J Clin Periodontol 2000; 27: 377–386 Copyright C Munksgaard 2000

Printed in Denmark . All rights reserved

ISSN 0303-6979

Review article

The periodontal abscess: a review David Herrera, Silvia Roldán and

Mariano Sanz
Section of Graduate Periodontology, Faculty
of Odontology, University Complutense,
Madrid, Spain

Herrera D, Roldán S, Sanz M: The periodontal abscess: a review J Clin Peri-

odontol 2000; 27: 377–386. C Munksgaard, 2000.

Abstract
Background/aims: The periodontal abscess is a frequent periodontal condition in
which periodontal tissues may be rapidly destroyed. Its importance is based on
the possible need of urgent care, the affectation of tooth prognosis, and the possi-
bility of infection spreading. There is scant information in the scientific litera-
ture regarding this condition and most of it has been published as case reports
and text books, where conclusions are not evidence-based, but rather empirical
observations made by recognised clinicians. The aim of this review was to criti-
cally analyse all available information on this subject in the dental and medical
literature, including information on its prevalence, proposed etiologies and
pathogenesis, diagnosis, microbiology and treatment alternatives.
Summary: The periodontal abscess is the 3rd most frequent dental emergency,
and it is specially prevalent among untreated periodontal patients and peri-
odontal patients during maintenance. Different etiologies have been proposed,
and 2 main groups can be distinguished, depending on its relation with peri-
odontal pockets. In the case of a periodontitis-related abscess, the condition may
appear as an exacerbation of a non-treated periodontitis or during the course of
periodontal therapy. In non-periodontitis related abscesses, impactation of for-
eign objects, and radicular abnormalities are the 2 main causes. The abscess
microflora seems to be similar to that of adult periodontitis, and it is dominated
by gram-negative anaerobic rods, including well-known periodontal pathogens.
Complications and consequences include tooth loss and the spread of the infec- Key words: periodontal abscess; literature
review; microbiology; diagnosis; classification;
tion to other body sites. Diagnosis and treatment is mainly based on empiricism, etiology; prevalence; therapy
since evidence-based data are not available. The rôle of systemic antibiotics, in
the treatment of periodontal abscesses, is especially controversial. Accepted for publication 21 June 1999

The periodontal abscess is a frequent to critically evaluate the available litera- and pericoronal abscess (Van Winkel-
periodontal condition in which peri- ture regarding the periodontal abscess. hoff et al. 1985). This nomenclature,
odontal tissues may be rapidly de- This condition has clinical implications, however, is somehow confusing, since
stroyed. This condition is one of the few not only diagnostic, but also, prognostic abscesses of pulp necrosis origin have
clinical situations in periodontics where and therapeutic in everyday periodontal been referred both as dental or peri-
patients may seek immediate care. Its practice. apical or dentoalveolar abscesses
importance lies not only with the prog- (Gill & Scully 1988). Acute dentoalve-
nosis of the periodontitis affected olar abscesses have been termed as the
Definition
tooth, but also with the possibility of most frequent infection in dentistry
infection spreading. There is scarce in- Odontogenic infections have various which demand emergency treatment
formation in the scientific literature re- possible sources, including pulp ne- (Lewis et al. 1990). However, in order
garding this condition and most of it crosis, periodontal infections, perico- to render appropriate therapy, it is im-
has been published as case reports and ronitis, trauma or surgery (Gill & Scul- portant to distinguish among abscesses
text books, where conclusions are not ly 1990). Odontogenic or dental ab- of endodontal and periodontal origin
evidence-based, but rather empirical scesses have been defined according to (Trope et al. 1988). The periodontal ab-
observations made by recognised clini- their infection source, as endodontal or scess has been defined as a lesion with
cians. The aim of the present review was periapical abscess, periodontal abscess an expressed periodontal breakdown,
378 Herrera et al.

occurring during a limited period of presented with an abscess. 23 of them different stages during the course of the
time, and with easily detectable clinical affected teeth in quadrants treated only infection: as an acute exacerbation of
symptoms (Hafström et al. 1994), with by coronal scaling, 3 in areas treated by an untreated periodontitis (Dello Russo
a localised accumulation of pus (De- root planing, and only 1 in areas treated 1985); during periodontal therapy
Witt et al. 1985, Carranza 1990), with modified Widman flap surgery. No (Dello Russo 1985, Carranza 1990); in
located within the gingival wall of the abscess was detected in areas treated by refractory periodontitis (Fine 1994); or
periodontal pocket (Carranza 1990). osseous flap surgery. 16 out of 27 ab- during periodontal maintenance
scess sites had initial probing pocket (Chace & Low 1993, McLeod et al.
depths deeper than 6 mm, while in 8 1997).
Prevalence
sites the probing depth was 5–6 mm. There are various reasons why an ab-
The prevalence of periodontal abscesses Consequently, the periodontal ab- scess occurs in relation to therapy.
has been studied in emergency dental scess is important, due to its relatively Smith & Davies (1986), studying the
clinics (Galego-Feal et al. 1996, Ahl et high prevalence, mostly in periodontitis treatment of 62 periodontal abscesses,
al. 1986), in general dental clinics patients. In these patients, a peri- reported that 20 out of the 55 patients
(Lewis et al. 1990), in periodontitis pa- odontal abscess is more likely to occur were undergoing periodontal treatment
tients before and during periodontal in a pre-existing periodontal pocket at the time of abscess development.
treatment (Gray et al. 1994), and in (Carranza 1990), and its importance When the periodontal abscess occurs
periodontitis patients during peri- lies not only on its occurrence, but also immediately after scaling or after a rou-
odontal maintenance (Kaldahl et al. how this abscess affects the prognosis tine prophylaxis, it has been related to
1996, McLeod et al. 1997). The peri- of the tooth. Teeth with an abscess are the dislodging of calculus fragments,
odontal abscess often requires emer- usually considered hopeless (Becker et which can be pushed into the tissues
gency treatment, therefore, its preva- al. 1984), and therefore the occurrence (Dello Russo 1985). It may also be due
lence can be calculated from registrars of an abscess may be one of the main to inadequate scaling which will allow
of emergency dental clinics. Among all reasons for tooth extraction during calculus to remain in the deepest pocket
emergency dental conditions, peri- periodontal maintenance (Chace & area, while the resolution of the in-
odontal abscesses represent approxi- Low 1993, McLeod et al. 1997). flammation at the coronal pocket area
mately 8% of all dental emergencies in will occlude the normal drainage and
Spain (Galego-Feal et al. 1996), and up then cause the abscess formation.
Etiology
to 14% in USA (Ahl et al. 1986). (Dello Russo 1985, Carranza 1990).
Data from a questionnaire of over Periodontal abscesses have been either Periodontal abscesses occurring im-
600 general practices in UK reported directly associated to periodontitis or to mediately after periodontal surgery
that periodontal abscesses were diag- sites without the prior existence of a have also been reported in the litera-
nosed in 6–7‰ of all patients treated in periodontal pocket. ture. Recently, a clinical study on
1 month (Lewis et al. 1990). The peri- guided tissue regeneration (Garrett et
odontal abscess was the third most al. 1997) reported that 10 out of 80 con-
Periodontal abscesses in
prevalent emergency infection, after trols (non-resorbable barrier) and 4 out
periodontitis
acute dento-alveolar abscesses (14– of 82 tests (bio-absorbable barrier)
25‰) and pericoronitis (10–11‰). Gray In periodontitis, a periodontal abscess showed abscess formation or suppu-
et al. (1994) reviewed the records from represents a period of active bone de- ration at the treated sites.
an army dental clinic studying peri- struction (exacerbation), although such Treatment with systemic antibiotics
odontitis and abscess formation. From events also occur without abscess for- without subgingival debridement in pa-
5467 records, 203 patients suffered from mation. The existence of tortuous tients with advanced periodontitis may
periodontitis (3.7%). Amongst these, pockets, with cul-de-sac, which eventu- also cause abscess formation (Helo-
periodontal abscesses were diagnosed in ally become isolated, may favour the vuo & Paunio 1989, Helovuo et al.
57 patients (27.5%). Patients under- formation of abscesses (Carranza 1993, Topoll et al. 1990). Topoll et al.
going active periodontal treatment had 1990). The marginal closure of a peri- (1990) reported on the development of
a prevalence of a periodontal abscess of odontal pocket, may lead to an exten- multiple abscesses (from 4 to 12) in 10
13.5%, while untreated patients showed sion of the infection into the surround- untreated periodontal patients, who re-
a higher figure, 59.7%. McLeod et al. ing periodontal tissues due to the press- ceived systemic antibiotic therapy (peni-
(1997) studied retrospectively 114 peri- ure of the suppuration inside the closed cillin, tetracycline or megacillin) for
odontal patients in maintenance ther- pocket (Kareha et al. 1981, Newman & non-oral infections. It has been attri-
apy, treated for moderate to severe peri- Sims 1979, DeWitt et al. 1985). Fibrin buted to a likely change in the compo-
odontitis, between 5–29 years before secretions, leading to the local accumu- sition of the subgingival microbiota,
(mean 12.5 years). 42 patients (37%) lation of pus may favour the closure of leading to a superinfection (Helovuo et
had suffered from a periodontal ab- the gingival margin to the tooth surface al. 1993). This condition was evaluated
scess. From 2899 treated teeth, 109 (Galego-Feal et al. 1995). Changes in by Helovuo and co-workers (Helovuo &
(3.7%) developed periodontal abscesses. the composition of the microflora, bac- Paunio 1989, Helovuo et al. 1993),
In the Nebraska prospective longitudi- terial virulence, or in host defences (Ka- studying 72 patients with untreated
nal study (Kaldahl et al. 1996) the oc- reha et al. 1981) could also make the periodontitis, who were followed for 12
currence of periodontal abscesses dur- pocket lumen inefficient to drain the in- weeks, after intake of systemic anti-
ing 7 years of periodontal maintenance creased suppuration. biotics for non-oral reasons. Patients
was also studied. From the 51 patients The development of a periodontal were divided into 3 groups according to
seeking treatment during this period, 27 abscess in periodontitis may occur at the antibiotic used: penicillin, erythro-
 Periodontal abscess 379

n.a., not available. pp, paper points. PCR, polimerase chain reaction. M-E., electronic microscope. ab.ex., antibiotic intake exclusion. m., months. spiros, spirochaetas. G-neg, gram-negatives. Aa.,
mycin and control (no antibiotic). 10

40.6% spiros
Pathogenesis and histopathology
out of 24 patients (42%) in the penicillin

7/9 G-neg
0% spiros
group developed abscesses within the The entry of bacteria into the soft tissue

Pmel Other
next 4 weeks. In 4 patients, almost pocket wall could be the first event to
every tooth was involved, while in the initiate the periodontal abscess. In-

25%
14.3%
22.2%
other 6 patients, the number of ab- flammatory cells are then attracted by
scesses ranged between 1–10. No ab- chemotactic factors released by the bac-
scesses were detected in the erythro- teria, and the concomitant inflamma-

71.4%
44.4%
mycin or the control groups. tory reaction leads to destruction of the

0%

55%

65%
Fn
Another systemic therapy that has connective tissues (DeWitt et al. 1985),
been related to the development of the encapsulation of the bacterial infec-
multiple abscesses is nifedipine. A case tion and the production of pus (Carran-

80%
Cr
report (Koller-Benz et al. 1992) showed za 1990).
that after initiation of this therapy, 8 Histologically, intact neutrophils are

14.3%
abscesses appeared in 5 days. The acute found surrounding a central area of soft

Bf
condition was treated with drainage, the tissue debris and destroyed leukocytes.
nifedipine therapy was discontinued, At a later stage, a pyogenic membrane,

0%
14.3%
55.6%
65%

25%
100%
and the abscesses resolved. 3 weeks later composed of macrophages and neutro-

Pi
the treatment was resumed, and after 2 phils, is organised. The rate of destruc-

A. actinomycetemcomitans. Pg, P. gingivalis. Pi, P. intermedia. Bf, B. forsythus. Cr, C. rectus. Fn, F. nucleatum. Pmel, P. melaninogenica.
weeks another abscess was detected, tion in the abscess will depend on the

25%
71.4%
77.8%
55%
100%
95%
100%
and the nifedipine treatment was defi- growth of bacteria inside the foci and

Pg
nitely terminated. The authors did not its virulence as well as on the local pH,
give any plausible explanation for this since an acidic environment will favour

25%
findings, and it was not clear whether the activity of lysosomal enzymes (De-

Aa
the patient suffered from periodontitis. Witt et al. 1985).
De Witt et al. (1985) studied biopsy

4
n

7
9
20
7
20
3
9
9
punches taken from 12 abscesses. The
Periodontal abscesses in the
biopsies were taken just apical to the

Table 1. Microbiological findings in periodontal abscesses: methodology and prevalence of selected pathogens
absence of periodontitis

%morphotypes
area of major fluctuance. They ob-

previous ab.
Periodontal abscesses can also develop served, from the outside to the inside:
in the absence of periodontitis, due to (a) a normal oral epithelium and lam-

exudate
control

apical
Ab-ex. Notes
the following causes: (a) Impactation of ina propria; (b) an acute inflammatory
foreign bodies (Kareha et al. 1981), such infiltrate; (c) an intense foci of inflam-
as an orthodontic elastic (Pini Prato et mation (neutrophil-lymphocyte) with
4 m.

6 m.
n.a.

n.a.
n.a.
n.a.
No
al. 1988), a piece of dental floss (Ab- the surrounding connective tissue de-
rams & Kopczyk 1983), a popcorn ker- stroyed and necrotic; (d) a destroyed
nel (Rada et al. 1987), a dislodged ce- and ulcerated pocket epithelium; (e) a
mental tear (Haney et al. 1992), a piece central region, as a mass of granular,
Technique

dark-field
of a toothpick (not confirmed) (Fuss et acidophilic, and amorphous debris. In
culture

culture

culture
al. 1986), a corn husk in peri-implant 7 out of 9 specimens evaluated by elec- culture
PCR

tissues (Ibbott et al. 1993), or an un- tron-microscopy, gram-negative bac- M-E

known object (Emslie, 1978, Palmer teria were seen invading the pocket epi-
1984). Periodontal abscesses caused by thelium and altered connective tissue.
biopsy punch

foreign bodies, related with oral hygiene Bacteria inside the abscesses were im-
Samples Sampling

swab-pus
punction

aids, have been named ‘‘oral hygiene ab- mersed in tissue exudate and sur-
barbed
broach

curette
3 pp

1 pp

scesses’’ (Gillette & Van House 1980). (b) rounded by necrotic tissues. The pres-
Perforation of the tooth wall by an endo- ence of fungi inside the abscess was also
dontic instrument (Carranza 1990, Ab- discussed.
22

20
7
20
3
12
9

rams et al. 1992). (c) Infection of lateral

cysts (Kareha et al. 1981). (d) Local fac-
Microbiology
tors affecting the morphology of the
Patients

root may predispose to periodontal ab- Review articles have pointed out that
20
7
10
3
12
9
9

scess formation. The presence of cervical purulent oral infections are poly-mi-
cemental tears has been related to rapid crobial, and caused by endogenous bac-
van Winkelhoff et al. (1985)

progression of periodontitis and the de- teria (Tabaqhali 1988). However, very
Newman & Sims (1979)

velopment of abscesses (Haney et al. few studies have investigated the specific
Ashimoto et al. (1998)
Hafström et al. (1994)

1992, Ishikawa et al. 1996). The presence microbiota of periodontal abscesses

DeWitt et al. (1985)
Topoll et al. (1990)

Trope et al. (1988)

of external root resorption (Yusof & (Table 1). Hafström et al. (1994) re-
Ghazali 1989), an invaginated tooth ported a microflora harbouring more
(Chen et al. 1990), or a cracked tooth than 106 total viable counts per sample.
(Goose 1981), have been also suggested Topoll et al. (1990) and Newman &
as predisposing factors for periodontal Sims (1979) reported that around 60%
abscess formation. of cultured bacteria were strict an-
380 Herrera et al.

aerobes. Newman & Sims (1979) lences of P. gingivalis (100%) and Tre- Although it is not clearly mentioned,
further described that the most frequent ponema denticola (71.4%) were also most studies report on the microbiology
type of bacteria were gram-negative an- found in a sample of 7 periodontal ab- of abscesses in patients with peri-
aerobic rods and gram-positive faculta- scesses (Ashimoto et al. 1998). odontitis. There is scarce information
tive cocci. In general, gram-negatives The periodontal abscess microbiota available on the microflora of gingival
predominated over gram-positives, and is usually indistinguishable from the mi- abscesses, or other type of abscesses
rods over cocci (Newman & Sims 1979), croflora found in the subgingival with other distinct etiology. The excep-
with percentages ranging between 40% plaque in adult periodontitis (New- tion may be the studies of the micro-
and 60% for a each group. man & Sims 1979). In one study flora of abscesses related with systemic
Trope et al. (1988), only studying mi- (Hafström et al. 1994), the microflora antibiotic intake in periodontitis pa-
crobial morphotypes, by means of of abscesses was compared to that from tients, without mechanical treatment
dark-field microscopy, found high pro- periodontitis and healthy sites. The mi- (Helovuo & Paunio 1989, Helovuo et al.
portions of spirochetes (40.6%) and a croflora from abscesses and deep 1993, Topoll et al. 1990). In this type of
low % of cocci (19.7%) and motile rods pockets was similar and harboured periodontal abscesses, besides an occur-
(7.5%). However, Van Winkelhoff et al. higher proportions of pathogens when rence of periodontal pathogens similar
(1985) could not find spirochetes in 3 compared to the microflora of shallow to other abscesses in periodontitis (To-
samples from periodontal abscesses. pockets. poll et al. 1990), opportunistic bacteria
Culture studies of periodontal ab- When comparing the microbiota were detected, and Staphylococcus au-
scesses (Fig. 1) have revealed high from the exudate of the abscess versus reus was found in abscesses of patients
prevalences of Porphyromonas gingi- samples from the apical part of the with previous penicillin intake. Penicil-
valis (55–100%), Prevotella intermedia same lesion (Newman & Sims 1979), lin resistance was also found in some of
(25–100%), and Fusobacterium nucleat- more different bacterial species were the strains of S. aureus isolated (Helo-
um (44–65%) (Topoll et al. 1990, Van found in the apical samples, but differ- vuo et al. 1993). The authors suggested
Winkelhoff et al. 1985, Hafström et al. ences were small. that this type of abscess could be con-
1994, Newman & Sims 1979). However, Bacterial species with capacity of sidered a superinfection.
other pathogens have also been re- producing proteinases, such as P. inter-
ported: Actinobacillus actinomycetem- media, are important, since they may in-
Diagnosis
comitans (25%) and Campylobacter rec- crease the availability of nutrients, and
tus (80%) (Hafström et al. 1994); Prevo- thereby, increasing the number of bac- Diagnosis of a periodontal abscess is
tella melaninogenica (22%) (Newman & teria inside the abscess (Jansen & Van based on the symptoms revealed by the
Sims 1979). Using PCR, high preva- der Hoeven, 1997, Jansen et al. 1996). patient, and the signs found during the

Fig. 1. Periodontal pathogens usually isolated from periodontal ab-

scesses.

Fig. 2. (a) Resolution of a periodontal abscess after successful treat-

ment: before treatment. (b) Resolution of a periodontal abscess after
successful treatment: after treatment.
 Periodontal abscess 381

oral examination. Additional infor- technique is for patients who are going conditions that may cause barodon-
mation can be obtained through a care- to receive radiotherapy for cancer treat- talgia.
ful medical and dental history, and ment, where the detection of anaerobic (c) Depending on the number, they
radiographic examination. The current infection is important to prevent osteor- have been divided into single versus
sign on examination is an ovoid elev- adionecrosis. multiple periodontal abscesses (Topoll
ation of the gingiva along the lateral Periodontal abscesses have been et al. 1990). Single periodontal ab-
part of the root (Carranza 1990), as classified in different ways depending scesses are usually related to local fac-
shown in Fig. 2. However, abscesses on the main criteria of classification. tors which contribute to the closure of
located deep in the periodontium may (a) Depending on the location of the the drainage of a periodontal pocket.
be less evident. Symptoms range from abscess, they have been divided into Multiple periodontal abscesses need
light discomfort to severe pain, tender- periodontal and gingival abscesses (Gil- more than a local explanation to be
ness of the gingiva, swelling, tooth mo- lette & Van House 1980, Ahl et al. 1986, understood. They have been reported in
bility, tooth elevation, sensitivity of the Carranza 1990). The gingival abscess is uncontrolled diabetes mellitus, medi-
tooth to palpation (Ibbott et al. 1993, described as localised painful swelling, cally compromised patients, and in pa-
Ahl et al. 1986, Carranza 1990). Hali- affecting only the marginal and inter- tients with untreated periodontitis after
tosis can also be reported (Galego-Feal dental gingiva. The main etiological systemic antibiotic therapy for non-oral
et al. 1995). Another common finding is factor in its development is the im- reasons (Helovuo & Paunio 1989, Helo-
suppuration, either spontaneous or pactation of foreign objets. Therefore, vuo et al. 1993, Topoll et al. 1990).
after pressure on the abscess (Carranza they may be present on a previously Multiple abscesses have also been de-
1990), combined with rapid tissue de- healthy gingiva (Ahl et al. 1986, Car- scribed in a patient with multiple exter-
struction and deep pocket formation ranza 1990). Periodontal abscesses nal root resorptions (Yusof & Ghazali
(Ibbott et al. 1993). share similar symptoms, but usually af- 1989), where this local factor was found
The radiographic examination may fect deeper periodontal structures, in- in several teeth.
reveal a normal appearance, or some cluding deep pockets, furcations and The differential diagnosis of peri-
degree of bone loss, ranging from a vertical osseous defects. They are odontal abscesses should always be
widening of the periodontal space to a usually located beyond the mucogingiv- made with other abscesses in the
dramatic radiographic bone loss. Sys- al line. Histologically the lesions are mouth. They may have a similar ap-
temic involvement has been reported in identical, but the periodontal abscess pearance and symptomatology, al-
some severe cases, including fever, mal- occurs in a periodontal pocket related though their etiologies are different:
aise, leukocytosis and regional lymph- to destruction by periodontitis (DeWitt periapical abscess, lateral periapical
adenopathy (Ibbott et al. 1993, Carran- et al. 1985), and the gingival abscess af- cyst, vertical root fracture, endo-peri-
za 1990). The dental history can pro- fects only the marginal soft tissues of odontal abscess, postoperative infection
vide information about previous usually previously healthy sites (DeWitt (Ahl et al. 1986, Barletta & Garcı́a
periodontal treatments, root canal ther- et al. 1985, Carranza 1990). 1988, Tejerina et al. 1991). Differential
apy and previous abscesses. Diagnosis (b) Depending on the course of the diagnosis will be made using different
of abscesses caused by foreign objects lesion, they have been divided into signs and symptoms, such as pulp vi-
(gingival abscess, oral hygiene ab- acute and chronic periodontal abscesses tality, the presence of dental caries ver-
scesses) is based on a careful anamnesis (Galego-Feal et al. 1995, Carranza sus periodontal pockets, the location of
(Gillette & Van House 1980). Van Win- 1990). The acute periodontal abscess the abscess, and a careful radiographic
kelhoff et al. (1985) established as diag- usually demonstrates symptoms like examination (Carranza 1990).
nostic criteria for the definition of a pain, tenderness, sensitivity to pal- There are other diseases that may ap-
periodontal abscess: association with pation, and suppuration upon gentle pear in the oral cavity with a similar ap-
pockets of 6 mm or more, presence of pressure. The chronic abscess is nor- pearance as a periodontal abscess. Parr-
bleeding on probing, evidence of radio- mally associated with a sinus tract, and ish et al. (1989) described 3 cases of
graphic alveolar bone loss, and absence it is usually asymptomatic, although the osteomyelitis in periodontitis patients.
of a periapical lesion. In specific situ- patient can refer mild symptoms (Car- The 3 patients were initially diagnosed
ations, some authors have rec- ranza 1990). An example of a chronic as suffering from a periodontal abscess,
ommended additional diagnostic tools: abscess, with a duration of 6 years, was and the treatment was scaling. The pain
Trope et al. (1988) recommended the described by Pini Prato et al. (1988) and was not controlled by analgesics. The
use of dark-field microscopical exam of this abscess was related to the presence final diagnosis was made after raising
the abscess microflora in order to ex- of a foreign body. flaps, and the infection was controlled
clude an endodontic origin, due to the A localised acute abscess may be- concomitantly with systemic antibiotic.
higher percentage of spirochetes in peri- come a chronic abscess when drainage Deeper pain, not controllable by anal-
odontal abscesses. is naturally established through a sinus gesics, could be the main factor to dis-
Liu et al. (1996) recommended the or through the sulcus (Carranza 1990). tinguish osteomyelitis from periodontal
use of positron emission tomography Also the opposite may occur, a chronic abscesses.
and a flurine-18-fluoromisonidazole abscess may have acute exacerbation Different tumoral processes can have
marker for detection of periodontal ab- (Carranza 1990). For example, Hodges the appearance of a periodontal ab-
scesses and other anaerobic infections (1978) reported a case of a chronic peri- scess. Some of them have been de-
in the mouth. Results from their clinical odontal abscess, which changed to scribed in the literature: a gingival
study showed that 100% of periodontal acute due to a change of atmospheric squamous cell carcinoma (Torabine-
abscesses were found with this pro- pressure. These authors included the jad & Rick 1980, Kirkham et al. 1985)
cedure. The main application of this periodontal abscesses among the oral was diagnosed by the irregularity of its
382 Herrera et al.

shape and its fast growth (Torabine- should rinse with warm saline and be depth of 4.3 mm, and a mean gain of
jad & Rick 1980); a metastatic carci- examined for the abscess resolution attachment of 3.8 mm. Two conclusions
noma, from pancreatic origin, was di- after 24–48 h. 1 week later, the defini- were suggested: firstly, the importance
agnosed by the occurrence of par- tive treatment should be carried out of the drainage (the first 4 abscesses
esthesia and rapid growth (Selden et al. (Ammons 1996, Ahl et al. 1986). Alter- were treated with antibiotic but without
1998); an eosinophilic granuloma was natively, drainage could need an exter- drainage, and 2 of them reappeared
diagnosed by the rapid bone destruc- nal incision or a flap, and topical anti- within 40 days); and, secondly, the po-
tion after standard periodontal therapy. septics may be applied after the drain- tential of regeneration demonstrated by
The tooth was extracted and the sur- age (Carranza 1990, Ammons 1996). the abscesses, which was supposed to be
rounding tissues analysed. A histo- The addition of systemic antibiotics enhanced by avoiding subgingival
pathological diagnosis of eosinophilic to the treatment regime of the peri- scaling.
granuloma was made. Biopsy may be odontal abscess is not a well defined Smith & Davies (1986) also studied
advisable in cases of non-responding issue. Some authors exclude systemic the behaviour of abscesses after therapy.
abscesses (Girdler 1991). antibiotics, unless a clear systemic in- They studied 62 periodontal abscesses.
Differential diagnosis should also be volvement is present (Lewis & MacFar- In 22 of them, the acute phase was
made with self-inflicted gingival in- lane 1986, Ammons 1996, Ahl et al. treated surgically by incision and drain-
juries. Some lesions caused by patient’s 1986), there is a need of pre-medication age, along with the administration of
habits can mimic periodontal abscesses, (Ammons 1996), or when the infection systemic metronidazole (200 mg, tid, 5
such as trauma of the gingiva with a is not well localised (Ammons 1996). days). At a later stage, periodontal ther-
pencil (Rodd 1995) or with a safety pin Other authors, however, recommend apy was carried out, including oral hy-
(Beckett et al. 1995). A careful anam- the use of systemic antibiotics as the giene plus clorhexidine, scaling and
nesis is the main factor to solve these only initial treatment, in cases when root planing, and, if necessary, peri-
cases, since conventional treatments adequate drainage can not be estab- odontal surgery. Out of the 22 treated
usually fail unless the habit is discon- lished. For example, in cases of large teeth, 14 were extracted for periodontal
tinued. abscesses with diffuse swelling, or ex- reasons within the 3 years of follow-up,
treme pain (Lewis & MacFarlane 1986). while only 8 teeth were still in place.
The duration and the type of the anti- Abscesses in patients with refractory
Treatment
biotic therapy is also a matter of dis- periodontitis, may be frequent. Fine
The treatment of a periodontal abscess cussion. Some authors have rec- (1994) reported 3 patients who suffered
has been a challenge for many years. ommended shorter antibiotic regimes, from 3 to 6 abscesses per year. The pro-
For example, in the XVII century, Louis claiming that they are as effective as posed therapy was to treat the patient
XIV of France, was treated for his peri- conventional regimes (Lewis & Mac- with full-mouth scaling and a systemic
odontal abscesses with masses of mixed Farlane 1986, Martin et al. 1997), at antibiotic selected after microbiological
bread and milk, in order to soften the least in the case of dento-alveolar ab- analyses of the subgingival microflora
swelling, and to allow drainage of the scesses. and antimicrobial susceptibility testing.
abscess (González-Iglesias 1990). The Some authors recommend the combi- Both 3 cases were treated success-
treatment of the acute periodontal ab- nation of basic treatments (incision, fully. Palmer (1984) reported a case of
scess usually includes two stages: the drainage, debridement) and antibiotic an acute lateral periodontal abscess
management of the acute lesion; and therapies (Galego-Feal et al. 1995). The treated successfully with a course of
the appropriate treatment of the orig- combination of incision and drainage oral penicillin, with complete regenera-
inal and/or residual lesion, once the with the systemic administration of tion of the destruction. In this case a
acute situation has been controlled penicillins has been considered as foreign object impactation was sus-
(Ammons 1996). If the tooth is severely ‘‘often successful’’ (Genco 1991). Peni- pected, and its elimination, with the
damaged, and its prognosis is bad, one cillins are the first drug of choice in the help of the antibiotic, led to the com-
of the most effective treatments could treatment of periodontal abscesses in plete resolution.
be tooth extraction (Smith & Davies the UK, being used by 57% of surveyed In the treatment of chronic peri-
1986, Ammons 1996). For the treat- dentists, followed by amoxicillin (21%) odontal abscesses, surgical therapy,
ment of gingival abscesses, the treat- and metronidazole (14%) (Lewis et al. either gingivectomy or flap procedures,
ment should include the following: 1990). has also been advocated (Carranza
elimination of the foreign object, Hafström et al. (1994) proposed a 1990), mainly in abscesses associated
through careful debridement (Ab- conservative treatment, aiming to get as with deep vertical defects, where the
rams & Kopczyk 1983), drainage much attachment gain as possible. resolution of the abscess may only be
through the sulcus with a probe or light Drainage was established through the achieved by a surgical operation (Kare-
scaling, rinsing with warm saline and periodontal pocket, and irrigation with ha et al. 1981). Surgical flaps have also
follow-up after 24–48 hours (Gillette & sterile saline was performed. Only been proposed in cases of post-prophy-
Van House 1980, Ahl et al. 1986). supragingival scaling was done, and te- laxis periodontal abscesses, in which
For the treatment of periodontal ab- tracycline was prescribed for 2 weeks (1 calculus is left subgingivally after the
scesses, a similar protocol has been rec- g/day). The protocol was tested clin- treatment. The main objective of the
ommended: drainage through the ically and microbiologically in a group therapy is to eliminate the remaining
pocket, scaling of the tooth surface, of 20 abscesses, 13 followed for 180 calculus and obtain drainage at the
compression and debridement of the days, and 7 for 42 days. The results same time. These authors justified their
soft tissue wall and irrigation with ster- were considered satisfactory, with a treatment with the report of 2 cases
ile saline. After therapy, the patient mean reduction of probing pocket (Dello Russo 1985). A therapy, with a
 Periodontal abscess 383

combination of an access flap with deep treatment, Actinomyces sp. from the cell crisis, in patients with sickle cell an-
scaling and irrigation with doxycycline, subgingival microflora had passed to aemia (Rada et al. 1987). During the cri-
has also been proposed. The author re- the lungs. Gallaguer et al. (1981) de- sis, the abscess must be treated with anti-
ported good results with more than 50 scribed a healthy patient with a peri- biotics, aiming to avoid pain and to pre-
patients, but scientific data was not pro- odontal abscess who was treated with vent dissemination of the infection.
vided (Quteish-Taani 1996). drainage and curettage, but without sys- Definitive treatment should be delayed
temic antibiotic. 2 weeks later a brain until resolution of the crisis.
abscess was diagnosed, and after ap-
Complications
proximately 1 month the patient ex-
Tooth loss Summary
pired. Microbiology of the lesions dem-
Periodontal abscesses are associated onstrated, among other bacteria, The periodontal abscess is the third
with tooth loss in cases of moderate to Bacteroides melaninogenicus and other most frequent dental emergency, repre-
advanced periodontitis and during the Bacteroides sp. The authors hypoth- senting 7–14% of all dental emerg-
maintenance phase (Chace & Low 1993, esised that bacteraemia associated with encies, and affecting 6–7‰ of all pa-
McLeod et al. 1997). Periodontal ab- the curettage of the abscess was the tients seen in a dental clinic. In peri-
scesses have been suggested as the main etiology of the fatal brain abscess. A odontal patients, higher prevalences
cause for extraction in the maintenance retrospective study on total knee have been calculated in retrospective
phase (Chace & Low 1993). A tooth arthroplasty infections (Waldman et al. studies on selected groups: 59.7% in un-
with a history of repeated abscess for- 1997) discovered that 9 out of 74 infec- treated patients; 13.5% during the ac-
mation is considered, together with tions had been previously treated for an tive treatment; and 37% during the
other findings, a tooth with a ‘‘hope- oral infection (the treatment was per- maintenance phase.
less’’ prognosis (Becker et al. 1984). In formed within the 2 weeks before the 2 main etiologies should be dis-
a retrospective study, 45% of teeth with onset of the infection, and microbio- tinguished: those related to a pre-
periodontal abscesses in a maintenance logical samples confirmed the oral ori- existing periodontal pocket; and those
population were extracted (McLeod et gin of the infection). 1 of the 9 cases which do not necessarily need a deepen-
al. 1997). Another retrospective study was the drainage of a periodontal ab- ed pocket, although they can coincide
on 455 of teeth with a questionable scess, and the development of the knee with a periodontal pocket. In the first
prognosis, showed that 55 (12%) were infection was not prevented although group, different etiological explanations
lost after a mean of 8.8 years, and the the patient was under systemic anti- are possible: exacerbations of the
main reason for tooth extraction was a biotic therapy. The prophylactic use of existing disease, post-therapy abscesses,
periodontal abscess (Chace & Low antibiotics was discussed for these pa- re-emergence of a cured disease, and su-
1993). In the treatment of periodontal tients. However, the risk of the bactera- per-infections. In the second, two main
abscesses, tooth extraction is a common emia during the drainage of an abscess, causes should be considered: im-
option. Smith & Davies (1986) evalu- may be reduced if, before the incision, pactation of foreign objects; and factors
ated 62 abscesses: 14 (22.6%) were ex- a needle aspiration of the content of the altering root morphology or root integ-
tracted as initial therapy, and 9 (14.5%) abscess is performed (Roberts & Sher- rity. This etiological classification of
after the acute phase was controlled. riff 1990, Flood et al. 1990). periodontal abscesses may be more use-
Out of the 22 treated and followed ab- ful than the other classifications re-
scessed teeth, 14 had to be extracted Bacteraemia in relation to an untreated viewed.
during the following 3 years. However, abscess The diagnosis of a periodontal ab-
some clinicians report a rapid and spec- Cellulitis in breast cancer patients has scess should take into account the dif-
tacular healing after the treatment of a been claimed to follow gingivitis or an ferential diagnostic possibilities de-
periodontal abscess (Ammons 1996). abscess (Manian 1997), due to transient scribed in the dental literature. Clear
bacteraemia and reduced host defences signs and symptoms, associated with
(radiation therapy and axillary dissec- each type of abscess should be analysed
Dissemination of the infection
tion). The breast and the upper extremi- in detail. The microflora related with
A number of publications, mainly case ties are particularly susceptible to infec- periodontal abscesses is complex, domi-
reports, have described different sys- tions of oral origin (Manian 1997). A nated by gram-negative, strict anaer-
temic infections in different parts of the periodontal abscess was associated with obe, rods. It does not seem to be speci-
body, in which the suspected source of the development of a cervical necrotising fic, but known periodontal pathogens
infection was a periodontal abscess. fascitis (Chan & McGurk 1997), which is such as P.gingivalis, P.intermedia, and
Two possibilities have been described: a rare entity, but it is frequently associ- F.nucleatum, are the most prevalent
the dissemination of the bacteria during ated with oropharingeal or odontogenic bacterial species. The periodontal ab-
therapy (bacteraemia); or bacteraemia infections. A necrotising cavernositis, scess, as an infection, has the possibility
related with an untreated abscess. which was treated with surgery and sys- to spread micro-organisms to other
temic penicillin, was thought to be re- body sites, with the possibility of caus-
Bacteraemia following the treatment of lated to a severe periodontal infection, ing serious infections which can eventu-
an abscess including 3 periodontal abscesses. Cul- ally be fatal. A tooth suffering from a
Suzuki & Delisle (1984) related a case tures from the corpora cavernosa periodontal abscess has a worse prog-
of pulmonary actinomycosis due to a showed Peptostreptococcus sp. and Fuso- nosis and is at a higher risk of being
periodontal abscesses, which was ultra- bacterium sp. The patient developed im- lost. In periodontal maintenance, the
sonically scaled one month previously. potency (Pearle & Wendel 1993). A peri- periodontal abscess is the main reason
The authors suggested that during odontal abscess may also cause a sickle for tooth extraction.
384 Herrera et al.

There is not enough scientific evi- Daten nicht verfügbar sind. Insbesondere die Ahl, D. R., Hilgeman, J. L. & Snyder, J. D.
dence in the literature to provide an Rolle von systemischen Antibiotika bei der (1986) Periodontal emergencies. Dental
unique treatment regime for peri- Behandlung des Parodontalabszesses wird Clinics of North America 30, 459–472.
kontrovers diskutiert. Ammons, W. J. (1996) Lesions in the oral
odontal abscesses. Three therapeutic
mucous membranes. Acute lesions of the
approaches have been discussed, includ- periodontium. In: Fundamentals of peri-
ing: drainage and debridement; sys- odontics, eds. Wilson, T. & Korman, K.,
Résumé
temic antibiotics with or without other pp. 435–440. Singapore: Quintessence.
treatments; and periodontal surgery L’abcès parodontal: revue de littérature Ashimoto, A., Tanaka, T., Ryoke, K. &
procedures. L’abcès parodontal est une affection paro- Chen, C. (1998) PCR detection of peri-
dontale fréquente, dans laquelle les tissus pa- odontal/endodontic pathogens associated
rodontaux peuvent rapidement être détruits. with abscess formation. Journal of Dental
Acknowledgements Son importance repose sur le besoin urgent Research 77, 854 (abstr. 1779).
de traitement qu’il peut nécessiter, l’établisse- Barletta, L. & Garcı́a, J. (1988) Diagnóstico
We wish to thank Professor Denis Kin- ment du pronostic de la dent et la possibilité diferencial en las alteraciones pulpoperi-
ane for his critical appraisal of this de dispersion de l’infection. Il existe dans la odontales. Avances en Odontoestomatolog-
manuscript. littérature scientifique peu d’informations sur ı́a 8, 403–405.
cette affection, et il s’agit dans la plupart des Becker, W., Berg, L. & Becker, B. E. (1984)
cas de comptes rendus de cas et de manuels, The long term evaluation of periodontal
Zusammenfassung où les conclusions ne sont pas basées sur des treatment and maintenance in 95 patients.
Der Parodontalabszess. Ein Übersichtsartikel indications bien documentées mais plutôt sur International Journal of Periodontics and
Der Parodontalabszess ist ein häufiger Zu- des observations empiriques faites par des Restorative Dentistry 2, 55–70.
stand bei dem die parodontalen Gewebe cliniciens reconnus. Cette revue a pour but Beckett, H., Buxey-Softley, G. & Gilmour, A.
rasch zerstört werden können. Seine Wichtig- de faire une analyse critique de toute l’infor- G. (1995) Self-inflicted gingival injury.
keit ist in der Notwendigkeit für eine schnelle mation accessible à ce sujet dans la littérature British Dental Journal 178, 246.
Hilfe begründet sowie in der Beeinflussung dentaire et médicale, avec les informations Carranza, F. J. (1990) Glickman‘s clinical
der Prognose der Zahns und der Möglichkeit sur sa prévalence, les étiologies et pathogé- periodontology. 7th edition. Philadelphia:
der Infektionsausbreitung. Es gibt wenig wis- nies proposées, le diagnostic, la microbiolo- WB, Saunders Company.
senschaftliche Literatur über diesen Zustand gie et les alternatives de traitement. L’abcès Chace, R. Jr. & Low, S. (1993) Survival
und das meiste davon sind veröffentlichte parodontal se situe parmi les urgences den- characteristics of periodontally-involved
Fallberichte und Lehrbücher, in denen sich taires les plus fréquentes, occupant la troisiè- teeth: a 40-year study. Journal of Periodon-
die Schlussfolgerungen nicht auf eine wissen- me place, et sa prévalence est surtout élevée tology 64, 701–705.
schaftliche Evidenz begründen, sondern eher parmi les patients parodontaux non traités et Chan, C. H. & McGurk, M. (1997) Cervical
empirische Beobachtungen von anerkannten les patients parodontaux en phase de mainte- necrotising fasciitis: a rare complication of
Klinikern darstellen. Das Ziel dieses Über- nance. Diverses étiologies ont été proposées, periodontal disease. British Dental Journal
sichtsartikels war es, eine kritische Analyse et on peut distinguer deux groupes princi- 183, 293–296.
der zu diesem Zustand verfügbaren Informa- paux, suivant la relation de l’abcès par rap- Chen, R-J., Yang, J-F. & Chao, T-C. (1990)
tionen aus der zahnärztlichen und medizini- port aux poches parodontales. Dans le cas Invaginated tooth associated with peri-
schen Literatur zu liefern unter Hinzuziehen d’un abcès lié à une parodontite, l’affection odontal abscess. Oral Surgery Oral Medi-
von Informationen über die Prävalenz, ver- peut se manifester comme l’exacerbation cine Oral Pathology 69, 659.
mutete Ätiologie und Pathogenesse, Diagno- d’une parodontite non traitée ou au cours Dello Russo, M. M. (1985) The post-prophy-
se, Mikrobiologie und Behandlungsalternati- d’un traitement parodontal. Dans les abcès laxis periodontal abscess: etiology and
ven. Der Parodontalabszess ist der dritthäu- non liés à une parodontite, les deux causes treatment. International Journal of Peri-
figste zahnärzlicht Notfall. Er ist principales sont les corps étrangers et les odontics and Restorative Dentistry 1, 29–
insbesondere vorherrschend unter unbehan- anomalies radiculaires. La flore microbienne 37.
delten Parodontitispatienten und bei Paro- de l’abcès semble analogue à celle de la paro- DeWitt, G. V., Cobb, C. M. & Killoy, W. J.
dontitispatienten während der Erhaltungspe- dontite de l’adulte, et est dominée par les bâ- (1985) The acute periodontal abscess: mi-
riode. Es wurden verschiedene ätiologische tonnets anaérobies gram-négatif, avec des crobial penetration of the tissue wall. In-
Faktoren vorgeschlagen unter denen 2 pathogènes parodontaux bien connus. Les ternational Journal of Periodontics and Re-
Hauptgruppen unterschieden werden kön- complications et les suites comprennent les storative Dentistry 1, 39–51.
nen, die abhängig sind von einer Beziehung pertes dentaires et l’envahissement d’autres Emslie, R. D. (1978) Some considerations on
zur parodontalen Tasche. Im Falle des mit parties du corps par l’infection. Pour le dia- the role of cementum in periodontal dis-
Parodontitis verbundenen Abszesses kann gnostic et le traitement, les bases utilisées ease. Journal of Clinical Periodontology 5,
dieser Zustand als eine Exazerbation der un- sont principalement empiriques, en l’absence 1–12.
behandelten Parodontitis oder während der de données basées sur des indications bien Fine, D. H. (1994) Microbial identification
Parodontalbehandlung erscheinen. Bei Ab- documentées. Le rôle des antibiotiques systé- and antibiotic sensitivity testing, an aid for
szessen, die nicht mit einer Parodontitis im miques dans le traitement des abcès parodon- patients refractory to periodontal therapy.
Zusammenhang stehen sind das Impaktieren taux est particulièrement discuté. Journal of Clinical Periodontology 21, 98–
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