Acute Apical Periodontitis — Treatment

Treatment

Acute Apical Periodontitis (No Abscess, No Swelling)

Pulpectomy and drainage through root canal; occlusal relief

• Local anesthesia (IAN block or buccal infiltration)
• Access opening and pulpectomy with complete necrotic tissue removal
• Canal instrumentation to working length to establish periapical drainage
• Copious NaOCl irrigation
• Occlusal reduction (reduce tooth from occlusion to relieve proprioceptive hypersensitivity)
• Calcium hydroxide intracanal medicament; temporary restoration
• NSAIDs (ibuprofen 600mg q6h); antibiotics only if systemic signs present

Acute Apical Abscess — Localized

Root canal access + incision and drainage (I&D) of abscess

• Administer LA where possible (may be ineffective in severely acidic abscess tissue)
• Root canal access, pulpectomy, and drainage through canal
• If fluctuant swelling: incision through mucosa with #15 blade; blunt dissection with hemostat to release pus
• Drain placement (penrose drain or gauze wick) to maintain drainage for 24–48 hours
• Copious saline irrigation of abscess cavity
• Antibiotics: amoxicillin 500mg TID x 5–7 days (first line); metronidazole 400mg TID if anaerobic emphasis; clindamycin if penicillin allergy
• Analgesics: ibuprofen ± acetaminophen; opioids reserved for severe cases
• Follow-up in 24–48 hours for drain removal and reassessment

Spreading Infection / Systemic Signs

Hospital admission, IV antibiotics, surgical drainage

• Emergency hospital referral if trismus, dysphagia, dysphonia, or airway compromise
• IV amoxicillin-clavulanate or piperacillin-tazobactam
• CT scan of neck with contrast to map fascial space involvement
• Surgical drainage in operating room under general anesthesia
• ICU monitoring if airway compromised
• Definitive dental treatment after systemic control

Definitive Endodontic Treatment

Complete root canal treatment after acute phase resolution