Periapical abscess


  • Associated with dental caries or nonviable teeth
  • Significant erosion of the pulp with bacterial overgrowth

Clinical Features

  • Acute pain, swelling, and mild tooth elevation
  • Exquisite sensitivity to percussion or chewing on the involved tooth
  • Swelling in surrounding gingiva, buccal, lingual or palatal regions
  • May see small white pustule (parulis) in gingival surface characteristic for abscesses

Differential Diagnosis

Dentoalveolar Injuries

Odontogenic Infections



  • Clinical evaluation
  • Radiographs


  • Analgesia with NSAIDs, opioids and/or local anesthetics
  • Dental follow-up within 48 hrs.
  • Emergent oral surgeon follow-up if complicated (Ludwig's angina, Lemierre's syndrome)


Treatment is broad and focused on polymicrobial infection

  • Amoxicillin-clavulanate 875 mg PO q12 hours x 7 days
  • Clindamycin 300 mg PO q8 hours x 7 days
  • Penicillin VK 500 mg PO q6 hours x 7 days (frequently prescribed but no longer recommended as monotherapy)
  • Ampicillin/Sulbactam 3g IV q6 hours x 7 days


  • Can be performed in ED depending on provider comfort or by a dental consultant


  • 11 or 12 blade stab incision
  • Hemostat blunt dissection +/- packing

See Also


    • ER Atlas
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