Management of Periodontal Abscess 2016

TABLES OF CONTENTS Page

LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION i
GUIDELINE DEVELOPMENT AND OBJECTIVES ii
CLINICAL QUESTIONS, TARGET POPULATION, TARGET GROUP/
iv
USER AND HEALTHCARE SETTINGS
GUIDELINES DEVELOPMENT GROUP v
REVIEW COMMITTEE vi
ALGORITHM FOR MANAGEMENT OF PERIODONTAL ABSCESS vii
LIST OF KEY MESSAGES AND RECOMMENDATIONS viii
1. INTRODUCTION 1
1.1 The Aetiology, Microbiology and Contributing Factors 2
1.2 Pathogenesis of Periodontal Abscess 3
2. HISTORY TAKING 4
2.1 Signs and Symptoms 4
2.2 Medical and Dental Histories 5
3. CLINICAL FEATURES 6
3.1 Systemic Manifestation or Involvement 6
3.2 Clinical Features 6
4. INVESTIGATIONS 8
4.1 Radiographs 8
4.2 Pulp Sensibility Test 8
4.3 Microbial Test 8
4.4 Others 8
5. DIAGNOSIS 8
6. TREATMENT 16
6.1 Control of Acute Condition 16
6.2 Management of Pre-existing and/or Residual Lesions 18
7. IMPLEMENTING THE GUIDELINES 18
7.1 Facilitating and Limiting Factors 19
7.2 Potential Resource Implications 20
7.3 Proposed Clinical Audit Indicators 20
REFERENCES 21
Appendix 1: Clinical Questions: Management of Periodontal
25
Abscess
Appendix 2: Recommended Systemic Antimicrobials 26
Appendix 3: Extraction versus Conservation 27
ACKNOWLEDGEMENTS 28
DISCLOSURE STATEMENT 28
SOURCE OF FUNDING 28
 2016 Management of Periodontal Abscess

ALGORITHM FOR MANAGEMENT OF PERIODONTAL ABSCESS

Initial Assessment
and Examination

Acute Periodontal Chronic Periodontal

Abscess Abscess

Extraction of
‘irrational to treat’/
hopeless tooth

Immediate
management

and/or refer to specialist

of abscess

Recall in
Control of condition

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LIST OF KEY MESSAGES AND RECOMMENDATIONS

Key Message 1

periodontium is a clue to aid diagnosis of periodontal abscess.

severe periodontal disease with higher prevalence of periodontal abscess.

Key Message 2

probing are the main clinical features of PA.

Key Message 3

without antibiotics is usually effective.

using either a hand or ultrasonic scaler to facilitate drainage.

Recommendation 1

(Grade C)

Recommendation 2
A thorough subgingival scaling and root surface debridement should be carried
out to treat abscesses in anatomically complex sites (e.g. furcation involvement
or intrabony pockets).
(Grade C)

Recommendation 3

or not responding to oral antibiotics should be referred to hospital immediately.

(Grade C)

carried out within 5 days.

(Grade C – Development Group’s consensus)

Recommendation 4
Diabetic patients with acute symptoms should be given prompt treatment.
25, Level III

(Grade C)

(Grade C)

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 Management of Periodontal Abscess 2016

1. INTRODUCTION

Periodontal abscess (PA) is a common emergency in the dental clinic,

being the third most prevalent emergency infection, after acute dento-
alveolar abscesses and pericoronitis. 1-3, Level lll

According to the 1999 Classification of Periodontal Diseases

and Conditions (AAP World workshop) 4, Level lll “Abscesses of the
Periodontium” include gingival, periodontal and pericoronal abscess
(Table 1).

Table 1: Classification of periodontal diseases and conditions 1999

I: Gingival diseases VI: Abscesses of the periodontium
A Dental plaque-induced gingival A Gingival abscess
diseases B Periodontal abscess
B Non-plaque-induced gingival C Pericoronal abscess
lesions VII: Periodontitis associated with endodontic
II: Chronic periodontitis lesions
A Localized A Combined periodontic–endodontic
B Generalized lesions
(>30% of sites are involved) VIII: Developmental or acquired
III: Aggressive periodontitis deformities and conditions
A Localized A Localized tooth-related factors
B Generalized that modify or predispose to
(>30% of sites are involved) plaque-induced gingival
IV: Periodontitis as a manifestation of diseases ⁄periodontitis
systemic diseases B Mucogingival deformities and
A Associated with conditions around teeth
hematological disorders C Mucogingival deformities and
B Associated with genetic disorders conditions on edentulous ridges
C Not otherwise specified D Occlusal trauma
V: Necrotizing periodontal diseases
A Necrotizing ulcerative gingivitis
B Necrotizing ulcerative
periodontitis

Periodontal abscess, which can be acute or chronic, is defined as

a lesion associated with periodontal breakdown occurring during a
limited period of time with detectable clinical symptoms, including a
localised accumulation of pus located within the gingival wall of the
periodontal pocket. 1,2, Level lll

A gingival abscess is defined as a localised, painful, rapidly expanding

lesion involving the marginal gingiva or interdental papilla sometimes
in a previously disease-free area. 2, Level III

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 2016 Management of Periodontal Abscess

A pericoronal abscess is a localized accumulation of pus within the

overlying tissue surrounding the crown of an incompletely erupted
tooth. 2, Level III

Abscesses occur more often in molar sites representing more than

50% of cases, 6,49, Level III probably because of the presence of furcation,
and complex anatomy and root morphology. 2, Level III

1.1 The Aetiology, Microbiology and Contributing Factors

An understanding of the aetiology of periodontal abscess is crucial

to ensure successful outcomes. Periodontal abscess occurs mainly in
periodontitis sites with deep pockets although it can develop in non-
periodontitis sites.

Microorganisms are the cause for the periodontal abscess. The

common microorganisms involved are: 5-7, Level III
a) Fusobacterium nucleatum
b) Porphyromonas gingivalis
c) Tannerella forsythia
d) Prevotella intermedia/nigrescens
e) Peptostreptococcus micros

Lower prevalences were observed for:

a) Prevotella melaninogenica
b) Campylobacter rectus
c) Aggregatibacter actinomycetemcomitans

Similar proportions of facultative and strict anaerobes were found, of

which a higher proportion were gram-positive facultative cocci, closely
followed by gram-negative anaerobic rods. 1,7, Level III

In periodontitis–affected sites, the mechanisms that may lead to

abscess formation include: 2, Level III
a) Exacerbation of a chronic lesion as a consequence of changes
in the subgingival microbiota composition, with an increase
in bacterial virulence, or a decrease in host defence. This is
further aggravated by the existence of tortuous pockets,
presence of furcation involvements and vertical defects, which
may result in a reduced capacity to self-drain.

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 Management of Periodontal Abscess 2016

b) During the course of periodontal therapy:

8, Level III

o inadequate scaling may allow calculus to remain in

deep pockets, whilst the healed marginal gingiva will
occlude pocket drainage
o dislodged calculus fragments may be embedded into the
surrounding tissues
9, Level II-2

o associated with presence of foreign bodies, such as

membranes for regenerative procedures or sutures

(maintenance) phase 2, Level III

c) Post-systemic antibiotic intake in pre-existing periodontitis

without scaling/root debridement 10, Level II-3; 11, Level III

d) Acute exacerbation of untreated periodontitis

Abscess can also occur in non-periodontitis/healthy sites, owing to:

2, Level III

a) impaction of foreign bodies including orthodontic elastics, piece

of dental floss, dislodged cemental tear, fragment of
toothpick,12,13, Level III piece of finger nail,14, Level III fish
bone and piece of popcorn kernel 11, Level III
b) anatomical variations such as invaginated tooth,15, Level III
enamel pearls / extensions and palatal groove 16, Level III
c) alteration of the root surface by different factors such as
perforation by endodontic instrument,13, Level III crack/fracture
of the root, 38, Level II-1 cervical cemental tear 16, Level III and
external root resorptions

1.2 Pathogenesis of Periodontal Abscess

Invasion of bacteria into soft tissues surrounding the periodontal

pocket will result in an inflammatory process through chemotactic
factors released by the bacteria. Both lowered tissue resistance,
and the virulence and number of bacteria will determine the course
of this infection. The formation of an acute inflammatory infiltrate and
encapsulation of bacterial mass will lead to extensive connective tissue
destruction and pus formation. 17-18, Level III

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2. HISTORY TAKING

The diagnosis of periodontal abscess should be based on overall

evaluation and interpretation of patient’s symptom, together with the
clinical and radiological signs found during the oral examination. 2, Level III

2.1 Signs and Symptoms

Symptoms of periodontal abscess can range from moderate to severe

pain (62%) to no pain (10%). 1,5,7, Level III Periodontal abscess may be
associated with intraoral swelling. The approximate duration of
swelling in patients can be 1-4 days (40%), between 5-10 days (25%)
and unknown in 15% of patients. 1, Level III In acute lesions, swellings are
more defined and localised. Other symptoms range from tenderness
of gingiva to palpation, 7, Level III tooth mobility, 1, Level III and extrusion of
teeth (23.3%). 5, Level III

Acute periodontal abscess is a lesion that progresses dramatically in a

short period to a crisis 19, Level III with severe pain, distress, and often with
complaint of tooth elevation as well as tenderness on biting. 20, Level III A
complaint of fever and discomfort due to regional lymphadenopathy
indicates systemic spread of infection. 21, Level III

Chronic periodontal abscess is usually asymptomatic and may be

associated with sinus tract. 2, Level III

Signs and symptoms of acute and chronic periodontal abscess

1, 22, Level III
are as in Table 2.

Table 2: Signs and Symptoms of Periodontal Abscess

Acute Periodontal Abscess Chronic Periodontal Abscess

deep pocket

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2.2 Medical and Dental Histories

Thorough medical and dental history including medication is important

in total patient management. 19, Level III Detailed history of periodontitis
experience and its treatment, particularly history of recent antibiotic
therapy is also important. Thus, the following points have to be
considered:
a) history of periodontitis 1, Level III
b) history of a traumatic event e.g. impaction of foreign body into the
periodontium 2, Level III
c) presence of untreated periodontitis (incidence of 62%) 7, Level III
d) current periodontal disease status 1, Level III
e) recent scaling and root planing 1,5, Level III (incidence of 14%) 7, Level III
f) recent dental treatment (restorative/orthodontic/endodontic)
2, Level III

g) recent systemic antibiotic therapy 2, Level III

h) supportive periodontal (maintenance) phase (incidence of 7%)
7, Level III

i) risk factors:

periodontal disease and do not respond predictably to treatment

23, Level lI-2

in diabetics especially those with poor glycaemic control

20, 22, Level III

(Syndromic and Non-Syndromic Periodontitis) 24, Level III

Development of periodontal abscess in periodontitis may occur as

an acute exacerbation of an untreated periodontitis, during active
periodontal therapy and supportive periodontal (maintenance) phase.
7, Level III

Key Message 1

the periodontium is a clue to aid diagnosis of periodontal

abscess.

more prone to severe periodontal disease with higher prevalence

of periodontal abscess.

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Recommendation 1

diagnosing PA.

(Grade C)

3. CLINICAL FEATURES

3.1 Systemic Manifestation or Involvement

Systemic involvement has been reported in some severe cases of

periodontal abscess which include:
a) fever
b) malaise
c) regional lymphadenopathy (10% of patients)
d) leucocytosis can be detected in approximately 1/3 of patients.
6,7,26,27, Level III

e) features that may indicate on-going systemic diseases, in particular

compromised immune system 28, Level III

3.2 Clinical Features

a) Extra oral
Periodontal abscess may be associated with:

that the swelling had occurred 1–4 days before; 25%

between 5–10 days; 20% between 15–30 days; and 15%
did not know. 6, 26, 28, 29, Level III
29, Level III

30, Level III

redness and sinus
6, 7, 26, 28, 29 Level III

b) Intra oral
Most prominent signs are: 6, Level III

root 2, 29, Level III

29, Level III

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 Management of Periodontal Abscess 2016

pressure from gingival sulcus or sinus

destruction (62.1% with pockets deeper than 6 mm)

5-7, 26, 29-30, Level III

29, Level III

Figure 1: Clinical features of Periodontal Abscesses

(Courtesy: Dr Norhani, Dr Izrawatie)

Key Message 2

and bleeding on probing are the main clinical features of PA.

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4. INVESTIGATIONS

4.1 Radiographs
Periapicals and OPG are commonly used for assessment.
31, 32, Level III
In presence of sinus, gutta percha point can be
placed through the opening to locate the origin of the sinus tract.

The radiographic examination of periodontal abscess may

reveal a normal appearance, widening of periodontal ligament
(PDL) spaces or some degree of radiographic bone loss of the
tooth involved in cases with pre-existing periodontal pocket.
2, 5, Level III

4.2 Pulp Sensibility Test

Pulp sensibility test (formerly known as pulp vitality test) could be
used to assess the vitality of the tooth. 33, Level III Teeth
with primary periodontal infection tend to respond positively to
pulp sensibility test such as thermal test and electric pulp test.
34, Level III

4.3 Microbial Test

Samples of pus from the sinus, abscess or gingival sulcus could
be sent for culture and sensitivity test. 5, 32, Level III Culture
studies have provided a substantial body of information about
the bacterial aetiology and the species involved. 35, Level III

4.4 Others
Glycaemic level of patients can be assessed through random
blood glucose, fasting blood glucose or glycosylated
haemoglobin (HbA1c) level, if indicated to identify undetected
diabetics and to assess glycaemic control in diabetics.
32, Level III

5. DIAGNOSIS

The diagnosis of periodontal abscess should be based on overall

evaluation which include the relevant medical and dental histories
along with clinical and radiological findings during the
examination. 2, Level III

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 Management of Periodontal Abscess 2016

Possible differential considerations include:

The characteristics and clinical / radiographic findings of the above

lesions for differential diagnosis are given in Table 3.

Table 3: Differential Diagnosis and Characteristics of Periodontal

Diseases
Differential
Characteristics and Clinical / Radiographic Findings
Diagnosis
1. Gingival
Abscess
2, level III

NO periodontal pocketing

e.g.: Case 1 (Courtesy: Dr Khamiza Zainal Abidin)

Gingival abscess on buccal aspect of 21 IOPa radiograph did not show

any significant findings.

e.g.: Case 2 (Courtesy: Dr Norhani Abd Rani)

Gingival abscess in
drug-induced gingival
enlargement case

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2. Periodontal Most prominent clinical signs are:

Abscess
2, 5-7, 26, 29-32,
level III

sulcus or sinus

percussion
The radiographic examination: may reveal a normal appearance,
widening of periodontal ligament (PDL) spaces or some degree
of radiographic bone loss of the tooth involved in cases with
pre-existing periodontal pocket.

e.g.: Case 1 (Courtesy: Dr Norhani Abd Rani )

Redness, swelling and deep periodontal pocket (9mm) on mesial of 41.

IOPa radiograph indicating horizontal bone loss

e.g.: Case 2 (Courtesy: Datin Dr Indra a/p Nachiapan)

Redness and swelling on OPG radiograph revealed

palatal surfaces of 25 and 26, widening of PDL space of teeth
with mobility and deep pockets 25 and 26. Bone loss >½ of root
length, with furcation involvement

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Management of Periodontal Abscess 2016

e.g.: Case 3 (Courtesy: Dr Izrawatie Shapeen)

Generalized swelling of gingival IOPa radiograph showed

tissue with suppuration especially severe bone loss to root tips
on mandibular region

e.g.: Case 4 (Courtesy: Dr Izrawatie Shapeen)

Redness, swelling and deep periodontal pocket (9mm) on mesial of 23. IOPa
radiograph revealed radiolucency at mesial of the tooth indicating bone loss

e.g.: Case 5 e.g.: Case 6

(Courtesy: Dr Izrawatie Shapeen) (Courtesy: Dr Izrawatie Shapeen)

Redness at marginal margin, Swelling and redness of gingival

swelling and suppuration at palatal tissue
surface of 11

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e.g.: Case 7 (Courtesy: Dr Nor Ziana Ibrahim)

Swelling of gingival tissue on IOPa radiograph showed bone loss

buccal aspect of 36 and 37 around the teeth

e.g.: Case 8 (Courtesy: Dr Izrawatie Shapeen)

Swelling, deep pockets and suppuration in drug-induced gingival

enlargement case

3. Periapical Formation of purulent exudate involving dental pulp and tissues

Abscess surrounding apex of tooth
2, level III

e.g.: Case 1 (Courtesy: Dr Nor Ziana Ibrahim)

Presence of sinus tract on buccal aspect of 46, traced with gutta percha(GP).

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 Management of Periodontal Abscess 2016

e.g.: Case 2 (Courtesy: Dr Izrawatie Shapeen)

Presence of sinus tract on labial surface of 21, IOPa radiograph

traced with gutta percha (GP), without presence of revealed gp traced
deep pocket to the apical
radiolucency of 22
e.g.: Case 3 (Courtesy: Dr Nor Ziana Ibrahim )

Presence of sinus tract on labial surface IOPa radiograph revealed

between 16 and 17, traced by gutta percha, gp traced adjacent to the
without presence of deep pocket periapical radiolucency
of 16

4. Perio-Endo Perio-Endo :
Lesion 37,
level III
/ Endo involve the furcation
–Perio
Lesion 37,
level III

/ Combined
Lesions Endo-Perio:

pockets

e.g.: Case 1 (Courtesy: Dr Izrawatie Shapeen)

Deep pocket, bleeding on probing (BOP), IOPa radiograph

suppuration on non-vital 33. revealed radiolucency
at middle portion of
the root extending
towards apical
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 2016 Management of Periodontal Abscess

e.g.: Case 2 (Courtesy: Dr Izrawatie Shapeen )

Swelling and
abscess on
distal aspect
of 36.

IOPa radiograph
revealed bone
loss involving
furcation

e.g.: Case 3 (Courtesy: Dr Izrawatie Shapeen)

Presence of deep pocket, BOP, and suppuration OPG radiograph

on distal of non-vital 43 revealed periapical
radiolucency
extending to the
whole root length

5. Cracked
Tooth
Syndrome
38, Level III

tooth slooth. Pain relief after placement of orthodontic band

e.g.: Case 1 (Courtesy: Dr Izrawatie Shapeen)

Crack line on 32 only visible under UV light (arrow)

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 Management of Periodontal Abscess 2016

6. Vertical
Root
Fracture
39, level III

fracture for long-standing fracture

periapical radiographs (‘J-shaped’ image)

e.g.: Case 1 (Courtesy: Dr Nor Ziana Ibrahim)

Presence of abscess IOPa radiograph Vertical fracture lines

on labial surfaces on revealed were visible on the
12 & 11 radiolucencies on root surfaces
apical region of
12 & 11

e.g.: Case 2 (Courtesy: Dr Izrawatie Shapeen)

IOPa radiograph Deep pocket, BOP Vertical

revealed periapical and suppuration on fracture line on
radiolucency of mesial mesiolingual surface of mesiolingual
root 46 mesial root. Upon full surface of mesial
thickness flap elevation, root
fracture line was visible

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6. TREATMENT

Treatment of periodontal abscess does not differ substantially from

other odontogenic abscesses. It should include two distinct phases.
2, Level III

a) Control of the acute condition to arrest tissue destruction and

alleviate the symptoms.
b) Management of pre-existing and/or residual lesion, especially in
patients with periodontitis.

6.1 Control of Acute Condition:

a) Drainage and debridement with/without antimicrobials

(systemic or local)
This includes drainage (by means of scaling of the pocket
or through an incision) and root surface debridement followed
by irrigation with normal saline/antiseptics.1, Level III If the
abscess is associated with a foreign-body impaction, the
foreign body must be removed. 1, 39, Level III

Key Message 3

periodontal pocket without antibiotics is usually

effective.

debride the root surface using either a hand or ultrasonic

scaler to facilitate drainage.

microorganisms.

Recommendation 2
A thorough subgingival scaling and root surface
debridement should be carried out to treat abscesses in
anatomically complex sites (e.g. furcation involvement or
intrabony pockets).

(Grade C)

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 Management of Periodontal Abscess 2016

b) Alleviation of pain
Analgesics should be prescribed to relieve pain. The selection of
analgesic depends on the patient’s history, allergy profile, and the
level of discomfort. Options include a non-steroidal anti-
inflammatory drug (NSAID) and/or an opioid analgesic.52, Level II

c) Antimicrobials
Drainage and debridement with an adjunctive antimicrobial should
be considered if there is systemic involvement. 2, 40, 41, 43,
Level III
Use of systemic antimicrobials 2, Level III as the sole treatment
may ONLY be recommended if:

Indications for systemic antimicrobials are as follows: 42, 44-47,

Level III

specific microbiological profile.

fever or malaise or when the infection is not well localised.

The choice of antibiotics should be based on sound pharmacological

and microbiological principles (Appendix 2). 48, Level III This antibiotic
regime should be followed by debridement within 5 days.

Patients shall be reviewed after 24-48 hours to evaluate resolution of

abscess. The definitive treatment should be carried out once the acute
phase has resolved.

Recommendation 3

or not responding to oral antibiotics should be referred to hospital

immediately.
(Grade C)

should be carried out within 5 days.

(Grade C – Development Group’s consensus)

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6.2 Management of Pre-existing and/or Residual Lesions

Management of pre-existing and/or residual lesions are as

follows:
Refer to periodontist for appropriate non-surgical / surgical
periodontal treatment
Surgical therapy has been advocated mainly in abscesses
associated with deep intrabony defects, furcation
involvement, residual calculus and tooth anomalies where
the resolution of the abscess can be achieved by surgical
access 1, 2, 8 ,49 Level III
Tooth extraction
If the tooth has a hopeless prognosis, or is irrational to treat,
as a result of severe destruction of the periodontium, the tooth
should be extracted. 2, 50 Level III Indications for tooth
extraction are:
and

and
and
51, Level III

Refer to Appendix 3 on decision making process for tooth retention

or extraction.

Recommendation 4
Diabetic patients with acute symptoms should be given prompt
treatment. 25, Level III
(Grade C)

(Grade C)

7. IMPLEMENTING THE GUIDELINES

It is important to standardise the management of periodontal abscess

at all healthcare levels in Malaysia using an evidence-based CPG in
order to manage it appropriately. Recognition of periodontal health
and periodontal abscess by a clinician, the knowledge of what to
do when a problem occurs, and the appropriate responses from the

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 Management of Periodontal Abscess 2016

health professional are major factors in management of periodontal

abscess. This professional awareness is influenced by factors such as
maintaining current understanding of the nature of periodontal abscess,
the appropriate management, continuing professional education and
an understanding of patient expectations.

As the outcomes of periodontal therapy is mostly dependent on the

timely and appropriate management of the condition, it is important
to disseminate the knowledge among healthcare providers, as well
as to the public. This can be facilitated through the development of
appropriate training modules and quick references.

Cost implications on management of periodontal abscess vary

depending on several factors such as patient’s expectations,
compliance and medical conditions. Successful treatment outcomes
would require active periodontal and supportive (maintenance) therapy;
thus involving further cost. Periodontal abscess sometimes results
in loss of teeth requiring rehabilitation. Appropriate management
of periodontal abscess would ensure better prognosis of affected
dentition.

7.1 Facilitating and Limiting Factors

Existing facilitators for application of the recommendations in the CPG

include:
a) Wide dissemination of the CPG to healthcare professionals
and teaching institutions via printed and electronic copies.
b) Continuing professional education on the management of
periodontal abscess for healthcare professionals.
c) Adequate facilities at primary care level for detection and
recognition of periodontal abscess.

Existing barriers for application of the recommendations of

the CPG include:
a) Lack of understanding or limited knowledge of periodontal
abscess.
b) Variation in treatment practice.
c) Constraints in clinical facilities.

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7.2 Potential Resource Implications

To implement the CPG, there must be strong commitment to:

a) ensure widespread distribution of the CPG to healthcare
professionals.
b) detect and recognise periodontal abscess by healthcare
professionals.
c) reinforce training of healthcare professionals to ensure
information is up to date.

7.3 Proposed Clinical Audit Indicators

To assist in the implementation of the CPG, the following are proposed

as clinical audit indicators for quality management:

1. Percentage of teeth Number of teeth with

with periodontal periodontal abscesses that
abscesses that resulted in extraction within
resulted in extraction 6 months*
= X 100
within 6 months*
No. of teeth with periodontal
abscesses at baseline
Standard:
a) Specialist care = less than 5%
b) Primary care = less than 20%
Note: *excluding teeth with hopeless prognosis

2. Percentage of teeth Number of teeth with periodontal

with periodontal abscesses that resulted in
abscesses that complete resolution with no
resulted in complete recurrence after 6 months*
= X 100
resolution with no
recurrence after
6 months* No. of teeth with periodontal
abscesses at baseline
Standard:
Specialist care = 70%

Note: The six months* period was based on Development Group Consensus
Complete resolution: healing with no further sign and symptoms.

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Appendix 1

Clinical Questions: Management of Periodontal Abscess

Introduction
1. What is the definition of Periodontal Abscess (PA)?

Etiology and pathogenesis

1. What are the etiology, microbiology and contributing factors of PA?
2. What is the pathogenesis of PA?

Investigation and Diagnosis

1. What are the common complaints and symptoms of PA?
2. What are the relevant medical and dental histories of patients with
PA?
3. Are there any systemic manifestations or involvement reported in
patients with PA?
4. What are the clinical features of PA?
5. What are the investigations needed to diagnose PA?
6. What are the differential and definitive diagnoses of PA?

Treatment
1. How is the acute condition of PA controlled?
2. Is there any indication for systemic antimicrobials for patient with
PA?
3. What are the effective and safe pharmacological treatments for PA?
4. When to review the presenting symptoms of PA?
5. What are the effective and safe treatments of residual / pre-existing
lesions of PA?
6. What are the indications for tooth extraction in PA?

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Appendix 2

Recommended Oral Antimicrobials

(As indicated in section 6.1c)

No. Antibiotics Dose Duration Note

Not allergic to Penicillin
1. Metronidazole 400mg PO 5 or 7 days 1. Contraindicated for
q8h pregnant patients
2. Alcohol consumption is
prohibited
2. Amoxycillin 500 mg PO 5 or 7 days
q8h
3. Amoxycillin 500 mg PO 5 or 7 days For Aggressive Periodontitis:
and q8h Amoxycillin 500 mg PO q8h
Metronidazole 200 mg PO and Metronidazole
q8h 400 mg PO q8h, 7 days
(NAG 2015)
4. Amoxycillin/ 500/125 5 or 7 days Augmentin is only
clavulanate mg PO q8h recommended for spreading
(Augmentin) infections and infections of
fascial spaces (with/without
systemic signs) (NAG 2015)
Allergic to Penicillin
1. Erythromycin 250 mg PO 5 or 7 days May increase levels
q6h of anticoagulants,
antiepileptics,
antipsychotics, anxiolytics/
hypnotics, cyclosporine,
theophylline
2. Clindamycin 150/300 5 or 7 days
mg PO q6h
3. Doxycycline 100 mg PO 7,10 or 14 days Caution in pregnant
q12h patients, breast-feeding
women, and children under
12 years old
4. Azithromycin 500 mg PO 3 consecutive
q24h days
Source: Herrera D et al 2002, Herrera D et al 2000, Bascones MA et al 2004; PV Patel 2011, NAG 2015

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Management of Periodontal Abscess

27

2016
Source: Avilla Gustavo Avila,*Pablo Galindo-Moreno, Stephan Soehren, Carl E. Misch, Thiago Morelli, and Hom-Lay Wang.
A novel decision-making process for tooth retention or extraction. J. Periodontol. 2009;80:476-491.