ABSCESS OF THE

PERIODONTIUM
PRESENTED BY
SHILPA SHIVANAND
II MDS
 Contents
 Introduction
 Abscess of the periodontium
 Periodontal abscess
O Definition
O Prevalence
O Classification
O Etiology
O Clinical features
O Pathogenesis and histopathology
O Microbiology
O Diagnosis
O Differential Diagnosis
O Treatment
O Complications and postoperative care.
 Gingival abscess
 Pericoronal abscess
 Conclusion
 References
 INTRODUCTION
O Abscess- Localised collection of pus purulent material
collected in a cavity caused by destruction of tissues.
(GPT)
O Abscesses of the periodontium have been classified
primarily, based on their anatomical locations in the
periodontal tissue. There are three types:
O Gingival abscess
O Pericoronal abscess
O Periodontal abscess.
O 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.

O It is a destructive process occurring in the

periodontium, resulting in localized collections of pus,
communicating with the oral cavity through the
gingival sulcus or other periodontal sites and not arising
from the tooth pulp
 Periodontal Abscess
O A localized purulent infection within the tissues
adjacent to the periodontal pocket that may lead to the
destruction of periodontal ligament and alveolar bone
 DEFINITION
O A periodontal abscess is a localized
purulent infection in the periodontal tissue

(GLICKMAN)

O A localized purulent inflammation of the periodontal

tissues. It is also known as Lateral periodontal abscess
or Parietal Abscess.

(AAP GLOSSARY 1992)

O An acute, destructive process in the periodontium

resulting in localized collection of pus communicating

with the oral cavity through the gingival sulcus or other
periodontal sites & not arising from the tooth pulp.
(RANNY 1977)
O A lesion with an expressed periodontal break down

occurring during a limited period of time & with easily

detectable clinical symptoms with a localized
accumulation of pus located within the gingival wall of
the periodontal pocket.

(Hafstrom et al-1994, Dewitt et al1985)

 CLASSIFICATION
I) Depending on the location of the abscess
(Gillette and Van House-1980, AhI et al 1986)
 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.
usually located beyond Mucogingival junction.
II) Depending on the course of the lesion
(Galego-Feul et al-1995, Carranza - 1990)
 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
III. Depending on the number
(Topell et al 1990)
 Single periodontal abscess – related to local factors,
which contribute to the closure of the drainage of a
periodontal pocket.
 Multiple periodontal abscess
O Seen in uncontrolled diabetes mellitus,
O medically compromised patients,
O in patients with untreated periodontitis after systemic
antibiotic therapy for non-oral reasons .
IV. According to periodontal tissue affected
(Meng -1999)
 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.
V. Depending on the cause of acute infectious
process
(Lindhe)
 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.
VI. Based on location of abscess
(Carranza)
 Abscess in the supporting periodontal tissues along
the lateral aspect of the root, sinus tract present.

 Abscess in the soft tissue wall of a deep periodontal

pocket.
 PREVALENCE
O 3rd most prevalent emergency infection, after acute
alveolar (14-25%) and periodontitis (10-11%).

O More likely to occur in a pre-existing periodontal

pocket.

O More in molar sites (> 50%)

O The prevalence of periodontal abscesses has been

studied in emergency dental clinics (Galego-Feal et al.

1996, Ahl et al. 1986)

O In general dental clinics (Lewis et al. 1990)

O In periodontitis patients before and during periodontal

treatment (Gray et al. 1994) and

O In periodontitis patients during periodontal maintenance

O Gray et al (1994) monitored periodontal patients in an
army clinic and found that periodontal abscess had
prevalence of 27.5%. In this population, 13.5% of
patients undergoing active periodontal treatment had
abscess formation and while in untreated patients it is
59.7%.
O Kaldahl et al (1996) in a 7-year prospective
longitudinal treatment study for occurrence of
periodontal abscess. From the 51 patients included, 27
developed abscesses were detected.

O 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.
 ETIOLOGY
O 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

(Periodontitis – Related Abscess)
O In periodontitis, a periodontal abscess represents a
period of active bone destruction (exacerbation).
O The existence of tortuous pockets, with cul-de-sac,
which eventually become isolated, may favor the
formation of abscesses .
O 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.
O The fibrin secretions leading to the local accumulation
of pus may favor the closure of the gingival margin to
the tooth surface.
O Changes in the composition of the microflora, bacterial
virulence, or in host defenses (Kareha et al. 1981)
could also make the pocket lumen inefficient to drain
the increased suppuration.
O The development of a periodontal abscess in
periodontitis may occur at different stages during the
course of the infection:
O As an acute exacerbation of an untreated periodontitis
(Dello Russo 1985)
O During periodontal therapy (Dello Russo 1985,
Carranza 1990)
O In refractory periodontitis (Fine 1994) or
O During periodontal maintenance (Chace & Low 1993,
McLeod et al. 1997)
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.
O due to inadequate scaling which will allow calculus
to remain in the deepest pocket area,
O while the resolution of the inflammation at the coronal

pocket area will occlude the normal drainage and then

cause the abscess formation.
O 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.

O Incomplete removal of sub gingival calculus or the

presence of foreign substance. Ex-sutures, regenerative

devices or periodontal pack.
O 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.
(Garrett et al 1997)
 Post-antibiotic periodontal abscess.

O Treatment with systemic antibiotics without subgingival

debridement in patients with advanced periodontitis

may also cause abscess formation.

O It is Attributed to a likely change in the composition of

subgingival microbiota, leading to a super infection and

massive inflammation.
O Topell et al (1990) reported on the development of

multiple abscess (4-10) in 10 untreated periodontal

patients who received systemic antibiotic therapy.
(Penicillin, tetracycline) for non-oral infections.

O Helovuo et al. (1993) studied 72 patients with untreated

periodontitis, who were followed for 12 weeks, after

intake of systemic antibiotics for non-oral reasons.
Patients were divided into 3 groups according to the
antibiotic used,
O 10 out of 24 patients (42%) in the penicillin group
developed abscesses within the next 4 weeks.
O The number of abscesses ranged between 1-10. No
abscesses were detected in the erythromycin or the
control groups.
O Koller-Benz et al. (1992) showed that after initiation of
nifedipine therapy, 8 abscesses appeared in 5 days.
O The nifedipine therapy was discontinued, and the
abscesses resolved. 3 weeks later the treatment was
resumed, and after 2 weeks another abscess was
detected.
2. Periodontal abscesses in the absence of Periodontitis
O Impaction of foreign bodies. Periodontal abscesses
caused by foreign bodies, related with oral hygiene
aids, have been named "oral hygiene abscesses“.
O Perforation of the tooth wall by an endodontic
instrument (Carranza 1990)
O Infection of lateral cysts (Kareha et al. 1981)
O Local factors affecting the morphology of the root
may predispose to periodontal abscess formation
 PATHOGENESIS AND
HISTOPATHOLOGY
O The entry of bacteria into the soft tissue pocket wall

could be the first event to initiate the periodontal

abscess.
O Inflammatory cells are then attracted by chemotactic

factors released by the bacteria, and

O The concomitant inflammatory reaction leads to

destruction of the connective tissues, the encapsulation

of the bacterial infection and the production of pus.
O Histologically, the intact Neutrophils are found

surrounding a central area of soft tissue debris and

destroyed leukocytes.
O At a later stage a pyogenic membrane, composed of

macrophages and neutrophils is organized.

O 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;
(c) An intense foci of inflammation (neutrophil-
lymphocyte) with the surrounding connective tissue
destroyed and necrotic;
(d) A destroyed and ulcerated pocket epithelium;
(e) A central region, as a mass of granular, acidophilic,
and amorphous debris.
 MICROBIOLOGY
O 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.
O The periodontal abscess microbiota is usually
indistinguishable from the microflora found in the
subgingival plaque in adult periodontitis.
O The microflora from abscesses and deep pockets was
similar and harbored higher proportions of pathogens
when compared to the microflora of shallow pockets.
OBacterial species with capacity of producing proteinases,
such as P. intermedia, are important, since they may in-
crease the availability of nutrients, and thereby, increasing
the number of bacteria inside the abscess (Jansen & Van
der Hoeven 1997)
Culture studies of periodontal abscesses have revealed
high prevalences of
 Porphyromonas gingivalis (55-100%),
 Prevotella intermedia (25-100%), and
 Fusobacterium nucleatum (44-65%) other pathogens

Which have been reported are

 Actinobacillus actinomycetemcomitans (25%)
 Campylobacter Rectus (80%)
 Prevotella Melaninogenica (22%)
O 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

 DIAGNOSIS
Diagnosis should be based on
O Patients chief complaint

O Clinical signs and symptoms

O Additional information can be obtained through a

careful medical and dental history, and radiographic

examination.
O Symptoms range from light discomfort to severe pain,

tenderness of the gingiva, swelling, tooth mobility,

tooth elevation, sensitivity of the tooth to palpation
O Another common finding is suppuration, either
spontaneous or after pressure on the abscess combined
with rapid tissue destruction and deep pocket formation.
O 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.
O Systemic involvement has been reported in some severe
cases, including fever, malaise, leukocytosis and
regional lymphadenopathy.
Van Winkelhoff et al (1985) established 4 diagnostic
criteria
O Association of pocket of >/= 6 mm,
O Presence of bleeding on probing,
O Evidence of radiographic bone loss &
O Absence of periapical lesion.
O Other recommended additional diagnostic tools: include

the use of Dark-Field Microscopical examination of

the abscess microflora in order to exclude an
endodontic origin, due to the higher percentage of
spirochetes in periodontal abscesses.
O Positron Emission Tomography and a Fluorine-18-

Fluoromisonidazole marker for detection of

periodontal abscesses and other anaerobic infections in
the mouth. Results from the clinical study showed that
100% of periodontal abscesses were found with this
procedure.
 DIFFERENTIAL
DIAGNOSIS
O Gingival abscess
O Periapical abscess,
O Lateral periodontal cyst,
O Pericoronitis
O Vertical root fracture,
O Osteomyelitis
O Eosinophilic granuloma
Periodontal abscess Gingival abscess

Involves supporting periodontal Confined to marginal and / or

structure interdental gingiva.

Often occurs in the course of Occurs in previously disease free

chronic destructive periodontitis areas.

X-ray- bone loss present Acute inflammatory response to

forcing of foreign material into the
gingiva. No bone loss

Pocket present No pockets

Periodontal abscess Gingival abscess

Pain – diffuse. Pain – dull

May affect the entire side of the localized.

face.

Affected by thermal changes Not affected by thermal changes.

Periodontal abscess Periapical abscess

Associated with preexisting Associated with deep restoration,

periodontal pockets, caries or caries or Tooth wear
both.

Pulp test- vital. Non-vital

Swelling generalized and located Swelling localized often with

around the involved tooth and fistulous tract opening in the
gingival margin, seldom with a apical area.
fistulous tract.
Periodontal abscess Periapical abscess

Pain – dull, constant, less severe, Pain - severe, throbbing, last for
localized and patient usually can long, deep, unable to locate the
locate the offending tooth offending tooth

Pain associated with the Severe than periodontal abscess.

movement or percussion is not as
severe as with a pulpal disease

Lateral radiolucency Apical radiolucency

Periodontal abscess Periapical abscess

Angular bone defects, Endodontic filling or

Furcation involvement Endodontic or post perforations

Responds dramatically well to Responds poorly or not at all to

sub gingival debridement. periodontal therapeutic
interventions
 Periodontal cyst (non-infected)
O No inflammatory signs
O More common in mandibular canine – premolar
region
O On radiograph well defined oval radiolucency on the
lateral surface of the root, with chronic border, < 1
cm in diameter.
O Microscopically thin, non-keratinized stratified
squamous epithelia with focal epithelial thickening.
Inflammatory cells seen if secondarily infected.
O Treatment – Enucleation.
 Pericoronitis
O Usually seen in incompletely erupted tooth
O Commonly associated with mandibular 3rd molar.

 Osteomyelitis
O Rapid diffuse bone destruction may occur with in a few
days
O Deeper pain being only symptom.
O X-ray – indistinct trabecular and disappearance of
lamina dura
O As infections increases, lymphadenopathy, fever and
malaise are more common.
 Eosinophilic granuloma

O Diagnosed by the rapid bone destruction after periodontal

therapy
O Biopsy.

 Vertical root fracture

O Loupes or operating microscopes assist in visualization of

cracks/fractures
O The bite test, Transillumination with fiber optic light and

use of dyes helps in detecting the suspected fracture

O Differential diagnosis should also be made with self-

inflicted gingival injuries.

O Some lesions caused by patient's habits can mimic

periodontal abscesses, such as trauma of the gingiva

with a pencil (Rodd 1995) or with a safety pin (Beckett
et al. 1995)
O A careful evaluation is the main factor to solve these

cases, since conventional treatments usually fail unless

the habit is discontinued.
 TREATMENT
Treatment of acute periodontal abscess usually
involves two stages
O Management of the acute lesion.
O 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
O Alleviate pain,

O Control the spread of infection, and

O To establish drainage.
Protocol recommended.
O Incision and drainage (closed or open approach)
O Scaling and Root planning
O Compression and debridement of soft tissue wall.
O Use of different systemically administered
antibiotics
O Tooth extraction.
Incision and drainage
O Through the pocket (Closed approach)
O Incision from the outer surface (Open approach)

Closed approach
O Anesthesia
O Flat instrument /probe – carefully introduced into the
pocket.
O Distend the pocket wall for drainage.
O Further drain and gently curettage the mass of tissue
internally.
Open approach
O Vertical incision through the most fluctuant part of the
swelling, extending to an area just apical to the abscess.
O Curette the granulomatous tissue internally.
O External aspect of the abscess is gently pushed to drain
the remaining pus.
O Saline irrigation
O Approximate to wound margin
O No sutures required.
Antibiotic administration
O Metronidazole – 200 mg, tid, 5 days –Smith and
Davies(1986)
O Tetracycline – 1 gm / day – 2weeks -Hafstrom(1994)
O Azithromycin, 500mg, OD, 3 days.
O Amoxicillin + Clavulanate, 500 + 125 mg, tid, 8days.
Chronic periodontal Abscess
Surgical therapy
O Gingivectomy

O Flap procedures

O Mainly in abscess associated with deep vertical defects,

where the resolution of the abscess may only be

achieved by a surgical operation.
O Objective : To eliminate the remaining calculus and to

obtain drainage at the same time.

For the treatment of Gingival Abscess, the protocol
should include the following:
O Elimination of the foreign object, through careful

debridement (Abrams 1983)

O Drainage through the sulcus with a probe or light

scaling,
O Rinsing with warm saline and follow-up after 24-48

hours
 COMPLICATIONS
 Tooth Loss
O Suggested as the main cause for extraction in the
maintenance phase.
O History of repeated abscess formation is considered as a
“hopeless” prognosis for the tooth.
O In a retrospective study, 45% of teeth with periodontal
abscesses in a maintenance population were extracted
(McLeod et al. 1997)
 Dissemination of the infection
Two possibilities have been described:
I. The dissemination of the bacteria during therapy
(bacteraemia); or
II. Bacteraemia related with an untreated abscess.

The Dissemination of the bacteria during therapy

O 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.
O Gallaguer et al. (1981) described a healthy patient with

a periodontal abscess who was treated with drainage

and curettage, but without systemic antibiotic.

O 2 weeks later a brain abscess was diagnosed,

Microbiology of the lesions demonstrated, among other

bacteria, Bacteroides melaninogenicus and other

bacteroides, species.
II.Bacteraemia related with an untreated abscess.
O Cellulitis in breast cancer patients has been claimed to
follow gingivitis or an abscess (Manian 1997)
O due to transient bacteraemia and reduced host defenses
(radiation therapy and axillary dissection). The breast
and the upper extremities are particularly susceptible to
infections of oral origin (Manian 1997)
O periodontal abscess is also associated with the
development of a cervical necrotizing fascitis. it is
frequently associated with oropharyngeal infections.
 Necrotising cavernositis :-
O Inflammation and necrosis of the Corpora
Cavernosa or Corpus Spongiosum of male
external genital organ leading to impotency.
O Culture from corposa carvernosa showed
Peptostreptococcus species and Fusobacterium
species. ( Pearle and Wendel 1993)
 Sickle cell crisis in patient with sickle cell anemia:

O A periodontal abscess may also cause a sickle cell

crisis, in patients with sickle cell anaemia (Rada et al.

1987)
O During the crisis, the abscess must be treated with

antibiotics, aiming to avoid pain and to prevent

dissemination of the infection.
O Definitive treatment should be delayed until resolution

of the crisis.
 Gingival Abscess
O A localized purulent infection that involves the
marginal gingiva or interdental papilla
Gingival Abscess
O Etiology
O Acute inflammatory response to foreign substances
forced into the gingiva
O Clinical Features
O Localized swelling of marginal gingiva or papilla
O A red, smooth, shiny surface
O May be painful and appear pointed
O Purulent exudate may be present
O No previous periodontal disease
O Treatment
O Elimination of foreign object

O Drainage through sulcus with probe or light scaling

O Follow-up after 24-48 hours

 Pericoronal Abscess
O A localized purulent infection within the tissue
surrounding the crown of a partially erupted tooth.
O Most common adjacent to mandibular third molars in
young adults; usually caused by impaction of debris
under the soft tissue flap
Pericoronal Abscess
O Clinical Features

• 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
O Treatment Options

• 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
O The treatment of pericoronal abscess is aimed at

 Managemant of acute abcess,followed by

 Resolution of the chronic condition.

O The acute pericoronal abscess is properly anaesthetized
O Drinage is established –lifting the soft tissue operculum
with periodontal probe or currette
O If the underlying debris is accessible, It must be
removed-followed gentle irrigation
O Systemic antibiotics are given- swelling,regional
lymphadenopathy.
O The patient is then instructed to rinse with warm water
for every 2 hours and reassesed for 24 hours.
O Analgesics also prescribed-discomfort.
O Acute phase has been controlled, the partially erupted
teeth may be definitely treated with ;

O Surgical excision of the overlying gingiva

O Removal of the offending tooth.
CONCLUSION
 REFERENCES
O Clinical Periodontology : Carranza,
Newman 9th Edition
O Clinical Periodontology and implant
dentistry – Lindhe 4th edition
O Periodontal abscess: a review. JCDR-2011
O Periodontal Abscess review, JCP-2000,
27:377-386.
O Perio 2000 volume 34, 2004.