Periodontal abscess

Periodontal abscess is a localised purulent infection in the tissues adjacent to the periodontal pocket that may lead to the destruction of the periodontal ligament and alveolar bone. Periodontal abscess is the third most prevalent emergency infection after acute alveolar abscess and pericoronitis. It could lead to complications due to bacteremia that may cause infection at distant locations. Proper management of the abscess is crucial to alleviate pain, establish drainage and control the spread of infection.

1. PERIODONTAL ABSCESS DR.SHRADDHA KODE

2. Abscess can be defined as the localised collection of purulent material collected in a cavity caused by destruction of tissues DEFINITION: Periodontal abscess is a localised purulent infection in the tissues adjacent to periodontal pocket that may lead to the destruction of periodontal ligament and alveolar bone.

3. It is also called as the lateral periodontal abscess or parietal abscess Periodontal abscess is the third most prevalent emergency infection after acute alveolar abscess (14-25%) and pericoronitis (10-11%)

4. Formed as a result of rapidly growing bacteria within a periodontal pocket leading to abscess formation Periodontal abscess can lead to complications due to bacteremia that may cause infection in distant location

5. Based on the location: Gingival Abscess – Localized painful swelling affecting only the marginal and interdental gingiva . Occurs due to impaction of foreign objects Periodontal Abscess – Usually affects deeper periodontal structures including deep pockets, furcations and vertical osseous defects Pericoronal abscess – Inflammation of the soft tissue associated with the crown of partially erupted tooth CLASSIFICATION:

6. Based on the course of the lesion: Acute periodontal abscess – sudden onset of pain on biting and deep throbbing pain , gingiva appears red, swollen and tender , as the disease progresses – pus discharge from gingival crevice, lymph node enlargement Chronic periodontal abscess – Infection is of prolonged duration and abscess develops slowly, involved tooth – mobile and tender , pus discharge or sinus in the overlying mucosa, pain of low intensity

7. Based on the number: Single periodontal abscess – associated with local factors – plaque, calculus, anatomic factors Multiple periodontal abscess – Associated with uncontrolled diabetes mellitus, medically compromised patients, in patients with untreated periodontitis after systemic antibiotic therapy

8. Based on the cause: Periodontitis related abscess - Results when the acute infection originates from biofilm present in a deepened periodontal pocket Non-periodontitis related abscess - Results when the acute infection originates from other local source like foreign body impaction or alteration in root integrity

9. IMPORTANT TO REMEMBER PERIODONTAL ABSCESS PERIAPICAL ABSCESS Associated with pre-existing periodontal pockets Associated with deep restoration, caries or tooth wear Pulp test - Vital Pulp test – Non-vital Localised swelling on the lateral aspect of the tooth Localised swelling in the apical area

10. IMPORTANT TO REMEMBER PERIODONTAL ABSCESS GINGIVAL ABSCESS Involves supporting periodontal structures Confined to interdental or marginal gingiva Radiograph – bone loss Acute inflammatory response to the forcing of foreign material into the gingiva. No bone loss

11. Association with tortuous pockets, cul-de-sac which eventually become isolated - represents a period of active bone destruction The marginal closure of the periodontal pocket may lead to an extension of the infection into the surrounding periodontal tissues due to the pressure of the suppuration inside the closed pocket CAUSE:

12. Changes in the composition of the microflora, bacterial virulence or in host defenses could also make the pocket lumen inefficient to drain the increased suppuration It may also occur as an acute exacerbation of an untreated periodontitis, during periodontal therapy, in refractory periodontitis cases or d uring periodontal maintenance

13. Post-scaling periodontal abscess – dislodegement of calculus or inadequate scaling Post-surgery abscess – incomplete removal of subgingival calculus or presence of foreign substance ex.sutures , periodontal dressing Post-antibiotic abscess – systemic antibiotics without subgingival debridement may cause an abscess due to change in the subgingival microbiota leading to superinfection and massive inflammation

14. Impaction of foreign bodies – piece of dental floss, popcorn kernel, fishbone, toothpick Perforation of the tooth wall by an endodontic instrument Infection of lateral cysts WHAT CAN BE THE OTHER CAUSES?

15. Bacterial entry – first event to initiate periodontal abscess Inflammatory cells are then attracted by the chemotactic factors released by the bacteria The concomitant inflammatory reaction leads to destruction of the connective tissues, the encapsulation of the bacterial infection and the production of pus PATHOGENESIS:

16. most frequent type of bacteria were gram-negative anaerobic rods and gram-positive facultative cocci

17. Throbbing pain in acute periodontal abscess and dull gnawing pain in chronic Edema and redness Involved tooth – sensitive to lateral percussion Increased mobility Increased probing depth CLINICAL FEATURES:

18. Suppuration – spontaneous or on putting lateral pressure Draining sinus Radiographic – bone loss in chronic cases Systemic involvement – fever malaise, lymph node enlargement

19. The purpose for the treatment of acute periodontal abscess : Alleviate pain, establish drainage and to control the spread of infection Protocol: Incision and drainage – Closed and open approach Scaling and root planing Debridement of soft tissue wall Antibiotics Last resort : Extraction TREATMENT:

20. a For the closed approach: Anesthesia Flat instrument /probe – carefully introduce into the pocket Distend the pocket wall for drainage Further drain and gently curettage the mass of tissue internally

21. For the open approach: Stab incision through the most fluctuant part of the swelling , extending to an area just apical to the abscess Curette the granulomatous tissue internally External aspect of the abscess is gently pushed to drain the remaining pus I rrigation Approximate to wound margin

22. The purpose for the treatment of chronic periodontal abscess : To eliminate the remaining calculus and to establish drainage Mainly where the resolution can be achieved only by surgical means (vertical bone loss and deep pockets) Gingivectomy Periodontal flap procedures

23. For the treatment of gingival abscess : Elimination of the foreign object through careful debridement Drainage through the sulcus with a probe or light scaling For the treatment of pericoronal abscess : Debridement of plaque and food debris under the pericoronal flap Establish drainage Irrigation using Povidone iodine solution Acute phase controlled: Decision regarding operculectomy or extraction

24. Periodontal abscess is a relatively common condition in patients with moderate to deep pockets Important to differentiate periodontal abscess from periapical and gingival abscess Important to treat the underlying cause for multiple abscesses Drainage of the abscess and removal of the underlying cause is required to ensure healing CONCLUSION: