The Periodontal Abscess - Lecture Notes PDF

THE PERIODONTAL ABSCESS Prof. Dr. Halil I. Taşer THE PERIODONTAL ABSCESS ODONTOGENIC ABSCESSES ARE ACUTE INFECTIONS THAT ORIGINATE FROM THE TOOTH AND/OR PERIODONTIUM. THE SYMPTOMS OF SUCH ABSCESSES INCLUDE: - LOCALIZED PURULANT INFLAMMATION WITH PAIN AND SWELLING ABSCESSES A...

THE PERIODONTAL ABSCESS Prof. Dr. Halil I. Taşer THE PERIODONTAL ABSCESS ODONTOGENIC ABSCESSES ARE ACUTE INFECTIONS THAT ORIGINATE FROM THE TOOTH AND/OR PERIODONTIUM. THE SYMPTOMS OF SUCH ABSCESSES INCLUDE: - LOCALIZED PURULANT INFLAMMATION WITH PAIN AND SWELLING ABSCESSES ARE ONE OF THE MAIN CAUSES OF PATIENTS TO SEEK EMERGENCY CARE IN THE DENTAL CLINIC. DEPENDING ON THE ORIGIN OF THE INFECTION, THE ABSCESSES ARE CLASSIFIED AS: -PERIAPICAL (In the apical third of the tooth, mainly of endodontic origin) -PERIODONTAL, and -PERICORONAL (related with partially erupted teeth, eg. third molars) ABSCESSES. PERIODONTAL ABSCESSES MAY BE CLASSIFIED AS: - ACUTE OR CHRONIC - SINGLE OR MULTIPLE - GINGIVAL ABSCESS (IF THE ABSCESS OCCURS IN PREVIOUSLY HEALTHY GINGIVA AND CAUSED BY IMPACTION OF FOREIGN BODIES) - PERIODONTAL ABSCESS (IN RELATION TO A PERIODONTAL POCKET)  THE MOST RATIONAL CLASSIFICATION IS BASED ON ETIOLOGY. DEPENDING ON THE CAUSE OF THE INFECTION, TWO TYPES OF PERIODONTAL ABSCESSES MAY OCCUR: - PERIODONTITIS RELATED ABSCESS, WHEN THE ACUTE INFECTION OCCURS FROM A BIOFILM PRESENT IN THE DEEPENED PERIODONTAL POCKET, - NON-PERIODONTITIS RELATED ABSCESS, WHEN THE ACUTE INFECTION ORIGINATES FROM ANOTHER LOCAL SOURCE SUCH AS FOREIGN BODY IMPACTION. PERIODONTITIS RELATED ABSCESS IN A PERIODONTITIS PATIENT, THE ABSCESS IS CAUSED BY EXTENSION OF THE INFECTION INTO THE STILL INTACT PERIODONTAL TISSUES AND RESULTS IN ACTIVE PERODONTAL TISSUE BREAKDOWN. THE ABSCESS FORMATION IS USUALLY DUE TO THE MARGINAL CLOSURE OF A DEEP PERIODONTAL POCKET AND LACK OF PROPER DRAINAGE. THE EXISTENCE OF DEEP POCKETS WITH FURCATION LESIONS, FAVORS THE FORMATION OF THE ACUTE CONDITION. AFTER THE ACUTE INFLAMMATION STARTS, TISSUE BREAKDOWN OCCURS AND PUS WILL BE FORMED. WITH THE RETENTION OF PUS IN THE POCKET, THE LESION WILL RAPIDLY PROGRESS TO THE DEEPER PARTS OF THE PERIODONTIUM.  PERIODONTITIS RELATED ABSCESSES MAY DEVELOP IN THE DEEPENED PERIODONTAL POCKET WITHOUT ANY OBVIOUS EXTERNAL INFLUENCE AND MAY OCCUR IN: - IN AN UNTREATED PERIODONTITIS PATIENT - AS A RECURRENT INFECTION IN SUPPORTIVE PERIODONTAL THERAPY AS AN EXACERBATION OF THE CHRONIC LESION. PERIODONTITIS RELATED ABSCESSES MAY ALSO DEVELOP DURING THE COURSE OF ACTIVE THERAPY. - THESE LESIONS MAY OCCUR IMMEDIATELY AFTER SCALING AND ARE USUALLY RELATED TO THE PRESENCE OF SMALL FRAGMENTS OF CALCULUS THAT OBSTRUCT THE POCKET ENTRANCE ONCE THE EDEMA IN THE GINGIVA HAS DISAPPEARED. - THIS TYPE OF ABSCESS FORMATION CAN ALSO OCCUR WHEN SMALL  AN ABSCESS OCCURING IMMEDIATELY AFTER PERIODONTAL SURGERY OFTEN RESULTS FROM INCOMPLETE REMOVAL OF SUBGINGIVAL CALCULUS, OR FROM THE PRESENCE OF FOREIGN BODIES SUCH AS SUTURES, REGENERATIVE MATERIALS OR PERIODONTAL PACK. TREATMENT WITH SYSTEMIC ANTIBIOTICS WITHOUT SUBGINGIVAL DEBRIDEMENT IN ADVANCED PERIODONTITIS PATIENTS MAY ALSO CAUSE PERIODONTAL ABSCESS FORMATION. IN SUCH PATIENTS, THE SUBGINGIVAL BIOFILM MAY BE PROTECTED FROM THE ANTIBIOTIC AND MAY LEAD TO A MASSIVE INFECTION WITHIN THE POCKET. NON-PERIODONTITIS-RELATED ABSCESS THE FORMATION OF THIS TYPE OF ABSCESS MAY ALSO OCCUR IN RELATION TO THE PERIODONTAL POCKET, BUT IN THIS CASE THERE IS ALWAYS AN EXTERNAL FACTOR THAT EXPLAINS THE ACUTE INFLAMMATION. SUCH FACTORS INCLUDE: - IMPACTION OF FOREIGN BODY IN THE GINGIVAL SULCUS OR PERIODONTAL POCKET, SUCH AS TOOTH PICKS, TOOTHBRUSH BRISTLES, ORTHODONTIC DEVICES OR FOOD PARTICLES. - ROOT MORPHOLOGY ALTERATIONS SUCH AS EXTERNAL ROOT RESORPTION, ROOT FRACTURES OR IATROGENIC ENDODONTIC PERFORATIONS. PREVALENCE AMONG ALL DENTAL CONDITIONS IN NEED OF EMERGENCY TREATMENT, PERIODONTAL ABSCESSES REPRESENT BETWEEN 8-14%. IN A RESEARCH STUDY, IT WAS SHOWN THAT 13.5% OF THE PATIENTS UNDERGOING ACTIVE PERIODONTAL TREATMENT HAD EXPERIENCED PERIODONTAL ABSCESS FORMATION, WHILE UNTREATED PATIENTS SHOWED A HIGHER FIGURE, 59,7%.  ABSCESSES OFTEN OCCUR IN MOLAR SITES AND REPRESENT MORE THAN 50% OF ALL CASES OF PERIODONTAL ABSCESS FORMATION. THE MOST LIKELY REASON FOR THIS HIGH PREVALENCE OF ABSCESSES IN MOLARS COULD BE LESIONS INVOLVING THE FURCATION AREAS AND THE COMPLEX ROOT MORPHOLOGY OF SUCH TEETH. THE OCCURRENCE OF A PERIODONTAL ABSCESS IS IMPORTANT NOT ONLY BECAUSE OF ITS RELATIVELY HIGH PREVALENCE, BUT BECAUSE HOW THIS ACUTE INFECTION MAY INFLUENCE THE PROGNOSIS OF AFFECTED TOOTH. SINCE ABSCESSES SOMETIMES DEVELOP DURING SPT IN TEETH WITH REDUCED PERIODONTAL SUPPORT, THE ADDITIONAL DESTRUCTION WITH ABSCESS FORMATION MAY CALL FOR TOOTH EXTRACTION.  IT IS BELIEVED THAT A PERIODONTAL ABSCESS IS FORMED BY OCCLUSION OR TRAUMA TO THE ORIFICE OF THE PERIODONTAL POCKET. THIS RESULTS IN EXTENSION OF THE INFECTION FROM THE POCKET INTO THE SOFT TISSUES OF THE POCKET WALL. THE ENTRY OF BACTERIA INTO THE SOFT TISSUE POCKET WALL INITIATES THE FORMATION OF THE ABSCESS. IT WAS SHOWN THAT APROXIMATELY 60% OF THE MICROBIOTA IN PERIODONTAL ABSCESSES WAS COMPRISED OF STRICT ANAEROBES. THE MICROBIATA OF THE PERIODONTAL ABSCESS, MAINLY GRAM NEGATIVE, STRICT ANAEROBIC, ROD SHAPED SPECIES, RESEMBLES THE MICROBIATA OF CHRONIC PERIODONTAL LESIONS. FROM THIS GROUP, PROBABLY THE MOST VIRULENT, PORPHYROMONAS GINGIVALIS, IS PRESENT IN ALMOST ALL CASES. OTHER ANAEROBIC SPECIES ARE PREVOTELLA INTERMEDIA, PREVOTELLA MELANINOGENICA, FUSOBACTERIUM NUCLEATUM AND BACTERIODES FORSYTHUS. DIAGNOSIS THE DIAGNOSIS OF A PERIODONTAL ABSCESS SHOULD BE BASED ON THE OVERALL EVALUATION AND UNDERSTANDING OF THE PATIENT’S CHIEF COMPLAINT, TOGETHER WITH THE CLINICAL AND RADIOLOGICAL EXAMINATION. THE MOST PROMINENT APPEARANCE OF A PERIODONTAL ABSCESS IS THE PRESENCE OF AN OVOID ELEVATION OF THE GINGIVA ALONG THE LATERAL SIDE OF THE ROOT.  ABSCESSES LOCATED DEEP IN THE PERIODONTIUM MAY BE MORE DIFFICULT TO IDENTIFY BY THE SWELLING OF THE SOFT TISSUE AND MAY PRESENT AS DIFFUSE SWELLINGS OR SIMPLY AS A RED AREA.  ANOTHER COMMON FINDING IS SUPPURATION, EITHER FROM A FISTULA OR MOST COMMONLY FROM THE POCKET. THIS SUPPURATION MAY BE SPONTANEOUS OR OCCUR AFTER PRESSURE ON THE OUTER SURFACE OF THE GINGIVA. THE CLINICAL SYMPTOMS INCLUDE PAIN (FROM LIGHT DISCOMFORT TO SEVERE PAIN), TENDERNESS OF THE GINGIVA, SWELLING AND SENSITIVITY TO PERCUSSION OF THE AFFECTED TOOTH.  OTHER RELATED SYMPTOMS ARE TOOTH ELEVATION AND INCREASED TOOTH MOBILITY. CLINICAL SIGNS AND SYMPTOMS OF PERIODONTAL ABSCESS ACUTE ABSCESS - Mild to severe discomfort - Localized red, ovoid swelling - Periodontal pocket - Mobility of the tooth - Elevation of the tooth within the socket - Tenderness to percussion or biting - Exudation - Elevated temperature * - Regional Lymphadenopathy (swelling of the lymph nodes)* *May indicate the need for systemic antibiotics. CLINICAL SIGNS AND SYMPTOMS IN PERIODONTAL ABSCESS CHRONIC ABSCESS - No pain or dull pain - Localized inflammatory lesion - Slight elevation of the tooth within the socket - Intermittent exudation - A fistulous tract often associated with a deep periodontal pocket - Uusually without systemic symptoms or signs (Very seldom, malaise or fever )  IN SOME PATIENTS THE OCCURRENCE OF A PERIODONTAL ABSCESS MAY BE ASSOCIATED WITH ELEVATED BODY TEMPERATURE, MALAISE AND REGIONAL LYMPHADENOPATHY. THE DIFFERENTIAL DIAGNOSIS OF PERIODONTAL ABSCESSES SHOULD ALWAYS BE MADE WITH OTHER ABSCESSES THAT CAN OCCUR IN THE ORAL CAVITY. ACUTE INFECTIONS, SUCH AS: *PERIAPICAL ABSCESSES, *LATERAL PERIODONTAL CYSTS, *VERTICAL ROOT FRACTURES, AND *ENDO-PERIODONTAL ABSCESSES MAY HAVE A SIMILAR APPEARANCE AND SYMPTOMS AS A PERIODONTAL ABSCESS, ALTHOUGH THE ETIOLOGY IS VERY CLEARLY DIFFERENT. SIGNS SUCH AS LACK OF PULP VITALITY, THE PRESENCE OF DEEP CARIES LESIONS AND RADIOGRAPHIC FINDINGS WILL HELP IN THE DISTINCTION BETWEEN DIFFERENT ABSCESSES.  DURING THE PERIODONTAL EXAMINATION, THE ABSCESS IS USUALLY FOUND AT A SITE WITH DEEP PERIODONTAL POCKET. SIGNS ASSOCIATED WITH PERIODONTITIS SUCH AS BLEEDING ON PROBING, SUPPURATION AND SOMETIMES INCREASED TOOTH MOBILITY ARE ALSO PRESENT. THE RADIOGRAPHIC EXAMINATION REVEALS SOME BONE LOSS, RANGING FROM A WIDENING OF THE PERIODONTAL LIGAMENT SPACE TO EXTENSIVE BONE LOSS INVOLVING MOST OF THE AFFECTED TOOTH. DIFFERENTIAL DIAGNOSIS OF PERİODONTAL AND PULPAL ABSCESS PERIODONTAL ABSCESS - Associated with a preexisting periodontal pocket, - Radiographs show periodontal angular (vertical) bone loss and radiolucency in the furcation area, - Test shows vital pulp, - Swelling usually includes gingival tissue, with an occasional fistula, - Pain is usually dull and localized, - Sensitivity to percussion may or may not be present.  PULPAL (PERIAPICAL) ABSCESS - There may be a large restoration or caries in the offending tooth, - The tooth may have no periodontal pocket or, if present, it probes as a narrow defect, - The tooth is non vital when tested for vitality, - The swelling is often localized towards the apex with a fistulous tract, - Pain is often very severe and difficult to localize - Sensitivity to percussion is noted. *The differential diagnosis of the periodontal and pulpal abscess is important due to the fact that these abscesses requre different treatment modalities. The importance of patient history and a careful examination should not be disregarded in establishing a differential diagnosis.  A HISTOPATHOLOGICAL EXAMINATION MAY BE NECESSARY TO RULE OUT THE POSSIBILITY OF SQUAMOUS CELL CARCINOMA, IF THE ABSCESS FAILS TO RESPOND TO CONVENTIONAL THERAPY. TREATMENT THE TREATMENT OF THE PERIODONTAL ABSCESS USUALLY INVOLVES TWO STAGES: -THE MANAGEMENT OF THE ACUTE LESION -THE APPROPRIATE TREATMENT OF THE ORIGINAL AND/OR RESIDUAL LESION, ONCE THE EMERGENCY SITUATION HAS BEEN CONTROLLED. FOR THE TREATMENT OF THE ACUTE LESION, THE ALTERNATIVES ARE: - INCISION AND DRAINAGE - SCALING AND ROOT PLANING - PERIODONTAL SURGERY - SYSTEMIC ANTIBIOTICS -TOOTH EXTRACTION WHEN NECESSARY.  ALTHOUGH A PURE MECHANICAL TREATMENT INCLUDING SURGICAL DRAINAGE THROUGH THE POCKET, SCALING AND PLANING THE ROOT SURFACE MAY BE RECOMMENDED, THIS PURE MECHANICAL TREATMENT MAY CAUSE DAMAGE TO THE HEALTHY PERIODONTAL TISSUES ADJACENT TO THE LESION. IN ORDER TO AVOID DAMAGE TO HEALTHY PERIODONTAL TISSUE, IT IS RECOMMENDED TO USE SYSTEMIC ANTIBIOTICS AS THE ONLY INITIAL TREATMENT IN THE ABSCESSES WITH MARKED SWELLING, TENSION AND PAIN. ONCE THE ACUTE CONDITION IS OVER, MECHANICAL DEBDRIDEMENT, INCLUDING ROOT PLANING IS PERFORMED.  THE INFECTION IS NOT RESOLVED ENTIRELY ONLY BY ANTOBIOTICS. MECHANICAL DEBRIDEMENT, SOMETIMES INCLUDING SURGICAL MEANS, IS ESSENTIAL IN THE DEFINITIVE TREATMENT OF PERIODONTAL ABSCESS. A HIGH DOSE OF ANTIBIOTIC DURING A SHORT PERIOD OF TIME IS RECOMMENDED. IF THE PATIENT IS RECOVERING PROPERLY, THE ANTIBIOTIC REGIMEN MAY NOT BE EXTENDED OVER 5 DAYS. (METRONIDAZOLE, AMOXYCILLINE, AZITHROMYCINE)  The medical and dental history of the patient is carefully evaluated to determine the diagnosis and treatment plan and to decide whether antiobiotic tratment is necessary or not before any treatment. In the first visit, to provide comfort to the patient, the abscess related area is anaesthetized with a topical or local anaethetic and the pocket wall is retracted with periodontal probe or a curette for the initial drainage of the abscess. For this purpose, mild digital pressure can be applied over the abscess and drainage through the periodontal pocket can be achieved. At this stage, if the abscess is mild, scaling and root planing procedure can be applied. THE PERIODONTAL ABSCESS a) BASELINE SITUATION (TREATMENT WITH AZITHROMYCINE FOR 3 DAYS WITHO MECHANICAL THERAPY) b) 5 DAYS AFTER ANTIBIOTIC THERAPY c) 12 DAYS AFTER ANTIBIOTIC THERAPY, BEFORE FINAL INSTRUMENTATION. COMPLICATIONS TOOTH LOSS STUDIES HAVE SHOWN THAT PERIODONTAL ABSCESSES ARE THE MAIN CAUSE FOR TOOTH EXTRACTION DURING SUPPORTIVE PERIODONTAL THERAPY. DISSEMINATION OF THE INFECTION IN A NUMBER OF PUBLICATIONS, SYSTEMIC INFECTIONS IN DIFFERENT PARTS OF THE BODY HAVE BEEN ATTRIBUTED TO THE PRESENCE OF PERIODONTAL ABSCESSES. TWO POSSIBILITIES HAVE BEEN DESCRIBED: -THE DISSEMINATION OF BACTERIA DURING THERAPY -BACTERIAL DISSEMINATION THROUGH THE BLOOD STREAM DUE TO BACTEREMIA FROM THE UNTREATED ABSCESS.  A PERIODONTAL ABSCESS CAN FUNCTION AS A SOURCE OF INFECTION, THEREFORE EXTRA CARE SHOULD BE TAKEN ESPECIALLY WITH IMMUNOCOMROMISED PATIENTS OR THOSE WITH HEART VALVE PROSTHESIS.