PERIODONTAL ABSCESS FINAL YEAR BDS PERIODONTICS

Periodontal Abscess final Year BDS

1. 1
ROYAL DENTAL COLLEGE
(Approved by Dental Council of India, affiliated to Kerala University of Health
Sciences)
(Promoted by Royal Education Foundation)
CHALISSERY, PALAKKAD (Dt.)


DEPARTMENT OF CLINICAL
PERIONDONTOLOGY AND
ORAL IMPLANTOLOGY
SEMINAR ON: ABSCESS OF
PERIODONTIUM
PRESENTED BY
ATHUL PAUL
3
rd
year

2. 2
C ONTENTS
Introduction
➤
Abscess of the periodontium
➤
Definition
Periodontal Abscess
Prevalence
Classification
Etiology
Clinical features
Pathogenesis and histopathology
Microbiology
Diagnosis
Treatment
Complications and postoperative care
➤ Gingival abscess
Pericoronal abscess
➤
➤ Periapical abscess
Conclusion
➤
References
➤

3. 3
INTRODUCTION
Abscess- Localised collection of pus purulent material
collected in a cavity caused by destruction of tissues. (GPT)
Abscesses of the periodontium have been classified
primarily, based on their anatomical locations in the
periodontal tissue. There are four types:
Gingival abscess
Pericoronal abscess
Periapical abscess
Periodontal abscess
Among all the abscesses of the periodontium, the
periodontal abscess is the most important one, which often
represents the chronic and refractory form of the disease.
It is a destructive process occurring in the periodontium,
resulting in localized collections of pus, communicating with

4. 4
the oral cavity through the gingival sulcus or other
periodontal sites and not arising from the tooth pulp.
PERIODONTAL ABSCESS
DEFINITION:
A localized purulent infection within the tissues adjacent to
the periodontal pocket that may lead to the destruction of
periodontal ligament and alveolar bone
It is typically found in patients with untreated periodontitis
and in association with moderate to deep periodontal
pockets

5. 5
CLASSIFICATION
1) Depending on the location of the abscess
Gingival Abscess : localized painful swelling affecting only
the marginal and interdental gingiva mainly due to impaction
of foreign objects. May be present on a previously healthy
gingiva
Periodontal Abscess - with similar symptoms, usually affect
deeper periodontal structures, including deep pockets,
furcations and vertical osseous defects.
2)Depending on the course of the lesion
Acute periodontal abscess : Presents with symptoms like
pain, tenderness, sensitivity to palpation and suppuration
upon gentle pressure.
Chronic periodontal abscess : Normally associated with a
sinus tract. Usually asymptomatic, can refer mild symptoms.
3)Depending on the number
➤ Single periodontal abscess : related to local factors, which
contribute to the closure of the drainage of a periodontal pocket.

➤
Multiple periodontal abscess :

6. 6
Seen in uncontrolled diabetes mellitus
Medically compromised patients
In patients with untreated periodontitis after systemic
antibiotic therapy for non-oral reasons.
4)According to periodontal tissue affected
Gingival abscess - in previously healthy sites and caused by
impaction of foreign bodies.
Periodontal abscess - either acute or chronic developing into
a periodontal pocket.
Pericoronal abscess - in incompletely erupted teeth.
5)According to periodontal tissue affected
Gingival abscess - in previously healthy sites and caused by
impaction of foreign bodies.
Periodontal abscess - either acute or chronic developing into
a periodontal pocket.
Pericoronal abscess - in incompletely erupted teeth.
6)Depending on the cause of acute infectious process

7. 7
Periodontitis related abscess : when the acute infection
originates from biofilm present in a deepened periodontal
pocket.
Non-periodontitis related abscess: - when the acute infection
originates from other local source, such as foreign body
impaction or alteration in root integrity

8. 8
PREVALENCE
3rd most prevalent emergency infection, after acute
alveolar (14-25%) and periodontitis (10-11%).
More likely to occur in a pre-existing periodontal pocket.
More in molar sites (> 50%)
In periodontitis patients before and during periodontal
treatment
In periodontitis patients during periodontal maintenance.
16 out of the 27 abscess sites had an initial probing
pocket depth greater than 6 mm, and in about 8 sites the
periodontal probing depth was 5-6 mm.

9. 9
ETIOLOGY
Periodontal abscesses have been either directly associated
to periodontitis or to sites without the prior existence of a
periodontal pocket.
1.Periodontal abscesses in periodontitis
In periodontitis, periodontal abscess represents a period
of active bone destruction (exacerbation).
The existence of tortuous pockets, with cul-de-sac, which
eventually become isolated, may favor the formation of
abscesses.
The marginal closure of a 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.
The fibrin secretions leading to the local accumulation of
pus may favor the closure of the gingival margin to the
tooth surface.
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.

10. 10
The development of a periodontal abscess in periodontitis
may occur at different stages during the course of the
infection:
As an acute exacerbation of an untreated periodontitis.
During periodontal therapy
In refractory periodontitis or during periodontal maintenance.
Different mechanisms behind formation are :
A. Exacerbation of chronic lesions:
Occur without any obvious external influences.
B.Post therapy periodontal abscess
Post scaling periodontal abscess-occur immediately after
scaling or routine prophylaxis
Due to inadequate scaling which will allow calculus to
remain in the deepest pocket area

11. 11
While the resolution of the inflammation at the coronal
pocket area will occlude the normal drainage and then
cause the abscess formation.
When the periodontal abscess occurs immediately after
scaling or after a routine prophylaxis, it has been related
to the dislodging of calculus fragments, which can be
pushed into the tissues.
Post-surgery periodontal abscess.
Incomplete removal of sub gingival calculus or the presence
of foreign substance. Ex-sutures, regenerative materials or
periodontal pack.
Clinical study on guided tissue regeneration reported that 10
out of 80 controls (non-resorbable barrier) and 4 out of 82
tests (bio-absorbable barrier) showed abscess formation or
suppuration at the treated sites.
Post-antibiotic periodontal abscess.
Treatment with systemic antibiotics without subgingival
debridement in patients with advanced periodontitis may also
cause abscess formation.

12. 12
It is Attributed to a likely change in the composition of
subgingival microbiota, leading to a super infection and
massive inflammation.
2.Periodontal abscesses in the absence of Periodontitis
Impaction of foreign bodies. Periodontal abscesses caused by
foreign bodies, related with oral hygiene aids, have been
named "oral hygiene abscesses".
Perforation of the tooth wall by an endodontic instrument.
Infection of lateral cysts.
Local factors affecting the morphology of the root may
predispose to periodontal abscess formation.
PATHOGENESIS
& HISTOPATHOLOGY
The entry of bacteria into the soft tissue pocket wall could be
the first event to initiate the periodontal abscess.
Inflammatory cells are then attracted by chemotactic factors
released by the bacteria

13. 13

The concomitant inflammatory reaction leads to destruction
of the connective tissues, the encapsulation of the bacterial
infection and the production of pus.
Histologically, the intact Neutrophils are found surrounding
a central area of soft tissue debris and destroyed leukocytes.
At a later stage a pyogenic membrane, composed of
macrophages and neutrophils is organized.
The rate of destruction in the abscess will depend on the
growth of bacteria and its virulence as well as the local pH,
since an acidic environment will favour the activity of
lysosomal enzymes
De Witt et al. (1985) studied biopsy punches taken from 12
abscesses. They observed, from the outside to the inside:
a)A normal oral epithelium and lamina propria
b)An acute inflammatory infiltrate

14. 14
c)An intense foci of inflammation (neutrophil- lymphocyte)
with the surrounding connective tissue destroyed and
necrotic
d)A destroyed and ulcerated pocket epithelium
MICROBIOLOGY
The most frequent type of bacteria were gram-negative
anaerobic rods and gram-positive facultative cocci. In
general, gram-negatives predominated over gram- positives
and rods over cocci.
The periodontal abscess microbiota is usually
indistinguishable from the microflora found in the
subgingival plaque in adult periodontitis.

15. 15
The microflora from abscesses and deep pockets was similar
and harbored higher proportions of pathogens
Culture studies of periodontal abscesses have revealed high
prevalences of
Porphyromonas gingivalis (55-100%),
Prevotella intermedia (25-100%),
Fusobacterium nucleatum (44-65%)
Other pathogens , Which have been reported are
Actinobacillus actinomycetemcomitans (25%)
Campylobacter Rectus (80%)
Clinical Features
➤ Smooth, shiny swelling of the gingiva
Painful, tender to palpation
➤
Purulent exudate
➤
Increased probing depth
➤
Mobile and/or percussion sensitive
➤
Tooth usually vital
➤

16. 16

17. 17
DIAGNOSIS
Diagnosis should be based on
Patients chief complaint
Clinical signs and symptoms
Additional information can be obtained through a careful
medical and dental history, and radiographic examination.
Symptoms range from light discomfort to severe pain,
tenderness of the gingiva, swelling, tooth mobility, tooth
elevation, sensitivity of the tooth to palpation
Another common finding is suppuration, either spontaneous
or after pressure on the abscess combined with rapid tissue
destruction and deep pocket formation.
The radiographic examination may reveal a normal
appearance, or some degree of bone loss, ranging from a
widening of the periodontal space to a dramatic radiographic
bone loss.
Systemic involvement has been reported in some severe
cases, including fever, leukocytosis.
Positron Emission Tomography and a Fluorine-18-
Fluoromisonidazole marker for detection of periodontal
abscesses and other anaerobic infections in the mouth.

18. 18
Results from the clinical study showed that 100% of
periodontal abscesses were found with this procedure.
TREATMENT
Treatment of acute periodontal abscess usually involves
two stages
Management of the acute lesion.
The appropriate treatment of the original and/or residual
lesion, once the acute situations has been controlled.
The purpose of treatment of acute periodontal abscess is
Alleviate pain,
Control the spread of infection,
To establish drainage
Incision and drainage
Abscess darainage through the pocket (Closed approach)
Incision from the outer surface (Open approach)

19. 19
Closed approach
Local anesthesia
required to treat periodontal abscess
Flat instrument /probe is carefully introduced into the pocket.
Distend the pocket wall for drainage.
Further, drain and gently curettage the mass of tissue
internally.
Open approach
Vertical 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.
Saline irrigation
Approximate to wound margin

20. 20
No sutures required.
Antibiotic administration
Metronidazole-200 mg, tid, 5 days
Tetracycline-1gm/day-2weeks
Azithromycin, 500mg, OD, 3 days.
Amoxicillin + Clavulanate, 500+ 125 mg, tid, 8days.
Chronic periodontal Abscess
Surgical Therapy
Gingivectomy : A gingivectomy ia a surgical procedure that
removes excess or overgrown gum tissues, and is sometimes
used to treat the abscess.
Gingivectomies can be used to treat periodontal abscesses
when the abscess is limited to a few adjacent teeth. The
procedure involves cutting into the pocket wall, scraping
away granulations and dental deposits, and draining any
pus,

21. 21
Flap procedures
A flap procedure recommended for patients with severe gum
diseases . This treatment can remove built-up plaque and
tartar around the roots and restore the health of gum tissue.
Mainly in abscess associated with deep vertical defects,
where the resolution of the abscess may only be achieved by
a surgical approach.
Objective: To eliminate the remaining calculus and to obtain
drainage at the same time.
COMPLICATIONS
Tooth Loss
Suggested as the main cause for extraction in the
maintenance phase.
Untreated periodontal abscess may result in systemic spread
of infection which lead to space infections.
PROGNOSIS
History of repeated abscess formation is considered as a
"hopeless" prognosis for the tooth.

22. 22
In a retrospective study, 45% of teeth with periodontal
abscesses in a maintenance population were extracted.
Dissemination of the infection
Two possibilities have been described:
I. The dissemination of the bacteria during therapy
(bacteraemia)
II. Bacteraemia related with an untreated abscess.
Association of abscess with systemic condition
I.The Dissemination of the bacteria during therapy
Suzuki & Delisle (1984) related a case of pulmonary
actinomycosis due to a periodontal abscesses, which was
ultra-sonically scaled.
It was suggested that during treatment, Actinomyces sp. from
the subgingival microflora had passed to the lungs.
Gallaguer et al. (1981) described a healthy patient with a
periodontal abscess who was treated with drainage and
curettage, but without systemic antibiotic.
2 weeks later a brain abscess was diagnosed, Microbiology
of the lesions demonstrated.

23. 23
II.Bacteraemia Related With an Untreated Abscess.
Cellulitis in breast cancer patients has been claimed to follow
gingivitis or an abscess (Manian 1997) due to transient
bacteraemia and reduced host defenses (radiation therapy and
axillary dissection).
Gingival Abscess
A localized purulent infection that involves the marginal
gingiva or interdental papilla
Etiology
Acute inflammatory
response to foreign substances forced into the gingiva
Clinical Features
Localized swelling of marginal gingiva or papilla
A red, smooth, shiny surface

24. 24
May be painful and appear pointed Purulent exudate may be
present
Treatment
Elimination of foreign object, through careful debridement.
Drainage through sulcus with probe or light scaling.
Rinsing with warm saline.
Follow-up after 24-48 hours.
Pericoronal Abscess
A localized purulent infection within the tissue surrounding
the crown of a partially erupted tooth.
Most common adjacent to mandibular third molars in young
adults; usually caused by impaction of debris under the soft
tissue flap
Clinical Features

25. 25
Operculum (soft tissue flap)
Localized red, swollen tissue
Area painful to touch
Tissue trauma from opposing tooth common
Purulent exudate, trismus, lymphadenopathy, fever, and
malaise may be present.
Treatment
Debride/irrigate under pericoronal flap
Tissue recontouring (removing tissue flap)
Extraction of involved and/or opposing tooth
Antimicrobials (local and/or systemic as needed)
Culture and sensitivity
Follow-up
The treatment of pericoronal abscess is aimed at
Managemant of acute abcess
Procedure
The acute pericoronal abscess is properly anaesthetized

26. 26
Drinage is established-lifting the soft tissue operculum with
periodontal probe or currette
If the underlying debris is accessible, It must be removed-
followed gentle irrigation.
Systemic antibiotics are given- swelling, regional
lymphadenopathy.
The patient is then instructed to rinse with warm water for
every 2 hours and reassesed for 24 hours.
The partially erupted teeth may be definitely treated with:-
Surgical excision of the overlying gingiva
Removal of the offending tooth.
Peri apical Abscess
A periapical abscess is a pocket of infection (pus) around the
tooth root.
This type of abscess forms when harmful bacteria from
the mouth invade the tooth pulp.
The infection can spread all the way to the tip of the root and
into the surrounding tissues.

27. 27
Left untreated, a periapical abscess can spread to other parts
of the body and cause serious, life-threatening complications.
Immediate care to be taken if abscess found.
Clinical Features
Presents features of acute inflammation of apical
peridontium
Tooth is extremely painful
Slightly extruded from its socket
Chronic periapical abscess generally presents no clinical
features
Mild, circumscribed area of suppuration that spread from
local area to causing cellulitis.

28. 28
Radiographic Feature
Slight thickening of periodontal membrane
No roentgenographic evidence of its presence
Chronic abscess, developing in a periapical granuloma
Well circumscribed area of radioluscency at apex
Treatment & Prognosis
Drainage must be established
• must undergo endodontic
therapy

29. 29
• extract the tooth
Left untreated, spread of infection
• osteomyelitis
• cellulitis
• formation of fistulous tract
CONCLUSION
Among several acute conditions occurring in the
periodontium, the abscess i of great clinical importance.
They are localized acute or chronic bacterial infections
confined to tissues of the periodontium
Early diagnosis and appropriate intervention are a must for
the management of abscess, since this condition ultimately
leads to the loss of the involved teeth if left untreated
Before treatment, the patient's medical history, dental history
and any systemic conditions (if present) are reviewed and

30. 30
evaluated to assist in the diagnosis and to determine the need
for systemic antibiotics.

31. 31
REFERENCES
Clinical Periodontology: Carranza, Newman 10th Edition
Clinical Periodontology and implant dentistry - Lindhe 4th
edition
Periodontal abscess: a review. JCDR-2011
Periodontal Abscess review, JCP-2000, 27:377-386.
Randomized trial J Periodontol . National Institute of Health
J B Suzuki, A L Delisle. National Institute of Health