Facial swelling and severe pain from a carious molar

§Chief complaint

Throbbing toothache with cheek swelling for 2 days

§Medical & dental history

• 01Healthy, no allergies
• 02Not pregnant
• 03Long-standing cavity in the upper right back tooth, previously painful

§Clinical examination

• 01Diffuse tender swelling of the right cheek with obliteration of the buccal sulcus
• 0216 grossly carious, tender to percussion, grade I mobile, non-responsive to cold
• 03Temperature 37.9 C; mouth opening 35 mm
• 04No eye closure, no orbital involvement, airway clear

§ figuresFigures (4)

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Periapical Abscess figures pending faculty review.

§Differential diagnosis

§Final diagnosis

Acute apical abscess of 16 with buccal space involvement

A non-vital, percussion-tender tooth with a diffuse facial swelling localises the source. Pulp vitality is the discriminator against a periodontal abscess, where the tooth typically remains vital.

§Investigations

• 01Periapical radiograph — periapical radiolucency and deep caries involving the pulp
• 02Pulp sensibility testing of 15, 16, 17
• 03Temperature, pulse and assessment of red flags (eye closure, trismus, dysphagia)

§Treatment plan

• 01Establish drainage — the primary treatment of an abscess
• 02Extraction of the unrestorable 16, or access and drainage if restorable
• 03Antibiotics only if there is spreading infection or systemic upset
• 04Analgesia and review in 24-48 hours

§Surgical procedure

• 01Extraction of 16 under local anaesthesia with drainage through the socket
• 02Amoxicillin plus metronidazole for 5 days given systemic features

§Follow-up & outcome

• 01Swelling substantially reduced at 48 hours
• 02Complete resolution at 1 week
• 03Prevention advice and restorative plan for remaining caries

§Clinical pearls / learning points

• 01Drainage, not antibiotics, treats an abscess.
• 02Look for the red flags of spreading infection: trismus, dysphagia, eye closure, raised floor of mouth.
• 03Always test vitality — it decides whether the problem is endodontic or periodontal.

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