The patient complains of severe, constant facial or dental pain, often associated with facial swelling, regional lymphadenopathy, and cellulitis, and may exhibit signs of systemic toxicity. The pain may be gnawing, throbbing, or sharp and shooting. Dental caries may or may not be apparent. Percussion of the offending tooth causes increased pain (Fig. 46.1). The severe toothache may be exacerbated by thermal changes, especially cold drinks. On the other hand, hot and cold sensitivity may no longer be present because of necrosis of the pulp. A fluctuant abscess may be palpated in the buccal or palatal gingiva, but usually extends toward the buccal side and to the gingival-buccal reflection.

 

See normal anatomy (Fig. 46.2) with subsequent development of periapical abscess and cellulitis (Fig. 46.3).