1. Periodontal abscess
Logien Al Ghazal /12/2015

2. Classifications A periodontal abscess
Is a localized purulent infection of periodontal tissues and is classified by its tissue of origin.
Classifications
Gingival abscess
Periodontal abscess
Acute
Acute or chronic
single
multiple
single
single
multiple
multiple

3. Periodontitis-related abscess
Classifications
Depending on the cause of the acute infectious
Periodontitis-related abscess
Exacerbation of a chronic lesion.
Post-therapy periodontal abscesses.
Post-surgery periodontal abscess
Post-antibiotic periodontal abscess.
Non-periodontitis-related abscess
Impaction of foreign body in the gingival sulcus or periodontal pocket.
Root morphology alterations.

4. Gingival Abscess. Etiology:
A gingival abscess is a localized, painful, rapidly expanding lesion that is usually of sudden onset.
It is generally limited to the marginal gingiva or interdental papilla.
It is acute in nature.
Etiology:
Acute inflammatory gingival enlargement results from bacteria carried deep into the tissues by the help of a foreign substance which is forcefully embedded into the gingiva.
Toothbrush bristle.
piece of apple core.
Lobster shell fragment.
The lesion is confined to the gingiva and should not be confused with periodontal or lateral abscesses.

5. Clinical appearance:
In its early stages it appears as a red swelling with a smooth, shiny surface.
Within 24 to 48 hours, the lesion usually becomes fluctuant and pointed with a surface orifice from which a purulent exudate may be expressed.
The adjacent teeth are often sensitive to percussion.
If permitted to progress, the lesion generally ruptures spontaneously.

7. Periodontitis-related abscess
Periodontal (Lateral) Abscess.
Periodontal abscesses generally produce enlargement of the gingiva, but they also involve the supporting periodontal tissues.
Periodontitis-related abscess
Exacerbation of a chronic lesion
Such abscesses may develop in a deepened periodontal pocket without any obvious external influence, and may occur in:
(a) an untreated periodontitis patient.
(b) as a recurrent infection during supportive periodontal therapy.

8. Post-therapy periodontal abscesses
Post-scaling periodontal abscess :When these lesions occur immediately after scaling or after a routine professional prophylaxis they are usually related to the presence of small fragments of remaining calculus that obstruct the pocket entrance.
Post-surgery periodontal abscess.
When an abscess occurs immediately following periodontal surgery, it is often the result of an:
Incomplete removal of subgingival calculus.
Presence of foreign bodies in the periodontal tissues, such as sutures, regenerative devices, or periodontal pack.

9. Post-antibiotic periodontal abscess
Treatment with systemic antibiotics without subgingival debridement in patients with advanced periodontitis.
In such patients, the subgingival biofilm may protect the residing bacteria from the action of the antibiotic, resulting in a super-infection leading to an acute process with the ensuing inflammation and tissue destruction.

10. Non-periodontitis-related abscess
Formation may also occur in relation to a periodontal pocket, but in such cases, there is always an external local factor that explains the acute inflammatory process. • Impaction of foreign body in the gingival sulcus or periodontal pocket.
It may be related to oral hygiene practices (toothbrush, toothpicks, orthodontic devices, food particles.)
• Root morphology alterations. In this instance local anatomic factors, such as an invaginated root, a fissured root, an external root resorption, root tears or iatrogenic endodontic perforations, may be the cause of the abscess formation.

12. Pathogenesis And Histopathology

13. The periodontal abscess lesion
Contains bacteria, bacterial products, inflammatory cells, tissue breakdown products, and serum.
The precise pathogenesis of this lesion is still obscure.
It is hypothesized that the occlusion of the periodontal pocket lumen, due to trauma or tissue tightening, will prevent drainage and result in extension of the infection from the pocket into the soft tissues of the pocket wall, resulting in the formation of the abscess.

14. The entry of bacteria into the soft tissue pocket wall could be the event that initiates the formation of a periodontal abscess, however it is the accumulation of leukocytes and the formation of an acute inflammatory infiltrate what will be the main cause of the connective tissue destruction, encapsulation of the bacterial mass, and formation of pus.
Histopathology of periodontal abscess

15. The histopathology
Its first phases, the central area of the abscess filled with neutrophils, in close vicinity with remains of tissue destruction and soft tissue debris.
At a later stage, a pyogenic membrane, composed of macrophages and neutrophils, is organized.
The rate of tissue destruction within the lesion will depend on the growth of bacteria inside the foci and their virulence, as well as on the local pH.
An acidic environment will favor the activity of lysosomal enzymes and promote tissue destruction.

16. Microbiology Porphyromonas gingivalis Prevotella intermedia.
Prevotella melaninogenica.
Fusobacterium nucleatum.
Tannerella forsythia
Micromonas micros.
Actinomyces spp.
Bifidobacterium

17. DIAGNOSIS

18. The diagnosis of a periodontal abscess should be based on the overall evaluation and interpretation of the patient´s chief complaint, with the clinical and radiological signs found during the oral examination.
Symptoms:
Presence of an ovoid elevation of the gingival tissues along the lateral side of the root.
may present as diffuse swellings or simply as a red area.
Another common finding is suppuration, either from a fistula or from the pocket.
This suppuration may be spontaneous or occur after applying pressure on the outer surface of the gingiva.
The clinical symptoms usually include pain (from light discomfort to severe pain).
Tenderness of the gingiva.
Sensitivity to percussion of the affected tooth.
Tooth elevation and increased tooth mobility.

19. The radiographic examination
May reveal either a normal appearance of the interdental bone or evident bone loss.
Ranging from just a widening of the periodontal ligament space to pronounced bone loss involving most of the affected root.

20. DIFFERENTIAL DIAGNOSIS

21. Periapical abscesses.
Lateral periapical cysts.
Vertical root fractures.
Endo-periodontal abscesses.
Gingival squamous cell.
Metastatic carcinoma from pancreatic origin.
Metastatic head and neck cancer.
Eosinophilic granuloma
NOTE (In cases where the abscess does not respond to conventional therapy, a biopsy and pathologic diagnosis are recommended )

22. TREATMENT

23. The treatment of the periodontal abscess usually includes two stages:
(1) the management of the acute lesion.
(2) the appropriate treatment of the original and/or residual lesion, once the emergency situation has been controlled.
For the treatment of the acute lesion, different alternatives have been proposed ranging from:
(1) incision and drainage.
(2) scaling and root planning. (3) periodontal surgery.
(4) the use of different systemically administered antibiotics.

24. Drainage through the Pocket
The area is anesthetized topically and, if necessary, local anesthesia is injected around the periphery of the abscess.
Care is taken not to inject into the swelling itself.
A flat instrument or a probe is carefully introduced into the pocket in an attempt to distend the pocket wall for drainage.
A curette can then be gently inserted into the pocket to further drain and gently curette the mass of tissue internal.

25. Drainage through an External Incision.
The abscess is isolated and dried with gauze sponges.
After the application of topical anesthesia, local anesthesia is injected around the periphery of the abscess.
A #15 blade is used to make a vertical incision through the most fluctuant part of the swelling, extending to an area just apical to the abscess.
A curette or periosteal elevator is used to gently elevate the tissue to create drainage and curette the granulomatous tissue in the internal aspect of the abscess.
The external aspect of the abscess is gently pushed to drain the remaining purulent material and approximate the wound edges.
Sutures are usually not require.

26. Antibiotics.

27. Complications
Tooth loss
Dissemination of the infection