A concise presentation on the abscesses of periodontal tissues, its etiology, diagnosis, management, differential diagnosis and potential sequelae and complications.

1. ABSCESSES OFTHE
PERIODONTIUM
Dr. ARAVIND NAIR

2. INTRODUCTION
An abscess is a painful collection of pus, usually caused by a bacterial infection.
Abscesses of periodontium can be defined as localised purulent inflammation of the
periodontal tissues.
In 1999,AAP classified abscesses of periodontium as
 Gingival abscess
 Periodontal abscess
 Pericoronal abscess

4. GINGIVAL ABSCESS
• Defined as the localized purulent infection that involves
marginal gingiva
• Diagnosis of gingival abscess is uncomplicated as it is
confined to only gingival marginal tissues which are
previously non-diseased sites
• Often an acute inflammatory response to food impaction or a
foreign body into gingiva
• The retrieval of foreign body is thus often diagnostic

5. • In early stages it appears as a red swelling with a smooth shiny
surface
• Within 24-48 hours the lesion usually becomes fluctuant and
pointed with a surface orifice from which a purulent educate may
be expressed
• Adjacent teeth are often sensitive to percussion
• If permitted to progress, the lesion generally ruptures
spontaneously

7. HISTOPATHOLOGY OF GINGIVAL ABCESS
• The gingival abscess consist of a purulent focus in the
connective tissue surrounded by polymorphonuclear
leukocytes, edematous tissue and vascular engorgement
• The surface epithelium has varying degrees of intracellular
and extracellular edema, varying degrees of leukocyte
invasion and sometimes ulceration.

8. ETIOLOGY OF GINGIVAL ABSCESS
• Acute inflammatory gingival enlargement results from
bacteria carried deep into the tissues when a foreign material
(eg: toothbrush bristle, a piece of apple core, lobster shell
fragment)is forcefully embedded into the gingiva.
• The lesion is confined in the gingiva and should not be
confused with periodontal and lateral abscess

9. PERICORONAL ASBCESS
• The peri-coronal abscess is associated with crown of partially
erupted tooth and is one of the complication of pericoronitis.
• It is most commonly associated with unerupted or impacted
mandibular third molars
• It may spread posteriorly into oropharyngeal areas and medially
to base of the tongue and the floor of the mouth, often causing
difficulty in swallowing.

10. SIGNS AND SYMPTOMS
• Depends on the severity of the infection
• Throbbing pain which may radiate to ear, throat, TMJ, posterior
submandibular region, and floor of the mouth
• Halitosis due to bacterial putrefaction, releasing volatile sulphur
compounds
• Discharge/exudation of pus
• Tenderness, erythema and oedema of tissues around the tooth
• Dysphagia and dyspnoea in cases where infection has spfread to
oropharynx

11. PERIODONTAL ABSCESS
• It is a localized purulent inflammation in
the periodontal tissue.
• Also known as lateral abscess or
periodontal abscess

12. CLASSIFICATION OF PERIODONTAL
ABSCESS
1. ACCORDINGTO
LOCATION
Abscess in supporting
periodontal tissue
along lateral aspect of
root
Abscess in soft tissue
wall of deep
periodontal pocket

13. 2. ACCORDINGTO ONSET OR
COURSE OF LEISON
ACUTE PERIODONTALABSCESS-
Bright red, ovoid elevation of gingiva,
which may be relatively firm or
pointed and soft. Pus may be
expressed from gingival margin by
applying gentle pressure
CHRONIC PERIODONTALABSCESS-
Usually present as sinus that opens
onto gingival mucosa .It is usually
asymptomatic. Patient may complain
of intermittent exudation, dull pain
slight elevation of tooth

14. 3. DEPENDING ON
NUMBER
SINGLE PERIODONTAL
ABSCESS - Related to
local factors
MULTIPLE PERIODONTAL
POCKET - Reported in
medically compromised
patient and in diabetes
mellitus

15. ETIOLOGY
• Periodontal abscesses occur either in association with periodontitis, or in sites
that were not affected by periodontitis
Periodontitis related Abscess
• The existence of tortuous pockets with cul-de-sac that eventually becomes
isolated, favours abscess formation and localization.
• Marginal closure of a periodontal pocket may lead to an extension of infections
into the surrounding periodontal tissues due to the presence of suppuration
inside the closed pocket.
• Changes in the composition of the microflora, bacterial virulence or in host
defences could also make the pocket lumen inefficient to drain the increased
suppuration

16. • Treatment with systemic antibiotics without subgingival debridement in
patients with advanced periodontitis may cause abscess
• Abscess can form due to inadequate scaling, which will allow calculus to
remain at the deepest pocket depth while resolution of inflammation at
the coronal part of the pocket occludes normal drainage and causes
entrapment of subgingival microflora within the pocket, thus enabling
abscess formation
Non-periodontitis related Abscess
• Impaction of foreign bodies such as bristle of a toothbrush, sharp food
items (fish bone, a piece of apple core, etc.) into gingival tissue if left
unresolved can cause abscess formation

17. • Lateral perforation of the tooth or root surface during endodontic
procedures can also pave the way for abscess formation.
• Local factors affecting morphology of root surface such as cemental
tears, external root resorption, invaginated tooth and cracked tooth may
predispose to abscess formation.

18. HISTOPATHOGENESIS
• Entry of bacteria into the soft tissue wall is most likely the first event
that initiates abscess formation.
• Inflammatory cells are then attracted by chemotactic factors released by
the bacteria and the concomitant inflammatory reaction that leads to
the destruction of connective tissues, the encapsulation of bacteria, and
the production of pus.
• Histologically intact neutrophils are found surrounding a central area of
soft tissue debris and destroyed leukocytes.
• At a later stage, a pyogenic membrane made of , macrophages and
neutrophils is organized.

19. • Acute inflammatory reaction surrounds the purulent area and overlying
epithelium exhibits intracellular and extracellular edema and invasion of
leukocytes.
• Gram –ve bacteria may be seen invading the pocket epithelium and the
altered connective tissue

20. SIGNSAND SYMPTOMSOF ACUTE
ABSCESS
LOCALISED RED ,
OVOID SWELLING
PERIODONTAL POCKET
MOBILITY
TOOTH ELEVATION IN
SOCKET
TENDERNESSTO
PERCUSSION OR
BITING
EXUDATION,ELEVATED
TEMPERATURE
REGIONAL
LYMPHADENOPATHY

21. SIGNS AND SYMPTOMS OF PERIODONTAL
ABSCESS

22. ● Requires correlation of the history and clinical and
radiographic findings
● Dental history : Provides information about previous
treatments, abscesses etc.
● Clinical finding :The suspected area is probed. Continuity
of lesion with gingival margin serves as clinical evidence
that the abscess is periodontal.
DIAGNOSIS

23. RADIOGRAPHIC
SIGNS
• It appears as a discrete area of radiolucency along the
lateral aspect of the root
• Lesions in the soft tissue wall of a periodontal pocket
are less likely to produce radiographic changes than
those deep in the supporting tissues.
• Abscesses on the facial or lingual surfaces are obscured
by the radiopacity of the root.

25. DIFFERENTIAL DIAGNOSIS
• Each of the different abscess of periodontium may be differentially
diagnosed interchangeably
• Specific diagnoses should be made using signs and symptoms such as pulp
vitality, location of abscess, presence of caries and a careful radiographic
examination.
• Periodontal abscesses are easily differentiated from both gingival abscess
and periapical abscess.

27. DIFFERENTIATION BETWEEN GINGIVAL AND
PERIODONTAL ABSCESS
GINGIVAL ABSCESS
• Confined to the gingival margin
• Occurs in former disease free areas
• It is an acute inflammatory response that
results when a foreign object is forcefully
embedded into the gingiva.
• Treatment involves only drainage and
irrigation.
PERIODONTAL ABSCESS
• Involves the supporting periodontal
structures
• Occur in the course of chronic destructive
periodontitis
• The occlusion of the orifice of a preexisting
pocket prevent drainage of the purulent
material leading to abscess.
• Treatment involves drainage,irrigation and
pocket elimination

28. DIFFERENTIATION BETWEEN PERIAPICAL
AND PERIODONTAL ABSCESS
PERIAPICAL ABSCESS
• Pain is sharp, intermittent, throbbing type
• Pain is not localized. Patient can’t locate the
offending tooth
• Vitality test shows nonvital pulp
• Tooth is painful to percussion
• abscess may be associated with deep
restoration.
• Swelling present in apical area. Sinus tract
formation is common.
• Clinically may have no periodontal pocket or
if present, probes as narrow defect
PERIODONTAL ABSCESS
• Pain is dull steady and continuous
• Pain is localised and patient can locate the
offending tooth
• Vitality test shows vital pulp
• Not painful to percussion or movement
• Abscess may be associated with a
preexisting periodontal pocket,caries or
both.
• Swelling usually includes gingival tissue.
fistula is uncommon
• Clinically pocket present.radiographically,
vertical or angular bone loss present

29. TREATMENT OF GINGIVAL ABSCESS
• The treatment of gingival abscess is aimed at reversal of acute
phase and when applicable immediate removal of the cause .
• To ensure procedural comfort ,topical or local anesthesia by
infiltration is administered
• When possible, scaling and root planing are completed to establish
drainage and remove microbial deposits .
• In more acute situations ,fluctuant area is incised with a no:15
scalpel blade, and educate may be expressed by gentle digital
pressure.

30. • Any foreign material (eg: dental floss, impression material) is
removed.
• The area is irrigated with warm water and covered with moist gauze
under light pressure
• Once bleeding has stopped, patient is dismissed with instructions to
rinse with warm salt water every 2 hours for the remainder of the day.
• After 24 hours ,the area is reassessed and if resolution is sufficient
,scaling not previously completed is undertaken
• If residual lesion is large or poorly accessible, surgical access is
required.

31. TREATMENT OF PERICORONAL ABCESS
• As with the other abscesses of periodontium ,the treatment of
the pericoronal abscess is aimed at management of acute
phase, followed by resolution of chronic condition.
• The acute pericoronal abscess is properly anesthetized for
comfort and drainage is established by gently lifting the soft
tissue operculum with a periodontal probe or curettage.
• If the underlying debris is easily accessible, it may be removed
followed by gentle irrigation with sterile saline.

32. • If there is regional swelling,lymphadenopathy or systemic signs,systemic
antibiotics is prescribed.
• The patient is dismissed with instructions to rinse with warm salt water saline
every 2 hrs and area is reassessed after 24 hrs.
• If discomfort was one of the original omplaints, analgesics should be
employed.
• Once the acute phase has been controlled the partially erupted tooth may be
definitively treated with surgical excision of overlying tissue or removal of
offended tooth.

33. TREATMENT OF PERIODONTAL ABSCESS
INCLUDES TWO PHASES:
1. Resolving the acute lesion
2. Management of resulting chronic condition.

34. TREATMENT OPTIONS
1. Drainage through pocket retraction or incision
2. Scaling and root planing
3. Periodontal surgery
4. Systemic antibiotics
5. Tooth removal

35. TREATMENT OF ACUTE ABSCESS
❖ Alleviate symptoms
❖ Control the spread of infection
❖ Establish drainage
Before treatment,
• Review and evaluate patient’s medical history, dental history and
systemic conditions if any.
• Determine the need for systemic antibiotics

36. INDICATIONS FOR ANTIBIOTIC THERAPY
IN PATIENTS WITH ACUTE ABSCESS
• CELLULITIS
• DEEP, INACCESSIBLE POCKET
• FEVER
• REGIONAL LYMPHADENOPATHY
• IMMUNOCOMPROMISED PATIENTS

37. ANTIBIOTIC OPTIONS FOR PERIODONTAL
INFECTIONS
ANTIBIOTIC OF CHOICE
• Amoxicillin, 500mg
• 1.0g loading dose, then 500mg three times a day
for 3 days.
• Reevaluation after 3 days to determine need for
continued or adjusted antibiotic therapy

38. IN CASE OF PENICILLIN ALLERGY,
1. CLINDAMYCIN
• 600mg loading dose, then 300mg four times a day for 3 days
2. AZITHROMYCIN OR CLARITHROMYCIN
• 1.0g loading dose, then 500mg once daily for 3 days

39. DRAINAGE THROUGH PERIODONTAL
POCKET
• Anesthesia
• Pocket wall gently retracted with a periodontal probe or curette in an
attempt to initiate drainage through the pocket entrance.
• Gentle digital pressure and irrigation may be used to express exudates
and clear the pocket.

41. DRAINAGE THROUGH EXTERNAL INCISION
• Abscess dried and isolated with gauze sponges.
• Topical anesthetic applied followed by LA injected peripheral to the lesion
• A vertical incision is made with no 15 surgical blade through the most
fluctuant centre
• The tissue lateral to the incision can be separated with a curette or periosteal
elevator.

43. POST TREATMENT INSTRUCTIONS
• Frequent rinsing with warm saline water
• Periodic application of chlorhexidine gluconate (rinsing or locally by
cotton tipped applicator).
• Reduce exertion and increased fluid intake
• Analgesics given for comfort
• If signs and symptoms persist after 24 h0urs, patient is instructed to
continue previous regimen for additional 24 hours .

44. TREATMENT OF CHRONIC ABSCESS
• Scaling and root planing or Surgical therapy
• Surgical therapy indicated when deep vertical or
furcation defects are encountered that are beyond
the therapeutic capabilities of non surgical
instrumentation.
• Antibiotic therapy may be indicated.

45. CONCLUSION
• Among several acute conditions occurring in the periodontium , the abscess is
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 evaluated to assist in the
diagnosis and to determine the need for systemic antibiotics.

46. REFERENCE
• NEWMAN and CARRANZA’S CLINICAL PERIODONTOLOGY (Third SOUTH ASIA EDITION)
• Periodontal Abscess: A Review by PUNITVAIBHAV PATEL, SHEELA KUMAR G, AMRITA
PATEL
• Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and
endo-periodontal lesions by DAVID HERRERA, BELEN RETAMAL-VALDES, BETTINA
ALONSO, MAGDA FERES (Journal of Periodontology)
https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.16-0642
• [Periodontal abscess: etiology, diagnosis and treatment] by PETERVALYI, ISTVAN GORZO
https://pubmed.ncbi.nlm.nih.gov/15495540/