Treatment of Gingival /

Periodontal Abscess
RESKY RAMADHANI

J035 212 004

OM
SLIDESMANIA.C

LECTURE : PROF.DR.DRG. SRI OKTAWATI,

SP.PERIO (K)
 The periodontal abscess is a localized purulent
inflammation of the periodontal tissues
OM
SLIDESMANIA.C
 It has been classified into three diagnostic groups:

Gingival abscess, involves the marginal

gingival and interdental tissues

Periodontal abscess is an infection located contiguous to the

periodontal pocket and may result in destruction of the
periodontal ligament and alveolar bone.
OM
SLIDESMANIA.C

Pericoronal abscess is associated with the

crown of a partially erupted tooth
 PERIODO
NTAL - Typically found in patients with untreated periodontitis and
in association with moderate to deep periodontal pockets.

ABSCESS - Periodontal abscesses often arise as acute exacerbations of

preexisting pockets

Fig. 1. (A) Deep furcation invasions are common locations for the periodontal abscess. (B)
Furcation anatomy often prevents the definitive removal of calculus and microbial plaque.
OM
SLIDESMANIA.C

Source : Carranza 13th editions

 PERIODONTAL
- Poorly controlled diabetes
mellitus has been considered a
predisposing factor for

ABSCESS
periodontal abscess formation
• Fig.2 Primarily related to incomplete
calculus removal, periodontal
abscesses have been linked to several
clinical situations

• They have been identified in patients after

periodontal surgery, after preventive
maintenance, after systemic antibiotic
therapy and as the result of recurrent
Fig.2. Postprophylaxis periodontal abscess resulting from disease
partial healing of a periodontal pocket over residual calculus.

Fig 4. Localized periodontal abscess of a

Conditions in which
mandibular right canine in a male adult with
periodontal abscesses are not poorly controlled type 2 diabetes mellitus. For
related to inflammatory some patients, periodontal abscess formation
may be the first sign of the disease.
periodontal disease include
tooth perforation or fracture,
OM
SLIDESMANIA.C

foreign body impaction.

Fig. 3 (A) Fistula is observed in attached gingiva of a maxillary right
canine. (B) Elevated flap shows the cause to be a root fracture.
 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. Clinical features
include a red, smooth, sometimes painful, often fluctuant swelling

Fig.5. Plaque-associated gingival abscess of a mandibular right canine.

OM
SLIDESMANIA.C

Source : Carranza 13th editions

 Results from inflammation of the soft tissue operculum, which

Pericorona
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

l Abscess
microbial plaque biofilm, food impaction, or trauma
OM
SLIDESMANIA.C
 Acute Versus Chronic
Abscess
• The acute abscess is often an exacerbation of a chronic
inflammatory periodontal lesion
● The chronic abscess forms after the spreading
infection has been controlled by spontaneous
● Influencing factors include increased number and drainage, host response, or therapy.
virulence of bacteria combined with lowered tissue ● Once homeostasis between the host and infection
resistance and lack of spontaneous drainage. has been reached, the patient may have few or no
● The drainage may have been prevented by deep, tortuous
symptoms
pocket morphology, debris, or closely adapted pocket
● However, dull pain may be associated with the
epithelium blocking the pocket orifice.
● Acute abscesses are characterized by painful, red, clinical findings of a periodontal pocket,
edematous, smooth, and ovoid swelling of the gingival inflammation, and a fistulous trac.
tissues
● Exudate may be expressed with gentle pressure; the tooth
may be percussion sensitive and feel elevated in the socket
● Fever and regional lymphadenopathy are occasional
findings
OM
SLIDESMANIA.C
 Periodontal Versus
Pulpal Abscess
● Periodontal Abscess Associated with a preexisting
● Pulpal Abscess The offending tooth may have large
periodontal pocket.
restoration.
● Radiographs show periodontal angular bone loss and
● The tooth may have no periodontal pocket or, if
furcation radiolucency.
present, it probes as a narrow defect.
● Tests show vital pulp.
● Tests show nonvital pulp.
● Swelling usually includes gingival tissue, with an
● Swelling is often localized to the apex, with a
occasional fistula.
fistulous tract.
● Pain is usually dull and localized.
● Pain is often severe and difficult to localize.
● Sensitivity to percussion may or may not be present
Sensitivity to percussion is noted.
OM
SLIDESMANIA.C

FIG. 6 (A) Maxillary right first molar with fistula on the attached
gingiva. (B) With local anesthesia, periodontal probe is
introduced through the fistula and angled toward the root end. FIG. 7 (A) Periodontal abscess of maxillary left first
(C) Surgical flap elevation demonstrates failed endodontic molar. (B) Periodontal probe is used to retract the 2610
therapy and tooth fracture as causing the fistula.
pocket wall gently.
 Differential Diagnosis of
Periodontal and Pulpal Abscess
Pulpal Abscess
Periodontal Abscess
• Associated with a preexisting • The offending tooth may have large restoration.
periodontal pocket. • The tooth may have no periodontal pocket or, if
• Radiographs show periodontal present, it probes as a narrow defect.
angular bone loss and furcation • Tests show nonvital pulp.
radiolucency. • Swelling is often localized to the apex, with a
• Tests show vital pulp. fistulous tract.
• Swelling usually includes gingival • Pain is often severe and difficult to localize.
tissue, with an occasional fistula. • Sensitivity to percussion is noted
• Pain is usually dull and localized.
Sensitivity to percussion may or may
not be present.
OM
SLIDESMANIA.C
 Treatment for 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
OM
SLIDESMANIA.C
Indications for Antibiotic Therapy
in Patients With Acute Abscess:
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
1. Cellulitis (nonlocalized, spreading • Reevaluation after 3 days to determine need for continued or
infection) adjusted antibiotic therapy
Penicillin Allergy
2. Deep, inaccessible pocket
Clindamycin
3. Fever • 600-mg loading dose, then 300 mg four times a day for 3 days
4. Regional lymphadenopathy Azithromycin (or Clarithromycin) a
• 1.0-g loading dose, then 500 mg four times a day for 3 days
5. Immunocompromised status
To be used with caution in patients with high baseline cardiovascular
risk
 Treatment Options for Periodontal Abscess

Drainage Scaling and Periodontal Systemic .Tooth removal

through pocket root planing surgery antibiotics
retraction or
incision
OM
SLIDESMANIA.C
 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 2612 in an attempt to initiate drainage through the pocket
entrance (Fig.7)
• Gentle digital pressure and irrigation may be used to express the
exudate and drain the pocket. (Fig 8)
• If the lesion is minimal and access is uncomplicated, debridement in FIG. 7 (A) Periodontal abscess of maxillary left first molar. (B) Periodontal probe
the form of scaling and root planing may be undertaken at this is used to retract the pocket wall gently.
appointment.
• 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.
Fig 8. Gentle digital pressure may be
• In these patients, use of adjunctive systemic antibiotics with a sufficient to express purulent discharge.
shortterm high-dose regimen is recommended. Antibiotic therapy
OM
SLIDESMANIA.C

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.
• In abscesses manifesting with severe swelling and
inflammation, aggressive mechanical instrumentation should
be delayed in favor of antibiotic therapy to avoid damage to
OM
SLIDESMANIA.C
healthy contiguous periodontal tissues
― Irene M. Pepperberg
•
•
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.
• 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 vertical pocket or
furcation defects are encountered that are beyond the
therapeutic capabilities of nonsurgical instrumentation Fig. 9.
• 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

Fig.9. (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.
OM
SLIDESMANIA.C

(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
Treatment of the gingival abscess is aimed at reversal of
the acute phase and, when applicable, immediate
removal of the cause. ● Once bleeding has stopped, the patient is dismissed
• To ensure comfort, topical or local anesthesia by with instructions to rinse with warm salt water every
infiltration is administered. 2 hours for the remainder of the day.
• When possible, scaling and root planing are completed to
establish drainage and remove microbial deposits.
● After 24 hours, the area is reassessed, and if
• In more acute situations, the fluctuant area is incised with
a no. 15 scalpel blade, and exudate may be expressed resolution is sufficient, scaling not previously
by gentle digital pressure. completed is undertaken.
• Any foreign material (e.g., dental floss, impression
material) is removed. ● If the residual lesion is large or poorly accessible,
• The area is irrigated with warm water and covered with surgical access may be required.
OM
SLIDESMANIA.C

moist gauze under light pressure.

 Pericoronal
• Abscess
As with other abscesses of the periodontium,
treatment of the pericoronal abscess is aimed at • The patient is dismissed with instructions to rinse with
management of the acute phase, followed by warm salt water every 2 hours, and the area is
resolution of the chronic condition. reassessed after 24 hours.
• The acute pericoronal abscess is properly • If discomfort was one of the original complaints,
anesthetized for comfort, and drainage is
appropriate analgesics should be used.
established by gently lifting the soft tissue
operculum with a curette.
• Once the acute phase has been controlled, the partially
• If the underlying debris is easily accessible, it may erupted tooth may be definitively treated with either
be removed, followed by gentle irrigation with surgical excision of the overlying tissue or removal of
sterile saline. the offending tooth.
• If the patient has regional swelling,
lymphadenopathy, or systemic signs, systemic
OM
SLIDESMANIA.C

antibiotics may be prescribed.

 Thank
you!
Do you have any
questions?
hello@mail.com
555-111-222

¡Graci
mydomain.com
OM
SLIDESMANIA.C

as!