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Acute Periodontal Lesions Periodontology 2000, Vol. 65, 2014, 149–177 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Printed in Singapore. All rights reserved PERIODONTOLOGY 2000 Acute periodontal lesions DAVID HERRERA,BETTINA ALONSO,LORENZO DE ARRIBA, ISABEL SANTA CRUZ,CRISTINA SERRANO &MARIANO SANZ Acute lesions in the periodontium, such as abscesses (210). A more comprehensive definition has also been and necrotizing periodontal diseases, are among the proposed: ‘a lesion with an expressed periodontal few clinical situations in periodontics where patients breakdown occurring during a limited period of time, may seek urgent care, mostly because of the associ- and with easily detectable clinical symptoms, includ- ated pain. In addition, and in contrast to most other ing a localized accumulation of pus located within periodontal conditions, rapid destruction of peri- the gingival wall of the periodontal pocket’ (130) odontal tissues may occur during the course of these (Fig. 1). lesions, thus stressing the importance of prompt diag- nosis and treatment. In spite of this, the available sci- Classification of periodontal abscesses entific knowledge on these conditions is limited and is based on somewhat outdated literature. This lack Different criteria have been used to classify periodon- of contemporary data makes it rather challenging to tal abscesses. devise evidence-based therapeutic guidelines. Hence, Location an update is imperative, although it must be confined to an evaluation of narrative reviews and expert Abscesses can be classiffied as gingival or periodontal opinions. abscesses (110). A gingival abscess is a localized pain- Other gingival and periodontal lesions may also show ful swelling that affects only the marginal and inter- an acute presentation, including different infectious dental gingiva and is normally associated with processes not related to oral bacterial biofilms, muco- subgingivally impacted foreign objects. These condi- cutaneous disorders, or traumatic and allergic lesions. tions may occur in a previously healthy gingiva (7). A This article provides an overview and updates of periodontal abscess is a localized painful swelling that existing information on acute conditions affecting the affects deeper periodontal structures, including deep periodontal tissues, including abscesses in the peri- pockets, furcations and vertical osseous defects, and odontium, necrotizing periodontal diseases and other is usually located beyond the mucogingival line. His- acute conditions. tologically, both lesions are identical, but a gingival abscess affects only the marginal soft tissues of previ- ously healthy sites, whilst a periodontal abscess Abscesses in the periodontium occurs in a periodontal pocket associated with a peri- odontitis lesion (76). Definition of periodontal abscess Course of the lesion Abscesses in the periodontium are odontogenic infec- The course of the lesion can be acute and chronic. tions that may be caused by pulp necrosis, periodon- An acute periodontal abscess usually manifests symp- tal infections, pericoronitis, trauma or surgery (109). toms such as pain, tenderness, sensitivity to palpation Odontogenic or dental abscesses are classified, and suppuration upon gentle pressure. A chronic according to the source of infection, into periapical abscess is normally associated with a sinus tract and (dentoalveolar) abscess, periodontal abscess and pe- it is usually asymptomatic, although the patient can ricoronal abscess (327). experience mild symptoms (250). A localized acute A periodontal abscess has been defined as a local- abscess may become a chronic abscess when drain- ized purulent infection in the periodontal tissues age is established through a sinus or through the 149 Herrera et al. Fig. 1. A periodontal abscess, manifesting as a localized Fig. 2. Pericoronal abscess associated with the right man- purulent lesion within the gingival wall of the periodontal dibular third molar. pocket. disease-free area’. A periodontal abscess (which can sulcus. Similarly, a chronic abscess may have an acute be acute or chronic) is defined as ‘a localized accu- exacerbation. mulation of pus within the gingival wall of a peri- Number of abscesses odontal pocket resulting in the destruction of the collagen fibre attachment and the loss of nearby alve- The number of periodontal abscesses (single and olar bone’. A pericoronal abscess is ‘a localized accu- multiple) has also been used for classification pur- mulation of pus within the overlying gingival flap poses (321). A single periodontal abscess is usually surrounding the crown of an incompletely erupted associated with local factors, which contribute to the tooth’ (Fig. 2). closure of the drainage of a periodontal pocket. Multi- ple periodontal abscesses have been reported in uncontrolled diabetes mellitus, in medically compro- Clinical significance of periodontal mised patients and in patients with untreated peri- abscess odontitis after systemic antibiotic therapy for nonoral A common periodontal emergency reasons (125, 126, 321). Multiple abscesses have also been described in a patient with multiple external Periodontal abscesses represented ca. 14% of all den- root resorptions (339). tal emergencies in a study in the USA (7). In general practices in the UK, 6–7& of the patients treated in Type of etiological factors 1 month suffered from a periodontal abscess, which A periodontal abscess is usually associated with a was the third most prevalent infection that demanded previously existing periodontal pocket, although it emergency treatment, after dentoalveolar abscesses can also develop in the absence of a pocket (130). (14–25&) and pericoronitis (10–11&) (177). In an Thus, different types of abscesses may be consid- army dental clinic, 3.7% of the patients had periodon- ered, as related to their etiological factors; this clas- titis and, among these, 27.5% had a periodontal sification will be described in the section on abscess, with clear differences between patients etiology. undergoing active periodontal treatment (13.5%) and untreated patients (59.7%) (117). Among patients in International Workshop for a Classification of supportive periodontal therapy, a periodontal abscess Periodontal Diseases and Conditions was detected in 37% of the patients and in 3.7% of the According to the International Workshop for a Classi- teeth followed for 5–29 years (mean 12.5 years) (209); fication of Periodontal Diseases and Conditions (year in the Nebraska prospective longitudinal study, 53% 1999), abscesses in the periodontium include gingival, of the patients followed for 7 years had a periodontal periodontal, pericoronal and periapical abscesses (210). abscess, and 85% of these abscesses were associated A gingival abscess is defined as ‘a localized, painful, with teeth treated only with coronal scaling. Sixteen rapidly expanding lesion involving the marginal gin- out of 27 abscess sites had initial probing pocket giva or interdental papilla sometimes in a previously depths deeper than 6 mm, and in eight sites probing 150 Acute lesions pocket depths were 5–6 mm (156). Abscesses occur (245), or a sickle-cell crisis in a patient with sickle-cell more often in molar sites, representing more than anemia (255). 50% of all sites affected by abscess formation (128, 209, 300), probably because of the presence of furca- Etiology, pathogenesis and tion, and complex anatomy and root morphology. histopathology of periodontal abscess However, one case series suggested that the mandi- bular anterior incisors were the most frequently Periodontal abscesses may develop in periodontitis- affected teeth (149). affected sites (with a pre-existing periodontal pocket) or in healthy sites (without a pre-existing Tooth loss pocket). Periodontal abscesses may lead to tooth loss, espe- In periodontitis, a periodontal abscess may repre- cially if they affect teeth with pre-existing moderate sent a period of disease exacerbation that is to severe attachment loss, as occurs during sup- favored by the existence of tortuous pockets, the portive periodontal therapy in patients with severe presence of furcation involvement (Fig. 3) or a ver- chronic periodontitis. In fact, periodontal abscess tical defect, in which marginal closure of the pocket has been considered as the main cause for tooth may lead to spread of the infection into the sur- extraction during supportive periodontal therapy rounding periodontal tissues (76, 158, 224). Also, (55, 209, 294, 300). Similarly, teeth with repeated changes in the composition of the subgingival abscess formation were considered to have a hope- microbiota, with an increase in bacterial virulence, less prognosis (36), and 45% of teeth with a peri- or a decrease in the host defence, could result in odontal abscess during supportive periodontal a diminished capacity to drain the increased therapy were extracted (209). The main reason for suppuration. Among periodontal abscesses in peri- tooth extraction in teeth with a questionable prog- odontitis patients, different subgroups can be nosis, followed for 8.8 years, was a periodontal distinguished: abscess (55). Taking these reports into account, it after nonsurgical periodontal therapy. After scal- has been suggested that when a periodontal ing or professional prophylaxis, dislodged calculus abscess is encountered in patients receiving sup- fragments can be pushed into the tissues (74), or portive periodontal therapy, early diagnosis and inadequate scaling may allow calculus to remain adequate therapy are crucial to preserve
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