Periodontal Abscess: A Review

PUNIT VAIBHAV PATEL, SHEELA KUMAR G, AMRITA PATEL

ABSTRACT
Periodontal abscess is the third most frequent dental emergency, representing 714% of all the dental emergencies. Numerous aetiologies have been implicated: exacerbations of the existing disease, post-therapy abscesses, the impaction of foreign objects, the factors altering root morphology, etc. The diagnosis is done by the analysis of the signs and symptoms and by the usage of supplemental diagnostic aids. Evidences suggest that the micro-flora which are related to periodontal abscesses are not specific and that they are usually dominated by gram-negative strict anaerobe, rods, etc. The treatment of the periodontal abscess has been a challenge for many years. In the past, the periodontal abscess in periodontal diseased teeth was the main reason for tooth extraction. Today, three therapeutic approaches are being discussed in dentistry, that include, drainage and debridement, systemic antibiotics and periodontal surgical procedures which are applied in the chronic phase of the disease. The localization of the acute periodontal abscess and the possibility of obtaining drainage are essential considerations for successful treatment. Several antibiotics have been advocated to be prescribed in case of general symptoms or if the complications are suspected. Antibiotics like Penicillin, Metronidazole, Tetracyclines and Clindamycin are the drugs of choice.

INTRODUCTION
Periodontium is the general term that describes the tissues that surround and support the tooth structure. The periodontal tissues include the gums, the cementum, the periodontal ligament and the alveolar bone. Among several acute conditions that can occur in periodontal tissues, the abscess deserves special attention. Abscesses of the periodontium are localized acute bacterial infections which are confined to the tissues of the periodontium. Abscesses of the periodontium have been classified primarily, based on their anatomical locations in the periodontal tissue.

 There are four types of abscesses which are associated with the periodontal tissues: 1) Gingival abscess which is a localized, purulent infection that involves the marginal gingiva or the interdental papilla. 2) Pericoronal abscesses which are localized purulent infections within the tissue surrounding the crown of a partially erupted tooth. 3) Combined periodontal/endodontic abscesses are the localized, circumscribed abscesses originating from either the dental pulp or the periodontal tissues surrounding the involved tooth root apex and/or the apical periodontium. 4) Periodontal abscesses which are localized purulent infections within the tissue which is adjacent to the periodontal pocket that may lead to the destruction of the periodontal ligament and the alveolar bone. These are also known as lateral periodontal abscesses or parietal abscesses.

 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. 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. The important characteristics of the periodontal abscess include: a localized accumulation of pus in the gingival wall of the periodontal pockets; usually occurring on the lateral aspect of the tooth; the appearance of oedematous red and shiny gingiva; may have a dome like appearance or may come to a distinct point. Depending on the nature and course of the periodontal abscess, an immediate attention is required to relieve pain and systemic complications. Moreover, the presence of an abscess may also modify the prognosis of the involved tooth and in many cases, may be responsible for its removal. Therefore, accurate diagnosis and the immediate treatment of the abscesses are the important steps in the management of patients presenting with such abscesses. This review focuses on the classification of periodontal abscesses and discusses their aetiology and clinical characteristics with management in clinical practice

PREVALENCE
The prevalence of periodontal abscess is relatively high, which is often the reason why a person seeks dental care. Periodontal abscess accounts for 6% - 14% of all dental emergencies. It is the third most common dental emergency [1st is Pulpal infection (14%-25%), followed by pericoronitis (10%11%)].Among all emergency dental conditions, periodontal abscesses represent approximately 8% of all dental emergencies in the world , and upto 14% in the USA.

CLASSIFICATION
Classification based on aetiological criteria 1) Periodontitis related abscess: When acute infections originate from a biofilm ( in the deepened periodontal pocket) 2) Non-Periodontitis related abscess: When the acute infections originate from another local source. eg. Foreign body impaction, alteration in root integrity.

Classification
Based on the course of the disease Acute periodontal abscess: The abscess develops in a short period of time and lasts for a few days or a week. An acute abscess often presents as a sudden onset of pain on biting and a deep throbbing pain in a tooth in which the patient has been tending to clench. The gingiva becomes red, swollen and tender. In the early stages, there is no fluctuation or pus discharge, but as the disease progresses, the pus and discharge from the gingival crevice become evident. Associated lymph node enlargement maybe present. Chronic periodontal abscess: This is the condition that lasts for a long time and often develops slowly. In the chronic stages, a nasty taste and spontaneous bleeding may accompany discomfort. The adjacent tooth is tender to bite on and is sometimes mobile. Pus may be present as also may be discharges from the gingival crevice or from a sinus in the mucosa overlying the affected root. Pain is usually of low intensity. Based on number 1. Single abscess:Abscess confined to a single tooth. 2. Multiple abscesses:Abscess confined to more than one tooth.

MICROBOLOGY
Streptococcus viridans is the most common isolate in the exudate of periodontal abscesses when aerobic techniques are used. It has been reported that the microorganisms that colonize the periodontal abscesses are primarily Gram negative anaerobic rods. Although they are not found in all cases of periodontal abscesses, high frequencies of Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Campylobacter rectus, and Capnocytophaga spp have been reported. The culture studies of periodontal abscesses have revealed a high prevalence of the following bacteria: 1. Porphyromonas gingivalis-55-100% (Lewis et al in 1995) 2. Prevotella intermedia- 25-100% (Newman and Sims in 1979) 3. Fusobacterium nucleatum -44-65% (Hafstrom et al in 1994) 4. Actinobacillus actinomycetemcomitans-25% (Hafstrom et al in 1994) 5. Camphylobacter rectus- 80% (Hafstrom et al in 1994) 6. Prevotella melaninogenica-22% (Newman and Sims in 1979)

PATHOGENESIS
After the infiltration of pathogenic bacteria to the periodontium, the bacteria and/or bacterial products initiate the inflammatory process, consequently activating the inflammatory response. Tissue destruction is caused by the inflammatory cells and their extracellular enzymes. An inflammatory infiltrate is formed, followed by the destruction of the connective tissue, the encapsulation of the bacterial mass and pus formation. The lowered tissue resistance and the virulence as well as the number of bacteria present, determine the course of infection. The entry of bacteria into the soft tissue wall initiates the formation of the periodontal abscess.

 Predisposing factors that may act to develop an abscess are: 1. 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. 2. Closure of the margins of the periodontal pockets may lead to the extension of the infection into the surrounding tissues, due to the pressure of the suppuration inside the closed pocket. Fibrin secretions leading to the local accumulation of pus, may favour the closure of the gingival margin to the tooth surface. 3. Tortuous periodontal pockets are especially associated with furcation defects. These can eventually become isolated and can favour the formation of an abscess.

PREDISPOSING FACTORS

4. After procedures like scaling where the calculus is dislodged and pushed into the soft tissue. It may also be due to inadequate scaling, which will allow the calculus to remain in the deepest pocket area, while the resolution of the inflammation at the coronal pocket area will occlude the normal drainage, and the entrapment of the subgingival flora in the deepest part of the pocket and then cause abscess formation. 5. Periodontal abscesses can also develop in the absence of periodontitis,due to the following causes: a) Impaction of foreign bodies. b) Infection of lateral cysts. c) Local factors affecting the morphology of the root may predispose to periodontal abscess formation.

The iatrogenic factors which are associated with periodontal abscess

1. Post non-surgical therapy periodontal abscess (Abscess may occur during the course of active non-surgical therapy) Post scaling periodontal abscess. (eg. Due to the presence of a small fragment of the remaining calculus that may obstruct the pocket entrance or when a fragment of the calculus is forced into the deep, non-inflamed portion of the tissue.) Post surgical periodontal abscess When the abscess occurs immediately following periodontal surgery. It is often due to the incomplete removal of the subgingival calculus. Perforation of the tooth wall by an endodontic instrument. The presence of a foreign body in the periodontal tissue (eg. Suture / pack) Post antibiotic periodontal abscess Treatment with systemic antibiotics without subgingival debridement in patients with advanced periodontis may cause abscess formation.

2. 3.

DIAGNOSIS
The severity of the pain and distress will differentiate an acute from a chronic abscess. The relevant medical and dental history is mandatory for the proper diagnosis of such cases. The important point to be considered while taking the history includes: 1. Whether the patient is under the care of a physician or a dentist. 2. Whether the patient is presently on any medication or whether he/she has any medical condition that may affect the periodontal diagnosis or treatment. 3. Any previous dental treatment that may affect the diagnosis or the treatment plan. 4. The smoking history is important because heavy smokers can develop a more severe periodontal disease and they do not respond very well to treatment.

Steps in examination
1. General examination 2. Extra oral examination 3. Intra oral examination

Supplemental Diagnostic Methods

1. RADIOGRAPHS 2. PULP VITALITY TEST 3. MICROBIAL TESTS 4. LAB FINDINGS The elevated numbers of the blood leukocytes and an increase in the blood neutrophils and monocytes may be suggestive of an inflammatory response of the body to bacterial toxins in the periodontal abscess.

DIFFERENTIAL DIAGNOSIS
PERIAPICAL ABSCESS PERIO-ENDO LESION ENDO-PERIO LESION CRACKED TOOTH SYNDROME ROOT FRACTURE

TREATMENT
The treatment of the periodontal abscess does not differ substantially from that of other odontogenic infections. 1. Local measures i. Drainage ii. Maintain drainage iii. Eliminate cause 2. Systemic measures in conjunction with the local measures i. Immediate management ii. Initial management iii. Definitive therapy

IMMEDIATE MANAGEMENT
Immediate management is usually advocated in lifethreatening infections which lead to space infections of the orofacial regions or to diffuse spreading infections (facial cellulites). Hospitalization with supportive therapy, together with intravenous antibiotic therapy, isusually recommended. However, depending on the severity of the infection and the local signs /symptoms, the clinical examination and the investigations and the initial therapy can be delayed to some extent. In non-life threatening conditions, systemic measures such as oral analgesics and antimicrobial chemotherapy will be sufficient to eliminate the systemic symptoms and severe trismus, if present.

INITIAL THERAPY
The initial therapy is usually prescribed for the management of acute abscesses without systemic toxicity or for the residual lesion after the treatment of the systemic toxicity and the chronic periodontal abscess. It comprises of: a. The irrigation of the abscessed pocket with saline or antiseptics b. When present, the removal of foreign bodies c. Drainage through the sulcus with a probe or light scaling of the tooth surface. d. Compression and debridement of the soft tissue wall e. Oral hygiene instructions f. Review after 24-48 hours; a week later, the definitive treament should be carried out.

 The treatment options for periodontal abscess under initial therapy are: 1. Drainage through pocket retraction or incision 2. Scaling and root planning 3. Periodontal surgery 4. Systemic antibiotics 5. Tooth removal

Drainage through the periodontal pocket

Drainage through the pocket is the treatment of choice if the abscess is not complicated by other factors. In general, the steps in the drainage through the pocket include: 1.Topical / local anaesthesia 2. The pocket wall is gently retracted with a probe / curette in an attempt to create an initial drainage through the pocket entrance. 3. Gentle digital pressure is applied 4. Irrigation may be used to express the exudates and to clear the pocket 5. If the lesion is small and has good access, scaling and curettage may be undertaken 6. If the lesion is large and drainage cannot be established, scaling/curettage and surgery is delayed until the major clinical signs have been resolved after antibiotic therapy. 7. In such patients, the use of systemic antibiotics with short term, high dose regimens is recommended 8. Antibiotic therapy alone, without subsequent drainage and subgingival scaling is contraindicated

Drainage through an external incision

If the lesion is sufficiently large, pin-pointed and fluctuating, an external incision can be made to drain the abscess. The steps are as follows: a. Abscess dried, isolated with gauze sponge. b. Local anaesthesia (nerve block is preferred). c. A vertical incision done through the most fluctuant centre of the abscess with a #15 or # 11 surgical blade. d. The tissue which is lateral to the incision is separated with a periosteal elevator / curette. e. Light digital pressure applied with moist gauze pad. f. In patients with abscess, with marked swelling, tension and pain, it is recommended to use systemic antibiotics as the only initial treatment in order to avoid the damage to the healthy periodontium. g. In such conditions, once the acute condition has receded, mechanical debridement including root planning is performed. h. Once the bleeding and the suppuration have ceased, the patient may be dismissed.

Post treatment instructions

a. Frequent rinsing with warm salt water. b. Periodic application of chlorhexidine gluconate (either rinsing/cleaning locally with a cotton tipped swab). 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.

Periodontal surgery
1. Surgical therapy (either gingivectomy or flap procedures) has also been advocated mainly in abscesses which are associated with deep vertical defects, where the resolution of the abscess may only be achieved by a surgical operation. 2. Surgical flaps have also been proposed in cases in which the calculus is left subgingivally after the treatment. 3. The main objective of the therapy is to eliminate the remaining calculus and to obtain drainage at the same time. 4. A therapy, with a combination of an access flap with deep scaling and irrigation with chlorhexidine, has also been proposed. 5. As an adjunct to conservative treatment, soft laser therapy could be used to decrease the pain and swelling of the gingiva

Systemic antibiotics with or without local drainage

Antibiotics are the preferred mode of treatment. However, the local drainage of the abscess is mandatory to eliminate the aetiologic factors. The recommended antibiotic regimen usually follows the culture and the sensitive tests. a. Phenoxymethyl penicilln 250-500mg qid 7 10 days b. Amoxycillin/ Augmentin 250- 500 tds 7- 10 days c. Metronidazole 250mg tds 7 10 days (Can be combined with amoxycillin. The use of metronidazole is contraindicated in pregnant patients/ consumption of alcohol) d. Tetracycline HCl 250mg qid 7-14 days e. Doxycyline 100mg bd 7-14 days (the use of tetracycline is contraindicated in pregnant patients and in children below 10 yrs)

Extraction of the teeth

Extraction of the tooth is the 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: a. Horizontal mobility more than 1mm. b. Class II-III furcation involvement of a molar. c. Probing depth > 8 mm. d. Poor response to therapy. e. 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 periodontium. Definitive periodontal treatment is done according to the treatment needs of the patient.

CONCLUSIONS
The occurrence of periodontal abscesses in patients who are under supportive periodontal treatment has been frequently described. Early diagnosis and appropriate intervention are extremely important for the management of the periodontal abscess, since this condition can lead to the loss of the involved tooth. A single case of a tooth diagnosed with periodontal abscess that responds favourably to adequate treatment does not seem to affect its longevity. In addition, the decision to extract a tooth with this condition should be taken, while taking into consideration, other factors such as the degree of clinical attachment loss, the presence of tooth mobility, the degree of furcation involvement, and the patients susceptibility to periodontitis due to the associated systemic conditions.