A 35-year-old female visited a dental office for evaluation of a painful gingival swelling.
Joen Iannucci Haring, DDS, MS
The patient first noticed the swelling approximately one week earlier. Since that time, the lesion appeared to increase in size. When questioned about symptoms, the patient stated that the swelling was accompanied by throbbing and severe pain. The patient further commented that the adjacent teeth appeared to be loose.
At the time of the dental appointment, the patient appeared to be in an overall good state of health. The medical history was reviewed, which included hospitalizations for childbirth, cholecystectomy and trauma. In addition, a history of controlled hypertension was noted.
A review of the dental history revealed multiple emergency visits and sporadic dental care. The patient`s last dental visit was approximately four years earlier.
Physical examination of the head and neck region revealed two enlarged, palpable and tender right submandibular lymph nodes. The patient`s temperature was not elevated, and the vital signs were all found to be within normal limits. No significant extraoral findings were noted.
Intraoral examination revealed an elevated nodule located superior to tooth #6 (see photo). The lesion measured approximately one centimeter in diameter and could be described as fluctuant when palpated. A smooth erythematous surface with a localized area of pus was noted.
Gentle pressure on the lesion resulted in the expression of pus from the sulcus around tooth #6. Teeth #6 and #7 were pulp tested for vitality, and both tested vital. Further examination revealed extreme mobility of both teeth. A periapical radiograph of the area was exposed, and extensive bone loss was noted around the teeth adjacent to the lesion.
Based on the clinical and radiographic information presented, which of the following is the most likely diagnosis?
- pyogenic granuloma
- gingival cyst
- periodontal abscess
- periapical abscess
__ periodontal abscess
The periodontal abscess is a common oral lesion that can be described as a localized collection of pus in gingival soft tissue that is produced following the occlusion of a deep periodontal pocket. The entrapment of a foreign body (for example, popcorn husks, seeds, or toothbrush bristles) in a periodontal pocket is often responsible for initiating the lesion.
The periodontal abscess has a sudden onset and progresses rapidly. Several millimeters of supporting bone can be destroyed within a few days. Symptoms often include severe and throbbing pain, extreme sensitivity to palpation, mobility of the adjacent teeth, a bad taste, and lymphadenopathy. In severe cases, the patient may experience fever, malaise, and leukocytosis.
The clinical appearance is fairly characteristic. The lesion appears as a shiny red gingival tumescence located adjacent to the deep periodontal pocket. The periodontal abscess feels fluctuant when palpated and varies in size. Purulent drainage may occur through a sinus tract or around the sulcus of the tooth.
Pus can be expressed by applying pressure to the lesion. With pus drainage, the pain subsides and a bad taste results.
On a clinical basis, the periodontal abscess may be confused with a number of other lesions including the pyogenic granuloma (RDH January 1991), the gingival cyst (RDH November 1994), and the periapical abscess. The periodontal abscess can be differentiated from such lesions by identifying the production of pus and determining the source of infection (such as the occluded periodontal pocket).
The diagnosis of a periodontal abscess can be made on a clinical basis. No biopsy is necessary. Diagnostic aids include pulp testing and periodontal probing of the teeth adjacent to the lesion. The dental radiograph can also be used as a valuable diagnostic aid.
The treatment of the periodontal abscess involves treating the occluded periodontal pocket. Both drainage and periodontal therapy are indicated. Once the underlying cause is treated, the periodontal abscess resolves and does not recur.
When evaluating the findings of research, it is essential to know if patients have been removed or "exited" from the study. It is not unusual for patients who show more than 2 millimeters of bone loss, or who lose a tooth, to be removed from the study in order to receive adequate therapy. Unfortunately, final evaluation of the data does not usually include these people.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Diagnostic Services, The Ohio State University College of Dentistry.