4. INTRODUCTION
• The periodontal abscess is a frequent periodontal
condition in which periodontal tissues may be rapidly
destroyed.
• This condition is one of the few clinical situations in
periodontics where patients may seek immediate care.
• Its importance lies not only with the prognosis of the
periodontitis affected tooth, but also with the possibility
of infection spreading
5. Definition:
• A periodontal abscess is a localized purulent inflamma-
tion in the periodontal tissues (Carranza)
• The periodontal abscess has been defined as a lesion
with an expressed periodontal breakdown, occurring
during a limited period of time, and with easily
detectable clinical symptoms (Hafström et al. 1994).
6. classification
• 1.Acute
• 2. Chronic
• 1.Periodontitis
related
• 2.Non – periodontiits
related
• 1.Single
• 2.Multiple
• 1.Periodontal
• 2.Gingival
• 3.Pericoronal
Location
Meng
1999
Number
Topoll et
al 1990
Course
Etiology
Galego- Fael et al,1995
Carranza 1990
7. Mechanism
1. Exacerberation of chronic lesion
Untreated periodontitis
Recurrent therapy during SPT
2. Post – therapy periodontal abscess
Post scaling periodontal abscess
Post surgery periodontal abscess
Post antibiotic periodontal abscess
8. Non periodontitis related abscess
1. Impaction of foreign body in sulcus / pocket
• Tooth brush / toothpicks(Gillette & Van House 1980, Abrams &
Kopczyk 1983)
• Orthodontic devices
• Food particles
2. root morphology alterations
• Invaginated root (Chen et al 1990)
• Fissured root(Goose 1981)
• External root resorption, root tears(Hany et al 1992)
• Iatrogenic endodontic perforations (Abrams 1992)
9. • Poorly controlled diabetes is considered a predisposing factor
for periodontal abscess formation
10. Acute Vs chronic periodontal abscess
Acute
• Exacerbation of
chronic abscess
• Virulence of bacteria
• Lowered tissue
resistance
• Lack of spontaneous
drainage
Chronic
• After spontaneous
drainage
• Host response
• Homeostasis between
host and infection
11. Signs and Symptoms
Acute
• Mild to severe discomfort
• Localised red, ovoid
swelling
• Periodontal pocket
• Mobility
• Tooth elevation in socket
• Tenderness to percussion
or biting
• Exudation
• Elevated temperature
• Regional lymadenopathy
Chronic
• No pain or dull pain
• Localised inflammatory
reaction
• Slight tooth elevation
• Intermittent exudation
• Fistulous tract often
associated with deep
pocket
• Usually without systemic
involvement
12. • Periodontal abscesses have been either
directly associated to periodontitis or to sites
without the prior existence of a periodontal
pocket.
Etiopathogenesis
13. 1. Extension of infection
from a periodontal
pocket deeply into the
supporting periodontal
tissues and localization
of the suppurative
inflammatory process
along the lateral aspect
of the root.
14. 2. Lateral extension of
inflammation from the inner
surface of a periodontal
pocket into the connective
tissue of the pocket wall.
Localization of the abscess
results when drainage into
the pocket space is
impaired.
15. 3. In a pocket that describes
a tortuous course around
the root, a periodontal
abscess may form in the
cul-de-sac, the deep end
of which is shut off from
the surface.
16. 4. Incomplete removal of
calculus during
treatment of a
periodontal pocket. In
this instance, the
gingival wall shrinks,
occluding the pocket
orifice, and a
periodontal abscess
occurs in the sealed off
portion of the pocket.
17. 5. A periodontal
abscess may occur
in the absence of
periodontal disease
after trauma to the
tooth or perforation of
the lateral wall of the
root in endodontic
therapy
18. histopathologically
Localized accumulation of viable, non viable PMNs within pocket
wall
PMN liberate enzymes
Digest cells & other structures-form liquid pus
An acute inflammatory reaction surrounds purulent area,overlying epiithelium IC
& EC edema & leukocyte invasion
Localized acute→ chronic
Purulent content drains through fistula into outer gingival surface
/ pocket
19. Microbiology
• Bacterial invasion reported: gram –ve cocci, diplococci,
fusiforms, spirochetes, invasive fungi (opportunistic invaders)
• Primarily :gram – ve anaerobic rods
• Prevalent : P .Intermedia
F. Nucleatum
P. Gingivalis
• Others: T . Forsythenius, P. Micros,C.Rectus,
Prevotella melaninogenica
De Witt
Cobb 1985
Newmann
Sims 1979
20. Radiographic features
• Discrete area of radioluscency along lateral aspect of root
• Radiographic picture not typical
• Due to
1. Stage of lesion : acute: no radiographic changes
2. Extent of bone destruction & morphologic variation
3. Location of abscess:in soft tissue wall of pocket no
radiographic view
• Radiograph alone not relied on diagnosis of periodontal
abscess
21. • Diagnosis based on overall evaluation & interpretation of
patients chief complaint with clinical & radiological findings
Diagnosis
Association with pockets of 6 mm or more,
Presence of bleeding on probing,
Evidence of radiographic alveolar bone loss & PDL
widening, and
Absence of a periapical lesion.
22. Differential diagnosis
• Gingival abscess : localized , rapidly expanding lesion
,usually of sudden onset
• Limited to marginal gingiva/ interdental papilla
• Red swelling with smooth shiny surface
• Within 24- 48 hours →fluctuant & pointed- surface orifice
exudate expressed
• Ruptures spontaneously
• Etiology : forceful embeddment due to:
toothbrush bristle
Piece of apple
Lobster shell fragment
23. Differential diagnosis
• Periapical abscess
• Lateral peripical cyst
• Vertical root fracture
• Endo – periodontal abscess
• Osteomyelitis (Parrish et al 1989)
• Gingival squamous cell carcinoma(Torabinajad 1980)
• Metastaic carcinoma from pancreatic origin(Selden et al 1998)
• Eosinophilic carcinoma(Girdler 1991)
24. Periodontal vs pulpal abscess
Periodontal abscess Pulpal abscess
Associated with preexisting periodontal
pocket
May have no periodontal pocket, or if
present, probes as a narrow defect.
Offending tooth may have a large
restoration.
Test show vital pulp Tests show non-vital pulp
Swelling usually includes gingival tissue,
with occasional fistula.
Swelling often localized to apex, with
fistulous tract.
Pain usually dull and localized Pain often severe and difficult to localize
Sensitivity to percussion may or may not
be present
Sensitivity to percussion present.
25. Treatment
• 2 stages
1. Managemnet of acute lesion
1. Incision & drainage
2. Scaling & root planing
3. Periodontal surgery
4. Systemic antibiotics
5. Tooth extraction
2. Appropriate treatment of original / residual
lesion(chronic lesion)
26. Acute abscess
• Treated to alleviate symptoms
• Control spread of infection
• Establish drainage
• Medical , dental history evaluated before antibiotic need
1. Drainage through pocket
2. Drainage through external incision
27. Drainage through periodontal pocket
• Closed Approach:
• Incision and drainage are often best obtained through the
pocket.
• Pocket is opened with the sharp curette to the depth of the
abscess and drained.
• The root surface is thoroughly planed & occluded pocket wall
is further opened and drainage enhanced.
• Irrigation with 0.1% povidone iodine and 3% H2O2 is done.
Antibiotic therapy in acute abscess
1.Cellulitis
2.Deep pocket
3. Fever
4.Lymphadenopathy
5.Immunocompromised patient
28.
29. Studies
Smith &
Davies(1986)
Incision & Drainage
Systemic
metronidazole
200mg t.i.d 5 days
Hafstrom 1994
Drainage ,irrigation
Supragingival
debridement
Systemic
Tetracylcine
2 weeks
Herrara et al 2000
2 sytemic antibiotics
(amox+clavunate &
azithromycin)
None of the antibiotic therapies entirely resolved the
infection- mechanical debridement &surgical means is
essential
30. Drainage through the external incision
After isolation and sufficient anaesthesia a vertical incision
through the most fluctuant center of the abscess is made
with a #15 surgical blade.
The tissue lateral to the incision can be separated with a
curette or periosteal elevator.
Fluctuant matter is expressed and the wound edges
approximated under light digital pressure with a moist gauze
pad.
31. In abscesses presenting with severe swelling and
inflammation:
aggressive mechanical instrumentation should be delayed
in favor of antibiotic therapy
to avoid damage to healthy contiguous periodontal
tissues.
Post-treatment instructions
• frequent rinsing with warm salt water (1 tbsp/8-oz. glass)
• periodic application of chlorhexidine gluconate either by
rinsing or locally with a cotton-tipped applicator
32. Chronic abscess
scaling and root planing or surgical therapy.
Surgery:deep vertical or furcation defects are encountered
that are beyond the therapeutic capabilities of nonsurgical
instrumentation.
The appearance of the gingiva returns to normal within 6 to 8
weeks; repair of the bone requires approximately 9 months.
33. Chronic abscess
Open Approach:
• Full thickness flap is raised both on facial and lingual surfaces.
•The initial internal bevel incision can be made intrasulcularly to
preserve as much as keratinized gingiva.
•If necessary, for access vertical incisions can be made over the
intact alveolar bone at the line angles of the adjacent non-
involved teeth.
•The attached gingival tissue is reflected and all visible bacterial
deposits, both hard and soft removed from the root surface.
•The exposed bone can be carefully debrided to remove soft
tissue from the osseous defect.
.
34. The goal of the open approach is to maximize healing and to
gain new attachment of the periodontal tissues to the
previously diseased root surface.
Some times Gingivectomy technique is also carried out
for the elimination of the suprabony periodontal abscess
Repair Potential:
Has an excellent potential for repair following adequate
treatment. (Naber et al 1964) noted that acute abscess repaired more
completely than chronic lesions
35. Indications for antibiotic therapy in
patients with acute abscess:
• Cellulitis
• Deep, inaccesible pocket
• Fever
• Regional lymphadenopathy
• Immunocompromised patient
.
36. Complications
• Tooth loss – due to extraction during SPT(Chace & Low
1993)
• Tooth with repeated abscess – questionable
prognosis(Becker et al 1984)
• Dissemination of infection
1. Bacteria disseminated inside tissues during therapy
2. Through blood stream due to bactermia from untreated
abscess
Periodontal abscess cellulitis ,brain abscess ,cervical
necrotizing fascitis (uncommon)
Manian 1997
Van winkelhoff
Chan 1997
37. conclusion
• Third most frequent dental emergency 7–14% of all dental
emergencies, &6–7‰ of all patients seen in a dental clinic
• Possibility to spread micro-organisms to other body sites
• Proper understanding of the etio-pathogenesis and differential
diagnosis are very much essential in treating this lesion with
correct treatment regimen.
38. • In these patients maintenance of high standard of oral
hygiene is essential, therefore regular inspection and scaling
should be organized, and patients suffering unexplained
recurrence should undergo medical examination for major
predisposing factors
