What Causes an Abscessed Tooth?

1. The purulent inflammation on the inner wall of the deep periodontal pocket expands into the deep connective tissues, and when the pus cannot be discharged into the pocket, an abscess in the soft tissue of the pocket wall can form;

Ouyang Xiangying	(Chief physician)	Department of Periodontology, Peking University Stomatological Hospital
Kang Jun	(Chief physician)	Department of Periodontology, Peking University Stomatological Hospital
Shi Dong	(Deputy Chief Physician)	Department of Periodontology, Peking University Stomatological Hospital

Periodontal abscess can occur in any type of periodontitis patient. It is a localized purulent inflammation located in the periodontal pocket wall or deep periodontal tissue, which can cause destruction of surrounding collagen fibers and bone. It is usually an acute process and may also have a chronic periodontal abscess. Periodontitis is a chronic infectious disease of periodontal support tissue caused by microorganisms in plaque, which leads to inflammation and destruction of periodontal support tissue. It is the leading cause of tooth loss in Chinese adults. Periodontitis progresses to middle and late stages, and after the emergence of deep periodontal pockets, periodontal abscesses can accompany it.

Western Medicine Name: Periodontal abscess
Affiliated Department: Department of Physiology-Stomatology

Disease site: Oral cavity
The main symptoms: Ulceration and drainage, repeated acute attacks
Main cause: Purulent inflammation on the inner wall of the deep periodontal pocket

Causes of periodontal abscess

2. The tortuous, deep periodontal pockets involving multiple tooth surfaces, the purulent exudate cannot be drained smoothly, especially when the root bifurcation area is involved.

3. When cleaning or scraping, the action is rough, pushing tartar fragments and bacteria into the deep tissue of the periodontal pocket, or damaging the gum tissue.

4. The curettage of deep periodontal pockets is incomplete, which causes the pockets of the periodontal pockets to tighten, but the inflammation at the bottom of the periodontal pockets still exists and no drainage is obtained.

5. Root canal or medullary chamber perforation, longitudinal root fissure, etc. can sometimes cause periodontal abscesses during endodontic treatment.

6. Decreased body resistance or severe systemic diseases, such as diabetes, are prone to periodontal abscesses. Patients with multiple or recurrent periodontal abscesses should be careful to rule out the possibility of diabetes.

7. Some highly virulent periodontal pathogenic microorganisms colonize and proliferate in periodontal pockets, exacerbating and spreading infection.

Periodontal abscess pathological changes

In the periodontal pocket wall, there is a large accumulation of living or necrotic neutrophils. Necrotic white blood cells release multiple protein waters

Hydrolyzing enzymes cause necrosis and lysis of surrounding cells and tissues to form pus, which is located in the center of the abscess. Acute inflammation around the abscess

In the disease area, the surface epithelium is highly edema, and a large number of white blood cells enter the epithelium.

Clinical manifestations of periodontal abscess

Periodontal abscess is usually an acute process, which can be self-destructive and abscessed, but it can become chronic periodontal abscess without active treatment or repeated acute attacks.

Acute periodontal abscess suddenly develops, forming oval or hemispherical swollen protrusions on the gums of the buccal or buccal side of the affected tooth. The gums are red and edema with a shiny surface. In the early stage of an abscess, extensive inflammation infiltrates, causing greater tissue tension, severe pain, and pulsating pain. The affected tooth has a "floating sensation", stinging pain and obvious looseness. In the later stage of the abscess, the abscess is limited, the surface of the abscess is soft, the percussion may have a sense of fluctuation, and the pain is slightly reduced. At this time, the pus may be left from the bag when the gum is gently pressed, or the abscess will rupture from the surface and the abscess subsides. Patients with acute periodontal abscess generally have no obvious systemic symptoms, and may have local lymphadenopathy, or a slight increase in white blood cells. Abscesses can occur in a single tooth. Molar root bifurcation is more common. It can also occur in multiple teeth at the same time, or one after another. Patients with such multiple periodontal abscesses are very distressed and are often accompanied by more pronounced general discomfort. Periodontal abscesses can be ulcerated and drained by themselves due to their shallow location. However, if there is a systemic disease or other adverse factors, the inflammation may spread.

Chronic periodontal abscess is usually caused by untreated in time after the acute phase, or repeated acute attacks. Generally there are no obvious symptoms. Sinus openings can be seen on the surface of the gums. The openings can be flat. You must check carefully to see the opening with a large needle tip. It can also be an opening with hyperplasia of granulation tissue. There is a little pus outflow when pressed. Pain pain is not obvious, and sometimes there is bite discomfort.

Diagnosis and identification of periodontal abscess

Periodontal abscess disease diagnosis

The diagnosis of periodontal abscess should be related to medical history and clinical manifestations, and refer to X-ray films. It should be distinguished from gingival abscess and alveolar abscess.

Differential diagnosis of periodontal abscess

1. Identification of periodontal abscess and gingival abscess: gingival abscess is limited to gingival papilla and gingival margin, showing limited swelling. There was no history of periodontitis, no periodontal pockets and loss of attachment, and no X-ray alveolar bone resorption. Generally there are obvious irritating factors such as foreign matter piercing into the gums. No other treatment is required after removing foreign matter and plaque calculus and draining pus. Periodontal abscess is a localized suppurative inflammation in the periodontal support tissue, with deep periodontal pockets and loss of attachment, and X-ray films show alveolar bone resorption. In chronic periodontal abscesses, diffuse bone destruction around the root side or around the apex can also be seen.

2. The identification of periodontal abscess and alveolar abscess: the source of infection and the path of inflammation spread are different, so the clinical manifestations are as follows:

Symptoms and signs	Periodontal abscess	Alveolar abscess
Source of infection	Periodontal pocket	Pulp disease or periapical lesions
Periodontal pocket	Have	Generally no
Dental condition	Generally no caries	Have dental caries or non-caries diseases
Pulp vitality	Have	no
Abscess site	Confined to periodontal pocket wall, closer to gingival margin	The area is more diffuse, with the center near the gingival buccal groove
Degree of pain	Relatively light	Heavier
Tooth looseness	Looseness is obvious, still loose after swelling	Looseness is lighter, but it can also be very loose. Teeth can be restored after healing
Ache	Relatively light	Heavy
X-ray phase	Alveolar epiphysis is damaged, may have subosseous pockets	Bone destruction may or may not be around the apex
Course of disease	Relatively short, usually self-destructive in 3 to 4 days	Relatively long. It takes about 5 to 6 days for the pus to drain from the apex to the mucosa.

Periodontal abscess treatment

The principles of treatment of acute periodontal abscess are analgesia, prevention of spread of infection and drainage of pus. Before the abscess has formed in the early stage of the abscess, you can remove large pieces of calculus, rinse the periodontal pocket, place antiseptic or antibacterial drugs in the periodontal pocket, and give antibiotics or supportive therapy as needed throughout the body. Premature incision and drainage can cause excessive bleeding and pain in the wound. When the pus is formed and fluctuates, you can choose to drain from the periodontal pocket or the gum surface according to the location of the abscess and the thickness of the mucosa on the surface. The former can be pierced into the pus cavity from the inner wall of the bag with a pointed probe, while the latter can be used to cut the abscess deep with a sharp blade under surface anesthesia so that the pus can be fully drained. After the incision, the pus cavity was thoroughly rinsed with normal saline, and then antibacterial and antiseptic drugs were applied. Do not flush the pus cavity with hydrogen peroxide solution, because the bubbles of new oxygen enter the tissue and cause severe pain. Within a few days after incision and drainage, patients should be instructed to gargle with saline or 0.12% chlorhexidine solution. For those who have teeth out and bite and touch pain, the obvious early contact point can be adjusted to give the affected teeth a chance to recover quickly.

For chronic periodontal abscess, periodontal surgery can be performed directly on the basis of clean treatment. Depending on the situation, abscess resection is performed, or flap surgery is performed to remove plaque from the root surface. Some people report that flap surgery can be performed as soon as possible after the drainage of pus in the acute stage, because acute inflammation changes the tissue metabolism and is conducive to the regeneration of bone. At this time, surgery is beneficial to the repair and healing of postoperative tissues. Chances of attachment are higher. ^[1-3]