periodontal abscess – a localized collection of pus a review

;’ Review
Article
PERIODONTAL ABSCESS – A LOCALIZED COLLECTION OF PUS
A REVIEW
Disha Gupta,1Paras Verma, 2 Garima Dhariwal,3 Shubhi Chaudhary 4
Post Graduate Student,1 Private Practioner,2Private Practioner, Post Graduate Student4
1. Department of Periodontics, Kotiwal Dental College& Research Centre ,Moradabad
2-3 Private Practitioner, New Delhi
4. Department of Periodontics, ITS Dental College & Research Centre, Gaziabad
Abstract
A variety of inflammatory diseases affect the human periodontium. Mostly chronic but some being acute, which if
untreated destroy the dental attachment apparatus resulting in tooth loss. The most common disease, chronic
periodontitis, is characterized by relatively long periods of stability, during which little destruction occurs, interspersed
with periods of acute exacerbation. These periods of increased disease activity may be precipitated by a change in the
bacterial flora, host resistance, or by the blockage of the pocket orifice leading to an acute periodontal abscess.
Key Words: - Dental Informatics, Health information system, Teledentistry
Introduction
The periodontal abscess has been defined as "an acute,
destructive process 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.1It is also known as
lateral abscess or parietal abscess.2
Its importance in clinical periodontal practice can be
summarised by:
a.
b.
c.
d.
Its high prevalence amongst dental emergencies,
and its high prevalence in periodontitis patients.3,4,5
It is usually closely related with periodontitis and
periodontal pockets, affecting not only untreated
patients, but also patients during active treatment
or during maintenance.6,7
Periodontal abscesses are one of the main causes
of tooth extraction and tooth loss, mainly in
maintenance patients.8
Periodontal abscesses may result in complications,
due to bacteremia, that may cause infections in
distant locations.9
Figure-1 Gingival Abscess
b) Periodontal abscess- A localized, purulent
infection involving a greater dimension of the gum
tissue,
extending apically and
adjacent
to
a periodontal pocket.
Classification of periodontal abscess10,11
There are different types of abscess that can involve the
periodontal tissues1) Classification based on etiological criteria
(a)Periodontitis related abscess: When acute infections
originatefrom a biofilm
in the deepened periodontal
pocket.
(b)Non-Periodontitis related abscess: When the acute
infectionsoriginate from another local source. eg. Foreign
body impaction,alteration in root integrity.
2) Classification based on location
a) Gingival abscess-A localized, purulent infection
involves only the soft gum tissue near the marginal
gingiva or the interdental papilla.
Figure-2 Periodontal Abscess
c)
Pericoronal abscess- A localized, purulent
infection within the gum 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).
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Changes in composition of the microflora, bacterial
virulence or in host defenses could also make the pocket
lumen inefficient to drain the increased suppuration. 14
After procedures like scaling, where calculus is dislodged
and pushed into the soft tissue. It may also be due to
inadequate scaling which will allow 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 entrapment of the subgingival flora in
the deepest part of the pocket then cause abscess
formation.15
Figure-3 Pericoronal Abscess
3) Classification based on course
a) Acute 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 with lymph node
enlargement may be present.
b) Chronic 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 over lying the affected root. Pain is
usually of low intensity.
a) Single-Abscess confined to a single tooth.
b) Multiple-Abscess confined to more than one tooth.
Etiology of periodontal abscess
Periodontal abscesses have been either directly associated
with Periodontitis or without the prior existence of a
periodontal pocket.
Periodontitis-related abscess- When acute infection
originates from bacteria present in the subgingival biofilm
in a deepest periodontal pocket. This type of abscess is
form due to-
II.
Non Periodontitis-related abscessWhen the acute infection originates from bacteria
originating from another local source, such as a foreign
body impaction or from alterations in the integrity of the
root leading to bacterial colonization. This type of abscess
form due to
i.
ii.
iii.
Impaction of foreign bodies, such as a toothbrush
bristle, food (such as fish bone) into the gingival
tissue.
Perforation of the lateral wall of a tooth by an
endodontic instrument during root canal therapy.13
Possible local predisposing factors for periodontal
abscess formation:
• External root resorption17
• Invaginated tooth 18
• Cracked tooth 19
• Local factors affecting morphology of roots
Diagnosis
4) Classification based on number
I.
Treatment with systemic antibiotics without subgingival
debridement in patients with advanced periodontitis leads to
a change in the composition of the subgingival microbiota,
leading to superinfection and abscess formation. 16
Closure of margins of periodontal pockets may lead to
extension of the infection into the surrounding tissue
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
gingival margin to the tooth surface.12
Tortuous periodontal pockets especially associated
with furcation defects.13
The diagnosis of a periodontal abscess is usually based on
the chief complaint and the history of the presenting illness.
Usually, the severity of the pain and distress will
differentiate an acute from a chronic abscess. The relevant
medical and dental history is taken for the proper diagnosis.
Following taking the proper history, the next important step
is to examine the patient and the lesion. The 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.20
b. Extra Oral features
Symmetry of face, swelling, redness, fluctuant, sinus,
trismus and examination of cervical lymph nodes.21
c. Intra Oral Features:
Including subjective and objective variables22
i.
Gingival swelling, redness and tenderness, pain
TMU J. Dent Vol. 2; Issue 1. Jan – Mar 2015 | 18
ii.
iii.
iv.
Suppuration either spontaneous, on pressure or
from sinus.
Mobility, elevation and tooth tender to percussion.
Bleeding on probing
Following examination the next step is to confirm the
clinical findings on the basis of radiographs, pulp vitality
test, microbial test, and other findings
Radiographs
11,15
There are several dental radiographical techniques which
are available (periapicals, bitewings and OPG) that may
reveal either a normal appearance of the interdental bone or
evident bone loss, ranging from just a widening of the
periodontal ligament space to pronounced bone loss
involving most of the affected cases.
Intra oral 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. A guttapercha point which is placed through the sinus might locate
the source of the abscess.
Pulp Vitality Test 11,15
later stage, a pyogenic membrane, composed of
macrophages and neutrophils, is organised. The rate of
destruction in the abscess will depend on the growth of
bacteria inside the foci and its virulence as well as on the
local pH, since an acidic environment will favour the
activity of lysosomal enzymes.12
De Witt et al. (1985)12 studied biopsy punches taken from
12 abscesses. The biopsies were taken just apical to the
centre of the abscess. 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(neutrophillymphocyte) 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.
In 7 out of 9 specimens evaluated by electron-microscopy,
gram-negative bacteria were seen invading the pocket
epithelium and altered connective tissue.
Thermal or electrical tests to assess the vitality of the tooth.
Microbial Test2,14
Sample of pus from the sinus, abscess or pruluent 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.
Clinical features of periodontal abscess
Common clinical features of periodontal abscess
 Presence of generalized periodontal disease with
pocketing and bone loss.
 Tooth is usually vital
 Overlying gingival erythematous, tender and
swollen.
 Painful at times
 Pus discharge via periodontal pocket or sinus
opening
 Possible cervical lymphadenopathy
Pathogenesis and histopathology
The entry of bacteria into the soft tissue pocket wall could
be the first event to initiate the periodontal abscess.
Inflammatory cells are then attracted by chemotactic factors
released by the bacteria, and the concomitant inflammatory
reaction leads to destruction of the connective tissues the
encapsulation of the bacterial infection and the production
of pus.
Histologically, in initial phase, the central area of the
abscess filled with neutrophils, in close vicinity with
remains of tissue destruction and soft tissue debris. At a
Figure-4, Schematic diagram showing histopathology of a
periodontal abscess
Microbiology of periodontal abscess
Most frequent type of bacteria was gram-negative anaerobic
rods and gram-positive facultative cocci. In general, gramnegatives predominated over gram-positive and rods over
cocci.
The microbiota of periodontal abscess is not different from
the microbiota of chronic periodontitis lesions. This
microflora is polymicrobial and dominated by non- motile,
Gram- negative, strict anaerobic, rod shaped species.
Porphyromonasgingivalis is probably the most virulent and
relevant microorganism. Other anaerobic species that are
usually found include Prevotellaintermedia, Prevotellamel
aninogenica, Fusobacterium nucleatum, and Tannerella
forsythia. The majority of the Gram –ve anaerobic species
are non-fermentative and display moderate to strong
proteolytic activity. Strict anaerobic, Gram-positive
bacterial species in periodontal abscesses include
TMU J. Dent Vol. 2; Issue 1. Jan – Mar 2015 | 19
Micromonas micros,
bacteriumspp.
Actinomycesspp.
and
Bifido-
The culture studies of periodontal abscesses have revealed a
high prevalence of the following bacteria:
Porphyromonas gingivalis- 55-100% (Lewis et al) 23
Prevotellaintermedia- 25-100% (Newman and Sims)24
Fusobacteriumnucleatum - 44-65% (Hafstrom et al) 25
Actinobacillus
actinomycetemcomitans25%
(Hafstromet al)25
5. Camphylobacter rectus- 80% (Hafstromet al)25
6. Prevotella melaninogenica- 22% (Newman and
Sims)24
1.
2.
3.
4.
Treatment of periodontal abscessThe principles of management of periodontal abscess are as
follows:
1. Local measuresa. Drainage
b. Elimination of the cause
2. Systemic measures: Antibiotics in conjunction with
local measures.
The management of a patient with periodontal abscess can
divided into three stages:
• Immediate management
• Initial management
• Definitive 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. Basically, the
initial therapy comprises of: 27,28
a.
b.
c.
d.
e.
f.
The irrigation of the abscessed pocket with saline
or antiseptics
Removal of foreign bodies, when present
Drainage through the sulcus with a probe or light
scaling of the tooth surface.
Compression and debridement of the soft tissue
wall
Oral hygiene instructions
Review after 24-48 hours; a week later, the
definitive treatment should be carried out.
The treatment options for periodontal abscess under
initialtherapy11,15,22
1. Drainage through pocket retraction or incision
2. Scaling and root planning
3. Periodontal surgery
4. Systemic antibiotics
5. Tooth removal
A. Drainage through the periodontal pocket
1. Immediate Management 26
a.
2. Initial Management:
In life threatening infections, hospitalization,
and supportive therapy together with
antimicrobial therapy will be necessary.
b. Depending on the severity of the infection and
local signs and symptoms the clinical
examination, investigations and initial therapy
can be delayed.
c. In non-life threatening conditions systemic
measures such as oral analgesics and
antimicrobial chemotherapy will be sufficient to
eliminate systemic symptoms, severe trismus
and diffuse spreading infection (facial
cellulitis).
d. Antibiotics are prescribed empirically after
microbiological
analysis
and
antibiotic
sensitivity of pus and tissue specimen.
e. The empirical regimens are dependent on the
severity of the infection. The common
antibiotics used are
f. Phenoxymethyle penicillin 250 -500 mg QID 57 days, Amoxycillin 250 - 500 mg TDS 5-7
days, Metronidazole 200 - 400 mg TDS 5-7
days.
If allergic to penicillin Erythromycin 250 –500 mg QID 5-7
days, Doxycyline 100mg BD 7-14 days, Clindamycin 150300 mg QID 5-7 days can be given.
The steps in surgical drainage through the periodontal
pocket have been demonstrated in the figures 1 to 8. In
general, the steps in the drainage through the pocket
include:
1.
2.
3.
4.
5.
6.
7.
8.
Topical / local anaesthesia (nerve block is
preferred)
The pocket wall is gently retracted with a probe /
curette in an attempt to create an initial drainage
through the pocket entrance
Gentle digital pressure is applied
Irrigation may be used to express the exudates and
to clear the pocket
If the lesion is small and has good access, scaling
and curettage may be undertaken
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.
In such patients, the use of systemic antibiotics
with short term, high dose regimens is
recommended.
Antibiotic therapy alone, without subsequent
drainage
and
subgingival
scaling
is
contraindicated.
B. Drainage through an external incision
However, 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.
b.
Abscess is dried, isolated with gauze sponge
Local anaesthesia (nerve block is preferred)
TMU J. Dent Vol. 2; Issue 1. Jan – Mar 2015 | 20
c.
d.
e.
f.
g.
A vertical incision is given through the most
fluctuant centre of the abscess with a #15 or # 11
surgical blade
The tissue which is lateral to the incision is
separated with a periosteal elevator / curette
Light digital pressure should be applied with moist
gauze pad
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.
In such conditions, once the acute condition has
receded, mechanical debridement including root
planning is performed.
C. Periodontal surgery
1.
2.
3.
4.
5.
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.
Surgical flaps have also been proposed in cases in
which the calculus is left subgingivally after the
treatment.
The main objective of the therapy is to eliminate
the remaining calculus and to obtain drainage at
the same time.
A therapy, with a combination of an access flap
with deep scaling and irrigation with
chlorhexidine, has also been proposed.
As an adjunct to conservative treatment, soft laser
therapy could be used to decrease the pain and
swelling of the gingiva.
D. 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 etiological factors. The recommended antibiotic
regimen usually follows the culture and the sensitive tests.
In general, the empirical antibiotic scan is implemented as
listed below:
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
Complications of Periodontal Abscess: 29
1.
Tooth lossPeriodontal abscesses are associated with tooth
loss in cases of moderate to advanced periodontitis
and during the maintenance phase. Periodontal
abscesses have been suggested as the main cause
for extraction in the maintenance phase. A tooth
with a history of repeated abscess formation is
considered, together with other findings, a tooth
with a ‘‘hopeless’’ prognosis.
Smith & Davies (1986) evaluated 62 abscesses: 14
(22.6%) were extracted as initial therapy, and 9
(14.5%) after the acute phase were controlled. Out
of the 22 treated and followed abscessed teeth, 14
had to be extracted during the following 3 years.
2. Dissemination of the infectionTwo possibilities of infection have been described:
a. The dissemination of the bacteria during
therapy (bacteremia)
b. The dissemination of the bacteria related
with an untreated abscess.
3. Definitive Therapy
Conclusion
Definitive treatment following reassessment after initial
therapy has to perform to restore, function, esthetics of
periodontium & to enable patient maintain periodontal
health. Gingivectomy or periodontal flap surgery with
systemic antibiotics or local antibiotics (tetracycline) is
indicated as definitive treatment of periodontal abscesses.
The periodontal abscess 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
TMU J. Dent Vol. 2; Issue 1. Jan – Mar 2015 | 21
from a periodontal abscess has a worse prognosis and is at a
higher risk of being lost.
17.
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Corresponding Author
Dr.Paras Verma
Private Practioner
MDS (Periodontics)
09555514495
TMU J. Dent Vol. 2; Issue 1. Jan – Mar 2015 | 22