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Periodontal Abscess
The document provides a comprehensive overview of periodontal abscesses, detailing their definition, clinical features, classification, etiology, and microbiology. It outlines diagnostic methods, treatment options, and potential complications related to periodontal abscesses. The conclusion emphasizes the importance of timely management to prevent the spread of infection and tooth loss.
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Periodontal Abscess
- 1. Periodontal Abscess Dr. RinishaSinha MDS Part I Department of Periodontology
- 2. 1) Introduction 2) Clinicalfeatures 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 PeriodontalAbscess 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 maybe 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 : HuanXin Meng -1999; Herrera D, Roldan S, Sanz M - 2000
- 6. Based on ETIOLOGICAL Criteria Periodontitisrelated 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 Alocalized, 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 ANDCOURSE 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 PeriodontalAbscess • 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 periodontalabscess 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 ofbacteria 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 diagnosisof 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• Intraoral 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 ofRecent 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 Retractionor Incision Scaling and Root Planing Periodontal Surgery Systemic Antibiotics Tooth Removal INITIAL THERAPY Reference : Ammons; 1996
- 17. PRINCIPLES OF MANAGEMENT Localmeasures 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 lifethreatening 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 initialtherapy 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 islarge 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 externalincision 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 • Mainobjective 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 rinsingwith 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 orwithout 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 followingreassessment 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 periodontalabscess 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