Review Article

Periodontal abscess –A sneak peek

Ramanarayana Boyapati1,*, Srikanth C2, Shyam Sunder S3, Arpita Paul R4, Kiran Kumar Nagubandi5
1,3Senior Lecturer, 2Professor & HOD, 4,5Professor, Mamata Dental College & Hospital, Khammam
Telangana State, India.

*Corresponding Author:
Email: dr.ramanarayana@gmail.com

Abstract
A periodontal abscess, synonyms being lateral abscess or parietal abscess, is characterized by accumulation of pus locally
within the supporting apparatus of periodontium. Generally these abscesses are acute or sudden in onset and are characteristically
classified on the basis of its location. Interestingly these periodontal abscess remain mostly painless and occurs as a sequel of
progressive periodontal diseases. The immune response of the host harnessed as local and systemic resistance demarcates the
proliferation and multiplication of the microorganisms within the gingival soft tissue. Incomplete debridement of the periodontal
pocket serves as another major etiology. Inoculation of the bacteria into the periodontal tissue occurs as a result of various
penetrating injuries like bristle of the toothbrush or food remnants like fish bone etc. Endondontic procedural accidents like root
canal perforations also could pave way for abscess formation as a result of an established endo-perio lesion. Signs and symptom:
the main symptom is pain, worsened by biting associated with mobile tooth surrounded by erythematous, swollen mucosa,
characterized by regional lymphadenitis and systemic illness. Treatment of periodontal abscess mainly involves adequate and robust
management of the acute lesion followed by addressing the original or underlying residual lesions. Incision and drainage being the
primary emergence protocol could be established through various pathways like pocket lumen, subgingival scaling and root
planning and curettage of the pocket epithelium followed by systemic antibiotics and analgesics.

Keywords: Periodontal abscess, Periodontal pocket, Tooth mobility, Gingival abscess

Introduction Gingival abscess in previously healthy site or infected

Periodontal abscess is one of the few clinical site:
situations in Periodontics, where patient may seek A. Periodontal abscess – either acute or chronic in
immediate care. Periodontal abscess is a localized origin
purulent infection of periodontal tissues seen with B. Periodontal abscess – in incompletely erupted teeth.
moderate and advanced periodontitis. Sometimes it can 5. Depending on the cause of acute infectious
even persist in patients who have already underwent process (Lindhe – 4th edition)
periodontal treatment and is in under maintenance phase. A. Periodontitis related abscess
It is known as “lateral abscess or parietal abscess”.(1) B. Non-periodontitis – related abscess.
Common periodontal pathogens have been observed in 6. According to Carranza (4th edition): Based on
this lesion and some etiologic factors may be responsible location (1990)
for its recurrence. This condition can be isolated or A. Abscess in the supporting periodontal tissues along
associated with factors that can change the prognosis of the lateral aspect of the root resulting in sinus
affected teeth.(14) formation in the bone that extends laterally from the
abscess to the external surface.
Classification(2)
1. Depending on the location of the abscess (Gillette
andVay House 1980 AGIet al 1986).
A. Gingival abscess –localized painful swelling
affecting only the marginal and inter dental gingival
caused by impaction of particles.
B. Periodontal abscess – affects deeper structures like
pockets, furcations, osseous defects usually located
beyond mucogingival junction.
2. Depending on the course of the lesion (Galego-
Feul etal 1995, carranza 1990)
A. Acute periodontal abscess.
B. Chronic Periodontal abscess
3. Depending on the number(Topollet al 1990)
A. Single periodontal abscess
B. Multiple periodontal abscess
4. According to Meng (1999)
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Ramanarayana Boyapati et al. Periodontal abscess –A sneak peek

B. Abscess in the soft tissue wall of a deep periodontal supporting structures are called gingival abscess
pocket. (Carranza – 4th Edition).

Etiology
 Forceful impaction of a foreign object into the
gingival sulcus.
 Either directly associated with periodontitis or in
sites without prior existence of a periodontal pocket.

Prevalence: There is high prevalence of periodontal

abscess which contributes to approximately 6-14% of all
dental emergencies. Of all commonly encountered dental
emergencies, periodontal abscess is rated in the third
position after pulpal infection (14%-25%), followed by
pericoronitis (10%-11%).
a. Post therapy periodontal abscess
1. Post scaling periodontal abscess – occurs due to
Definition: A periodontal abscess is a localized purulent
small fragments of remaining calculus or the
inflammation in the periodontal tissues. (Glickman)
fragments which have been accidentally forced into
deep pockets.
Pathogenesis of peridontal abscess
2. Post-surgery periodontal abscess –occasionally the
Formation of periodontal abscess might occur in the
presence of foreign substances like sutures,
following ways:
regenerative materials and periodontal pack and
1. Localization of the infectious inflammatory process
incomplete removal of sub gingival calculus could
occurs along the lateral surface of the root as a result
pave way for post-surgical periodontal abscess.
of extension of infection into deeper periodontal
3. Post-antibiotic periodontal abscess – change in the
supporting tissues form periodontal pocket.
sub gingival microbiota occurs as a result of
2. The inflammatory process can also penetrate into
treatment of advanced periodontitis with only
the connective tissue of the pocket wall as a result
systemic antibiotics without subgingival
of lateral extension of the infection along the inner
debridement resulting in unresolved inflammation
surface of the pocket depending on the pathway of
and superinfection.
least resistance.
3. In furcations two walled defect as seen in cul-de-sac
b. Non-periodontitis related abscess: could be of
defect, the periodontal abscess generally follows a
gingival or periapical origin. Ex: impingement of
tortuous course along the root.
foreign bodies like orthodontic elastics, piece of
4. Occlusion of the pocket orifice resulting in the
dental floss /tooth pick, dislodged restoration,
shrinkage of the gingival wall as a result of
cemental tear etc.
incomplete removal of the calculus during
periodontal pocket treatment.
c. Oral hygiene abscess
5. Periodontal abscess can also occur in the absence of
Periodontal abscess caused by foreign bodies related to
periodontal disease in situations of perforations of
oral hygiene aids is known as oral hygiene abscess.
lateral wall of the root during endodontic
therapy.(1),(10)
Clinical features: Associated with a pre-existing
periodontal pockets or with impaction of foreign
Gingival Abscess
particles.
Abscess localized in the gingiva, caused by injury to
Signs: associated bleeding on probing, suppuration and
the outer surface of the gingival and not involving the
sometimes increased tooth mobility.

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Ramanarayana Boyapati et al. Periodontal abscess –A sneak peek

Symptoms: 4. Radiological examination.

 5. Microbial tests
Gingival and / oral mucosal swelling associated with
erythematous classical symptoms of inflammation. 6. Also include information regarding impaction of

Affected tooth / Teeth – tender on chewing and foreign objects (in case of gingival abscess and oral
sensitive to percussion. hygienic abscess).(5)

Tooth may feel high on occlusion as a result of
extrusion from the alveolar socket associated with A. Von Winkel Hoff et al (1985) diagnostic criteria for
appreciable mobility. periodontal abscess
 1. Association with pocket of > 6 mm
Presence of sinus tracts in chronic abscess.

Spontaneous suppuration or upon pressure. 2. Bleeding on probing.

Regional lymphadenopathy and systemic illness.(10) 3. Evidence of radio alveolar bone loss, and
4. Absence of periapical lesions.
Radiological Findings: Radiographic findings of the
may either present as a normal appearing tooth with B. Trope et al (1988) recommended Dark field
widening of the periodontal ligament space or as a microscopic examination to exclude on endodontic
radiolucent area along the lateral aspect of the root origin.
surface.
C. Liu et al (1996) recommended – position emission
Histopathology of Periodontal Abscess: Periodontal tomography and a flurine –18 – fluromisonidazole
abscess contains bacteria and its byproducts along with marker for detection of periodontal abscess.
cells of inflammation and tissue breakdown elements.
Periodontal abscess is formed by occlusion or trauma to Differential diagnosis (Carranza – 1990)
the orifice of the pocket resulting in spread of the 1. Gingival Abscess.
inflammation from the pocket into the soft tissue pocket 2. Pericoronal Abscess.
wall. Concomitant inflammatory reaction leads to 3. Periapical Abscess
destruction of the connective tissue, encapsulation of the 4. Non infected Periodontal Cyst
bacterial infection and the production of pus. 5. Osteomyelitis
Histologically, intact neutrophils are found 6. Eosinophilic granuloma
surrounding a central area of soft tissue debris and 7. Endo Perio lesions and Perio Endo lesions
destroyed leukocytes. At a later stage a pyogenic
membrane, composed of macrophages and neutrophils is
organized. The destructive process is also guided by the
virulence of the bacteria, host resistance, local pH.

Dewitt et al (1985) gives 5 zone from the outside to the

inside.
1. Abnormal oral epithelium and lamina propria
2. An acute inflammatory infiltrate
3. Intense foci of inflammation
4. A destroyed and ulcerated pocket epithelium.
5. A central region, as a mass of granular, acidophillic
debris.

Microbiology
 Periodontal abscess is caused by Polymicrobes and
orally inhabited bacterial flora. Streptococcus Pericoronal Abscess
viridans, Staphylococcus, Non haemolytic Treatment
streptococci, Neisseria, diphtheroids and Treatment of acute periodontal abscess usually involves
Escherichia coli. 2 stages
 Using Dark field microscopy high proportion of 1. As abscess is considered as a dental emergency
spirochetes (40-6%) & low percentage of cocci arising in acute duration, the primary and initial
(19.7%) and motile rods 7.5% (Trope et al 1988). therapy is aimed at management of the acute lesion.
2. After addressing the acute lesion in the emergency
Diagnosis phase, the underlying etiology has to be treated in
1. Patients chief complaint the subsequent treatment phase.
2. Clinical signs and symptoms
3. Pulp vitality tests

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Ramanarayana Boyapati et al. Periodontal abscess –A sneak peek

Acute periodontal abscess untreated as it displays the possibility to spread

Purpose microorganisms to other parts of body which can results
1. To alleviate the pain into bacteremia, infection of orofacial region, Ludwig’s
2. Control the spread of infection, to prevent further angina, pulmonary actinomycosis or brain abscess. The
periodontal attachment loss. risk of bacteremia during drainage of an abscess can be
3. Establish drainage. reduced if, before incision a needle aspiration of content
of abscess is done. Tooth loss is seen cases of advanced
Protocol recommended to moderate periodontitis.6)
1. Incision and drainage (closed approach – through Cervical necrotising fasciitis, Necrotising
pocket) cavernositis, Gingival necrotizing fascitis can also result
2. Scaling and Root planning as severe complication of periodontal abscess.
3. Compression and debridement of soft tissue wall
(open approach - curettage of granulation tissue) Conclusion
4. Saline irrigation As mentioned above, among all the frequently
5. Use of systemically administered antibiotics encountered dental emergencies, periodontal abscess is
6. Tooth extraction graded as the third most prevalent emergency. Among
several factors associated with formation of the
Instructions periodontal abscess, a few includes occlusion of the
 Rinse with warm saline orifice of a deep periodontal pocket, systemic antibiotic
 Follow up for the abscess reduction after 24-48 hrs. therapy without periodontal treatment and poorly
 Instructed to avoid exertion and placed on a copious controlled diabetes. When it comes to diagnosis of the
fluid diet periodontal abscess, the information gathered from the
 Analgesic and antibiotic. patient in the form of chief complaint, along with clinical
 Definitive treatment is carried out 1 week later. and radiological findings play a crucial role. The
microbial flora is primarily Gram –ve anaerobic rods and
Antibiotic administrations(8) is unspecific, periodontal pathogen such as P.gingivalis,
1. Metronidazole – 400mg (BID ) 5 days P. intermedia, F. nucleatum are most prevalent. The
2. Tetra cycline – 1 gm / day – 2weeks periodontal abscess has the possibility to spread to other
3. Azithromycin, 500mg, OD, 3 days, (Bacteriostatic) sites with the possibility of causing serious infections.
4. Amoxicillin + Clavulanate potassium , 500 + 125
mg, TID, 8days (Bacteriocidal) References
5. Penicillins(cidal) 1. Clinical periodontology – 11th and 12th edition.
2. Clinical periodontology and implant dentistry – 5th edition
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7. Self – inflected gingival injury – BDJ-1995,Vol. 178,246
treatment lies in restoration of the function and aesthetics
(Bechett H et al).
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Surgical therapy - gingivectomy & flap procedures Fogorv Sz, Valvi P, Gorbz, 2004 Aug;97(4):151-5.
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Complication: Like any other infectious process, even
periodontal abscess possesses a serious threat when left

International Journal of Periodontology and Implantology, October-December 2016;1(3):81-84 84