A periodontal abscess also called lateral abscess, or parietal abscess is a localized collection of pus within the tissues of the periodontium. Gum abscess is a type of a dental abscess. The gingival abscess involves only the gingiva of the gums and causes minimal damage. On successful treatment its effects are reversible. A pericoronal abscess is mostly seen in association with developing third molars. A periodontal abscess is an advanced gum disease involving the periodontium and the bone surrounding the teeth. A periodontal abscess can lead to loss of tooth and spread of infection if not tended to in time. Let us understand in detail about gum abscess.
Classification of gum abscess
Four types of abscesses can involve the periodontal tissues –
It is a localized, purulent infection which affects only the soft gum tissue, the marginal gingiva or the interdental papilla and does not involve the periodontium.
It is a localized, purulent infection involving the periodontium, extending through a periodontal pocket (1). The periodontal abscess can also involve the alveolar bone and the crestal bone.
It is a localized, purulent infection involving the gum tissue surrounding the crown of a partially erupted or impacted tooth (2). They usually are associated with an acute episode of pericoronitis around a partially erupted and impacted mandibular third molar.
Combined periodontal/endodontic abscess
This involves abscess that is formed due to both, endodontic and periodontic condition (3).
Clinical diagnostic procedures for gum abscess
A thorough visual inspection of the lips, oral mucosa, palate, cheeks, tongue, and muscles should be done. The alveolar mucosa and the attached gingiva should be examined for the presence of any inflammation, ulcerations or sinus tracts. Generally, the presence of a sinus tract is associated with a periapical abscess (4).
Palpation is an application of firm digital pressure to the mucosa overlying the roots and apices. With the fingers, the mucosa is pressed against the cortical bone.
This will detect the presence of any underlying periradicular abnormalities which produces a sharp response to digital pressure.
This test indicates the presence of a periradicular inflammation. A positive response to percussion indicates inflammation of the periodontium that may be either be from a periapical or periodontal abscess (5).
This test helps identify the location of the pain. It should be performed gently, especially in highly sensitive teeth.
Tooth mobility is directly proportional to the extent of inflammation in the periodontal ligament (6). Mobility is quite common in cases of primary endodontic involvement and should not be confused with true mobility caused by periodontal destruction. The movement related to primary endodontic pathology resolves within a week of endodontic therapy.
Identifying whether the abscess is periapical or lateral can also be done through radiographic examination. Often, the initial phases of periradicular bone resorption due to abscess are confined only to cancellous bone. The radiograph only shows the cases that have progressed to compact bone.
Chronic endodontic or periodontal infection may sometimes develop a fistulous sinus track (7). The inflammatory exudates tunnel through the tissues and structures of minor resistance and open anywhere on the oral mucosa or facial skin.
Intraorally, the opening is usually visible in the vestibule or on the attached buccal gingiva. Fistula tracking is done by inserting a semirigid radiopaque material into the sinus track until resistance is met.
Gutta-percha cones commonly used for fistula tracking. A radiograph is then taken, which reveals the course of the sinus tract and the offending tooth.
Causes of gum abscess
Mechanical injury to the gingiva for example, with a toothbrush bristle, fishbone, toothpick or periodontal instrument, may inoculate bacteria into the tissues.
Injury to the tissues, due to trauma to a tooth or excessive pressure on teeth during an orthodontic procedure, can be a possible cause as well.
Leaving a gingival retraction cord after a dental procedure in the sulcus will lead to loosening of the gingival cuff, this can also lead to the development of a gingival abscess.
A periodontal abscess most commonly occurs as a complication of the advanced periodontal disease. A periodontal pocket contains, bacteria, dental plaque, and subgingival calculus.
An inflammatory response occurs when the bacteria invade and multiply within the periodontal pocket. An abscess forms when our immune system attempts to isolate this infection from spreading (8).
Usually, a periodontal abscess communicates with the oral environment via the opening of the periodontal pocket. However, in some cases, the opening of a periodontal pocket becomes obstructed.
This occurs in advanced cases if the pocket has become very deep, with furcation involvement of the tooth. In such cases, the plaque and tartar are trapped inside.
Systemic conditions such as diabetes make a person more prone to develop a periodontal abscess. Certain iatrogenic errors such as perforation of a root canal during endodontic therapy can lead to a periodontal abscess.
Improper contact or increased height of restoration will increase the occlusal overload leading to the development of a periodontal abscess. During the restoration, especially in between the teeth, if any overhangs are left, a periodontal pocket can develop (9).
The pericoronal abscess occurs in relation to a tooth is incompletely erupted or partially impacted mostly seen with partially erupted lower-third molars.
As this is the last tooth of the jaw, it has incomplete access for cleansing, and the overlying flap traps the food debris. The bacteria from plaque multiplies thriving on this food giving rise to an abscess,
Treatment of gum abscess
Identifying and eliminating the cause will help prevent the spread of gingival abscess. It mostly occurs when a food particle or an object remains wedged in the gum for a long time.
A routine scaling and polishing will help reduce the inflammation and pain associated. If the causative factor is harsh brushing, switch to a brush with softer bristles. Warm saline rinses and chlorhexidine mouthwash will reduce the progress and help in recovery.
An important factor in forming a treatment plan is to decide whether the involved tooth is to be retained or extracted. A history of recurrent periodontal abscesses significantly compromises the periodontal support and weaken that the prognosis for the tooth.
The primary management of a periodontal abscess involves control of the infection. When the abscess is drained, it will provide relief from the pain and will also control the spread of the infection.
If the tooth is to be extracted, drainage will occur through the socket. If the tooth is to be retained, and the pus is already discharging from the periodontal pocket, irrigation and deep scaling of the pocket is done. Incision and drainage can be done in cases of deep pockets.
Antibiotics are generally prescribed for severe and recurrent infections, which causes local swelling. Since periodontal abscesses frequently involve anaerobic bacteria, oral antibiotics such as amoxicillin, clindamycin or metronidazole are given.
In some instances, the height of the tooth requires a slight reduction, so it no longer contacts the opposing tooth. This ensures speedy recovery of the tooth.
The management following the primary phase involves correcting the factors which lead to the formation of a periodontal abscess. It is advised that patients should use hot salt water mouthwashes regularly which will keep the periodontal pocket clean till it heals completely.
If the cause of a pericoronal abscess is not eliminated, it may present as a recurrent condition which requires multiple episodes of treatment.
There are several factors on which treatment of pericoronitis depends, such as the inflammation severity, the systemic complications and whether the tooth is going to be retained or extracted.
First, the operculum or the flap is numbed by topical anesthesia and the area is irrigated with warm saline to flush away any irritants or food debris. If the abscess is seen after elevating the pericoronal flap, the area is swabbed with an antiseptic liquid, and an incision is made.
Drainage is encouraged, and the flap is cauterized or excised to prevent further entrapment of any food particles.
Final words on gum abscess
Using chlorhexidine mouthwash reduces the bacteria in your mouth, but be sure to check the concentration of the same with your dentist.
At the first sign of swelling or inflammation visit your dentist. This will help curb the abscess in its initial stage and can also help prevent loss of a tooth (10). A periodontal abscess can lead to loss of a healthy tooth, so practice regular oral hygiene to avert this outcome.
People with diabetes should go for regular health checkups and have regular dental examinations. Regular brushing and flossing will keep your gums healthy. Also, go for proper scaling and polishing at the dental office to prevent the formation of calculus on your teeth.
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