Everything a dentist needs to know about a periodontal abscess is here. Along with all the relevant facts, references, definitions, classifications, and each and every statement is given with proper detail

1. Periodontal Abscess
Dr. Rinisha Sinha
MDS Part I
Department of
Periodontology

2. 1) Introduction
2) Clinical features
3) Classification
4) Etiology
5) Pathogenesis and Histopathology
6) Microbiology
7) Diagnosis
8) Differential Diagnosis
9) Treatment
10) Complications
11) Conclusion
12) References

3. INTRODUCTION
• A Periodontal Abscess is a localized
accumulation of pus within the gingival wall of
periodontal pocket.
• A localized purulent infection within the tissue
adjacent to the periodontal pocket that may
lead to the destruction of periodontal ligament
and alveolar bone.
(Consensus report 1999)
• It is the third most common dental
emergency.
• Also known as a Lateral Abscess or Parietal
Abscess.
Reference : Carranza FA, Newman MG
Periodontal Abscess in relation to
the Upper Right Central Incisor

4. CLINICAL FEATURES
It may be acute or chronic in its onset.
• The patient complains of pain
 In an acute periodontal abscess : throbbing pain
 In a chronic periodontal abscess : dull and gnawing pain
• Edema and redness at the affected site.
• The involved tooth is sensitive to lateral percussion.
• Increased mobility of the involved tooth
• Increased probing depth.
• Bleeding or purulent exudates on probing.
• Suppuration can be spontaneous or may be present on
putting lateral pressure on the involved surface of gingiva.
• Draining sinus may be present.
• In chronic cases, bone loss can be seen in the radiograph.
• In delayed cases of periodontal abscess, the patient may
have lymph node enlargement, fever and malaise.
Reference : Ibbot et al. – 1993; Carranza - 1990, Newman MG

5. CLASSIFICATI
ON
Reference : Huan Xin Meng -1999; Herrera D, Roldan S, Sanz M - 2000

6. Based on
ETIOLOGICAL Criteria
Periodontitis related
abscess
• When acute infections
originate from a biofilm
in the deepened
periodontal pocket.
Non-Periodontitis related
abscess
• When the acute infections
originate from another local
source.
 Foreign body impaction,
 Alteration in root integrity.
Reference : Lindhe

7. According to
LOCATION
Gingival Abscess
A localized, purulent
infection involves
only the soft gingival
tissue near the
marginal gingiva or
the interdental
papilla.
Periodontal Abscess
A localized, purulent
infection involving a
greater dimension of the
gingival tissue,
extending apically and
adjacent to a
periodontal pocket.
Pericoronal Abscess
A localized, purulent
infection within the gingival
tissue surrounding the crown
of a partially or fully erupted
tooth. Usually associated
with an acute episode of
pericoronitis around a
partially erupted and
impacted mandibular third
molar (lower wisdom tooth).
Reference : Huan Xin Meng -1999; Herrera D, Roldan S, Sanz M - 2000

8. According to ONSET
AND COURSE OF LESION
Acute Periodontal Abscess
• Appears during a short period of time; within
days or a week
• Clinical picture : as a bright red ovoid
elevation of the gingiva, relatively firm or
pointed and soft
• Pus expressed from the gingival margin by
gentle digital pressure.
• Accompanied symptoms :
 Sudden onset of pain
 Throbbing, radiating Pain
 Sensitivity to percussion
 Tooth mobility
 In Some instances, Lymphadenopathy and
systemic effects such as fever and malaise
• Often Subside but persist in chronic state
Chronic Periodontal Abscess
• Infection of prolonged duration
• Presents a sinus that opens onto the
gingival mucosa along the root length
• Asymptomatic
• Patient may complain of :
 Mobile and tender tooth
 Intermittent exudation
 Dull, gnawing pain
 Slight elevation of the tooth
 Desire to bite down or grind the tooth
• Frequently undergo acute exacerbation
Reference : Huan Xin Meng -1999; Herrera D, Roldan S, Sanz M - 2000

9. Depending on
NUMBER
Single Periodontal Abscess
• Related to local factors that
contribute to the closure of
the periodontal pocket.
Multiple Periodontal Abscess
• Reported in Diabetes Mellitus
and medically compromised
patients.
Reference : Topell et al - 1990

10. ETIOLOGY
• The periodontal abscess usually develops
in an association with moderate to deep
periodontal pockets.
• Other etiological factors include :
o Incomplete calculus removal
o Embedding of foreign body
o Uncontrolled Diabetes mellitus
o Systemic therapy with Nifedipine
o Tooth perforation
o Root fracture
Reference : Dello Russo; 1985
Reference : Carranza; 1990
Reference : Koller Benz at al. 1992

11. PATHOGENESIS AND
HISTOPATHOLOGY
Entry of bacteria in the soft tissue pocket wall first event
releases
Chemotactic
Factors
Inflammatory
Cells
attracted
• The destruction of the connective tissues
• The encapsulation of the bacterial
infection
• The production of pus
Concomitant Inflammatory reaction
Reference : DeWitt et al. - 1985
Reference : Carranza - 1990
Histologically, the central area of the
abscess is filled with intact neutrophils
Bacteria
Reference : DeWitt et al. - 1985
At a later stage, a pyogenic membrane,
composed of macrophages and
neutrophils, is organised.
Decreased Tissue Resistance
Virulence and no. of bacteria

12. MICROBIOLOGY of
Periodontal Abscess
 Most frequent type of bacteria : gram-negative anaerobic rods.
 The microbiota of periodontal abscess is not different from the microbiota of chronic
periodontitis lesions.
 This microflora is polymicrobial and Streptococcus viridans most common amongst
gram-positive microorganisms.
Porphyromonas gingivalis is probably the most virulent and relevant microorganism.
Other anaerobic species include :
Prevotella intermedia,
Prevotella melaninogenica,
Fusobacterium nucleatum,
Campylobacter rectus,
Tannerella forsythia,
Actinobacillus actinomycetemcomitans
( uncommon )
Reference : Newman and Sims 1979
Reference : Topoll et al. - 1990;
Van Winkelhoff et al. - 1985;
Hafstrom et al - 1994;
Newman and Sims - 1979
55-100% (Lewis et al)
25-100% (Newman and Sims)
44-65% (Hafstrom et al)
80% (Hafstrom et al)
22% (Newman and Sims)
22% (Hafstrom et al)

13. DIAGNOSIS
• The diagnosis of a periodontal abscess is based on
 the chief complaint
 the history of the presenting illness.
• The next steps in examination include :
a. General features
 Healthy or unhealthy features that may indicate on-going systemic diseases, competency of
immune system, extremes of age, distress, fatigue.
b. Extra Oral features
 Symmetry of face, swelling, redness, sinus, trismus and examination of cervical lymph
nodes.
c. Intra Oral Features
1. Gingival swelling, redness and tenderness, pain
2. Suppuration either spontaneous, on pressure or from sinus.
3. Mobility, elevation and tooth tender to percussion.
4. Bleeding on probing
• Following examination, confirmation of the clinical findings on the basis of radiographs, pulp
vitality test, microbial test, and other findings.
Reference :Ibbot et al. 1993; Ahl et al. 1986; Carranza 1990

14. RADIOGRAPHS AND
TESTS• Intra oral radiographs, like periapical and vertical bite-wing views, are
used to assess marginal bone loss and the periapical condition of the
tooth which is involved.
 Pulp Vitality Test
• Thermal or electrical tests to assess the vitality of the tooth.
 Microbial Test
• Sample of pus from the sinus, abscess or puruluent material expressed
from the gingival crevice could be sent for culture and sensitivity test.
• Others
• Assessment of diabetic status through blood glucose and glycosylated
haemoglobin.
Reference : Newman and Sims 1979
Microbial Test
Pulp Vitality Test

15. DIFFERENTIAL
DIAGNOSIS
GINGIVAL ABSCESS
History of Recent Trauma
Localization to the gingiva
No Periodontal Pocketing
ENDO-PERIO LESION
• Pulp infection spreading via the lateral canals into
the periodontal pockets
• Tooth usually non- vital with periapical
radiolucency
PERIAPICAL ABSCESS
• Located over the Root Apex
• Non-vital tooth, heavily restored or large filling
• Large Caries with Pulpal Involvement
• History of Sensitivity to Hot and Cold
• No signs and symptoms of Periodontal
Disease
• Periapical Radiolucency on Intraoral
Radiograph
CRACKED TOOTH SYNDROME
• History of Pain on Mastication
• Crack line noted on the Crown
• Vital Tooth
• Pain upon releasing after biting
• No relief on pain after endodontic
treatment
PERIO-ENDO LESION
• Severe Periodontal Diseases with furcation
• Severe Bone loss close to apex
Reference : Punit V Patel et al; Periodontal Abscess : A Review

16. Resolving
the Acute
Lesions
Management
of the
resulting
Chronic
Condition
Treatment
for
Periodontal
Abscess
Drainage
through
Pocket
Retraction or
Incision
Scaling
and Root
Planing
Periodontal
Surgery
Systemic
Antibiotics
Tooth
Removal
INITIAL
THERAPY
Reference : Ammons; 1996

17. PRINCIPLES OF
MANAGEMENT
 Local measures
a. Drainage
b. Elimination of the cause
 Systemic measures
Antibiotics in conjunction with local measures in the following
three steps
• Immediate management
• Initial management
• Definitive therapy
Reference : Herrera D, Roldan S, Sanz M – 2000 ; Dello Russo NM – 1985; Helovuo H, Hakkarainen K, Paunio K - 1993

18. IMMEDIATE
MANAGEMENTa. In life threatening infections, hospitalization, supportive therapy
together with antimicrobial therapy will be necessary.
b. In non-life threatening conditions, systemic measures such as
oral analgesics and antimicrobial chemotherapy will be sufficient.
c. The common antibiotics used are :
 Phenoxymethylpenicillin 250 - 500 mg 4 times a day for 5-7 days
 Amoxycillin 250 - 500 mg 3 times a day for 5-7 days
 Metronidazole 200 - 400 mg 3 times a day for 5-7 days
 If allergic to penicillin,
 Erythromycin 250 - 500 mg 4 times a day for 5-7 days
 Doxycycline 100 mg 2 times a day for 7-14 days
 Clindamycin 150 - 300 mg 4 times a day for 5-7 days
Reference : Herrera D, Roldan S, Sanz M – 2000 ; Dello Russo NM – 1985; Helovuo H, Hakkarainen K, Paunio K – 1993; Carranza; Smith
RG, Davies RM - 1986

19. INITIAL
MANAGEMENT
• The initial therapy is usually prescribed for the
 management of acute abscesses without systemic toxicity, or
 residual lesion after the treatment of the systemic toxicity, and
 the chronic periodontal abscess
Reference : Herrera D, Roldan S, Sanz M – 2000 ; Dello Russo NM – 1985; Helovuo H, Hakkarainen K, Paunio K - 1993

20. If lesion is large and drainage cannot
be established
Scaling and Curettage and Surgery
delayed until major clinical signs
resolved
Drainage through
Periodontal Pocket
Topical
Local
Anesthesia
Gentle
digital
pressure is
applied to
drain the
abscess
If the lesion is small & accessible
Scaling and Curettage
In such patients,
short term high dose Antibiotic
regimens is recommended
Pocket wall
gently retracted
with a probe /
curette to create
initial drainage
through pocket
entrance

21. Drainage through an
external incision
If the lesion is sufficiently
large, pin-pointed and fluctuating,
an External Incision can be made
Abscess is
dried,
isolated with
gauze
sponge
Local
anesthesia
(Nerve Block
is preferred)
A Vertical Incision is given through the
most fluctuant center of the abscess with
a #15 or #11 surgical blade
The tissue lateral to the
incision is separated
with a Periosteal
elevator / Curette
Light digital
pressure should be
applied with moist
gauze pad
In patients with
marked swelling,
tension, pain, use
Systemic
Antibiotics as the
only initial
treatment to avoid
the damage to the
healthy
periodontium
Mechanical debridement
including root planning is
performed.

22. Periodontal surgery
• Main objective of the therapy is to eliminate the remaining
calculus and to obtain drainage at the same time.
• Surgical therapy (either gingivectomy or flap procedures)
has been advocated in abscesses associated with deep
vertical defects.
• Surgical flaps have been proposed in cases in which the
calculus is left sub-gingivally after the treatment.
• As an adjunct to conservative treatment, soft laser therapy
could be used to decrease the pain and swelling of the
gingiva.
Reference : Herrera D, Roldan S, Sanz M – 2000 ;; Smith RG, Davies RM – 1986; Kareha MJ, Rosenberg ES, DeHaven H - 1981

23. Post-treatment
Instructions
a. Frequent rinsing with warm salt water.
b. Periodic application of chlorhexidine
gluconate.
c. Reduce exertion and increase fluid
intake.
d. Analgesics for patient comfort.
e. Repair potential for acute periodontal
abscess is excellent.
f. Gingiva returns to normal within 6 to 8
weeks.
g. Gentle digital pressure may be sufficient
to express the purulent discharge.
Reference :Gillette and Van House – 1980; Ahl et al. 1986
Reference : Herrera D, Roldan S, Sanz M – 2000 ; Dello Russo NM – 1985; Carranza FA Jr., Newman MG, eds. Glickman’s Clinical
Periodontology, 8th ed; Smith RG, Davies RM - 1986

24. Systemic antibiotics
with or without local
drainage• Antibiotics are the preferred mode of treatment. The
recommended antibiotic regimen usually follows the
culture and the sensitive tests.
o Phenoxymethyl penicillin 250-500 mg 4 times a day 7-10
days
o Amoxycillin/ Augmentin 250-500 mg 3 times a day for 7-
10 days
o Metronidazole 250 mg 3 times a day for 7-10 days
o Tetracycline HCl 250 mg 4 times a day for 7-14 days
o Doxycyline 100 mg 2 times a day for 7-14 days
The use of tetracycline is contraindicated in pregnant
patients and in children below 10 years.
Reference : Herrera D, Roldan S, Sanz M – 2000 ; Dello Russo NM – 1985; Carranza

25. Extraction of the
teeth• Last resort to treat the periodontal abscess.
• However, there are certain guidelines for assessing poor/
hopeless prognosis before extracting the tooth.
• The guidelines are as follows
 Horizontal mobility more than 1mm.
 Class II-III furcation involvement of a
molar.
 Probing depth > 8 mm.
 More than 40% alveolar bone loss.
 Poor response to therapy.
Reference : Herrera D, Roldan S, Sanz M – 2000 ; Carranza FA Jr., Newman MG, eds. Glickman’s Clinical Periodontology, 8th ed

26. DEFINITIVE
TREATMENT
The treatment following reassessment after the
initial therapy is
• to restore the function and aesthetics
• to enable the patient to maintain the health of
the periodontium.
 Definitive periodontal treatment is done
according to the treatment needs of the patient.
Reference : Ammons et al 1996

27. Periodontal Abscess : Initial
Assessment
Acute
Abscess
Chronic
Abscess
Life
threatening
conditions
• No systemic
toxicity,
• Localized infection,
• Able to drain
• Systemic toxicity
• Spreading
infection
• Unable to drain
Immediate
Management
Initial
Therapy
Reassessme
nt
Definitive
Treatment
Reference : Gillette, Van House -1980; Ahl et al - 1986

28. Complications of
Periodontal Abscess
• Tooth loss - Associated with tooth loss in cases of
moderate to advanced periodontitis and during the
maintenance phase.
• Smith & Davies (1986) evaluated 62 abscesses: 14
(22.6%) were extracted as initial therapy and 9 (14.5%)
after the acute phase was controlled. Out of the 22 treated
and followed abscessed teeth, 14 had to be extracted
during the following 3 years.
• Dissemination of the infection –
a. The dissemination of the bacteria during therapy
(bacteremia).
b. The dissemination of the bacteria related with an
untreated abscess.
Reference : D.E. McLeod, P.A. Lainson, and J.D. Spivey - 1997; R. Chace, and S. Low - 1993

29. Conclusion
• The periodontal abscess depicts typical clinical and
histopathological features.
• The most prevalent organism cultured from periodontal abscess are
P. gingivalis, P. intermedia and Fusobacterium sp.
• Different therapeutic alternatives have been proposed for the
treatment of the periodontal abscess. Among these, incision and
drainage, scaling and root planning and different antibiotics, are the
sole therapies for the treatment of periodontal abscesses.
• An infection has the possibility to spread micro-organisms to other
body sites, with the possibility of causing serious diseases which
can eventually be fatal.
• A tooth suffering from a periodontal abscess has a worse prognosis
and is at a higher risk of being lost.

30. References
 Carranza’s Clinical
Periodontology :
10th Edition
 Periobasics : A
textbook of
Periodontics and
Implantology
 Journal of
Pharmaceuticals and
Scientific Innovation
 Herrera D, Roldan S, Sanz M:
The Periodontal Abscess; a review
 PUNIT VAIBHAV PATEL, SHEELA
KUMAR G, AMRITA PATEL :
The Periodontal Abscess; a review
 Disha Gupta, Paras Verma, Garima
Dhariwal, Shubhi Chaudhary :
PERIODONTAL ABSCESS – A LOCALIZED
COLLECTION OF PUS A REVIEW Disha