DENTAL ABSCESS WITH OR WITHOUT FASCIAL SPACE INVOLVEMENT

Question 1

• A 8.5 years old girl complaining of irregular teeth, no family member shows similar malocclusion - Panoramic radiograph: mixed dentition, apical radiolucency at 85 (over 45) - Extra-oral photographs: Straight profile at both CO & CR (even slightly convex at CR) - Intra-oral photographs: Class III incisor relationship at CO, edge to edge occlusion at CR - Cephalometric analysis: In both CO & CR positions, everything is normal except decreased SNA & increased SNB - Study cast: mandibular displacement shown at CO a. What is the cause of the dental abscess at 85? (1)

Answer 1

Caries

Question 2

• A 8.5 years old girl complaining of irregular teeth, no family member shows similar malocclusion - Panoramic radiograph: mixed dentition, apical radiolucency at 85 (over 45) - Extra-oral photographs: Straight profile at both CO & CR (even slightly convex at CR) - Intra-oral photographs: Class III incisor relationship at CO, edge to edge occlusion at CR - Cephalometric analysis: In both CO & CR positions, everything is normal except decreased SNA & increased SNB - Study cast: mandibular displacement shown at CO
  b. What are the complications if the abscess at 85 is left untreated? (2)

Answer 2

 Affects development of 45, delayed eruption  Malformation of tooth germ  Spread of infection  Cellulitis

Question 3

• A 8.5 years old girl complaining of irregular teeth, no family member shows similar malocclusion - Panoramic radiograph: mixed dentition, apical radiolucency at 85 (over 45) - Extra-oral photographs: Straight profile at both CO & CR (even slightly convex at CR) - Intra-oral photographs: Class III incisor relationship at CO, edge to edge occlusion at CR - Cephalometric analysis: In both CO & CR positions, everything is normal except decreased SNA & increased SNB - Study cast: mandibular displacement shown at CO
  c. State the treatment options for 85. (2)

Answer 3

 Prescribe antibiotics  Pulpectomy + SS crown  Extraction + space maintainer

Question 4

• A 8.5 years old girl complaining of irregular teeth, no family member shows similar malocclusion - Panoramic radiograph: mixed dentition, apical radiolucency at 85 (over 45) - Extra-oral photographs: Straight profile at both CO & CR (even slightly convex at CR) - Intra-oral photographs: Class III incisor relationship at CO, edge to edge occlusion at CR - Cephalometric analysis: In both CO & CR positions, everything is normal except decreased SNA & increased SNB - Study cast: mandibular displacement shown at CO d. If this patient experience pain after office hour, where can she receive emergency treatment? (2)

Answer 4

A&E / so me private dental clinic provide 24 hrs services

Question 5

• A 8.5 years old girl complaining of irregular teeth, no family member shows similar malocclusion - Panoramic radiograph: mixed dentition, apical radiolucency at 85 (over 45) - Extra-oral photographs: Straight profile at both CO & CR (even slightly convex at CR) - Intra-oral photographs: Class III incisor relationship at CO, edge to edge occlusion at CR - Cephalometric analysis: In both CO & CR positions, everything is normal except decreased SNA & increased SNB - Study cast: mandibular displacement shown at CO
  e. Under what circumstances would you prescribe antibiotics to this patient? State the antibiotic and regime for this patient. (3)

Answer 5

 Aggressive periodontitis

 Ulcerative periodontitis (ANUG)

 Abscess with systemic involvement

 Fever

 Lymphadenopathy

 Cellulitis

 Immunocompromised patient: radiotherapy, AIDS, DM

 Antibiotics

 Amoxicillin 125-250 mg tid 5 days

 Metronidazole 7.5 mg/kg tid 3 days

Question 6

Given: 8 1⁄2 year old patient, with edge to edge biting at CR and class 3 malocclusion at CO History: no familial history of class 3 malocclusion

a. What is the cause of the abscess at 85?

Answer 6

Untreated caries invade into pulp and subsequent pulpal necrosis and spread apically to form localized abscess

Question 7

Given: 8 1⁄2 year old patient, with edge to edge biting at CR and class 3 malocclusion at CO History: no familial history of class 3 malocclusion

b. What are the complications if left untreated?

Answer 7

 Pain –> disruption of quality of life, difficult to concentrate

 Arrest of unerupted permanent tooth development or enamel defects –> make permanent teeth prone to caries

 Spread of infection to fascial spaces –> life threatening conditions (Ludwig’s angina)

 Premature loss of deciduous teeth –> drifting of adjacent teeth and cause malalignment

 Space loss –> psychological impact, speech, mastication

Question 8

Given: 8 1⁄2 year old patient, with edge to edge biting at CR and class 3 malocclusion at CO History: no familial history of class 3 malocclusion

c. Where could the patient go in case of dental emergency?

Answer 8

 Dental Clinics with General Public Sessions (under Department of Health)

 For emergency dental services (limited to pain relief and extraction)

 Or 24 hour opening private clinics

Question 9

Given: 8 1⁄2 year old patient, with edge to edge biting at CR and class 3 malocclusion at CO History: no familial history of class 3 malocclusion

d. What are the treatment options?

Answer 9

 Extraction, incision and drainage, followed by space maintainer

Question 10

Given: 8 1⁄2 year old patient, with edge to edge biting at CR and class 3 malocclusion at CO History: no familial history of class 3 malocclusion

e. What antibiotics would you prescribe? Give the dosage.

Answer 10

 Amoxicillin clavulanic acid / metronidazole

 Same as adults, simple pulpitis, apical periodontitis, sinus tract, localized intraoral swelling normally do not require antibiotics

 Except for acute facial swelling, cellulitis, systemic involvement (All Guidelines from AAPD) Antibiotic table on page 45

Question 11

Given: periapical radiolucency at 21/22

a. Give the differential diagnosis of the lesion.

Answer 11

 Acute apical periodontitis

 Chronic apical periodontitis (apical granuloma)

 Acute / chronic apical abscess

 Radicular cyst

 Osteomyelitis

Question 12

Given: periapical radiolucency at 21/22

b. No caries was found on 21/22, what could be the other causes of the radiolucency?

Answer 12

 Trauma / Cracked tooth / Perio endo lesion

 Ortho treatment

 Accessory canal

 Deep abrasion

 Exposure during treatment

 Cyst

 Granuloma

Question 13

Given: periapical radiolucency at 21/22

c. Why lymph node would swell?

Answer 13

 Lymph nodes drain for a specified area

 When infection, microorganism is drained to the corresponding lymph node through tissue fluid

 Fluid containing foreign bodies pass through lymph node will stimulate the initiation of immune response including proliferation of defense cells (WBC, marcophages)

Question 14

Given: periapical radiolucency at 21/22

d. Outline the treatment in emergency and preventive phase. Explain your rationale.

Answer 14

 Emergency: emergency RCT (Remove causative agents, prevent spread of infection)

 Preventive: OHI, scaling and root debridement, f luoride application, removal of plaque retentive factors

Question 15

Given: periapical radiolucency at 21/22

e. What are the signs of systemic involvement of an abscess?

Answer 15

 Malaise, lymphadenopathy, fever, leukocytosis

Question 16

Given: periapical radiolucency at 21/22

f. What would be your management in case of systemic involvement?

Answer 16

 Prescribe systemic antibiotics

 Incision and drainage and eliminate causative agents)

Question 17

What are symptoms for the abscess?

Answer 17

 Symptoms: pain, swelling, reddening, hot felt from overlying gingivae, pain when mastication or percuss laterally, feeling the tooth is elevated

 Systemic involvement: malaise, fever, cervical lymphadenopathy

Question 18

Periodontal abscess

b. Treatment suggested

Answer 18

Note: antibiotics usage suggested by Dr. Stanley Lai are:  Amoxicillin 500mg TID 5/7 OR metronidazole 400mg TID 5/7

Anson: If image is unclear look at page 48

Question 19

Information given: 70-year-old woman with DM Pain on lower left molar region. PAN: Edentulous span (upper PM to PM, lower multiple span) + Root treated 37 with likely fracture on 37MO + Horizontally impacted 48 + Large radiolucency in Q4 posterior region, connected to the crown of the 48. Clinical findings: Vertical fracture of 37 extending to root Further information: The patient come back later after 3 days. He complaint of airway constriction. The body temperature is 37.9 degree Celsius. Clinical you can find a raised sublingual floor and swelling of neck.

a. What is the likely diagnosis? (1)

Answer 19

Ludwig’s angina, a severe form of celluitis involving bilateral submandibular and sublingual spaces infection and almost simultaneously readily spread into lateral pharyngeal and pterygoid space and can extent into mediastinum

 Clinical features include swelling and pain of upper neck and floor of mouth on both sides, swelling tracks down the neck and spread to glottis if parapharyngeal space is involved, swallowing and opening of mouth is difficult, floor of mouth raising and tongue pushed up against soft palate

 Patient soon become desperately ill, with fever, malaise, headache, respiratory distress

Question 20

Information given: 70-year-old woman with DM Pain on lower left molar region. PAN: Edentulous span (upper PM to PM, lower multiple span) + Root treated 37 with likely fracture on 37MO + Horizontally impacted 48 + Large radiolucency in Q4 posterior region, connected to the crown of the 48. Clinical findings: Vertical fracture of 37 extending to root Further information: The patient come back later after 3 days. He complaint of airway constriction. The body temperature is 37.9 degree Celsius. Clinical you can find a raised sublingual floor and swelling of neck.

b. How will you manage the patient? (4)

Answer 20

 Immediate referral to A&E for hospitalization

 Ensure patient airway open, secure by tracheostomy if necessary

 ( Maintain fluid balance )

 Collect pus sample for culturing and sensitivity testing

 High dose antibiotic therapy once bacteriological result released (IV)

 Surgical drainage of pus

 Eliminate primary source of infection (non-vital tooth)

Question 21

Information Given: 72 year-old female C/O: Pain of upper left molar region. Pain on biting. HPC: Swollen gum 2 months ago. Spontaneous pain. Visited dentist and subsized 1 month after. DH: The dentist she visited performed “a cut” to relieve her symptoms. MH: unremakable I/O: Pain of percussion //Peri showing 25 – 28

a. What is the likely procedure that the “cut” of the dentist performed? (1)

Answer 21

 Incision and drainage

Question 22

a. Suggest causes for periodontal abscess in patient.

Answer 22