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Treatment of Periodontal Abscess

Philip R. Melnick and Henry H. Takei



SPECIFIC TREATMENT APPROACHES Acute Abscess Chronic Abscess Gingival Abscess Pericoronal Abscess

CLASSIFICATION OF ABSCESSES Periodontal Abscess Gingival Abscess Periocoronal Abscess Acute versus Chronic Abscess Periodontal versus Pulpal Abscess

The periodontal abscess is a localized purulent inflammation of the periodontal tissues.6 It has been classified into three diagnostic groups: gingival abscess, periodontal abscess, and pericoronal abscess. The gingival abscess involves the marginal gingival and interdental tissues. The periodontal abscess is an infection located contiguous to the periodontal pocket and may result in destruction of the periodontal ligament and alveolar bone. The pericoronal abscess is associated with the crown of a partially erupted tooth.22

tooth perforation or fracture2,24 (Figure 48-3) and foreign body impaction.1,23 Poorly controlled diabetes mellitus has been considered a predisposing factor for periodontal abscess formation22 (Figure 48-4). Formation of periodontal abscess has been reported as a major cause of tooth loss.12-21 However, with proper treatment followed by consistent preventive periodontal maintenance, teeth with significant bone loss may be retained for many years7 (see Figure 48-10).

Gingival Abscess
The gingival abscess is a localized, acute inflammatory lesion that may arise from a variety of sources, including microbial plaque infection, trauma, and foreign body impaction.22 Clinical features include a red, smooth, sometimes painful, often fluctuant swelling (Figure 48-5).

Periodontal Abscess
The periodontal abscess is typically found in patients with untreated periodontitis and in association with moderate to deep periodontal pockets.5,25 Periodontal abscesses often arise as an acute exacerbation of a preexisting pocket6 (Figure 48-1). Primarily related to incomplete calculus removal, periodontal abscesses have been linked to a number of clinical situations.8,15,16,24 They have been identified in patients after periodontal surgery,12 after preventive maintenance (Figure 48-2),7,10,17,21 after systemic antibiotic therapy,26 and as the result of recurrent disease.15,16 Conditions in which periodontal abscess is not related to inflammatory periodontal disease include 714

Periocoronal Abscess
The pericoronal abscess results from inflammation of the soft tissue operculum, which covers a partially erupted tooth. This situation is most often observed around the mandibular third molars. As with the gingival abscess, the inflammatory lesion may be caused by the retention of microbial plaque, food impaction, or trauma.

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25 Exudate may be expressed with gentle pressure. Diabetic patients have an increased propensity for periodontal abscesses.11.16. Acute periodontal abscesses can often be treated successfully with a complete restoration of periodontal health. Periodontal abscesses need to be treated with drainage. indicating localized engorgement of the blood vessels. B. tortuous pocket morphology. will require additional therapy after resolution of the acute phase. indicating an aggressive white blood cell reaction. Uncorrected page proofs shown. Acute versus Chronic Abscess Abscesses are categorized as acute or chronic.g. Fever and regional lymphadenopathy are occasional findings. usually obtained by curettage of the pocket or by incision through gingival tissue. Deep furcation invasions are a common location for the periodontal abscess. Furcation anatomy often prevents the definitive removal of calculus and microbial plaque. all patients with an abscess should have a radiograph taken of the region. This reaction therefore may represent an effective host reaction to a defined etiologic agent or event (e. or inability to provide drainage. Different etiologies can account for abscess formation. red. Severe inflammation is also usually present.15. Treatment usually involves dramatic improvement in the tissues and rapid resolution of the abscess.25 The drainage may have been prevented by a deep. Some patients.22 The chronic abscess forms after the spreading infection has been controlled by spontaneous drainage. The differential diagnosis of a periodontal abscess must include periapical abscesses. host Figure 48-2 Postprophylaxis periodontal abscess resulting from partial healing of a periodontal pocket over residual calculus. food impaction. lymphadenopathy. Therefore. ovoid swelling of the gingival tissues. Acute abscesses are characterized by painful.Treatment of Periodontal Abscess s CHAPTER 48 715 SCIENCE TRANSFER An abscess can occur in the periodontal tissues. A B Figure 48-1 A. fever. and in most cases the offending agent or condition is easily identified. systemic antibiotics are needed. however. smooth. and this should be considered if episodes recur. Thus. the gingiva. The acute abscess is often an exacerbation of a chronic inflammatory periodontal lesion. or closely adapted pocket epithelium blocking the pocket orifice. debris. edematous. In cases of cellulitis. Influencing factors include increased number and virulence of bacteria present. Copyright © 2006 elsevier.. the host inflammatory response is accentuated in a very localized area. Purulence is often observed. . combined with lowered tissue resistance and lack of spontaneous drainage. as well as in immunocompromised patients. or the periocoronal tissues and can be acute or chronic. although occurring in a predictable sequence. together with a complete history and clinical examination that includes pocket measurements and tooth vitality tests. the tooth may be percussion sensitive and feel elevated in the socket (Figure 48-6). fractured tooth).

Uncorrected page proofs shown. Box 48-1 compares the signs and symptoms of the acute and chronic abscess. followed by the management of the resulting chronic condition24 (Box 48-3). it is often necessary to perform a differential diagnosis between a periodontal and pulpal abscess4 (Box 48-2).22 SPECIFIC TREATMENT APPROACHES Treatment of the periodontal abscess includes two phases: resolving the acute lesion. periodontal abscess formation may be the first sign of the disease. (See Figures 48-6 to 48-8.716 PART 7 s Treatment of Periodontal Disease A B Figure 48-3 A. the patient may have few or no symptoms.9 However. or therapy. dull pain may be associated with the clinical findings of a periodontal pocket. Periodontal versus Pulpal Abscess Figure 48-5 Plaque-associated mandibular right canine. Fistula is observed in attached gingiva of maxillary right canine. Figure 48-4 Localized periodontal abscess of mandibular right canine of male adult with poorly controlled type 2 diabetes mellitus. Signs of tissue distention and exudation are evident. Copyright © 2006 elsevier. Figure 48-6 Patient presenting with acute abscess complained of dull pain and a sensation of tooth elevation in the socket. Elevated flap shows the cause to be a root fracture. . Once homeostasis between the host and infection has been reached. For some patients.) response. inflammation. B. gingival abscess of To determine the cause of an abscess and thus establish a proper treatment plan. and a fistulous tract.

May have no periodontal pocket. Maxillary right first molar with fistula on the attached gingiva. Swelling often localized to apex.Treatment of Periodontal Abscess s CHAPTER 48 717 BOX 48-1 Signs and Symptoms of Periodontal Abscess Acute Abscess Mild to severe discomfort Localized red. Copyright © 2006 elsevier. 1999. A B C Figure 48-7 A. Copenhagen. 2000. BOX 48-2 Differential Diagnosis of Periodontal and Pulpal Abscess Periodontal Abscess Associated with preexisting periodontal pocket. Sensitivity to percussion. Pain often severe and difficult to localize. B. Surgical flap elevation demonstrates failed endodontic therapy and tooth fracture as causing the fistula. with occasional fistula. periodontal probe is introduced through the fistula and angled toward the root end. Herrera D. Swelling usually includes gingival tissue. Using local anesthesia. 2004. with a fistulous tract. 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 Data from Dahlen G: Periodontol 2000 28:206. *May indicate the need for systemic antibiotics. van Winkelhoff AJ: The periodontal abscess. or if present. Radiographs show periodontal angular bone loss and furcation radiolucency. Pulpal Abscess Offending tooth may have large restoration. probes as a narrow defect. 2002. C. Tests show nonvital pulp. Pain usually dull and localized. Sensitivity to percussion may or may not be present. and Sanz M. . Uncorrected page proofs shown. Munksgaard. Tests show vital pulp. In Clinical periodontology. Meng HX: Ann Periodontol 4:79. Modified from Corbet EF: Periodontol 2000 34:204.

2. spreading infection) Deep. 5.0-g loading dose. In Clinical periodontology. the patient’s medical history.0-g loading dose. Munksgaard. 2000. 500 mg • 1. Antibiotic Options for Periodontal Infections Antibiotic of Choice Amoxicillin. dental history. B.718 PART 7 s Treatment of Periodontal Disease A B Figure 48-8 A. control the spread of infection. BOX 48-3 Treatment Options for Periodontal Abscess 1. and systemic condition are reviewed and evaluated to assist in the diagnosis and to determine the need for systemic antibiotics (Boxes 48-4 and 48-5). Periodontal abscess of maxillary left first molar. and establish drainage. Drainage through pocket retraction or incision Scaling and root planing Periodontal surgery Systemic antibiotics Tooth removal BOX 48-4 Indications for Antibiotic Therapy in Patients with Acute Abscess 1.19 Before treatment. inaccessible pocket Fever Regional lymphadenopathy Immunocompromised patient Modified from Sanz M. Herrera D. 2004. van Winkelhoff AJ: The periodontal abscess. then 500 mg three times a day for 3 days • Reevaluation after 3 days to determine need for continued or adjusted antibiotic therapy Penicillin Allergy Clindamycin • 600-mg loading dose. 3. If the lesion is large and drainage cannot be established. 4. The pocket wall is gently retracted with a periodontal probe or curette in an attempt to initiate drainage through the pocket entrance (see Figure 48-8). Cellulitis (nonlocalized. If the lesion is small and access uncomplicated. Uncorrected page proofs shown. 2. 5. root debridement by scaling and root planing or surgical Copyright © 2006 elsevier. 4. BOX 48-5 Acute Abscess The acute abscess is treated to alleviate symptoms. Gentle digital pressure and irrigation may be used to express exudates and clear the pocket (Figure 48-9). Copenhagen. 3. Periodontal probe is used to retract the pocket wall gently. then 500 mg four times a day for 3 days Data from American Academy of Periodontology: J Periodontol 67:1553. then 300 mg four times a day for 3 days Azithromycin (or clarithromycin) • 1. debridement in the form of scaling and root planing may be undertaken. Drainage through Periodontal Pocket. The peripheral area around the abscess is anesthetized with sufficient topical and local anesthetic to ensure comfort. .

topical or local anesthesia by infiltration is administered. use of adjunctive systemic antibiotics13-16 with short-term high-dose regimens is recommended20 (see Box 48-5). The tissue lateral to the incision can be separated with a curette or periosteal elevator. and exudate may be expressed by gentle digital pressure.g. To ensure procedural comfort. the patient is dismissed with instructions to rinse with warm salt water every 2 hours for the remainder of the day. appropriate analgesics should be employed. the chronic abscess is usually treated with scaling and root planing or surgical therapy. impression material) is removed. aggressive mechanical instrumentation should be delayed in favor of antibiotic therapy so as to avoid damage to healthy contiguous periodontal tissues. dental floss. posttreatment instructions include frequent rinsing with warm salt water (1 tbsp/8-oz. and if resolution is sufficient.Treatment of Periodontal Abscess s CHAPTER 48 719 24 hours. Reduced exertion and increased fluid intake are often recommended for patients showing systemic involvement.24 Once bleeding and suppuration have ceased. . The abscess is dried and isolated with gauze sponges. After 24 hours the area is reassessed. The acute pericoronal abscess is properly anesthetized for comfort. Copyright © 2006 elsevier. Any foreign material (e. Fluctuant matter is expressed and the wound edges approximated under light digital pressure with a moist gauze pad. Figure 48-9 Gentle digital pressure may be sufficient to express purulent discharge. Topical anesthetic is applied. If not. it may be removed. The patient should be advised of the possible postoperative sequelae usually associated with periodontal nonsurgical and surgical procedures. scaling and root planing are completed to establish drainage and remove microbial deposits. glass) and periodic application of chlorhexidine gluconate either by rinsing or locally with a cotton-tipped applicator.18 In these patients. followed by resolution of the chronic condition. the patient is instructed to continue the previously recommended regimen for an additional Pericoronal Abscess As with the other abscesses of the periodontium. Once bleeding has stopped. Once the acute phase has been controlled. In more acute situations the fluctuant area is incised with a #15 scalpel blade. and the area is reassessed after 24 hours. Analgesics may be prescribed for comfort. If discomfort was one of the original complaints.14 Drainage through External Incision. access should be delayed until the major clinical signs have abated. lymphadenopathy. the signs and symptoms have usually subsided. By the following day. The area is irrigated with warm water and covered with moist gauze under light pressure. The patient is dismissed with instructions to rinse with warm salt water every 2 hours. For those who do not need systemic antibiotics. If the residual lesion is large or poorly accessible. the treatment of the pericoronal abscess is aimed at management of the acute phase. the patient may be dismissed. systemic antibiotics may be prescribed. In abscesses presenting with severe swelling and inflammation. or systemic signs. Surgical treatment is suggested when deep vertical or furcation defects are encountered that are beyond the therapeutic capabilities of nonsurgical instrumentation (Figure 48-10). and drainage is established by gently lifting the soft tissue operculum with a periodontal probe or curette. followed by local anesthetic injected peripheral to the lesion. This often results in satisfactory healing.25 Gingival Abscess Treatment of the gingival abscess is aimed at reversal of the acute phase and.25 Chronic Abscess As with a periodontal pocket. and the lesion can be treated as a chronic abscess. As with the acute abscess.. If the underlying debris is easily accessible. Antibiotic therapy alone without subsequent drainage and subgingival scaling is contraindicated. immediate removal of the cause. the partially erupted tooth may be definitively treated with either surgical excision of the overlying tissue or removal of the offending tooth. surgical access may be required. scaling not previously completed is undertaken. If there is regional swelling. A vertical incision through the most fluctuant center of the abscess is made with a #15 surgical blade. When possible. Uncorrected page proofs shown. antibiotic therapy may be indicated. followed by gentle irrigation with sterile saline. when applicable.

Copyright © 2006 elsevier. exposing severe bone dehiscence. Full-thickness flap has been replaced to its original position and sutured with absorbable sutures. a full-thickness flap is elevated. F. Using local anesthesia. Using mesial and distal vertical incisions. gingival tissues are pink. Root surface has been planed free of calculus and the restoration smoothed.720 PART 7 s Treatment of Periodontal Disease A B C D E F Figure 48-10 A. . and root calculus. Chronic periodontal abscess of maxillary right canine. a subgingival restoration. E. C. D. Uncorrected page proofs shown. with minimal periodontal probing depth. B. periodontal probe is inserted to determine severity of the lesion. and well adapted to the tooth. At 3 months. firm.

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