Treatment of Periodontal Abscess

Philip R. Melnick and Henry H. Takei

48
CHAPTER

HAPTER OUTLINE
SPECIFIC TREATMENT APPROACHES Acute Abscess Chronic Abscess Gingival Abscess Pericoronal Abscess

CLASSIFICATION OF ABSCESSES Periodontal Abscess Gingival Abscess Periocoronal Abscess Acute versus Chronic Abscess Periodontal versus Pulpal Abscess

CLASSIFICATION OF ABSCESSES
The periodontal abscess is a localized purulent inflammation of the periodontal tissues.6 It has been classied into three diagnostic groups: gingival abscess, periodontal abscess, and pericoronal abscess. The gingival abscess involves the marginal gingival and interdental tissues. The periodontal abscess is an infection located contiguous to the periodontal pocket and may result in destruction of the periodontal ligament and alveolar bone. The pericoronal abscess is associated with the crown of a partially erupted tooth.22

tooth perforation or fracture2,24 (Figure 48-3) and foreign body impaction.1,23 Poorly controlled diabetes mellitus has been considered a predisposing factor for periodontal abscess formation22 (Figure 48-4). Formation of periodontal abscess has been reported as a major cause of tooth loss.12-21 However, with proper treatment followed by consistent preventive periodontal maintenance, teeth with signicant bone loss may be retained for many years7 (see Figure 48-10).

Gingival Abscess
The gingival abscess is a localized, acute inflammatory lesion that may arise from a variety of sources, including microbial plaque infection, trauma, and foreign body impaction.22 Clinical features include a red, smooth, sometimes painful, often fluctuant swelling (Figure 48-5).

Periodontal Abscess
The periodontal abscess is typically found in patients with untreated periodontitis and in association with moderate to deep periodontal pockets.5,25 Periodontal abscesses often arise as an acute exacerbation of a preexisting pocket6 (Figure 48-1). Primarily related to incomplete calculus removal, periodontal abscesses have been linked to a number of clinical situations.8,15,16,24 They have been identied in patients after periodontal surgery,12 after preventive maintenance (Figure 48-2),7,10,17,21 after systemic antibiotic therapy,26 and as the result of recurrent disease.15,16 Conditions in which periodontal abscess is not related to inflammatory periodontal disease include 714

Periocoronal Abscess
The pericoronal abscess results from inflammation of the soft tissue operculum, which covers a partially erupted tooth. This situation is most often observed around the mandibular third molars. As with the gingival abscess, the inflammatory lesion may be caused by the retention of microbial plaque, food impaction, or trauma.

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SCIENCE TRANSFER
An abscess can occur in the periodontal tissues, the gingiva, or the periocoronal tissues and can be acute or chronic. Different etiologies can account for abscess formation, and in most cases the offending agent or condition is easily identified. Purulence is often observed, indicating an aggressive white blood cell reaction. Severe inflammation is also usually present, indicating localized engorgement of the blood vessels. Thus, although occurring in a predictable sequence, the host inflammatory response is accentuated in a very localized area. This reaction therefore may represent an effective host reaction to a defined etiologic agent or event (e.g., food impaction, fractured tooth). Treatment usually involves dramatic improvement in the tissues and rapid resolution of the abscess. The differential diagnosis of a periodontal abscess must include periapical abscesses. Therefore, all patients with an abscess should have a radiograph taken of the region, together with a complete history and clinical examination that includes pocket measurements and tooth vitality tests. Periodontal abscesses need to be treated with drainage, usually obtained by curettage of the pocket or by incision through gingival tissue. In cases of cellulitis, fever, lymphadenopathy, or inability to provide drainage, as well as in immunocompromised patients, systemic antibiotics are needed. Diabetic patients have an increased propensity for periodontal abscesses, and this should be considered if episodes recur. Acute periodontal abscesses can often be treated successfully with a complete restoration of periodontal health. Some patients, however, will require additional therapy after resolution of the acute phase.

Figure 48-1 A, Deep furcation invasions are a common location for the periodontal abscess. B, Furcation anatomy often prevents the definitive removal of calculus and microbial plaque.

Acute versus Chronic Abscess

Abscesses are categorized as acute or chronic. The acute abscess is often an exacerbation of a chronic inflammatory periodontal lesion. Influencing factors include increased number and virulence of bacteria present, combined with lowered tissue resistance and lack of spontaneous drainage.11,25 The drainage may have been prevented by a deep, tortuous pocket morphology, debris, or closely adapted pocket epithelium blocking the pocket orice. Acute abscesses are characterized by painful, red, edematous, smooth, ovoid swelling of the gingival tissues.15,16,25 Exudate may be expressed with gentle pressure; the tooth may be percussion sensitive and feel elevated in the socket (Figure 48-6). Fever and regional lymphadenopathy are occasional ndings.22 The chronic abscess forms after the spreading infection has been controlled by spontaneous drainage, host

Figure 48-2 Postprophylaxis periodontal abscess resulting from partial healing of a periodontal pocket over residual calculus.

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Figure 48-3 A, Fistula is observed in attached gingiva of maxillary right canine. B, Elevated flap shows the cause to be a root fracture.

Figure 48-4 Localized periodontal abscess of mandibular right canine of male adult with poorly controlled type 2 diabetes mellitus. For some patients, periodontal abscess formation may be the first sign of the disease.

Figure 48-6 Patient presenting with acute abscess complained of dull pain and a sensation of tooth elevation in the socket. Signs of tissue distention and exudation are evident.

Box 48-1 compares the signs and symptoms of the acute and chronic abscess.

Periodontal versus Pulpal Abscess

Figure 48-5 Plaque-associated mandibular right canine. gingival abscess of To determine the cause of an abscess and thus establish a proper treatment plan, it is often necessary to perform a differential diagnosis between a periodontal and pulpal abscess4 (Box 48-2). (See Figures 48-6 to 48-8.)

response, or therapy. Once homeostasis between the host and infection has been reached, the patient may have few or no symptoms.9 However, dull pain may be associated with the clinical ndings of a periodontal pocket, inflammation, and a stulous tract.22

SPECIFIC TREATMENT APPROACHES

Treatment of the periodontal abscess includes two phases: resolving the acute lesion, followed by the management of the resulting chronic condition24 (Box 48-3).

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BOX 48-1
Signs and Symptoms of Periodontal Abscess Acute Abscess Mild to severe discomfort Localized red, ovoid swelling Periodontal pocket Mobility Tooth elevation in socket Tenderness to percussion or biting Exudation Elevated temperature* Regional lymphadenopathy* Chronic Abscess No pain or dull pain Localized inflammatory lesion Slight tooth elevation Intermittent exudation Fistulous tract often associated with a deep pocket Usually without systemic involvement
Data from Dahlen G: Periodontol 2000 28:206, 2002; Meng HX: Ann Periodontol 4:79, 1999; and Sanz M, Herrera D, van Winkelhoff AJ: The periodontal abscess. In Clinical periodontology, Copenhagen, 2000, Munksgaard. *May indicate the need for systemic antibiotics.

BOX 48-2
Differential Diagnosis of Periodontal and Pulpal Abscess Periodontal Abscess Associated with preexisting periodontal pocket. Radiographs show periodontal angular bone loss and furcation radiolucency. Tests show vital pulp. Swelling usually includes gingival tissue, with occasional fistula. Pain usually dull and localized. Sensitivity to percussion may or may not be present. Pulpal Abscess Offending tooth may have large restoration. May have no periodontal pocket, or if present, probes as a narrow defect. Tests show nonvital pulp. Swelling often localized to apex, with a fistulous tract. Pain often severe and difficult to localize. Sensitivity to percussion.
Modified from Corbet EF: Periodontol 2000 34:204, 2004.

Figure 48-7 A, Maxillary right first molar with fistula on the attached gingiva. B, Using local anesthesia, periodontal probe is introduced through the fistula and angled toward the root end. C, Surgical flap elevation demonstrates failed endodontic therapy and tooth fracture as causing the fistula.

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Figure 48-8 A, Periodontal abscess of maxillary left first molar. B, Periodontal probe is used to retract the pocket wall gently.

BOX 48-3
Treatment Options for Periodontal Abscess 1. 2. 3. 4. 5. Drainage through pocket retraction or incision Scaling and root planing Periodontal surgery Systemic antibiotics Tooth removal

BOX 48-4
Indications for Antibiotic Therapy in Patients with Acute Abscess 1. 2. 3. 4. 5. Cellulitis (nonlocalized, spreading infection) Deep, inaccessible pocket Fever Regional lymphadenopathy Immunocompromised patient

Modified from Sanz M, Herrera D, van Winkelhoff AJ: The periodontal abscess. In Clinical periodontology, Copenhagen, 2000, Munksgaard.

BOX 48-5
Acute Abscess
The acute abscess is treated to alleviate symptoms, control the spread of infection, and establish drainage.19 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 (Boxes 48-4 and 48-5). Antibiotic Options for Periodontal Infections Antibiotic of Choice Amoxicillin, 500 mg 1.0-g loading dose, then 500 mg three times a day for 3 days Reevaluation after 3 days to determine need for continued or adjusted antibiotic therapy Penicillin Allergy Clindamycin 600-mg loading dose, then 300 mg four times a day for 3 days Azithromycin (or clarithromycin) 1.0-g loading dose, then 500 mg four times a day for 3 days
Data from American Academy of Periodontology: J Periodontol 67:1553, 2004.

Drainage through Periodontal Pocket.

The peripheral area around the abscess is anesthetized with sufcient topical and local anesthetic to ensure comfort. The pocket wall is gently retracted with a periodontal probe or curette in an attempt to initiate drainage through the pocket entrance (see Figure 48-8). Gentle digital pressure and irrigation may be used to express exudates and clear the pocket (Figure 48-9). If the lesion is small and access uncomplicated, debridement in the form of scaling and root planing may be undertaken. If the lesion is large and drainage cannot be established, root debridement by scaling and root planing or surgical

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24 hours. This often results in satisfactory healing, and the lesion can be treated as a chronic abscess.25

Chronic Abscess
As with a periodontal pocket, the chronic abscess is usually treated with scaling and root planing or surgical therapy. Surgical treatment is suggested when deep vertical or furcation defects are encountered that are beyond the therapeutic capabilities of nonsurgical instrumentation (Figure 48-10). The patient should be advised of the possible postoperative sequelae usually associated with periodontal nonsurgical and surgical procedures. As with the acute abscess, antibiotic therapy may be indicated.25

Gingival Abscess
Treatment of the gingival abscess is aimed at reversal of the acute phase and, when applicable, immediate removal of the cause. To ensure procedural comfort, topical or local anesthesia by inltration is administered. When possible, scaling and root planing are completed to establish drainage and remove microbial deposits. In more acute situations the fluctuant area is incised with a #15 scalpel blade, and exudate may be expressed by gentle digital pressure. Any foreign material (e.g., dental floss, impression material) is removed. The area is irrigated with warm water and covered with moist gauze under light pressure. Once bleeding has stopped, the patient is dismissed with instructions to rinse with warm salt water every 2 hours for the remainder of the day. After 24 hours the area is reassessed, and if resolution is sufcient, scaling not previously completed is undertaken. If the residual lesion is large or poorly accessible, surgical access may be required.

Figure 48-9 Gentle digital pressure may be sufficient to express purulent discharge.

access should be delayed until the major clinical signs have abated.18 In these patients, use of adjunctive systemic antibiotics13-16 with short-term high-dose regimens is recommended20 (see Box 48-5). Antibiotic therapy alone without subsequent drainage and subgingival scaling is contraindicated.14

Drainage through External Incision.

The abscess is dried and isolated with gauze sponges. Topical anesthetic is applied, followed by local anesthetic injected peripheral to the lesion. A vertical incision through the most fluctuant center of the abscess is made with a #15 surgical blade. The tissue lateral to the incision can be separated with a curette or periosteal elevator. Fluctuant matter is expressed and the wound edges approximated under light digital pressure with a moist gauze pad. In abscesses presenting with severe swelling and inflammation, aggressive mechanical instrumentation should be delayed in favor of antibiotic therapy so as to avoid damage to healthy contiguous periodontal tissues.24 Once bleeding and suppuration have ceased, the patient may be dismissed. For those who do not need systemic antibiotics, posttreatment instructions include frequent rinsing with warm salt water (1 tbsp/8-oz. glass) and periodic application of chlorhexidine gluconate either by rinsing or locally with a cotton-tipped applicator. Reduced exertion and increased fluid intake are often recommended for patients showing systemic involvement. Analgesics may be prescribed for comfort. By the following day, the signs and symptoms have usually subsided. If not, the patient is instructed to continue the previously recommended regimen for an additional

Pericoronal Abscess
As with the other abscesses of the periodontium, the treatment of the pericoronal abscess is aimed at management of the acute phase, followed by resolution of the chronic condition. The acute pericoronal abscess is properly anesthetized for comfort, and drainage is established by gently lifting the soft tissue operculum with a periodontal probe or curette. If the underlying debris is easily accessible, it may be removed, followed by gentle irrigation with sterile saline. If there is regional swelling, lymphadenopathy, or systemic signs, systemic antibiotics may be prescribed. The patient is dismissed with instructions to rinse with warm salt water every 2 hours, and the area is reassessed after 24 hours. If discomfort was one of the original complaints, appropriate analgesics should be employed. Once the acute phase has been controlled, the partially erupted tooth may be denitively treated with either surgical excision of the overlying tissue or removal of the offending tooth.

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Figure 48-10 A, Chronic periodontal abscess of maxillary right canine. B, Using local anesthesia, periodontal probe is inserted to determine severity of the lesion. C, Using mesial and distal vertical incisions, a full-thickness flap is elevated, exposing severe bone dehiscence, a subgingival restoration, and root calculus. D, Root surface has been planed free of calculus and the restoration smoothed. E, Full-thickness flap has been replaced to its original position and sutured with absorbable sutures. F, At 3 months, gingival tissues are pink, firm, and well adapted to the tooth, with minimal periodontal probing depth.

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REFERENCES
1. Abrams H, Kopczyk R: Gingival sequela from a retained piece of dental floss, J Am Dent Assoc 106:57, 1983. 2. Abrams H, Cunningham C, Lee S: Periodontal changes following coronal/root perforation and formocresol pulpotomy, J Endod 18:399, 1992. 3. American Academy of Periodontology: Position paper: Systemic antibiotics in periodontics, J Periodontol 67:1553, 2004. 4. Ammons WF Jr, Harrington GW: The periodontic-endodontic continuum. In Newman MG, Takei HH, Carranza FA, editors: Carranzas clinical periodontology, ed 9, Philadelphia, 2002, Saunders. 5. Becker W, Berg L, Becker B: The long-term evaluation of periodontal treatment and maintenance in 95 patients, Int J Periodont Restor Dent 2:55, 1984. 6. Carranza FA, Camargo PM: The periodontal pocket. In Newman MG, Takei HH, Carranza FA, editors: Carranzas clinical periodontology, ed 9, Philadelphia, 2002, Saunders. 7. Chace R, Low SB: Survival characteristics of periodontally involved teeth: a 40-year study, J Periodontol 64:701, 1993. 8. Corbet EF: Diagnosis of acute periodontal lesions, Periodontol 2000 34:204, 2004. 9. Dahlen G: Microbiology and treatment of dental abscesses and periodontal-endodontic lesions, Periodontol 2000 28:206, 2002. 10. Dello Russo NM: The post-prophylaxis periodontal abscess: etiology and treatment, Int J Periodont Restor Dent 5:29, 1985. 11. Epstein S, Scopp IW: Antibiotics and the intraoral abscess, J Periodontol 48:236, 1977. 12. Garrett S, Polson A, Stoller N, et al: Comparison of a bioabsorbable GTR barrier to a non-absorbable barrier in treating human class II furcation defects: a multi-center parallel design randomized single-blind study, J Periodontol 668:667, 1997. 13. Genco RJ: Using antimicrobials agents to manage periodontal diseases, J Am Dent Assoc 122:31, 1991.

14. Hafstrom CA, Wikstrom MB, Renvert SN, Dahlen GG: Effect of treatment on some periodontopathogens and their antibody levels in periodontal abscesses, J Periodontol 65:1022, 1994. 15. Herrera D, Roldan S, Sanz M: The periodontal abscess: a review, J Clin Periodontol 27:377, 2000. 16. Herrera D, Roldan S, Gonzalez I, Sanz M: The periodontal abscess. I. Clinical and microbiology ndings, J Clin Periodontol 27:287, 2000. 17. Kaldahl WB, Kalwarf KL, Patil KD, et al: Long-term evaluation of periodontal therapy. I. Response to 4 therapeutic modalities, J Periodontol 67:93, 1996. 18. Lewis MA, MacFarlane TW: Short-course high dosage amoxicillin in the treatment of acute dento-alveolar abscess, Br Dent J 161:299, 1986. 19. Manson JD: Periodontics, ed 3, Philadelphia, 1975, Lea & Febiger. 20. Martin MV, Longman LP, Hill JB, Hardy P: Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy, Br Dent J 183:135, 1997. 21. McLeod DE, Lainson PA, Spivey JD: Tooth loss due to periodontal abscess: a retrospective study, J Periodontol 68:963, 1997. 22. Meng HX: Periodontal abscess, Ann Periodontol 4:79, 1999. 23. OLeary TJ, Standish SM, Bloomer RS: Severe periodontal destruction following impression procedures, J Periodontol 44:43, 1973. 24. Sanz M, Herrera D, van Winkelhoff AJ: The periodontal abscess. In Clinical periodontology, Copenhagen, 2000, Munksgaard. 25. Takei HH: Treatment of the periodontal abscess. In Newman MG, Takei HH, Carranza FA, editors: Carranzas clinical periodontology, ed 9, Philadelphia, 2002, Saunders. 26. Topoll H, Lange D, Muller R: Multiple periodontal abscesses after systemic antibiotic therapy, J Clin Periodontol 17:268, 1990.

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