Abscess of periodontium is a topic which is must to be read by a dentist or dental surgeon. Also the slide is made from carranza's periodontology, which can help the readers to grasp the concepts in few minutes. thank you.

1. ABSCESS OF
PERIODONTIUM
PERIODONTOLOGY

2. A periodontal abscess is a localized purulent inflammation in the
periodontal tissue. It is also known as lateral abscess or parietal abscess.
INTRODUCTION
ETIOLOGY
Periodontal abscess i.e either related directly to periodontium or to the
site where PDL donot exist and also a pocket donot exist.
So there are 2 types of abscess:
1. Periodontitis related abscess
2. Non-periodontitis related abscess

3. The periodontal abscess is a localized purulent inflammation of the periodontal
tissues.
It has been classified into three diagnostic groups:
1. Gingival abscess
2. Periodontal abscess
3. Pericoronal abscess.
• The gingival abscess involves the marginal gingival and interdental tissues.
• The periodontal abscess is an infection located contiguous to the
periodontal pocket and may result in destruction of the periodontal ligament
and alveolar bone.
• The Pericoronal abscess is associated with the crown of a partially erupted
tooth.
CLASSIFICATION:

4. Periodontitis related abscess
 Presence of a torturous pocket after cul-de-sac operation can cause abscess.
 Periodontal abscess can occur as a result of a periodontal therapy or a
surgery. This occurs because there is a fibrin secretion which favors closure of
gingival margin to tooth surface which leads to abscess.
 Changes in microflora as composition can make the pocket lumen inefficient
to drain the suppuration produced inside it.
 Treatment with systemic antibiotics without subgingival debridement in
patients with advanced periodontitis may also cause abscess formation.

5. The periodontal abscess is usually found in patients with untreated
periodontitis and in association of periodontal pockets.
Periodontal abscess often arises as an acute exacerbation of a
preexisting pocket. They are primarily related to incomplete calculus
removal, periodontal surgery, after administration of systemic
antibiotics.
Poorly controlled diabetes mellitus has been considered a
predisposing factor for periodontal abscess formation.
Conditions in which periodontal abscess is not related to
inflammatory periodontal disease include tooth perforation or
fracture and foreign body impaction.
Periodontal abscess

6. The gingival abscess is a localized, acute inflammatory
lesion that may arise from a variety of sources, including
microbial plaque infection, trauma and foreign body
impaction. Clinical features include a red, smooth,
sometimes painful, often fluctuant swelling.
Gingival abscess:

7. ETIOLOG
Y OF
GINGIVAL
ABSCESS
It usually occurs due to impaction of food or foreign substances
into the gingiva. This lead to an inflammatory response and
abscess formation.
Foreign substances:
1. Tooth brush bristle
2. Piece of apple core
3. Lobster shell fragment
The lesion is confined to gingiva and shouldn’t be confused with
periodontal abscess.

8. FOOD
IMPACTION
between
adjacent tooth is
a COMMON
ETIOLOGY of
GINGIVAL
ABSCESS

9. Pericoron
al Abscess

10. The peri coronal abscess results from inflammation of the
soft tissue operculum, which covers a partially erupted
tooth. This situation is most often observed around the
mandibular 3rd molar.
However, in gingival abscess, the inflammatory lesion may
be caused by retention of microbial plaque, food
impaction or trauma.
Pericoronal Abscess

11. The acute abscess is often an exacerbation of a chronic inflammatory
periodontal lesion.
The main influencing factor include, increased number and virulence of
bacteria present, combined with lowered tissue resistance and lack of
spontaneous drainage.
The drainage may be prevented by a deep, tortuous pocket morphology, debris
or closely adapted pocket epithelium blocking the pocket orifice.
Acute abscess are characterized by painful, red, edematous, smooth and
ovoid swelling of the gingival tissues. The exudate may be expressed with
gentle pressure. And the tooth may be percussion sensitive and feel elevated in
in the socket. Fever and regional lymphadenopathy are occasional findings.
ACUTE ABSCESS

12. CHRONIC
ABSCESS:
The chronic abscess forms after the spreading infection have
been controlled by spontaneous drainage, host response or
therapy. So once homeostasis between the host and infection
has been reached, the patient may have few or no symptoms.
However dull pain may be associated with the clinical findings of
a periodontal pocket, inflammation and a fistulous tract.

13. Signs and
Symptoms
of
PERIODON
TAL
ABSCESS
Acute abscess
• Mild to severe discomfort
• Localized red ovoid swelling
• Periodontal pocket
• Mobility
• Tooth elevation in socket
• Tenderness to percussion or biting
• Exudation
• Elevated temperature
• Regional lymphadenopathy
Chronic abscess
• No pain or dull pain
• Localized inflammatory lesion
• Slight tooth elevation
• Intermittent exudation
• Fistulous tract often associated with a deep pocket
• Usually without systemic involvement

14. Abscess formation can also form due to inadequate scaling, so the calculus
remain in deepest pocket and can initiate an inflammation. This blocks the
normal drainage from the pocket lumen into oral cavity.
CALICULUS In
DEEP
POCKETS can
initiate
INFLAMMATI
ON leading to
ABSCESS
formation.

16. Non Periodontitis related
abscess
Foreign bodies such as tooth brush bristle, a piece of dental floss when get
dislodged into the gingival tissue can lead to abscess formation. Periodontal
abscess caused by foreign bodies related with oral hygiene aids is termed as oral
hygiene abscess.
Lateral perforation of root during endodontic treatment can lead to periodontal
abscess.
Local factors which affect morphology of the tooth like:
• Cemental factors
• External root resorption
• Invaginated tooth
• Cracked tooth
All of them can lead to periodontal abscess.
External root resorption
Cracked tooth

17. Pathogene
sis AND
Histopatho
logy
The main cause of an abscess formation is plaque. When any plaque accumulates
on tooth surface it initiates bacterial colonization. This in turn activates host
defense mechanism leading to inflammation. This causes destruction of
connective tissue and production of pus. This ultimately leads to abscess
formation.

18. Peri-apical abscess Periodontal abscess
1. Pain is sharp, severe and diffuse
2. Pain is not localized and patient may not be
able to locate the tooth
3. Swelling is present at apical area and a sinus
tract can form
4. Periodontal pocket is not present
1. Pain is dull, steady and continuous
2. Pain is localized and patient can locate the
tooth.
3. Swelling is present at gingival tissue and sinus
tract cannot form
4. Periodontal deep pockets are present
5. Radiographically there is vertical or angular
bone loss
Difference between peri-apical and
periodontal abscess

19. PERIODONTAL ABSCESS

21. MANAGEMENT of ACUTE
ABSCESS:
The steps taken or considered in this type of abscess is to decrease the
symptoms, control the already existing infection and to establish
drainage.
A patient’s medical and dental history should be evaluated. This
helps in diagnosis and to determine the type of antibiotics should be
given.
Treatment option:
1. Drainage through pocket
2. Scaling and root planning
3. Periodontal surgery
4. Systemic antibiotics
5. Tooth removal

22. • The surrounding tissue around the pocket should be anesthetized. The
pocket wall is gently retracted with a probe to initiate drainage through
the pocket.
• After the pocket wall is retracted, gentle digital pressure and irrigation
must be done to clear the pocket.
• If the lesion is small and access is small, then scaling and root planning
must be done.
• If the lesion is large and drainage cannot be established. So the patient is
advised to take systemic antibiotics [amoxicillin 500 mg / clindamycin
600 mg].
ANTIBIOTICS:
Amoxicillin 500 mg 3x for 3 days. Then re-evaluate Penicillin allergy –
clindamycin [600 mg loading dose] then 300mg 4x a day.
DRAINAGE
THROUGH
PERIODON
TAL
POCKET

24. Fig: A, Periodontal abscess of maxillary left first molar. B,
Periodontal probe is used to retract the pocket wall gently.
DRAINAGE
THROUGH
PERIODON
TAL
POCKET

25. Gentle digital
pressure may be
sufficient to
express purulent
discharge.

26. DRAINAGE
THROUGH
EXTERNAL
INCISION

27. The abscess can be drained by an incision on the external soft tissue surface of the
swelling.
STEPS:
1. Initially, the abscess is dried with sponge and local anesthesia is injected
peripheral to the lesion. Then a vertical incision is made through the most
fluctuant center of abscess with a NO.15 surgical blade. Then the tissue is
separated with a periosteal elevator. Then the pus is drained out and wound
edges are closed with slight digital pressure or a moist gauze.
2. In severe swelling and inflammation, aggressive mechanical instrumentation
should be done with systemic antibiotics.
3. Once bleeding is stopped, the patient who donot need antibiotics should be
advised to take periodic chlorhexidine gluconate rinsing.
DRAINAGETHROUGH
EXTERNAL INCISION:

28. 4. For those who don’t need systemic antibiotics, the patient is asked to
frequently rinse the mouth with warm salt water [1tbsp/8-oz glass] and
periodic application of chlorhexidine gluconate either by rinsing or locally
with a cotton-tipped applicator.
5. Increased fluid intake is often recommended for patients showing systemic
involvement.
6. Analgesics may be prescribed for comfort.
7. By the next day signs and symptoms should subside, if not the patient is
instructed to continue the previously recommended regimen for an additional
24 hours. This often results in satisfactory healing and the lesion can be
treated as a chronic abscess.

29. MANAGEMENT OF
GINGIVAL
ABSCESS
1. The initial step is to remove the cause [remove foreign material]
2. Then topical or local anesthetic should be administered.
3. Scaling and root planning are required to establish drainage
and to remove microorganisms.
4. An incision is placed on the gingival tissue with a no.15 blade
and exudate is released out by gentle digital pressure.
5. If there is severe bleeding, it should be stopped and the patient is
instructed to rinse with warm water every 2 hours.

30. MANAGEMENT OF
CHRONIC
ABSCESS
Chronic abscess is usually treated with scaling and root planning or
with surgical therapy. Surgical treatment is very necessary when
deep vertical or furcation defects are present.

31. A, Deep furcation invasions are a
common location for the periodontal
abscess.
B, Furcation anatomy often prevents
the definitive removal of calculus and
microbial plaque.

32. Post-prophylaxis periodontal abscess resulting from
partial
healing of a periodontal pocket over residual calculus.
POST-
PROPHYLAXIS
PERIODONTAL
ABSCESS due
to residual
calculus

33. A, Fistula is observed in attached gingiva
of maxillary right canine.
B, Elevated flap shows the cause to be a
root fracture.

34. A, Maxillary right first molar with fistula on the attached gingiva. B, Using local anesthesia, periodontal probe is
introduced through the fistula and angled toward the root end. C, Surgical flap elevation demonstrates failed
endodontic therapy and tooth fracture as causing the fistula.

35. A, Chronic periodontal abscess of maxillary right canine. B, Using local anaesthesia, periodontal
probe is inserted to determine severity of the lesion. C, Using mesial and distal vertical incisions, a
full-thickness flap is elevated, exposing severe bone dehiscence, a subgingival restoration, and root
calculus.

36. D, Root surface has been planed free of calculus and the restoration smoothed. E, Full-
thickness flap has been replaced to its original position and sutured with absorbable sutures.
F, At 3 months, gingival tissues are pink, firm, and well adapted to the tooth, with minimal
periodontal probing depth.

37. All patients with abscess affecting periodontal tissue
including gingiva should have a periapical radiograph
that tests the vitality of the teeth in the region. This
allows the clinician to clarify if the origin of the abscess is
periodontal or pulpal and thus provide the appropriate
treatment.
SCIENCE
TRANSFER

38. All abscess require drainage, and periodontal abscesses can often be
managed by curetting the pocket under local anesthesia to remove
plaque or any other etiological material such as food debris, resulting in
drainage of pus, blood and edema fluid.
If the drainage is not obvious, then a gingival incision parallel or
perpendicular to the long axis of the teeth may be necessary.
SCIENCE
TRANSFER

39. Systemic antibiotics are only used if there is evidence of
inflammatory spread beyond the gingiva in healthy patients and
in immunocompromised patients and diabetics.
SCIENCE
TRANSFER

40. Occlusal adjustments will often help reduce pain because the affected
teeth are often extruded from the inflamed periodontal tissues. Post-
operative plaque control is necessary.
Appropriate treatment of acute abscess can undergo complete resolution
in 8 weeks in some patients so atleast 8 weeks should pass before further
treatment decisions are made.
SCIENCE
TRANSFER

41. THE END
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