PERIODONTAL ABSCESS : A REVIEW

• PUNIT VAIBHAV PATEL,SHEETAL KUMAR,AMRITA PATEL

• JCDR – JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH

• YEAR: 2011 |MONTH: April|Volume :5 | Issue: 2

• By-• Navneet Singh Randhawa

• MDS 1st year-• Deptt.of Periodontology and Oral Implantology

INTRODUCTION

• Among several acute conditions occuring in the periodontium,the abscess is the most important.

• Abscesses of the periodontium are localised acute baterial infections confined to tissues of the periodontium.

• The Periodontal abscess represents a chronic and refractory form of the disease.

• It is a destructive process resulting in localized collection of pus,communicating with oral cavity predominantly through gingival sulcus

CHARACTERISTICS

• Localised accumulation of pus in gingival wall of periodontal pockets

• Usually occuring on the lateral aspect of the tooth

• Oedematous red and shiny gingiva• Dome like appearance or may come to a

distinct point

PREVALENCE

• Prevalence of periodontal abscess is relatively high

• Accounts for 6-14% of all emergencies• It is the 3d most common dental emergency

after pulpal infection and pericoronitis• Among dental emergencies periodontal

abscesses represent appr. 8% of all dental emergencies in the world

CLASSIFCATION

3 types of classifications :---Based on anatomic locations--Based on course of disease--Based on number

•Based on anatomic locations :-Gingival abscess which is a localised purulent

infection involving marginal gngivaPericoronal abscessesCombined perio/endo abscessesParietal abscesses

• Based on course of diseaseAcute periodontal abscessChronic periodontal absce

• Based on numberSingle abscess - confined to a single toothMultiple abscess – Abscess confined to more

than one tooth

MICROBIOLOGY

• Micro organisms colonizing periodontal abscesses are primarily Gram negative anaerobic rods

• Porphyromonas gingivalis has highest prevalence present in about 55-100% of cases

• Fusobacterium nucleatum comes next with presence in 44-65%

• Capylobacter rectus ,another common bacteria, has a prevalence rate of about 36%

• Prevotella intermedia,Prevotella melaninogenica have a prevalence rate of 25-100% and 22-30% respectively

PATHOGENESIS

The sequelae of periodontal abscess is as follows:-

Infiltration of pathogenic bacteria

Initiation of inflammatory response

Tissue destruction cased by inflammatory cells

• Formation of inflammatory infiltrate

• Destruction of connective tissue

• Encapsulation of bacterial mass and pus formation

• Entry of bacteria into soft tissue wall initiates periodontal abscess formation

PREDISPOSING FACTORS• Changes in composition of microflora,bacterial virulence and

host defence• Closure of the margins of periodontal pockets can lead to

extension of infection in surrounding tissue • Fibrin secretions lead to local accumulation of pus• Tortuous periodontal pockets assoiated with furcation

defects become isolated and favour the formation of periodontal abscess

• Inadequate scaling allows calculus to remain in deep pockets,resolution occurs in coronal portion which subsequentely blocks drainage

In absence of periodontitis periodontal abscess can develop due to:-

ImpactionInfection of lateral cystsLocal factors affecting the morphology of

root

IATROGENIC FACTORS ASSOSIATED WITH PERIDONTAL ABSCESS

• Post non surgical periodontal abscess can occur due to presence of small remaining fragment of calculus which obstructs pocket entrance

• Post surgical periodontal abscess occurs immediately following periodontal surgery

• It can be due to:- Incomplete removal of subgingival calculus Perforation of tooth wall by endodontic instrument Presence of foreign body in periodontal tissue Post antibiotic periodontal abscess Treatment with systemic antibiotics without subgingival debridement

in patients with advanced periodontitis

DIAGNOSIS

• The diagnosis of periodontal abscess is based on the chief complaint and the history of presenting illness

• Points to be noted while taking history are:-Any medical conditionWhether patient is currently on medication or notAny previous dental treatmentSmoking history

• The main steps and aids in diagnosis are:-

• GENERAL EXAMINATION– Examination of features that may indicate on going systemic

diseases, immune status, fatigue, extremes of age etc• EXTRA ORAL EXAMINATION

– Includes evaluation of symmetry of face for swelling, redness, fluctuance, sinus, trismus and examination of cervical lymph nodes

• INTRA ORAL EXAMINATION– Examination of the oral mucosa and dentition for gingival

swelling, redness and tenderness, checking for suppuration, checking for mobility and elevation, evaluation of oral hygiene and examination of periodontium including periodontal screening

• Supplemental diagnostic aids are:-

RADIOGRAPHSPULP VIALITY TESTSMICROBIAL TESTSLAB FINDINGS

• RADIOGRAPHS– Radiographical techniques such as IOPA,BITEWIGS,OPG are

useful in detection of level of crestal bone,marginal bone loss and periapical condition of tooth involved

• PULP VITALTY TEST– Thermal tests or electrical tests are used to assess the viality

of tooth and the subsequent ruling out of the pulpal infections

• MICROBIAL TESTS– Samples of pus from sinus/abscess expressed from gingival

sulcus could be sent for culture and senstivity tests.• LAB FINDINGS– Lab tests such as TLC,DLC whose elevated levels can be an

indication of inflammatory response of body to bacterial toxins

– Assesment of blood glucose level through HbA1c test/random blood glucose test/fasting blood glucose levels is mandatory in diabetic patients as it can predispose to abscess formation

DIFFRENTIAL DIAGNOSIS

• The periodontal abscess should be ruled out from the following similar conditions and lesions:-

• GINGIVAL ABSCESS– Diffrentiating features of gingival abscess are:-History of recent traumaLocalisation to the gingivaNo periodontal pocket

• PERIAPICAL ABSCESS– Diffrentiated from periodontal abscess by the

following:-Located over root apexNon vital toothLarge caries with pulpal involvementSenstivity to hot and coldPeriapical radiolucency on IOPA

• PERIO-ENDO LESION– Diffrentiated from periodontal abscess by:-Severe periodontal disease involving furcationSevere bone loss close to apexNon vital tooth which is sound or minimally restored

• ENDO-PERIO LESION– Differentiated from periodontal abscess by :-Pulp infection spreading via lateral canalsTooth nonvital with periapical radiolucencyLocalised deep pocketing

• CRACKED TOOTH SYNDROME:-– Diffrentiated from periodontal abscess by:-History of pain on masticationCrack line noted on the crownVital toothPain upon release after biting on cotton rollNo relief of pain after endodontic treatment

• ROOT FRACTURE– Diffrentiated from periodontal abscess by:-Heavily restored crownNonvital tooth with mobilityPost crown with threaded postPossible fracture line and halo radiolucency

around the root which are visible in IOPAsLocalised deep pocketing

TREATMENT

• Principles for the management of simple dental infections are:-

• LOCAL MEASURES:-DrainageMaintain drainageEliminate cause

• SYSTEMIC MANAGEMENT IN 3 STAGES Immediate management Initial managementDefinitive therapy

IMMEDIATE MANAGEMENT

• Advocated in life threatening infections which lead to space infections of orofacial regions

• Hospitalization with supportive therapy plus systemic antibiotics is recommended

• In non life threatening infections oral analgesics and antimicrobial chemotherapy are sufficient

• Dosage of antibiotics depends on severity of infection

• Common antibiotics used are:-1. Phenoxymethylpenicillin 250-500mg qid 5/72. Amoxycillin 250-500 mg tds 5-7 days3. Metronidazole 200-400 mg tds 5-7 days• In case of allergy to pencilln:-1. Erythromycin 250-500 mg qid 5-7 days2. Doxycyline 100 mg bd 7-14 days3. Clindamycin 150-300 mg qid 5-7 days

INITIAL THERAPY

• It comprises of:-1) Irrigation of abscessed pocket with saline2) Removal of foreign bodies if present3) Drainage through sulcus with a probe4) Compression and debridement of soft tissue5) Oral hygiene instructions6) Review after 24-48 hrs

TREATMENT OPTONS OF PERIODONTAL ABSCESS UNDER INTIAL THERAPY

• Drainage through periodontal pocketTreatment of choice if no other complicationSteps are:-

Topical/local anaesthesiaRetraction of pocket wall with probe/curetteGentle digital pressure If lesion is small and has good access then treatment

modality Scaling + Curettage If lesion is large and drainage cannot be established then

treatment modality Antibiotic therapy +Scaling + Curettage

• Drainage through an external incision:-

• If lesion is large,pin pointing and fluctuating,an external incision can be made to drain the abscess

• The steps are as follows:- Topical/local anaesthesia Vertical incision placed with #11 or #15 blade The tissue lateral to incision is separated with a periosteal

elevator Digital pressure applied with gauze In patients with marked swelling tension and pain systemic

antibiotics only should be used as initial treatment After acute condition has receded mechanical debridement is

performed

• Periodontal surgery:-• Main objective of surgical therapy is to

eliminate remaining calculus and to obtain drainage

• Surgical therapy is advocated in cases of:- Deep vertical defectsWhen calculus is left subgingivally after treatment

• Systemic antibiotics with or without local drainage• Antibiotics are the prefferred mode of treatment• Local drainge of abscess is mandatory to eliminate etiological factors• Recommended antibiotic regimen is as follows:-

1. Phenoxymethylpenicillin 250-500mg qid 5/72. Amoxycillin 250-500 mg tds 5-7 days3. Metronidazole 200-400 mg tds 5-7 days

• In case of allergy to pencilln:-1. Erythromycin 250-500 mg qid 5-7 days2. Doxycyline 100 mg bd 7-14 days3. Clindamycin 150-300 mg qid 5-7 days

• Extraction of teeth• Extraction of teeth/tooth is the last resort to treat the

periodontal abscess• Certain guidelines for assessing poor prognosis before

extracting tooth are:-a) Horizontal mobility more than 1mmb) Class 2-3 furcation involvement of a molarc) Probing depth >8 mmd) Poor response to therapye) More than 40% alveolar bone loss

DEFINITIVE TREATMENT

• The treatment following reassessment after the initial therapy is to restore the function and aesthetics and to enable the patient to maintain the health of the periodotium.

• Definitive treatment is done according to the treatment needs of the patient

CONCLUSION

• Early diagnosis and appropiate intervention are extremely important for the management of periodontal abscess

• A single tooth diagnosed with periodontal abscess that responds favourably to treatment will not affect longevity of tooth

• Decision to extract a tooth should be taken only after through clinical assessment