PERIODONTAL

ABSCESS
DR.RAJEEV ARUNACHALAM
TYPES OF DENTAL ABSCESS
CLASSIFICATION OF ABSCESSES

• Three diagnostic groups:

➢ Gingival abscess
➢ Periodontal abscess
➢ Pericoronal abscess
GINGIVAL ABSCESS
INVOLVES THE MARGINAL GINGIVAL AND INTERDENTAL TISSUES.
PERIODONTAL
ABSCESS

➢ Periodontal or lateral /parietal abscess is a

localized area of inflammation in which the
pus has taken place in the periodontal tissues.

➢ Defined as localized accumulation of pus

located within the gingival wall of the
periodontal pocket[Carranza et al 1990].

➢ The periodontal abscess is an infection

located contiguous to the periodontal
pocket and may result in destruction of
the periodontal ligament and alveolar
bone. [Carranza et al 13th edition].
PERIODONTAL ABSCESS

• It is produced by endogenous pyogenic microorganisms

,possibly toxic factors in the plaque and or some reduction
in the host resistance caused by the local or systemic
factors.
• It most commonly complicates advanced periodontitis but can occur when
lesions of pulpal origin drain via the periodontal ligament and discharge from
the gingival crevice.
• Thus, a precise diagnosis must be established since in the latter situation
rapid endodontic treatment needs to be carried out.
PERICORONAL ABSCESS
THE PERICORONAL ABSCESS IS ASSOCIATED WITH THE CROWN OF A PARTIALLY ERUPTED TOOTH.
FACTORS THAT PROVOKE ABSCESS
FORMATION:
1. Obstruction of opening to a deep pocket ,frequently one which is tortuous , e.g.,
associated with furcation defect.
2. Gingival injury with a foreign body , e.g., toothbrush bristle or wood stick.
3. Incomplete removal of plaque and subgingival calculus from the depths of the
pocket
4. Infection of tissues damaged by excessive occlusal stress which can be
produced by:
• A blow on a tooth
• Excessive orthodontic pressure
• Bruxism
CAUSES OF PERIODONTAL ABSCESS- AS A
CONSEQUENCE OF PULPAL DISEASE

• Where a periapical lesion spreads up the lateral surface of a tooth

• Where lateral pulp canals link with the periodontal ligament. This is
especially common in the furcation.
• Perforation of the lateral wall of the tooth during endodontics.
CAUSES OF PERIODONTAL ABSCESS- ALTERED HOST
RESPONSE AS IN DIABETES.

Diabetes has sometimes been diagnosed following the appearance of multiple

periodontal abscesses.
IMPORTANT FACT REG:
PERIODONTAL ABSCESS
• The main direct cause of a lateral abscess is bacterial invasion of the soft
tissue wall of the pocket and multiplication therein.
• This leads to an acute inflammatory response with the formation of pus.
CLINICAL FEATURES

• The onset of symptoms can be sudden with pain on biting and a deep
throbbing pain.
• The involved tooth may feel high and mobile.
• The overlying gingiva becomes red , swollen and tender but at first there is
no fluctuation or discharge of pus.
• There may be enlargement of the associated lymph glands.
HOW PERIODONTAL ABSCESS
PROGRESSES FURTHER
• The next stage is characterized by the presence of the pus.
• This may discharge into a periodontal pocket when the symptoms reduce, or the
pus may track through the bone to form an abscess under alveolar
mucoperiosteum.
• Once the pus enters the soft tissue the severe pain diminishes and the abscess
appears red ,shiny and very tender swelling over the alveolus.
• The abscess usually points and discharges but if this does not happen the
inflammation may spread into the surrounding connective tissue to produce
cellulitis.
SEQUALAE TO CELLULITIS

• This occurs mostly if the patient's resistance is low.

• If the abscess is on the upper jaw , depending upon the tooth involved, the
lip , cheek, side of the nose or the infra-orbital area and lower eyelid may
swell.
• Infection in the vicinity of the infraorbital region is dangerous.
• If the abscess is in the lower jaw , the lower lip, chin, angle of the mandible
and neck may swell.
• If infection involves the lower third molar there may also be trismus and
difficulty in swallowing.
• At this stage the patient is obviously unwell, in pain and distressed and his
temperature may be elevated.
DIFFERENTIAL DIAGNOSIS

• These clinical features can be produced by both periapical and periodontal

abscesses and a differential diagnosis must be made because the treatment
modalities for the two forms of abscess are different.
FEATURES CONSIDERED:

1. The position of the abscess swelling . If this is over the root apex it is more
likely periapical.
2. The presence of the periodontal disease with the pocketing and bone
destruction makes it more likely for the abscess to be of periodontal origin.
3. If the involved tooth is heavily filled it is likely that pulp pathology is there.
4. If the tooth is non-vital the abscess could be mostly periapical in origin.
Pulp vitality tests can be extremely misleading but if the tooth gives a normal
reading this points to periodontal infection.
If the tooth is caries free and unfilled the abscess is likely to be periodontal.
• Radiographs taken in the earliest stages provide little information but once
the lesion is established can be identified.
• A radiograph taken with gutta-percha point inserted gently into the
suspected pocket can help to define the origin of the abscess.
BACTERIOLOGY OF THE LATERAL
PERIODONTAL ABSCESS
• The microflora of the lateral periodontal abscess resembles that of the
periodontal pocket.
• It a complex mixture of gram-positive and gram negative cocci and rods,
filaments , motile rods and spirochaetes which are either facultative or
totally anaerobic.
• The predominating species are P.gingivalis, P.melanogenica, Prevotella
intermedia, T. forsynthentia, C.rectus.
 TREATMENT OPTIONS FOR
PERIODONTAL ABSCESS
1. Drainage through pocket retraction or incision
2. Scaling and root planing
3. Periodontal surgery
4. Systemic antibiotics
5. Tooth removal

Modified from Sanz M, Herrera D, van Winkelhoff AJ: The periodontal abscess. In Lindhe J, editor: Clinical periodontology, Copenhagen, 2000, Munksgaard.
INDICATIONS FOR ANTIBIOTIC THERAPY IN PATIENTS
WITH ACUTE ABSCESS

1. Cellulitis (nonlocalized, spreading infection)

2. Deep, inaccessible pocket
3. Fever
4. Regional lymphadenopathy
5. Immunocompromised status
 ANTIBIOTIC OPTIONS FOR PERIODONTAL
INFECTIONS

Antibiotic of Choice

• Amoxicillin, 500 mg

• 1.0-g loading dose, 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, then 300 mg four times a day for 3 days

• Azithromycin (or Clarithromycin)- 1.0-g loading dose, then 500 mg four

times a day for 3 days

American Academy of Periodontology: Position paper: systemic antibiotics in periodontics. J Periodontol 67:1553, 2004.
TREATMENT

• Depends on the stage of abscess development , the amount of bone

and whether pulpal pathology is also involved.
• Treatment of the periodontal abscess includes two phases:
resolving the acute lesion, then managing the resulting chronic
condition.
• The initials aims of treatment are relief of pain and control of
infection by drainage.
• Once this has been achieved the residual lesion must be treated.
• If the prognosis of the teeth is poor, then it should be extracted .
SPECIFIC TREATMENT APPROACHES-
ACUTE ABSCESS

• The acute abscess is treated to alleviate symptoms, control

the spread of infection, and establish drainage.
• Before treatment, the patient’s medical history, dental
history, and systemic condition are reviewed and evaluated
to assist in the diagnosis and determine the need for
systemic antibiotics
DRAINAGE THROUGH THE PERIODONTAL POCKET

• The peripheral area around the abscess is anesthetized with

sufficient topical and local anesthetic agents to ensure
comfort.
• The pocket wall is gently retracted with a periodontal
probe or curette to initiate drainage through the pocket
entrance
• Gentle digital pressure and irrigation may be used to
express the exudate and drain the pocke
IF LESION IS LARGE -

• 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 such patients, use of adjunctive systemic antibiotics with
a short-term high-dose regimen is .Antibiotic therapy alone
without subsequent drainage and subgingival scaling is
contraindicated.
DRAINAGE THROUGH AN EXTERNAL INCISION

• To drain the abscess, the lesion is dried and isolated with gauze
sponges.
• A topical anesthetic agent is applied, followed by a local anesthetic
agent injected peripheral to the lesion.
• A vertical incision through the most fluctuant center of the abscess is
made with a no. 15 surgical blade.
• The tissue lateral to the incision can be separated with a curette or
periosteal elevator.
• The fluctuant matter is expressed, and the wound edges are
approximated under light digital pressure with a moist gauze pad.
DRAINAGE THROUGH AN EXTERNAL
INCISION-CONTD..

• In abscesses manifesting with severe swelling and inflammation,

aggressive mechanical instrumentation should be delayed in favor of
antibiotic therapy to avoid damage to healthy contiguous periodontal
tissues.
• Once bleeding and suppuration have ceased, the patient may be
dismissed.
• For patients who do not need systemic antibiotics, posttreatment
instructions include frequent rinsing with warm salt water (1 tbsp/8-
oz glass) and periodic application of chlorhexidine gluconate 0.12%
oral rinse either by rinsing or applied locally with a cotton-tipped
applicator.
DRAINAGE THROUGH AN EXTERNAL
INCISION-CONTD..

• Reduced physical exertion and increased fluid intake are often

recommended for patients showing systemic involvement.

• Analgesics may be prescribed for comfort.

• By the following day, the signs and symptoms have usually subsided. If the
problem continues and the patient is still uncomfortable, the previously
recommended regimen is repeated for an additional 24 hours.

• This often results in satisfactory healing, and the lesion can be treated as a
chronic abscess
SPECIFIC TREATMENT APPROACHES-
CHRONIC ABSCESS

• As with a periodontal pocket, the chronic abscess is usually treated

with scaling and root planing and, if indicated, surgical therapy .
• Surgical treatment is suggested when deep vertical pocket or
furcation defects are encountered that are beyond the therapeutic
capabilities of nonsurgical instrumentation.
• Access to subgingival calculus must be achieved in areas of deep
pockets.
• The patient should be advised of the possible postoperative sequelae
usually associated with periodontal nonsurgical and surgical
procedures.
• As with the acute abscess, antibiotic therapy may be indicated
A) Chronic periodontal abscess of a maxillary right canine. (B) With local anesthesia, periodontal probe is inserted to determine severity of the lesion.
(C) With mesial and distal vertical incisions, a full-thickness flap is elevated, exposing severe bone dehiscence, a subgingival restoration, and root
calculus. (D) Root surface has been planed free of calculus, and the restoration has been smoothed. (E) Full-thickness flap has been replaced to its
original position and sutured with absorbable sutures. (F) At 3 months, gingival tissues are pink, firm, and well adapted to the tooth, with minimal
periodontal probing depth.
GINGIVAL ABSCESS-
MANAGEMENT
• Treatment of the gingival abscess is aimed at reversal of the acute
phase and, when applicable, immediate removal of the cause.
• To ensure comfort, topical or local anesthesia by infiltration is
administered.
• When possible, scaling and root planing are completed to establish
drainage and remove microbial deposits.
• In more acute situations, the fluctuant area is incised with a no. 15
scalpel blade, and exudate may be expressed by gentle digital 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
GINGIVAL ABSCESS-MANAGEMENT
CONTD..

• 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.
• If the residual lesion is large or poorly accessible, surgical
access may be required.
PERICORONAL ABSCESS-
MANAGEMENT
• 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, and drainage is established by gently lifting the soft
tissue operculum with a curette.
• If the underlying debris is easily accessible, it may be removed,
followed by gentle irrigation with sterile saline.
• If the patient has regional swelling, lymphadenopathy, or
systemic signs, systemic antibiotics may be prescribed
PERICORONAL ABSCESS-MANAGEMENT
CONTD…

• 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 used.

• 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.
THE COMBINED PERIODONTAL –
PERIAPICAL LESION
• The combined lesion can develop in number of ways:
1. Where the apical lesion has spread laterally to create a periodontal lesion or united with
pre-existing lateral lesion.
2. Where pulp infection has spread via accessory canal into the periodontal tissues. This is
more frequent in the furcation where accessory canals are common.
3. Where a periodontal lesion extends close to the tooth apex and causes secondary pulpal
infection.

At one time , the presence of a combined periapical-periodontal lesion justified extraction,

especially occurring in a furcation. today, endodontics has achieved high level of success and
predictability and the prognosis for the tooth involved in the combined lesion can be good.
TREATMENT

• Once the acute inflammation has been controlled and the occlusion adjusted
, root canal treatment should be initiated.
• A lateral compression technique is necessary to occlude accessory canals
and when endodontics has been satisfactorily completed periodontal
surgery can be carried out.
THANK
YOU