PERIODONTAL ABSCESS

Dr. Ahmed Shawkat Lecturer of Periodontology Minia University

Dr. Ahmed Shawkat

Abscesses of the periodontium are:

Gingival abscess Periodontal abscess Periapical abscess Pericoronal abscess The gingival abscess is localized in the gingiva, caused by injury to the outer surface of the gingiva or impacted foreign object, and does not involve the supporting structures. Clinical features include a red, smooth, sometimes painful, often fluctuant swelling.
Dr. Ahmed Shawkat

Treatment of gingival abscess:

Local anaesthesia is applied. The most fluctuant area is incised with a # 15 blade and the incision is gently widened to permit drainage. The area is cleaned with warm water and covered with gauze. After bleeding stops, the patient is dismissed and instructed to rinse with warm saline for 24 hours.

Dr. Ahmed Shawkat

The pericoronal abscess is associated with the crown of a partially erupted tooth, due to inflammation of the soft tissue operculum. It is most often observed around mandibular third molars. It may be caused by retention of microbial plaque, food impaction, or trauma. The periodontal abscess is an infection located contiguous to the periodontal pocket and may result in destruction of the periodontal ligament and alveolar bone. Periodontal abscess often arises as an acute exacerbation of a preexisting pocket. It is also known as lateral abscess.
Dr. Ahmed Shawkat

Causes of periodontal abscess:

Incomplete removal of calculus during treatment, and subsequent shrinkage of gingival wall that occlude the pocket orifice. Periodontal pocket with tortuous course, when the deep end of the pocket is shut off from the surface. After endodontic therapy due to perforation of the lateral wall of the root or furcation area. Lateral extension of inflammation from the inner surface of periodontal pocket into the connective tissue of the pocket wall. Extension of infection from deep pocket into the supporting periodontal tissues and localization of the suppurative inflammatory process along the lateral aspect of the tooth.
Dr. Ahmed Shawkat

Clinical picture:
The acute periodontal abscess appears as an ovoid elevation of the gingiva along the lateral aspect of the root. Pus may be expressed from the gingival margin with gentle digital pressure. The tooth may be percussion sensitive, and feel elevated in the socket, with throbbing radiating pain. Fever and regional lymphadenopathy are occasional findings.

Dr. Ahmed Shawkat

The chronic periodontal abscess forms after the spreading infection has been controlled by spontaneous drainage. Clinically, it presents as a sinus that opens into the gingival mucosa somewhere along the root. The orifice of the sinus may be probed to reveal a sinus tract deep in the periodontium. This abscess is usually asymptomatic, however, the patient may complain of dull pain. The treatment is the same of a periodontal pocket.

Dr. Ahmed Shawkat

Microbiology:
It has been found that bacteria in periodontal abscess are the same as those recognized as periodontal pathogens such as P. gingivalis ( most virulent), F. nucleatum, P. intermedia, P. micros, and T. forsythia. Since the bacteria associated with periodontal abscess are similar to those of chronic periodontitis, the antimicrobial therapy is quite the same.
Dr. Ahmed Shawkat

Diagnosis of periodontal abscess:

The suspected area should be probed along the gingival margin to detect a channel from marginal area to deeper periodontal tissues. Continuity of the lesion with the gingival margin is a clinical evidence that the abscess is periodontal. In children (deciduous dentition), a sinus orifice along the lateral aspect of a root is usually a result of periapical infection, not periodontal. Clinical findings are more diagnostic than radiographic findings.
Dr. Ahmed Shawkat

Periodontal abscess Associated with preexisting periodontal pocket.

Pulpal abscess Offending tooth may have large restoration.

Radiograph show periodontal May have no periodontal angular bone loss, and pocket. furcation radiolucency. Tests show vital pulp. Tests show non-vital pulp. Swelling usually includes gingival tissue, with occasional fistula. Pain usually dull and localized. Swelling often localized to the apex, with a fistulous tract. Pain often severe and difficult to be localized.

Sensitivity to percussion may Sensitivity to percussion. or may not be present.

Dr. Ahmed Shawkat

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Treatment of periodontal abscess:

The purpose of treatment of acute abscess is to alleviate the pain, control spread of infection, and establish drainage. Before treatment, the patients medical history, dental history, and systemic condition are reviewed and evaluated to assist in the diagnosis and to determine the need for systemic antibiotics.

Dr. Ahmed Shawkat

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Drainage may be established through the pocket or by means of an incision from the outer surface.
Drainage through the pocket: The peripheral area around the abscess is anaesthetized with sufficient topical and local anaesthetic to ensure comfort. Care should be taken not to inject into the swelling itself. A flat instrument or probe is gently introduced into the pocket in an attempt to distend the pocket wall for drainage. Gentle digital pressure and irrigation may be used to express exudates and clear the pocket. A curette can then be inserted into the pocket to further drain and gently curette the mass of tissue.
Dr. Ahmed Shawkat

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Drainage through external incision: the abscess is dried and isolated with gauze sponges, then anaesthetized. A # 15 blade is used to make a vertical incision through the most fluctuant part of the swelling, extending to an area just apical to the abscess. The tissue lateral to the incision can be separated with a curette to drain remaining purulent material, then approximate the wound edges. Sutures are not usually required. The area is then painted with antiseptic, and the patient instructed to rinse with a solution of 1 tsp. salt in a glass of warm water. In abscess presenting with severe swelling and inflammation, aggressive mechanical instrumentation should be delayed in favor of antibiotic therapy. Also, analgesics may be prescribed for comfort.
Dr. Ahmed Shawkat

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Indications for antibiotic therapy in patients with acute abscess:

Cellulitis (non-localized, spreading infection). Deep, inaccessible pocket. Fever. Regional lymphadenopathy. Immunocompromised patients. N.B. In these patients, use of adjunctive antibiotics with short-term high-dose regimen is recommended.
Dr. Ahmed Shawkat

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Recommended antibiotics:
Amoxicillin(500mg): 1gm loading dose. Then, 500mg 3 times daily for 3 days. Reevaluation after 3 days to determine need for continued or adjusted antibiotic therapy. In case of penicillin allergy, give clindamycin (300mg): 600mg loading dose. Then 300mg 4 times daily for 3 days. If amoxicillin was initially prescribed, metronidazole is added to control the residual condition.
Dr. Ahmed Shawkat

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Dr. Ahmed Shawkat

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