm) and 10 lesions as small (<5 mm). DNA extracts from purulent exudate aspirates of 21 cases of acute apical abscess and 10 control samples were evaluated for the presence of viral loads using real-time PCR methods following the kit protocols recommended by the manufacturers. Statistical analysis was performed using chi-squared test with Yates's correction and Fisher's exact test. RESULTS: HCMV DNA was detected in 27% of large and in 10% of small abscess lesions. EBV was identified in 18% of large and in 10% of small abscess lesions. HPV and HHV-6 DNA were found in 9% of large abscess lesions. None of the small abscess lesions contained HPV or HHV-6 DNA. Viral coinfections were found in two samples as the pair of HCMV/EBV and HCMV/HHV-6 from large abscess lesions. No significant associations were found between any of the target viruses and size of periapical lesions. As for the healthy pulps used as noninflamed controls, no control specimens contained viral DNA. CONCLUSIONS: HCMV was the most frequent herpesvirus amongst the target viruses in samples from both large and small apical abscess lesions. In large lesions, EBV and HHV-6 tended to occur in coinfection with HCMV. Additional studies are required to elucidate the role of herpesviruses in the pathogenesis of periapical abscess.

The value of cone beam CT in assessing and managing a dilated odontome of a maxillary canine.

A case of an unusual anomaly in a maxillary canine is described. A deep enamel invagination resulted in pulpal necrosis, longstanding infection and development of an associated radicular cyst. Diagnostic X-ray imaging was invaluable in demonstrating the complex root anatomy of the dilated odontome. In particular, a cone beam CT scan helped in the formulation of an appropriate treatment plan. Clinical Relevance: Three-dimensional imaging using cone beam CT was valuable in this case to demonstrate the complicated anatomy of a rare dental anomaly, and to help plan treatment.

The Use of Facial CT for the Evaluation of a Suspected Simple Dentoalveolar Abscess in the Emergency Department.

INTRODUCTION: Facial computed tomography (CT) is often performed in the emergency department as a part of the diagnostic workup for patients presenting with the signs and symptoms of dentoalveolar abscess (DA). This investigation evaluated the diagnostic yield of the facial CT and its effects on management change in patients suspected of DA. Furthermore, we assessed secondary consequences of routine facial CT use in this population by using turn-around time (TAT), cost, and radiation exposure as the key parameters. MATERIAL AND METHODS: We retrospectively reviewed records of suspected DA patients over a 5-year period, from June 2008 to June 2013. TAT was calculated for patients from the time the examination was ordered by the emergency department physician, to the time the report was finalized by the attending radiologist. Effective radiation dose for facial CT was calculated by multiplying dose length product by the standard conversion coefficient K (K = 0.0021 mSv/mGy x cm). CT cost was included for reference but was not analyzed extensively due to the lack of standardization of costs across the various institutions. RESULTS: Our investigation consisted of 117 patients; 75 males of average age 41 (±12) years and 42 females of average age 44 (±17) years. Out of the total 117 patients that underwent CT for the suspicion of a simple DA, only a single individual (0.85%) underwent a management change. Mean TAT of facial CT was 110 (±63) minutes, and a median TAT was 87 (±71) minutes. Average effective radiation dose for a facial CT was 2.4 (±0.4) mSv. Approximate estimated cost of a contrast enhanced facial CT was $253 and non-contrast facial CT was $209. CONCLUSION: Our study shows that routine use of facial CT has a very limited diagnostic value in the workup of simple DA and rarely results in management change. The overall impact on patient management is miniscule in the context of prolonged TAT, radiation exposure, and adding to the rising medical costs.

Usefulness of ultrasonography for rapidly diagnosing cutaneous sinus tracts of dental origin.

BACKGROUND: Cutaneous sinus tracts of dental origin are frequently misdiagnosed and incorrectly treated. Intraoral roentgenograms are valuable for diagnosing such tracts. Since these lesions are usually not accompanied by dental symptoms, patients tend initially to consult dermatologists or general physicians, who are not familiar with oral diseases or intraoral X-rays. OBJECTIVES: We sought to determine the usefulness of ultrasonography for detecting cutaneous sinus tracts of dental origin. MATERIALS AND METHODS: Three patients who had skin lesions that were suspected of being cutaneous sinus tracts based on the findings of clinical and histological examinations were enrolled in this study. B mode and color Doppler ultrasonography were used to image the skin lesions in their entirety and to assess the associations between the subcutaneous lesions and any alveolar bone defects. RESULTS: In each case, ultrasonography depicted a hypoechoic band that originated from the cutaneous lesion and extended through the subcutaneous tissue to the alveolar bone. Bone loss was also observed, and color Doppler ultrasonography detected increased blood flow in the peripheral regions of the tracts. CONCLUSIONS: In the present study, the patients' sinus tracts were rapidly detected using ultrasonography, which enabled appropriate treatment. Thus, ultrasonography is a convenient tool for diagnosing cutaneous sinus tracts of dental origin.

The use of cone-beam computed tomography in the preservation of pulp vitality in a maxillary canine with type 3 dens invaginatus and an associated periradicular lesion.

INTRODUCTION: Dens invaginatus type 3 is an anomaly characterized by an invagination of enamel and dentin that can extend up to the root apex. It may pose treatment challenges when nonsurgical root canal therapy is deemed necessary. Conventional diagnostic aids such as periapical radiographs play an important role in the assessment of complex root canal morphologies. However, these modalities may sometimes yield insufficient diagnostic information. Cone-beam computed tomographic imaging produces 3-dimensional digital images and provides the clinician with a more in-depth understanding of the true morphology of the root canal system. METHODS: This case report describes the diagnosis and conservative treatment of an unusual case of a maxillary canine with an infected type 3 dens invaginatus and an associated periradicular lesion in which the vitality of the surrounding pulp was maintained. Mineral trioxide aggregate was used to fill the entire invagination, whereas the circular true root canal system around the invagination with vital pulp was left untreated. RESULTS: At the 1-year follow-up examination, clinical and radiographic findings showed that a diligent nonsurgical endodontic treatment can result in satisfactory periradicular healing and complete root formation. CONCLUSIONS: The use of cone-beam computed tomographic imaging as an auxiliary tool for both diagnosis and planning the treatment of these anomalies is highlighted.

Computed tomographic features of apical infection of equine maxillary cheek teeth: a retrospective study of 49 horses.

REASONS FOR PERFORMING STUDY: Computed tomographic (CT) studies evaluating the relevance of individual CT features of apical infection in maxillary cheek teeth are lacking. OBJECTIVES: To study the prevalence and relationship of single CT features in horses with and without clinical evidence of apical infection in maxillary cheek teeth. STUDY DESIGN: Retrospective case-control study. METHODS: Multislice CT scans of the head of 49 horses were evaluated retrospectively. Changes of the infundibulum, pulp, root, lamina dura, periodontal space and alveolar bone in maxillary cheek teeth were recorded. RESULTS: Single CT changes were much more prevalent in the 28 horses with clinical signs. However, infundibular changes and a nondetectable lamina dura were also common in the 21 horses without clinical evidence of apical infection. Computed tomographic abnormalities of the pulp, root, periapical bone and periodontal space and the presence of a tooth fracture were significantly related. Infundibular changes were not associated with other CT signs of apical infection. Although nondetectable lamina dura was the most frequent CT change in all teeth in both studied groups, it was most commonly a solitary feature in otherwise normal teeth. Apical infections, defined as ≥3 CT changes, occurred mainly in the 108/208, 109/209 and 110/210 (Triadan numbers) and were found only in horses with clinical evidence of apical infection, except in one horse without clinical signs that had one affected root. CONCLUSIONS: Combined CT changes of the pulp, root, lamina dura, periapical bone and periodontal space and the presence of a tooth fracture appear to be reliable features to diagnose apical infection in maxillary cheek teeth. As a solitary feature, a nondetectable lamina dura should be interpreted cautiously and may even be considered normal due to its minor thickness and/or too low resolution of the imaging modality.