Periodontal abscess

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Periodontal abscess
GingivalAbscess.jpg
A gingival abscess between the lower left canine and first premolar.
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A periodontal abscess (also termed lateral abscess, [1] or parietal abscess), [1] is a localized collection of pus (i.e. an abscess) within the tissues of the periodontium. It is a type of dental abscess. A periodontal abscess occurs alongside a tooth, and is different from the more common [2] periapical abscess, which represents the spread of infection from a dead tooth (i.e. which has undergone pulpal necrosis). To reflect this, sometimes the term "lateral (periodontal) abscess" is used. In contrast to a periapical abscess, periodontal abscesses are usually associated with a vital (living) tooth. Abscesses of the periodontium are acute bacterial infections [3] classified primarily by location. [4]

Contents

Signs and symptoms

The main symptom is pain, which often suddenly appears, and is made worse by biting on the involved tooth, which may feel raised and prominent in the bite. The tooth may be mobile, and the lesion may contribute to destruction of the periodontal ligament and alveolar bone. [4] The pain is deep and throbbing. The oral mucosa covering an early periodontal abscess appears erythematous (red), swollen and painful to touch. [3] The surface may be shiny due to stretching of the mucosa over the abscess. Before pus has formed, the lesion will not be fluctuant, and there will be no purulent discharge. There may be regional lymphadenitis.

When pus forms, the pressure increases, with increasing pain, until it spontaneously drains and relieves the pain. When pus drains into the mouth, a bad taste and smell are perceived. Usually drainage occurs via the periodontal pocket, or else the infection may spread as a cellulitis or a purulent odontogenic infection. Local anatomic factors determine the direction of spread (see fascial spaces of the head and neck). There may be systemic upset, with an onset of pain and fever.

Causes

A periodontal abscess most commonly occurs as a complication of advanced periodontal disease. [5] A periodontal pocket contains dental plaque, bacteria and subgingival calculus. [6] Periodontal pathogens continually find their way into the soft tissues, but normally they are held in check by the immune system. [7] A periodontal abscess represents a change in this balance, related to decreased local or systemic resistance of the host. [8] An inflammatory response occurs when bacteria invade and multiply within the soft tissue of the gingival crevice/periodontal pocket. [9] A pus-filled abscess forms when the immune system responds and attempts to isolate the infection from spreading. [10]

Communication with the oral environment is maintained via the opening of the periodontal pocket. [11] However, if the opening of a periodontal pocket becomes obstructed, as may occur if the pocket has become very deep (e.g. with furcation involvement), then plaque and calculus are trapped inside. [12] Food impaction may also obstruct a periodontal pocket. [13] Food impaction is usually caused by failure to accurately reproduce the contact points when dental restorations are placed on the interproximal surfaces of teeth. [14] Another potential cause occurs when a periodontal pocket is scaled incompletely. [15] Following this procedure, the gingival cuff tightens around the tooth, which may be enough to trap the bacteria left in the pocket. A gingival retraction cord which is accidentally left in situ is an occasional cause of a periodontal abscess.

Penetrating injury to the gingiva—for example, with a toothbrush bristle, fishbone, toothpick or periodontal instrument—may inoculate bacteria into the tissues. [16] Trauma to the tissues, such as serious impact on a tooth or excessive pressure exerted on teeth during orthodontic treatment, can be a possible cause as well. [17] Occlusal overload may also be involved in the development of a periodontal abscess, but this is rare and usually occurs in combination with other factors. Bruxism is a common cause of excessive occlusal forces. [18]

Systemic immune factors such as diabetes can predispose a person to the formation of periodontal abscesses.

Perforation of a root canal during endodontic therapy can also lead to a periodontal abscess which if left untreated could become "prolonged" ultimately rupture then enter the blood stream and could lead to serious situations such as endocarditis. [19]

Diagnosis

Periodontal abscesses may be difficult to distinguish from periapical abscesses. Since the management of a periodontal abscess is different from a periapical abscess, this differentiation is important to make (see Dental abscess#Diagnostic approach) For example, root canal therapy is unnecessary and has no impact on pain in a periodontal abscess.

Classification

There are four types of abscesses that can involve the periodontal tissues: [3]

  1. Gingival abscess—a localized, purulent infection involves only the soft gum tissue near the marginal gingiva or the interdental papilla. [3]
  2. Periodontal abscess—a localized, purulent infection involving a greater dimension of the gum tissue, extending apically and adjacent to a periodontal pocket. [3]
  3. Pericoronal abscess—a localized, purulent infection within the gum tissue surrounding the crown of a partially or fully erupted tooth. [3] Usually associated with an acute episode of pericoronitis around a partially erupted and impacted mandibular third molar (lower wisdom tooth).
  4. combined periodontal/endodontic abscess

Treatment

An important factor is whether the involved tooth is to be extracted or retained. Although the pulp is usually still vital, a history of recurrent periodontal abscesses and significantly compromised periodontal support indicate that the prognosis for the tooth is poor and it should be removed.

The initial management of a periodontal abscess involves pain relief and control of the infection. [20] The pus needs to be drained, which helps both of these aims. If the tooth is to be removed, drainage will occur via the socket. Otherwise, if pus is already discharging from the periodontal pocket, this can be encouraged by gentle irrigation and scaling of the pocket whilst massaging the soft tissues. If this does not work, incision and drainage is required, as described in Dental abscess Treatment.

Antibiotics are of secondary importance to drainage, which if satisfactory renders antibiotics unnecessary. Antibiotics are generally reserved for severe infections, in which there is facial swelling, systemic upset and elevated temperature. [20] Since periodontal abscesses frequently involve anaerobic bacteria, oral antibiotics such as amoxicillin, clindamycin (in penicillin allergy or pregnancy) and/or metronidazole are given (although metronidazole should be used in conjunction with a penicillin given its lack of aerobic gram positive coverage). [20] [21] Ideally, the choice of antibiotic is dictated by the results of microbiological culture and sensitivity testing of a sample of the pus aspirated at the start of any treatment, but this rarely occurs outside the hospital setting.

Other measures that are taken during management of the acute phase might include reducing the height of the tooth with a dental drill, so it no longer contacts the opposing tooth when biting down; and regular use of hot salt water mouth washes (antiseptic) that encourages further drainage of the infection.

The management following the acute phase involves removing any residual infection, and correcting the factors that lead to the formation of the periodontal abscess. Usually, this will be therapy for periodontal disease, such as oral hygiene instruction and periodontal scaling.

Related Research Articles

<span class="mw-page-title-main">Periodontal disease</span> Disease of the tissues surrounding the teeth (periodontium)

Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cause of tooth loss for adults worldwide. In its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. Halitosis may also occur.

<span class="mw-page-title-main">Toothache</span> Medical condition of the teeth

Toothaches, also known as dental pain or tooth pain, is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the teeth by non-dental diseases. When severe it may impact sleep, eating, and other daily activities.

<span class="mw-page-title-main">Periodontal fiber</span> Group of specialized connective tissue fibers

The periodontal ligament, commonly abbreviated as the PDL, are a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which they sit. It inserts into root cementum on one side and onto alveolar bone on the other.

Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

A dental emergency is an issue involving the teeth and supporting tissues that are of high importance to be treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source. Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency.

<span class="mw-page-title-main">Gingival sulcus</span> Space between a tooth and gums

In dental anatomy, the gingival sulcus is an area of potential space between a tooth and the surrounding gingival tissue and is lined by sulcular epithelium. The depth of the sulcus is bounded by two entities: apically by the gingival fibers of the connective tissue attachment and coronally by the free gingival margin. A healthy sulcular depth is three millimeters or less, which is readily self-cleansable with a properly used toothbrush or the supplemental use of other oral hygiene aids.

<span class="mw-page-title-main">Dental abscess</span> Collection of pus in or around a tooth

A dental abscess is a localized collection of pus associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by tooth decay, broken teeth or extensive periodontal disease. A failed root canal treatment may also create a similar abscess.

<span class="mw-page-title-main">Gingival and periodontal pocket</span> Abnormally deep space between a tooth and the gums


In dental anatomy, the gingival and periodontal pockets are dental terms indicating the presence of an abnormal depth of the gingival sulcus near the point at which the gingival (gum) tissue contacts the tooth.

<span class="mw-page-title-main">Scaling and root planing</span> Dental procedure

Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus and then smoothing, or planing, of the (exposed) surfaces of the roots, removing cementum or dentine that is impregnated with calculus, toxins, or microorganisms, the agents that cause inflammation. It is a part of non-surgical periodontal therapy. This helps to establish a periodontium that is in remission of periodontal disease. Periodontal scalers and periodontal curettes are some of the tools involved.

Gingivectomy is a dental procedure in which a dentist or oral surgeon cuts away part of the gums in the mouth.

<span class="mw-page-title-main">Gingivitis</span> Inflammation of the gums

Gingivitis is a non-destructive disease that causes inflammation of the gums; ulitis is an alternative term. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms that are attached to tooth surfaces, termed plaque-induced gingivitis. Most forms of gingivitis are plaque-induced.

A phoenix abscess is an acute exacerbation of a chronic periapical lesion. It is a dental abscess that can occur immediately following root canal treatment. Another cause is due to untreated necrotic pulp. It is also the result of inadequate debridement during the endodontic procedure. Risk of occurrence of a phoenix abscess is minimised by correct identification and instrumentation of the entire root canal, ensuring no missed anatomy.

Chronic periodontitis is one of the seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by the accumulation of profuse amounts of dental plaque. Periodontitis initially begins as gingivitis and can progress onto chronic and subsequent aggressive periodontitis according to the 1999 classification.

Aggressive periodontitis describes a type of periodontal disease and includes two of the seven classifications of periodontitis as defined by the 1999 classification system:

  1. Localized aggressive periodontitis (LAP)
  2. Generalized aggressive periodontitis (GAP)
<span class="mw-page-title-main">Peri-implantitis</span> Inflammatory disease

Peri-implantitis is a destructive inflammatory process affecting the soft and hard tissues surrounding dental implants. The soft tissues become inflamed whereas the alveolar bone, which surrounds the implant for the purposes of retention, is lost over time.

In dentistry, numerous types of classification schemes have been developed to describe the teeth and gum tissue in a way that categorizes various defects. All of these classification schemes combine to provide the periodontal diagnosis of the aforementioned tissues in their various states of health and disease.

<span class="mw-page-title-main">Periapical periodontitis</span> Inflammation at the apex of a tooth root

Periapical periodontitis or apical periodontitis (AP) is an acute or chronic inflammatory lesion around the apex of a tooth root, most commonly caused by bacterial invasion of the pulp of the tooth. It is a likely outcome of untreated dental caries, and in such cases it can be considered a sequela in the natural history of tooth decay, irreversible pulpitis and pulpal necrosis. Other causes can include occlusal trauma due to 'high spots' after restoration work, extrusion from the tooth of root filling material, or bacterial invasion and infection from the gums. Periapical periodontitis may develop into a periapical abscess, where a collection of pus forms at the end of the root, the consequence of spread of infection from the tooth pulp, or into a periapical cyst, where an epithelial lined, fluid-filled structure forms.

<span class="mw-page-title-main">Tooth mobility</span> Medical condition

Tooth mobility is the horizontal or vertical displacement of a tooth beyond its normal physiological boundaries around the gingival (gum) area, i.e. the medical term for a loose tooth.

There are many circumstances during dental treatment where antibiotics are prescribed by dentists to prevent further infection. The most common antibiotic prescribed by dental practitioners is penicillin in the form of amoxicillin, however many patients are hypersensitive to this particular antibiotic. Therefore, in the cases of allergies, erythromycin is used instead.

References

  1. 1 2 Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds. (2012). Carranza's clinical periodontology (11th ed.). St. Louis, Mo.: Elsevier/Saunders. p. 137. ISBN   978-1-4377-0416-7.
  2. ↑ Hupp JR, Ellis E, Tucker MR (2008). Contemporary oral and maxillofacial surgery (5th ed.). St. Louis, Mo.: Mosby Elsevier. p. 293. ISBN   9780323049030.
  3. 1 2 3 4 5 6 American Academy of Periodontology (May 2000). "Parameter on acute periodontal diseases. American Academy of Periodontology" (PDF). J. Periodontol. 71 (5 Suppl): 863–6. doi:10.1902/jop.2000.71.5-S.863. PMID   10875694. Archived from the original (PDF) on 2010-11-28.
  4. 1 2 American Academy of Periodontology (1999). "Consensus report: Abscesses of the Periodontium". Ann. Periodontol. 4 (1): 83. doi:10.1902/annals.1999.4.1.83.
  5. ↑ Yousefi, Yasamin; Meldrum, Jane; Jan, Abdul H. (2024), "Periodontal Abscess", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   32809460 , retrieved 2024-05-21
  6. ↑ Shi, Meng; Wei, Yiping; Hu, Wenjie; Nie, Yong; Wu, Xiaolei; Lu, Ruifang (2018-05-01). "The Subgingival Microbiome of Periodontal Pockets With Different Probing Depths in Chronic and Aggressive Periodontitis: A Pilot Study". Frontiers in Cellular and Infection Microbiology. 8: 124. doi: 10.3389/fcimb.2018.00124 . ISSN   2235-2988. PMC   5938363 . PMID   29765908.
  7. ↑ Bhuyan, Ruchi; Bhuyan, Sanat Kumar; Mohanty, Jatindra Nath; Das, Srijit; Juliana, Norsham; Juliana, Izuddin Fahmy (2022-10-21). "Periodontitis and Its Inflammatory Changes Linked to Various Systemic Diseases: A Review of Its Underlying Mechanisms". Biomedicines. 10 (10): 2659. doi: 10.3390/biomedicines10102659 . ISSN   2227-9059. PMC   9599402 . PMID   36289921.
  8. ↑ Rinčić, Goran; Gaćina, Petar; Jukić, Lucija Virović; Rinčić, Nives; Božić, Darko; Badovinac, Ana (2021). "Association between Periodontitis and Liver Disease". Acta Clinica Croatica. 60 (3): 510–518. doi:10.20471/acc.2021.60.03.22. PMC   8907939 . PMID   35282488.
  9. ↑ Könönen, Eija; Gursoy, Mervi; Gursoy, Ulvi (2019-07-31). "Periodontitis: A Multifaceted Disease of Tooth-Supporting Tissues". Journal of Clinical Medicine. 8 (8): 1135. doi: 10.3390/jcm8081135 . ISSN   2077-0383. PMC   6723779 . PMID   31370168.
  10. ↑ Parahitiyawa, N. B.; Jin, L. J.; Leung, W. K.; Yam, W. C.; Samaranayake, L. P. (2009). "Microbiology of Odontogenic Bacteremia: beyond Endocarditis". Clinical Microbiology Reviews. 22 (1): 46–64. doi:10.1128/CMR.00028-08. ISSN   0893-8512. PMC   2620633 . PMID   19136433.
  11. ↑ Frédéric, Lasserre; Michel, Brecx; Selena, Toma (2018-09-22). "Oral Microbes, Biofilms and Their Role in Periodontal and Peri-Implant Diseases". Materials. 11 (10): 1802. doi: 10.3390/ma11101802 . ISSN   1996-1944. PMC   6213094 . PMID   30248991.
  12. ↑ Peeran, Syed Wali; Ramalingam, Karthikeyan; Sethuraman, Sathya; Thiruneervannan, Madhumala; Peeran, Syed Wali; Ramalingam, Karthikeyan; Sethuraman, Sathya; Thiruneervannan, Madhumala (2024-03-10). "Furcation Involvement in Periodontal Disease: A Narrative Review". Cureus. 16 (3): e55924. doi: 10.7759/cureus.55924 . ISSN   2168-8184. PMC   11004587 . PMID   38601385.
  13. ↑ Latheef, P; Sirajuddin, Syed; Gundapaneni, Veenadharini; Mn, Kumuda; Apine, Ashwini (2015-06-26). "Iatrogenic Damage to the Periodontium Caused by Periodontal Treatment Procedures". The Open Dentistry Journal. 9 (1): 203–207. doi:10.2174/1874210601509010203. ISSN   1874-2106. PMC   4541311 . PMID   26312087.
  14. ↑ Harish, Pv; Joseph, Sonila Anne; Sirajuddin, Syed; Gundapaneni, Veenadharini; Chungkham, Sachidananda (2015-06-26). "Iatrogenic Damage to the Periodontium Caused by Fixed Prosthodontic Treatment Procedures". The Open Dentistry Journal. 9 (1): 190–196. doi:10.2174/1874210601509010190. ISSN   1874-2106. PMC   4541334 .
  15. ↑ Aschheim, Kenneth W. (2015). "14 - Esthetics and periodontics". Esthetic Dentistry (3rd ed.). Mosby. pp. 281–317. doi:10.1016/C2011-0-08344-8. ISBN   978-0-323-09176-3 . Retrieved 2024-05-21.
  16. ↑ Iwakami, K.; Watanabe, Y. (1989). "[Gingival response by the effect of brushing method and hardness of the toothbrush bristle]". Meikai Daigaku Shigaku Zasshi = the Journal of Meikai University School of Dentistry. 18 (2): 244–266. ISSN   0916-0701. PMID   2489671.
  17. ↑ Rafiuddin, Syed; Yg, Pradeep Kumar; Biswas, Shriparna; Prabhu, Sandeep S; Bm, Chandrashekar; Mp, Rakesh (2015-06-26). "Iatrogenic Damage to the Periodontium Caused by Orthodontic Treatment Procedures: An Overview". The Open Dentistry Journal. 9 (1): 228–234. doi:10.2174/1874210601509010228. ISSN   1874-2106. PMC   4541303 . PMID   26312093.
  18. ↑ Fan, Jingyuan; Caton, Jack G. (2018). "Occlusal trauma and excessive occlusal forces: Narrative review, case definitions, and diagnostic considerations". Journal of Periodontology. 89 (S1): S214 –S222. doi:10.1002/JPER.16-0581. ISSN   0022-3492. PMID   29926937.
  19. ↑ Zoumpoulakis, M.; Anagnostou, F.; Dalampiras, S.; Zouloumis, L.; Pliakos, C. (2016). "Infective Endocarditis Prophylaxis in Patients Undergoing Oral Surgery" (PDF). Balkan Journal of Dental Medicine. 20 (1): 5–14. doi:10.1515/bjdm-2016-0001. ISSN   2335-0245. Archived (PDF) from the original on 2024-05-21. Retrieved 2024-05-21.
  20. 1 2 3 Yousefi, Yasamin; Meldrum, Jane; Jan, Abdul H. (2022), "Periodontal Abscess", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   32809460 , retrieved 2022-08-16
  21. ↑ Sanders, Justin L.; Houck, Richard C. (2022), "Dental Abscess", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   29630201 , retrieved 2022-08-16
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