periodontal abscess

PERIODONTAL  ABSCESS : A REVIEW

• PUNIT VAIBHAV PATEL,SHEETAL KUMAR,AMRITA PATEL

• JCDR – JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH

• YEAR: 2011 |MONTH: April|Volume :5 | Issue: 2 

• By-

• Navneet Singh Randhawa

• MDS 1

st

year-

• Deptt.of Periodontology and Oral Implantology

 Dr . Hussein al dabbagh

INTRODUCTION

• Among several acute conditions occuring in the 

periodontium,the abscess is the most important.

• Abscesses of the periodontium are localised 

acute baterial infections confined to tissues of the 
periodontium.

• The Periodontal abscess represents a chronic and 

refractory form of the disease.

• It is a  destructive process resulting in localized 

collection of pus,communicating with oral cavity 
predominantly through gingival sulcus

CHARACTERISTICS

• Localised accumulation of pus in gingival wall 

of periodontal pockets

• Usually occuring on the lateral aspect of the 

tooth

• Oedematous red and shiny gingiva
• Dome like appearance or may come to a 

distinct point

PREVALENCE

• Prevalence of periodontal abscess is relatively 

high

• Accounts for 6-14% of all emergencies
• It is the 3d most common dental emergency 

after pulpal infection and pericoronitis

• Among dental emergencies periodontal 

abscesses represent appr. 8% of all dental 
emergencies in the world

CLASSIFCATION

3 types of classifications :-

--Based on anatomic locations
--Based on course of disease
--Based on number

• Based on anatomic locations 

:-

Gingival abscess which is a localised purulent 

infection involving marginal gngiva

Pericoronal abscesses
Combined perio/endo abscesses
Parietal abscesses

• Based on course of disease

Acute periodontal abscess
Chronic periodontal absce

• Based on number

Single abscess - confined to a single tooth
Multiple abscess – Abscess confined to more 

than one tooth

MICROBIOLOGY

• Micro organisms colonizing periodontal abscesses 

are primarily Gram negative anaerobic  rods

• Porphyromonas gingivalis has highest prevalence 

present in about 55-100% of cases

• Fusobacterium nucleatum comes next with 

presence in 44-65%

• Capylobacter rectus ,another common bacteria, 

has a prevalence rate of about 36%

• Prevotella intermedia,Prevotella melaninogenica

have a prevalence rate of 25-100% and 22-30% 

respectively

PATHOGENESIS

The sequelae of periodontal abscess is as 

follows:-

Infiltration of pathogenic bacteria

Initiation of inflammatory response

Tissue destruction cased by inflammatory cells

• Formation of inflammatory infiltrate

• Destruction of connective tissue

• Encapsulation of bacterial mass and pus 

formation

• Entry of bacteria into soft tissue wall initiates 

periodontal abscess formation

PREDISPOSING FACTORS

• Changes in composition of microflora,bacterial

virulence and host defence

• Closure of the margins of periodontal pockets can lead 

to extension of infection in  surrounding tissue 

• Fibrin secretions lead to local accumulation of pus
• Tortuous periodontal pockets assoiated with furcation

defects become isolated and favour the formation of 
periodontal abscess

• Inadequate scaling allows calculus to remain in deep 

pockets,resolution occurs in coronal portion which 
subsequentely blocks drainage

In absence of periodontitis periodontal 

abscess can develop due to:-

Impaction
Infection of lateral cysts
Local factors affecting the morphology of 

root

IATROGENIC FACTORS ASSOSIATED 

WITH PERIDONTAL ABSCESS

• Post non surgical periodontal abscess can occur due to 

presence of small remaining fragment of calculus 

which obstructs pocket entrance

• Post surgical periodontal abscess occurs immediately 

following periodontal surgery

• It can be due to:-

 Incomplete removal of subgingival calculus
 Perforation of tooth wall by endodontic instrument
 Presence of foreign body in periodontal tissue
 Post antibiotic periodontal abscess
 Treatment with systemic antibiotics without subgingival

debridement in patients with advanced periodontitis

DIAGNOSIS 

• The diagnosis of periodontal abscess is based 

on the chief complaint and the history of 
presenting illness

• Points to be noted while taking history are:-

Any medical condition
Whether patient is currently on medication or not
Any previous dental treatment
Smoking history 

• The main steps and aids in diagnosis are:-

• GENERAL EXAMINATION

– Examination of features that may indicate on going 

systemic diseases, immune status, fatigue, extremes of age 

etc

• EXTRA ORAL EXAMINATION

– Includes evaluation of symmetry of face for swelling, 

redness, fluctuance, sinus, trismus and examination of 

cervical lymph nodes

• INTRA ORAL EXAMINATION

– Examination of the oral mucosa and dentition for gingival 

swelling, redness and tenderness, checking for 

suppuration, checking for mobility and elevation, 

evaluation of oral hygiene and examination of 

periodontium including periodontal screening

• Supplemental diagnostic aids are:-

RADIOGRAPHS
PULP VIALITY TESTS
MICROBIAL TESTS
LAB FINDINGS

• RADIOGRAPHS

– Radiographical techniques such as IOPA,BITEWIGS,OPG are 

useful in detection of level of crestal bone,marginal bone loss 
and periapical condition of tooth involved

• PULP VITALTY TEST

– Thermal tests or electrical tests are used to assess the viality

of tooth and the subsequent ruling out of the pulpal
infections

• MICROBIAL TESTS

– Samples of pus from sinus/abscess expressed from 

gingival sulcus could be sent for culture and senstivity

tests.

• LAB FINDINGS

– Lab  tests such as TLC,DLC whose elevated levels can 

be an indication of inflammatory response of body to 

bacterial toxins

– Assesment of blood glucose level  through HbA1c 

test/random blood glucose test/fasting blood glucose 

levels is mandatory in diabetic patients as it can 

predispose to abscess formation

TREATMENT

• Principles for the management of simple dental 

infections are:-

• LOCAL MEASURES:-

Drainage
Maintain drainage
Eliminate cause

• SYSTEMIC MANAGEMENT IN 3 STAGES

Immediate management
Initial management
Definitive therapy

IMMEDIATE MANAGEMENT

• Advocated in life threatening infections which 

lead to space infections of orofacial regions

• Hospitalization with supportive therapy plus 

systemic antibiotics is recommended

• In non life threatening infections oral 

analgesics and antimicrobial chemotherapy  
are sufficient 

• Dosage of antibiotics depends on severity of 

infection

• Common antibiotics used are:-
1. Phenoxymethylpenicillin 250-500mg qid 5/7
2. Amoxycillin 250-500 mg tds 5-7 days
3. Metronidazole 200-400 mg tds 5-7 days
• In case of allergy to pencilln:-
1. Erythromycin 250-500 mg qid 5-7 days
2. Doxycyline 100 mg bd 7-14 days
3. Clindamycin 150-300 mg qid 5-7 days

INITIAL THERAPY

• It comprises of:-
1) Irrigation of abscessed pocket with saline
2) Removal of foreign bodies if present
3) Drainage through sulcus with a probe
4) Compression and debridement of soft tissue
5) Oral hygiene instructions
6) Review after 24-48 hrs 

• Drainage through periodontal pocket
Treatment of choice if no other complication
Steps are:-

Topical/local anaesthesia
Retraction of pocket wall with probe/curette
Gentle digital pressure
If lesion is small and has good access then treatment 

modality Scaling + Curettage

If lesion is large and drainage cannot be established 

then treatment modality Antibiotic therapy +Scaling + 

Curettage  

• Drainage through an external incision:-

• If lesion is large,pin pointing and fluctuating,an

external incision can be made to drain the abscess

• The steps are as follows:-

 Topical/local anaesthesia
 Vertical incision placed with #11 or #15 blade
 The tissue lateral to incision is separated with a periosteal

elevator 

 Digital pressure applied with gauze
 In patients with marked swelling tension and pain systemic  

antibiotics only should be used  as initial treatment

 After  acute condition has receded mechanical 

debridement is performed

• Periodontal surgery:-

• Main objective of surgical therapy is to 

eliminate remaining calculus and to obtain 
drainage

• Surgical therapy is advocated in cases of:-

Deep vertical defects
When calculus is left subgingivally after treatment

• Systemic antibiotics with or without local 

drainage

• Antibiotics are the prefferred mode of treatment
• Local drainge of abscess is mandatory to eliminate etiological factors

•

Recommended antibiotic regimen is as follows:-

1. Phenoxymethylpenicillin 250-500mg qid 5/7
2. Amoxycillin 250-500 mg tds 5-7 days
3. Metronidazole 200-400 mg tds 5-7 days

•

In case of allergy to pencilln:-

1. Erythromycin 250-500 mg qid 5-7 days
2. Doxycyline 100 mg bd 7-14 days
3. Clindamycin 150-300 mg qid 5-7 days

• Extraction of teeth

• Extraction of teeth/tooth is the last resort to treat 

the periodontal abscess

• Certain guidelines for assessing poor prognosis 

before extracting tooth are:-

a) Horizontal mobility more than 1mm
b) Class 2-3 furcation involvement of a molar
c) Probing depth >8 mm
d) Poor response to therapy
e) More than 40% alveolar bone loss

CONCLUSION

• Early diagnosis and appropiate intervention 

are extremely important for the management 
of periodontal abscess

• A single tooth diagnosed with periodontal 

abscess that responds favourably to treatment 
will not affect longevity of tooth

• Decision to extract a tooth should be taken 

only after through clinical assessment