• Periodontal abscesses (PA) are important because they represent common

dental emergencies requiring immediate management and can result in

rapid destruction of the periodontium with a negative impact on the
prognosis of the affected tooth.
• In certain circumstances, PA may have severe systemic consequences.
• Although the prevalence of necrotizing periodontal diseases (NPD) is low,
their importance is clear, because they represent the most severe conditions
associated with dental biofilm, leading to very rapid tissue destruction.
• Whereas, endo‐periodontal lesions (EPL), in spite of being relatively rare in
clinical practice, might severely compromise the prognosis of the tooth, and
are considered one of the most challenging problem faced by clinicians,
because they require multidisciplinary evaluation, diagnosis, and treatment.
Abscesses in the Periodontium

one of the main

reasons patients seek emergency
care in the dental clinic.
Classification of Abscesses

classified into three diagnostic

groups
The gingival abscess The periodontal The pericoronal
abscess abscess

involves the marginal is an infection located is associated with the

gingival and contiguous to the crown of a partially
interdental tissues. periodontal pocket erupted tooth
and may result in
destruction of the
periodontal ligament
and alveolar bone.
 Classification of Abscesses
based on aetiology.
1. Periodontitis‐related abscess: the acute
infection
originates from bacteria present at the subgingival
biofilm in a deepened periodontal pocket

2. Non‐periodontitis‐related abscess: the acute

infection originates from bacteria coming from
another local source, such as a foreign body
impaction, or from alterations of the integrity of
the root leading to bacterial colonization.
Periodontal Abscess
 Periodontal Abscess

Localized purulent inflammation present in the

periodontal tissues .
Causes pain and swelling, and, depending on the
origin of the infection, they can be associated with
different symptoms.
Most periodontal abscesses are due to
the incomplete removal of subgingival
calculus in a periodontal pocket.
 Different pathogenic mechanisms can lead to abscess
formation in the periodontium:

In a periodontitis patient :
• Exacerbation of a chronic lesion.
may develop in a deepened periodontal pocket
without any obvious external influence, and may
occur in
– (1) an untreated periodontitis patient or
– (2) as a recurrent infection during supportive
periodontal therapy
 In a periodontitis patient :
• Post‐therapy periodontal abscesses.
– Post‐scaling periodontal abscess :dislodged calculus
fragments could be pushed into the tissues, or
inadequate scaling could allow calculus to remain in deep
pocket areas, whereas the coronal part would occlude
the normal drainage.
– Post‐surgery periodontal often the result of incomplete
removal of subgingival calculus or the presence of foreign
bodies such as membranes for regeneration or sutures.
– Post‐antibiotic periodontal abscess : without subgingival
debridement,  probably related to an overgrowth of
opportunistic bacteria.
Non–periodontitis‐related abscess formation

• A foreign body impacted in the gingival sulcus or

Periodontal pocket
 Oral hygiene devices (toothbrush, tooth picks, etc.),
 Orthodontic appliances,
 Food particles,
 Pieces of nail in subjects with nail‐biting habits
• Anatomic factors affecting the root morphology:
– Invaginated roots
– External root resorption,
– Iatrogenic endodontic perforations
 Poorly controlled diabetes mellitus has been
considered a predisposing factor for periodontal
abscess formation
Smoking is a risk factor for periodontal abscesses
 Pathogenesis
• The lesion contains : bacteria,
bacterial products, inflammatory
cells, tissue breakdown products,
and serum.
• The precise pathogenesis of this
Lesion is still obscure.

• Hypothesis: occlusion of the

periodontal pocket lumen, due to
trauma or tissue tightening,
– prevent proper drainage,
– extension of the infection from the
pocket into the soft tissues of the
pocket wall,
– formation of the abscess.
 Pathogenesis
• Accumulation of leukocytes and the formation of an acute
inflammatory infiltrate =>
– The connective tissue destruction,
– Encapsulation of the bacterial mass,
– Formation of pus.
• Secretion of extracellular enzymes and inflammatory
mediators, such as catabolic cytokines, is the main cause of
connective tissue destruction.
• The bacterial load and virulence, together with the tissue
resistance, will determine the course of this acute
inflammatory process.
 MICROBIOLOGY
• Does not differ from the microbiota of chronic periodontitis
lesions.
• This microflora is polymicrobial and dominated by non‐motile,
gram‐negative,
• Strict anaerobic, rod‐shaped species.
• Among these bacteria, porphyromonas gingivalis is probably the
most virulent and relevant microorganism.
 Diagnosis
• The diagnosis of a periodontal abscess should
be based on the overall evaluation and
interpretation of
• the patient’s symptomatology,
++
– the clinical
– and radiologic signs found during the oral
examination
 Clinical findings
The presence of an Abscesses located Suppuration either
ovoid elevation in deep may be more through a fistula or,
the periodontal difficult to identify as most commonly,
tissues along the they may manifest through the pocket
lateral side of the as a diffuse swelling opening
root or simply a red area
 The clinical symptomatology usually
includes

• Pain (from light discomfort to severe pain),

• Tenderness of the gingiva,
• Swelling, and
• Sensitivity to percussion of the affected
tooth. Other related symptoms are:
– Tooth elevation
– Increased tooth mobility
 Periodontal examination
• The abscess is usually
found at a site with a
deep periodontal
pocket.
• Signs associated with
periodontitis :
– Bleeding on probing,
– Suppuration, and
– Sometimes increased
tooth mobility.
 Radiographic examination
• May either reveal :
• A normal appearance of the interdental bone or
• Evident bone loss, ranging from just a widening of
the periodontal ligament space to pronounced
bone loss involving most of the affected root.
 Periodontal abscesses
Acute Abscess
• Mild to severe discomfort
• 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
 The acute abscess is often an exacerbation
of a chronic nflammatory periodontal
lesion. Influencing factors include :
Increased number and virulence of bacteria
combined with
lowered tissue resistance
and lack of spontaneous drainage.
Differential diagnosis
 Periodontal Abscess
• Associated with a preexisting
periodontal pocket.
• Radiographs show periodontal
angular bone loss and furcation
radiolucency.
• Tests show vital pulp.
Pulpal Abscess
• Swelling usually includes gingival • The offending tooth may have
tissue, with an occasional fistula. large restoration.
• Pain is usually dull and localized. • The tooth may have no
• Sensitivity to percussion may or periodontal pocket or, if present,
may not be present. it probes as a narrow defect.
• Tests show nonvital pulp.
• Swelling is often localized to the
apex, with a fistulous tract.
• Pain is often severe and difficult
to localize.
• Sensitivity to percussion is noted.
The principal differences are location and history

Gingival Abscess Periodontal Abscess

• The gingival abscess is
confined to the marginal
gingiva, and it often
• occurs in previously disease-
free areas.
• It is usually an acute
inlammatory response to
the forcing of foreign
material into the gingiva.
• The periodontal abscess
involves the supporting
periodontal structures,
• and it generally occurs
during the course of chronic
destructive periodontitis
 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
Specific Treatment Approaches

Treatment of the periodontal abscess includes two

phases:
• Resolving the acute lesion,
• Then managing the resulting chronic condition.
 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
anaesthetic agents 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 may be used
to express the exudate and drain the pocket .
• If the lesion is minimal and access is uncomplicated,
debridement in the form of scaling and root planing
may be undertaken at this appointment.
• If the lesion is large and
drainage cannot be
established, root
debridement should be
delayed.
• use of adjunctive systemic
antibiotic with a short-term
high-dose regimen is
recommended with those
patients.
 Antibiotic therapy alone without subsequent
drainage and subgingival scaling is contraindicated.
 • To drain the abscess, the lesion is
Drainage dried and isolated with gauze
sponges.
• A topical anaesthetic agent is
Through an applied, followed by a local
anaesthetic agent injected
External Incision •
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.
• In abscesses manifesting with severe
swelling and inlammation,
aggressive mechanical
instrumentation should be delayed
in favour of antibiotic therapy to
avoid damage to healthy contiguous
periodontal tissues.
• Once bleeding and suppuration have
ceased, the patient may be
dismissed.
 Drainage Through an External Incision

• For patients who do not need systemic antibiotics, post

treatment 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.
• 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.
 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 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.

• As with the acute abscess, antibiotic therapy may be

indicated
Periodontal abscesses have been suggested as the
main cause for tooth extraction during the phase
of Supportive Peridontal Therapy
 Antibiotics ??
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
• Revaluation 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)a
• 1.0-g loading dose, then 500 mg four times
a day for 3 days
 New classification
The 1999 classification for abscesses in the periodontium included
gingival, periodontal, pericoronal, and periapical abscesses. Relevant
problems associated with this classification system included:
(1) the differentiation between gingival and PA, which could be confusing,
because this differentiation was simultaneously based on location and
etiology;
(2) considering a PA as chronic or acute may not be adequate, because an
abscess, by definition, is an acute lesion; and
(3) the inclusion of pericoronitis and periapical abscesses in the
classification together with PA might not be appropriate.
Pericoronal abscesses were included in the 1999 classification, but no
solid scientific basis for this was found in the article associated with the
topic.