Abscesses of the

Periodontium

Dentoalveolar abscesses consist of two main types:

1. The endodontic (periapical) abscess

formed after necrosis of the dental pulp and subsequent

infection of the root canal.

2. The periodontal abscess

formed after infection of the periodontal tissues by bacteria

Periodontal abscess Periapical abscess

Associated with preexisting periodontal

pocket.

May have no periodontal pocket, or if

present, probes as a narrow defect.

Tests show vital pulp. Tests show non-vital pulp.

Swelling usually includes gingival tissue,

with occasional fistula.

- Offending tooth may have large

restoration

- Swelling often localized to apex, with a

fistulous tract.

Radiographs show periodontal angular

bone loss and furcation radiolucency.

Presence of a periapical radiolucency

Pain usually dull and localized. Pain often severe and difficult to

localize.

Sensitivity to percussion may or may not

be present.

Sensitivity to percussion.

Periodontal abscesses have been classified in different ways

depending on the main criteria of classification.

1. Depending on the location of the abscess, they have been divided

into periodontal and gingival abscesses

2. Depending on the course of the lesion, they have been divided

into acute and chronic periodontal abscesses.

3. Depending on the number, they have been divided into single

versus multiple periodontal abscesses.

Definition

Periodontal abscess: is a localized purulent

inflammation of the periodontal tissues.

Abscesses are one of the main causes for patients

to seek emergency care in the dental clinic.

Depending on the origin of the infection

the lesions can be classified:

Gingival abscess:involves the marginal gingival andinterdental tissues, caused by impaction of foreignbodies.

Periodontal abscess:is an infection locatedcontiguous to the periodontal pocket and may resultin destruction of the periodontal ligament andalveolar bone.

Pericoronal abscess: is associated with the crown of apartially erupted tooth.

Periodontal Abscess

Occurs :

In patients with untreated periodontitis and in

association with moderate-to-deep periodontal pockets.

With improper use of oral irrigating devices that

introduce bacteria into the tissues.

Subsequent to a scaling session when a piece of calculus

becomes dislodged and remains in the pocket.

The periodontal abscess lesion contains bacteria as:

- Gram negative, anaerobic species which include Porphyromonas

gingivalis, Prevotella intermedia, Prevotella melaninogenica,

Fusobacterium nucleatum, andTannerella forsythia.

- Gram-positive bacterial species in periodontal abscesses

include Micromonas micros, Actinomyces spp., and Bifidobacterium

Clinical features:

- Pain

- Swelling

- Teeth tender on chewing and sensitive to percussion.

- Tooth is mobile and may even extrude from the alveolar socket

and feel "high" to the occlusion.

- Purulent exudate can often be noted in the periodontal pocket

around the affected tooth.

- Lymphadenopathy

- Slight increase of body temperature

Periodontal abscess on the palatal aspect of a maxillary right first molar with a

periodontal probe in place demonstrating deep probing depth, with gingival

enlargement and discoloration

Gingival Abscess

It is a localized, acute inflammatory lesion that may arise

from a variety of sources, including:

- microbial plaque infection

- Trauma

- foreign body impaction.

- Clinical features: include a red, smooth, sometimes painful,

often fluctuant swelling.

Pericoronal Abscess

The pericoronal abscess results from inflammation of the

soft tissue operculum, which covers a partially erupted

tooth.

Inflammatory lesion may be caused by the retention of

microbial plaque, food impaction, or trauma.

Acute vs. Chronic Abscess

Acute Abscess

Mild to severe discomfort with pain

Localized red, ovoid swelling

Periodontal pocket

Mobility

Tooth elevation in socket

Tenderness to percussion or biting

Exudation

Elevated temperature

Regional lymphadenopathy

Chronic abscess

No pain or dull pain

Localized inflammatory lesion

Slight tooth elevation

Intermittent exudation

Fistulous tract often associated

with a deep pocket

Usually without systemic

involvement

Multiple abscess

Treatment

The treatment of the periodontal abscess usually includes

two stages:

(1) Management of the acute lesion

(2) Appropriate treatment of the original and/or residual

lesion, once the emergency situation has been controlled.

Treatment options

1- Drainage through pocket retraction or incision

2- Scaling and root planing

3- Periodontal surgery

4- Systemic antibiotics

5- Tooth removal

Acute Periodontal Abscess- The acute abscess is treated to alleviate symptoms, control the

spread of infection, and establish drainage.

1. Drainage through Periodontal Pocket

- The peripheral area around the abscess is anesthetized with

sufficient topical and local anesthetic to ensure comfort.

- The pocket wall is gently retracted with a periodontal probe or

curette in an attempt to initiate drainage through the pocket

entrance.

- Gentle digital pressure and irrigation to clear the pocket.

- If the lesion is small and access uncomplicated, debridement in

the form of scaling and root planing may be undertaken.

- If the lesion is large and drainage cannot be established, root

debridement by scaling and root planing or surgical access should

be delayed until the major clinical signs have abated.

- In these patients, use of adjunctive systemic antibiotics with short-

term high-dose regimens is recommended.

Antibiotic therapy alone without subsequent drainage

and subgingival scaling is contraindicated

Antibiotic option Amoxicillin, 500 mg

- 1.0-g loading dose, then 500 mg 3 times a day for 3 days.

- Reevaluation after 3 days to determine need for continued or

adjusted antibiotic therapy.

* If there is Penicillin Allergy use:

Clindamycin

- 600 mg loading dose, then 300 mg 4 times a day for 3 days.

- Azithromycin (or clarithromycin) 1.0-g loading dose, then 500

mg 4 times a day for 3 days.

2. Drainage through External Incision

- The abscess is dried and isolated with gauze sponges.

- Topical anesthetic is applied, followed by local anesthetic

injected peripheral to the lesion.

- Vertical incision through the most fluctuant center of the

abscess is made with a surgical blade.

- The tissue lateral to the incision can be separated with a

curette or periosteal elevator.

- Pus is expressed, and the wound edges approximated under

light digital pressure with a moist gauze pad.

- Post-treatment instructions include frequent rinsing with warm

salt water (1 tbsp/8-oz glass) and periodic application of

chlorhexidine gluconate either by rinsing or locally with a

cotton-tipped applicator.

- Analgesics may be prescribed for comfort.

- By the following day, the signs and symptoms will usually subside

and the lesion can be treated as a chronic abscess.

Chronic Periodontal abscess

- As with a periodontal pocket, the chronic abscess is usually

treated with scaling and root planing or surgical therapy.

- Surgical treatment is suggested when deep vertical or

furcation defects are encountered that are beyond the

therapeutic capabilities of nonsurgical instrumentation.

- As with the acute abscess, antibiotic therapy may be

indicated.

Gingival Abscess- Treatment of the gingival abscess is aimed at reversal of the

acute phase and when applicable, immediate removal of thecause.

- Topical or local anesthesia by infiltration is administered.

- When possible, scaling and root planing are completed toestablish drainage and remove microbial deposits.

- In more acute situations the fluctuant area is incised with a#15 scalpel blade, and exudate may be expressed by gentledigital pressure.

- Any foreign material (e.g., dental floss, impression material)is removed.

- The area is irrigated with warm water and covered with moist

gauze under light pressure.

- Once bleeding has stopped, the patient is dismissed with

instructions to rinse with warm salt water every 2 hours for

the remainder of the day.

- After 24 hours the area is reassessed, and if resolution is

sufficient, scaling not previously completed is undertaken.

Pericoronal Abscess- The treatment of the pericoronal abscess is aimed at management

of the acute phase, followed by resolution of the chronic

condition.

- The acute pericoronal abscess is properly anesthetized for

comfort.

- Drainage is established by gently lifting the soft tissue operculum

with a periodontal probe or curette. If the underlying debris is

easily accessible, it may be removed, followed by gentle irrigation

with sterile saline.

- If there is regional swelling, lymphadenopathy, systemic

antibiotics may be prescribed.

- The patient is dismissed with instructions to rinse with warm

salt water every 2 hours, and the area is reassessed after 24

hours.

- If discomfort was one of the original complaints, appropriate

analgesics should be employed.

- Once the acute phase has been controlled, the partially

erupted tooth may be definitively treated with either surgical

excision of the overlying tissue or removal of the offending

tooth.

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