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Ann Periodontol

Periodontal Abscess
Huan Xin Meng*

* Beijing Medical University, Beijing, China.

This review focuses on the classification of periodontal abscesses,

which are localized purulent infections of periodontal tissues,
and discusses their etiology and clinical characteristics. Ann
Periodontol 1999;4:79-82.
KEY WORDS

A
periodontal abscess is a localized
Periapical abscess/classification; periapical abscess/etiology; purulent infection of periodontal
periodontal abscess/classification; gingival abscess. tissues and can be a common clin-
ical feature in patients with moderate or
advanced periodontitis.1-8 Although it is
more frequently seen in untreated than in
treated periodontitis patients, a recent ret-
rospective study5 indicated that it may
also occur in patients receiving mainte-
nance treatments. This review focuses on
the classification of periodontal abscesses
and discusses their etiology and clinical
characteristics.
MICROBIOLOGY
Streptococcus viridans is the most com-
mon isolate in the exudate of periodon-
tal abscesses when aerobic techniques
are used.9 It has been reported that the
microorganisms that colonize the peri-
odontal abscesses are primarily Gram-
negative anaerobic rods.10,11 Although
not found in all cases of periodontal
abscesses, high frequencies of Porphy-
romonas gingivalis, Prevotella interme-
dia, Fusobacterium nucleatum, Campylo-
bacter rectus, and Capnocytophaga spp
have been reported.10,12-15 Actinobacil-
lus actinomycetemcomitans is not usually
detected.10 The disappearance of P. gin-
givalis from abscessed sites after treat-
ment suggests a close association of this
microorganism with abscess formation.12
Spirochetes have been found as the pre-
dominant cell type (mean, 40.6%
10.9%) in periodontal abscesses when
assessed by darkfield microscopy.16
Strains of Peptostreptococcus, Strepto-
coccus milleri (S. anginosus and S. inter-

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Periodontal Abscess
medius), Bacteroides capillosus, Veillonella, B. fragilis,
and Eikenella corrodens have also been isolated.11
Overall, studies have noted that the microbiota found
in abscesses are similar to those in deep periodontal
pockets.
FACTORS ASSOCIATED WITH DEVELOPMENT
OF PERIODONTAL ABSCESSES
Periodontal abscesses usually result from pre-existing
cases of chronic periodontitis4-8 and are precipitated
by changes in the subgingival microflora, decreased
host resistance, or both.17 Among the factors that have
been associated with the formation of acute periodontal
abscesses are: 1) occlusion of pocket orifices; 2) fur-
cation involvement; 3) systemic antibiotic treatment;
and 4) diabetes.
Occlusion of the Orifice of a Deep Periodontal
Pocket
Most investigators believe that periodontal abscesses
are induced by occlusion of the periodontal pocket ori-
fice leading to reduced clearance of bacteria and accu-
mulation of host cells.1-3,6,18 As a consequence, the
infection spreads from the pocket into supporting tis-
sues and is then localized. Tissue damage in the
abscessed area is considered to be the result of lyso-
somal enzymes released from neutrophils participat-
ing in the defense of the host.19 Occlusion of pocket ori-
fices caused by local factors such as impaction of food
and foreign bodies20-22 prevents drainage of exudate
formed by inflamed tissues adjacent to the pocket. Peri-
odontal abscesses are rare in children and, if they occur,
are usually caused by the introduction of a foreign body
into previously healthy periodontal tissues.23,24
Periodontal abscess formation may also occur as a
result of incomplete removal of calculus during treat-
ment of a periodontal pocket.1-3,25 In such cases, the
gingival wall shrinks, occluding the pocket orifice, and
the abscess occurs in the sealed-off portion of the
pocket. The fact that patients were undergoing peri-
odontal treatment when abscesses developed could
indicate that instrumentation may force bacteria into
the tissues, provoking a localized purulent exu-
date.7,26
Furcation Involvement
Abscesses are frequently found in furcations.27 In one
study addressing the incidence of acute periodontal
abscesses, clinical and/or radiologic evidence of fur-
cation involvement was noted in the majority of the
molars.7 In another study, most periodontal abscesses
occurred in molars (37 of 40 cases, 92.5%).28 A study
in a private periodontal practice reported periodontal
abscess was the primary reason for molar extraction.29
Furthermore, when loss of abscessed teeth was com-
pared between furcated and nonfurcated teeth, more
furcated teeth were lost than nonfurcated teeth.3
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Volume 4 Number 1 December 1999
Systemic Antibiotic Therapy
In some cases, multiple periodontal abscesses cannot
be explained by local factors alone, and it has been
suggested that systemic administration of antibiotics
may trigger their formation. It has been reported that
periodontal abscesses occurred in patients with
untreated advanced periodontal disease shortly after
receiving antibiotics for non-oral infections.8,30 In one
of these studies, Bacteroides gingivalis, Fusobacterium
nucleatum, and Streptococcus intermedius were the
most prevalent species associated with the multiple
periodontal abscesses8 and in the other, a significant
increase in subgingival Staphylococcus aureus was
found.30 Based on these results it appears that the sys-
temic administration of antibiotics in patients with
untreated periodontitis may lead to superinfection with
opportunistic organisms resulting in development of
periodontal abscesses.
Diabetes
The predisposition of patients with diabetes to puru-
lent infections makes them prone to acute periodon-
tal abscesses. Systemic alterations in diabetics that
may have a significant influence on the formation of
periodontal abscesses include lowered host resistance
such as impaired cellular immunity, decreased leuko-
cyte chemotaxis/phagocytosis and bactericidal activ-
ity. Diabetics also have vascular changes and altered
collagen metabolism that may increase susceptibility
to abscess formation.18,31 Enhanced interaction of
advanced glycosylation end products (AGEs) with their
cellular receptor (RAGE) has been suggested as one
of the pathogenic mechanisms of accelerated peri-
odontal disease in diabetes.32 Critical consequences of
hyperglycemia are non-enzymatic glycation and oxi-
dation of proteins and lipids, resulting in the formation
of the AGEs which accumulate in plasma, tissues,33
and gingiva of diabetic patients.34
Other Factors
Other factors associated with periodontal abscess for-
mation include trauma to the tooth such as perforation
of the lateral wall of the root in endodontic therapy1-3,35
and anatomic dental anomalies such as enamel pearls36
in molar furcations and invaginated roots.37
CLINICAL FEATURES
An abscessed area may manifest the following signs
and symptoms: swelling, suppuration, visible redness,
extrusion of the tooth involved, loosening, and ten-
derness to even slight percussion. A slight tempera-
ture elevation is an occasional finding.4,7,19 Types of
abscesses that affect the periodontium include: gin-
gival, periodontal, pericoronal, and periapical. Peri-
apical abscesses are discussed in another paper.38
Previously periodontal abscesses were also referred
to as lateral and parietal abscesses. However, these
A15_IPC_AAP_Annals_553640 6/7/00 8:56 AM Page 81
Ann Periodontol
terms may be misleading and therefore their use
should be discontinued.
Gingival Abscess
A gingival abscess is a localized, painful, rapidly
expanding lesion involving the marginal gingiva or inter-
dental papilla sometimes in a previously disease-free
area. It is usually an acute inflammatory response to for-
eign substances forced into the gingiva and in its early
stages appears as a red swelling with a smooth, shiny
surface. Within 24 to 48 hours, the lesion is usually
fluctuant and pointed, with a surface orifice from which
a purulent exudate may be expressed. If permitted to
progress, the lesion generally ruptures spontaneously.
Symptoms may include pulpal hypersensitivity.1-4
Periodontal Abscesses
A periodontal abscess is a localized accumulation of
pus within the gingival wall of a periodontal pocket
resulting in the destruction of the collagen fiber attach-
ment and the loss of nearby alveolar bone. It is usu-
ally associated with more advanced involvement of
periodontal structures, including tortuous periodontal
pockets, furcation involvement, and intrabony defects.
Calculus is often detected on the root surface. The
lesions may be acute or chronic. A localized acute
abscess may progress to a chronic abscess if its puru-
lent contents drain through a fistula into the outer gin-
gival surface or into the periodontal pocket.1-5
An acute periodontal abscess appears as an ovoid
elevation of the gingiva along the lateral aspect of the
root. The gingiva is edematous and red, with a smooth,
shiny surface. In most cases, pus may be expressed
from the gingival margin by gentle digital pressure.
The symptoms of an acute periodontal abscess vary
from slight discomfort to severe pain and swelling. As
an abscess develops, a feeling of pressure in the
gums is common. Inflammation involving the sup-
porting structures may be accompanied by increased
tooth mobility, elevation of the tooth in its socket, and
tenderness to percussion or on mastication. Regional
lymphadenopathy can be detected in some patients.1-8,19
If an acute periodontal abscess is left untreated, it
may become a chronic lesion. A chronic periodontal
abscess may exist for an extended period and have a
history of intermittent exudation for which patients
seek treatment. It usually presents as a fistulous tract
that originates from deep supporting tissues and opens
onto the gingival mucosa along the length of the root.
The orifice of the fistula may appear as a difficult-to-
detect pinpoint opening and be covered by a small,
pink mass of granulation tissue. A chronic periodon-
tal abscess is usually asymptomatic. However, some
patients may feel dull or gnawing pain, slight elevation
of the tooth, and a desire to bite tightly and grind.
Chronic lesions may become acute abscesses if the ori-
fice of the sinus tract becomes occluded.4
Meng
Pericoronal Abscess
The pericoronal abscess is a localized accumulation of
pus within the overlying gingival flap surrounding the
crown of an incompletely erupted tooth, usually occur-
ring in the mandibular third molar area. The gingival
flap appears red and swollen. The infection may spread
posteriorly into the oropharyngeal area and medially
to the base of the tongue and involve the regional
lymph nodes. Patients usually have a history of peri-
coronitis and may experience difficulty in swallowing.
The severity of pericoronitis and development of
abscess formation have been associated with increas-
ing proportions of Gram-negative anaerobic pathogens.39
Some patients may also have systemic symptoms such
as fever, leukocytosis, or malaise.1-3
DIAGNOSIS
Periodontal abscesses are the most common type of
abscesses involving the periodontium. A diagnosis of
periodontal abscess should be made after on overall
evaluation and interpretation of the patients chief com-
plaint, medical/dental history, and clinical and radi-
ographic examinations. A periodontal abscess is usu-
ally associated with pre-existing periodontitis. Drainage
of the pus may occur during periodontal probing or
without provocation. Most periodontal abscesses occur
interstitially,7 but they do not always drain on the same
surface of the root on which the pocket is present. For
instance, a pocket on the facial surface may give rise
to a periodontal abscess interproximally.1-3 Radi-
ographs and assessment of pulp status may provide
additional information relative to the etiology of the
swelling.4 The percentage of spirochetes as seen by
darkfield microscopy may be of value.16,40
CONCLUSION
A periodontal abscess is a localized purulent infection
of periodontal tissues and can be a common clinical
finding among patients with moderate to advanced peri-
odontitis. The microorganisms in periodontal abscesses
are primarily Gram-negative anaerobic rods, and are
similar to bacteria detected in deep periodontal pock-
ets. However, no specific microorganism has been found
in periodontal abscesses. Several factors are associ-
ated with the formation of the acute abscess, includ-
ing occlusion of the orifice of a deep periodontal pocket,
systemic antibiotic therapy in the absence of periodontal
treatment, and poorly controlled diabetes. The diag-
nosis of a periodontal abscess is based on information
from patient history and clinical and radiographic exam-
inations. The periodontal abscess needs to be differ-
entiated from gingival abscess and periapical abscesses.
If the abscess is limited to marginal gingiva or inter-
dental papilla with no previous disease, and a foreign
material or trauma exists, the lesion is likely to be a gin-
gival abscess. If the abscessed tooth is nonvital, the
lesion is most likely a periapical abscess. According to
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Periodontal Abscess
the tissues affected, in this review, 3 types of abscesses
of the periodontium have been described.
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Send reprint requests to: Dr. Huan Xin Meng, Beijing Med-
ical University, School of Stomatology, Weigongcun, Haidian
District, Beijing 100081 China. Fax: 86-10-6217-3402; e-
mail: hxmeng@public.east.cn.net