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Chronic abscesses that have not been treated result in the development of a fistula, by which seropurulent or sanguinopurulent exudate is periodically discharged from the cavity until it empties. The opening is then obstructed and remains closed until a new collection of pus accumulates. Alternatively, the pus may not drain by way of the fistula, but may be absorbed by the blood vessels or lymph nodes of the body.

The chronic dentoalveolar abscess is usually asymptomatic. Sometimes, though, mild intermittent pain (which is due to the temporary obstruction of the fistula) or mild edema and redness of the tissues of the periapical region may be noted. The tooth is sensitive to percussion and the pulp of the offending tooth usually tests nonvital.

Dentoalveolar fistulas develop intraorally as well as extraorally. Intraoral fistulas are usually observed buccally and more rarely palatally or lingually (Figs. 9.80–9.82), while extraoral fistulas are the result of chronic suppuration of the cheek, mental region, or the superior region of the neck, resulting in a puckered appearance on the skin (Figs. 9.83, 9.84). The exudate discharged from the fistula dries up on the skin, resulting in the formation of a crusted surface.

Radiographically, limited or extensive diffuse radiolucency is observed in cases of chronic dentoalveolar abscesses, which is due to bone destruction.

Treatment consists of eliminating the infection from the responsible tooth with endodontic therapy or in conjunction with surgical treatment (apicoectomy), when endodontic therapy alone does not produce the desired results. Usually in intraoral fistulas, the fistulous tract disappears a few days after endodontic therapy begins, without requiring intervention for excision of the opening. In extraoral fistulas, though, after treating the infected site, the fistulous tract must be excised as far as the bone cavity and, after debridement, must be sutured tightly.

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