1. Abscess of Periodontal Tissues
Suryono,DDS&Ph.D

2. What is different ?

3. ICD-10 K04.6 Periapical abscess with sinus Dental Dentoalveolar
K04.7 Periapical abscess without sinus
Periapical

4. Clinically
1. Gingival Abscess 2. Periodontal Abscess 3. Periapical Abscess
Dental abscess : Periodontal abscess and/or Periapical abscess
Periodontal abscesses: Gingival and/or Periodontal abscess
synonyms; Lateral / parietal abscess
Dento Alveolar Abcsess; Periodontal and Periapical abscess non vital teeth

5. Gingival abscess
A gingival abscess is a pus-filled sac that forms in the gum line (gingiva) of the teeth.
Gingival abscess is caused by infection from bacteria that enter the gums following injury from aggressive tooth brushing, toothpick punctures, or from food that is forced into the gumline. The infection may spread into surrounding tissue, and if left untreated, it can progress, damaging the support structure of the teeth.

6. Gingival Abcsess Localized in Gingival tissues
Primarily caused by Mechanical trauma ; tooth brush, instrument, food

7. Gingival abscess
History: Although most gingival abscesses develop quickly, a slow-developing gingival abscess may go unnoticed and present no symptoms until it has become severe. Symptoms may include tenderness and swelling in the gum line, a feeling of loose teeth, or teeth that have become unusually sensitive to heat and cold. If the abscess has progressed, it may be releasing a foul-tasting pus. Severe abscesses can cause fever, headache, chills, diarrhea, nausea, and a dull, throbbing pain. There may be difficulty opening the mouth or swallowing.
Physical exam: In its initial stages, a gingival abscess causes the gum line to swell and appear red and shiny. A point may appear from which pus can be released under gentle pressure. Lymph nodes in the neck may also be swollen.
Tests: Tests are usually not required to diagnose a gingival abscess. An x-ray will help to determine the exact location of the abscess and to see if the abscess has penetrated the structure supporting the teeth (periodontal structure).

8. Treatment of Gingival abscess
The first step of treatment is to drain all pus that has accumulated in the abscess. One way to accomplish the drainage is to pass a probe into the abscess and to gently scrape away the infected material. It may be necessary to make a small incision in the gums in order to reach the abscess. If the abscess has not progressed into the periodontal structure, antibiotic therapy is usually effective in eliminating the infection.
If the abscess has progressed into the periodontal structure, deep cleaning will be required for the gum pocket. If too much bony support and periodontal ligament attachment have been lost or if the tooth is too loose, the tooth may need to be removed (dental extraction).

9. Periodontal abscess
A Periodontal abscess (also termed lateral abscess,or parietal abscess),is a localized collection of pus (i.e. an abscess) within the tissues of the periodontium.
Periodontal abscesses are usually associated with a vital (living) tooth. Abscesses of the periodontium are acute bacterial infections classified primarily by location

10. Periodontal Abscess

11. Classification Periodontal abscess
There are four types of abscesses that can involve the periodontal tissues:
Gingival abscess-- a localized, purulent infection involves only the soft gum tissue near the marginal gingiva or the interdental papilla.
Periodontal abscess-- a localized, purulent infection involving a greater dimension of the gum tissue, extending apically and adjacent to a periodontal pocket.
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).
combined periodontal/endodontic abscess

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

13. Causes of Periodontal abscess
Communication with the oral environment is maintained via the opening of the periodontal pocket. 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. Food packing may also obstruct a periodontal pocket.
Food packing is usually caused by failure to accurately reproduce the contact points when dental restorations are placed on the interproximal surfaces of teeth.
Another potential cause of a periodontal abscess occurs when a periodontal pocket is scaled incompletely.

14. Causes of Periodontal abscess
Penetrating injury to the gingiva e.g. with a toothbrush bristle, fishbone, toothpick or periodontal instrument may inoculate bacteria into the tissues.
Trauma to the tissues, e.g. caused by an impact on a tooth, or excessive pressure exerted on teeth during orthodontic treatment. Occlusal overload may also be involved in the development of a periodontal abscess, but this is rare and usually in combination with other factors. Bruxism is a common cause of excessive occlusal forces.
Systemic immune factors such as diabetes can predispose to the formation of periodontal abscesses.

15. Microbial in Periodontal abscess
Periodontal pathogen : P.gingivalis, F.Nucleatum, P intermedia, B. forsytus
Gram negative anaerobe

16. Sign & Symptoms Periodontal abscess
The main symptom is pain, which often suddenly appears, 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.
The pain is deep and throbbing.
The oral mucosa covering an early periodontal abscess appears erythematous (red), swollen and painful to touch.

17. Sign & Symptoms Periodontal abscess
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 relieving the pain.
When pus drains into the mouth, a bad taste is 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 malaise and pyrexia.

18. Diagnosis Periodontal abscess
Periodontal abscess 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. For example, root canal therapy is unnecessary and has no impact on pain in a periodontal abscess.

19. Treatment Periodontal abscess
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. 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.

20. Treatment Periodontal abscess
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.
Since periodontal abscesses frequently involve anaerobic bacteria, oral antibiotics such as amoxicillin, clindamycin (in penicillin allergy or pregnancy) and/or metronidazole are given. 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.

21. Treatment Periodontal abscess
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 and 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.

22. Periapical Abscess
A periapical abscess is a collection of pus, usually caused by an infection that has spread from a tooth to the surrounding tissues.
The result of a chronic, localized infection located at the tip, or apex, of the root of a tooth
Usually, pus from a tooth infection spreads from the root tip through the bone into the gums so the gums swell near the root of the tooth. The swelling from the pus is often the cause of intense pain. Depending on the location of the tooth, the infection may spread further into soft tissues (cellulitis), causing swelling in the jaw, into the floor of the mouth, or in the area of the cheeks. Eventually, the tissue may break open, allowing the pus to drain.

23. Periapical Abscess
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 (or combinations of these factors). A failed root canal treatment may also create a similar abscess.

24. Periapical Abscess

25. Periapical Abscess
A periapical abscess is a collection of pus, usually caused by an infection that has spread from a tooth to the surrounding tissues.

26. Sign & Symptoms
When there is a periapical abscess, you may observe some of the following signs upon examination:
A severe pain reaction is experienced when light pressure is applied to the affected tooth.
A gumboil.
Facial swelling (general or localized).
Tooth mobility.
An elevated temperature.
Enlarged lymph nodes

27. Diagnosis
Generally, periodontal abscesses will be more tender to lateral percussion than to vertical, and periapical abscesses will be more tender to apical percussion.
A periodontal abscess may be difficult to distinguish from a periapical abscess.
sometimes they can occur together. Since the management of a periodontal abscess is different from a periapical abscess, this differentiation is important to make

28. Periodontal or Periapical abscess?
If the swelling is over the area of the root apex, it is more likely to be a periapical abscess; if it is closer to the gingival margin, it is more likely to be a periodontal abscess.
Similarly, in a periodontal abscess pus most likely discharges via the periodontal pocket, whereas a periapical abscess generally drains via a parulis nearer to the apex of the involved tooth.
If the tooth has pre-existing periodontal disease, with pockets and loss of alveolar bone height, it is more likely to be a periodontal abscess; whereas if the tooth with relatively healthy periodontal condition, it is more likely to be a periapical abscess.
In periodontal abscesses, the swelling usually precedes the pain, and in periapical abscesses, the pain usually precedes the swelling.
A history of toothache with sensitivity to hot and cold suggests previous pulpitis, and indicates that a periapical abscess is more likely.

29. Periodontal or Periapical abscess?
If the tooth which gives normal results on pulp sensibility testing, is free of dental caries and has no large restorations; it is more likely to be a periodontal abscess.
A dental radiograph is of little help in the early stages of an dental abscess, but later usually the position of the abscess, and hence indication of endodontal/periodontal etiology determined. If there is a sinus, a gutta percha point is sometimes inserted before the x-ray in the hope that it will point to the origin of the infection.
Generally, periodontal abscesses will be more tender to lateral percussion than to vertical, and periapical abscesses will be more tender to apical percussion.

30. Treatment Periapical abcsess
Successful treatment of abscess centers on the reduction and elimination of the offending organisms. This can include treatment with antibiotics and drainage. If the tooth can be restored, root canal therapy can be performed. Non-restorable teeth must be extracted, followed by curettage of all apical soft tissue.
Unless they are symptomatic, teeth treated with root canal therapy should be evaluated at 1- and 2-year intervals after the root canal therapy to rule out possible lesional enlargement and to ensure appropriate healing.

31. Abscesses may fail to heal for several reasons:
Cyst formation
Inadequate root canal therapy
Vertical root fractures
Foreign material in the lesion
Associated periodontal disease
Penetration of the maxillary sinus
Following conventional, adequate root canal therapy, abscesses that do not heal or enlarge are often treated with surgery and filling the root tips; and will require a biopsy to evaluate the diagnosis.

32. References
Newman MG, Takei HH, Klokkevold PR, Carranza FA (2012). Carranza's clinical periodontology (11th ed.). St. Louis, Mo.: Elsevier/Saunders. p. 137. ISBN 
Hupp JR, Ellis E, Tucker MR (2008). Contemporary oral and maxillofacial surgery (5th ed.). St. Louis, Mo.: Mosby Elsevier. p. 293. ISBN 
American Academy of Periodontology (May 2000). "Parameter on acute periodontal diseases. American Academy of Periodontology" (PDF). J. Periodontol. 71 (5 Suppl): 863–6. doi: /jop S.863. PMID 
American Academy of Periodontology (1999). "Consensus report: Abscesses of the Periodontium". Ann. Periodontol. 4 (1): 83. doi: /annals