|Year : 2016 | Volume
| Issue : 1 | Page : 24-28
Periodontal abscess among patients attending a Nigerian specialist periodontology clinic
Clement Chinedu Azodo, Agnes Obhajaje Umoh
Department of Periodontics, University of Benin, Benin City, Edo State, Nigeria
|Date of Web Publication||17-Dec-2015|
Clement Chinedu Azodo
Room 21, 2nd Floor, Prof. AO Ejide Dental Complex, University of Benin Teaching Hospital, PMB - 1111 Ugbowo, Benin City - 300001, Edo State
Background: The objective of the study was to determine the prevalence and characteristics of patients attending a Nigerian specialist periodontology clinic with periodontal abscess. Materials and Methods: This retrospective study was conducted among patients attending the Specialist Periodontology Clinic of University of Benin Teaching Hospital, Benin City, Edo State, Nigeria, with periodontal abscess between January 2008 and April 2014. Results: Out of the 10,110 patients seen, 43 had periodontal abscess; the prevalence of periodontal abscess in this study was 0.43%. Subsequent analysis was done on only 25 out of the 43 cases whose case notes could be retrieved. The major descriptor of pain of periodontal abscess was severe, spontaneous, throbbing, radiating, or nonradiating pain associated with sleep disturbance, aggravated by mastication and drinks of extreme temperature but temporarily relieved by analgesics. The majority visited the dentist within 1 week of the onset of symptoms. The affected patients who were majorly nonalcoholics and nontobacco users cleaned their teeth once daily, had visited the dentist, and received treatment. Hypertension and diabetes mellitus (DM) were the main systemic diseases in the patients. Less than half of the patients had partial edentulism and the abscess occurred mostly in relation to posterior teeth. Curettage or incision and drainage with drugs resolved a significant proportion of the periodontal abscess and a few were subjected to tooth extraction. Conclusion: The overall prevalence of periodontal abscess that predominantly affected older males of the lower social class with systemic diseases and complete dentition in a Nigerian specialist periodontology clinic was low. Curettage or incision and drainage with drugs adequately resolved majority of cases.
Keywords: Extraction, incision and drainage, periodontal abscess, periodontology clinic, treatment
|How to cite this article:|
Azodo CC, Umoh AO. Periodontal abscess among patients attending a Nigerian specialist periodontology clinic. Trop J Med Res 2016;19:24-8
| Introduction|| |
Dentoalveolar abscess is an orofacial lesion characterized by the localization of pus in the structures that surround the teeth. It is considered periodontal abscess when the localized, purulent infection involves the periodontium. Periodontal abscess is, therefore, a destructive process in the periodontium, resulting in localized collection of pus communicating with the oral cavity through the gingival sulcus or other periodontal sites and not arising from the tooth pulp that may be of acute or chronic presentation.
Periodontal abscess is a prevalent painful periodontal condition and a significant emergency among periodontal patients. It has been cited as the third most frequent emergency seen in dental practice. Periodontal abscess is, therefore, considered as one of the periodontal conditions that requires urgent attention to relieve pain, improve the prognosis of the affected tooth, and prevent systemic complications. It is considered as an unusual but very treatable cause of pyrexia of unknown origin. The presence of periodontal abscess can modify the prognosis of the involved tooth and may be responsible for its removal in many cases.
Periodontal abscess occurs more commonly in patients who have untreated and poorly treated periodontitis. It has been cited as one of the complications of supportive periodontal treatment  and 62% of periodontal abscesses occurred in untreated periodontitis patients in a study. Although periodontal abscess can be caused by poor periodontal health and can result from the lack of proper and timely periodontal care, it may also occur in people with underlying medical conditions that compromise host immune response like diabetes and postradiation/chemotherapy cancer care.
Periodontal abscess that is usually precipitated by a change in subgingival flora, a decrease of host response, or both has several etiologies essentially grouped into two, namely, periodontitis-related abscess and nonperiodontitis-related abscess.
Periodontitis-related abscess occurs as an acute exacerbation of untreated chronic periodontitis or as a consequence of the treatment of chronic periodontitis. The majority of periodontal abscesses occur when drainage of a deep or tortuous preexisting periodontal pocket gets occluded, as then infectious materials within the pocket accumulate and build up into purulent discharge.
Nonperiodontitis-related abscess occurs due to foreign body impaction or due to alterations in the integrity of the root, leading to bacteria colonization. Periodontal abscesses can be triggered by minor trauma in the oral cavity from fish bones, an orthodontic elastic separator, and finger nail biting., Pernicious bruxism and occlusal trauma can also result in periodontal abscess. Continuing trauma to the periodontium results in the destruction of the periodontal ligament fibers and consequent abscess formation. Periodontal abscesses can also arise following secondary infection of lateral periodontal cysts or as a result of' trauma to the periodontium, for example, perforation of a root canal.
The most common symptom of periodontal abscess is pain. The tissues surrounding the painful tooth/teeth are usually swollen, varying from a small localized enlargement to diffuse swelling involving the gingiva and the alveolar and oral mucosa. Individuals suffering from acute periodontal abscess usually present with severe throbbing pain, gingival swelling and color change, and disturbances in oral functions and sleep. Other presentations include malaise, anorexia, pyrexia, and regional lymphadenopathy. The affected tooth and often the adjacent teeth are usually tender to bite with and sensitive to percussion because of mobility and extrusion. Suppuration, either spontaneous or provoked by periodontal probing, through a fistula or from a periodontal pocket, is also a notable feature. The affected tooth is usually vital. Radiographs are often useful in confirming the diagnosis, revealing the presence of a radiolucent area along the lateral aspect of the tooth involved. However, no radiographic evidence may be detected if the abscess is located on the buccal or palatal aspects of the tooth.
The diagnosis of periodontal abscess is usually based on medical and dental history as well as oral examination to detect pocket depth, swelling, suppuration, mobility, and tooth sensibility. However, it has been reported that tooth abscess can be diagnosed based solely on clinical findings and treated using a few basic instruments. Once periodontal abscess is diagnosed, emergency treatment needs to be provided to resolve the infection. Drainage is usually achieved by incision or through the pocket as part of the root planning procedure to clean the plaque and calculus deposits from the root surfaces and the insertion of a sharp curette to the base of the abscess after adequate anesthesia. If the abscessed tooth does show advanced attachment loss and its prognosis is poor, extraction should be the recommended course of action. Antibiotics are prescribed in the presence of systemic symptoms or in medically compromised patients. Chlorhexidine or homemade warm saline mouthwash is usually advised. Review appointments are scheduled to monitor the resolution of the abscess. If the root surface has been difficult to debride due to the presence of anatomical features such as furcations or deep grooves, periodontal surgery may be required in order to reduce the risk of recurrence. The objective of the study was to determine the prevalence of periodontal abscess in the Specialist Periodontology Clinic of University of Benin Teaching Hospital, Benin City, Edo State, Nigeria.
| Materials and Methods|| |
This retrospective study was conducted among patients attending the Specialist Periodontology Clinic of University of Benin Teaching Hospital, Benin City, Nigeria between January 2008 and April 2014. The Departmental logbook was reviewed and all cases of periodontal abscess were selected. The diagnosis of periodontal abscess is usually based on pain, swelling, pulp sensibility test, and the evidence of radiolucency on the lateral aspect of the tooth. The cases of periodontal abscess were divided by the total number of cases seen during the study period to determine the prevalence of periodontal abscess in the study. However, further analysis was done strictly on patients whose case notes were retrieved and contained relatively complete information. Patient information retrieved from the case notes using the anonymous data capture form without any personal identifiers included the age, gender, ethnicity, social class, presenting complaint, pain characteristics, tobacco use, alcohol consumption, teeth cleaning frequency, diagnosed medical problem, past dental history, nature of dentition, oral hygiene status, type of abscess and the involved tooth/teeth, treatment rendered, number of prescribed drugs, and recall duration. The social class was categorized into classes I-IV using the classification that has been used in Nigerian dental health-care services.
| Results|| |
A total of 43 out 10,110 patients seen and treated during the study period had periodontal abscess. The prevalence of periodontal abscess in this study was 0.43%. This was retrieved from the clinical logbook with the patients' age and gender. Older individuals with mean age 50.88 ± 17.73 years were affected and there was a slight male [22 (51.2%)] preponderance over females [21 (48.8%)]. However, it was 25 out of the 43 patients whose case notes could be retrieved; the former had relatively complete data, which were further analyzed. There were 13 (52.0%) males and 12 (48.0%) females. The affected patients were of different ethnic backgrounds and residents of different parts of Benin City. The indigenous ethnic groups of Edo State ( the Bini, Esan, and Etsako) accounted for 68.0% (17 persons), while from the neighboring state, namely, Delta State, the Urhobo and Itskeri accounted for 12.0% (3/25) and the Igbos 20.0% (5/25). A total of 15 (60.0%) persons were from the lower social class [social class III = 13 (52.0%) and social class IV = 2 (8.0%)]. There were 10 (40.0%) persons from the higher social class [social class I = 3 (12.0%) and social class II = 7 (28.0%)]. The majority were from a monogamous setting with a relatively small family size. The systemic diseases reported among the 13 (56.0%) patients were hypertension, diabetes mellitus (DM), peptic ulcer disease (PUD), allergy to sulfonamide in either isolation or combination, or asthma [Table 1]. The affected patients who were majorly nonalcoholics and nontobacco users cleaned their teeth once daily. The majority, i.e. 18 (72.0%) patients had visited the dentist and received different treatments prior to the presentation with abscess. The predominant prior treatment received was tooth extraction. Less than half, i.e. 12 out of 25 (48.0%) of patients had partial edentulism while the remaining had complete dentition. Fair oral hygiene status predominated over both good hygiene and poor hygiene among the patients [Table 2].
|Table 2: Dentition status, oral hygiene status, and practices of the patients|
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Pain only and swelling only was the presenting complaints in 17 (68.0%) and 4 (16.0%) patients, respectively. Both pain and swelling were the presenting complaints in 3 (12.0%) patients and the complaint of a fish bone stuck in the gum came from the remaining 1 (4.0%) patient. The majority, i.e. 17 (68.0%) patients visited the dentist within 1 week of the onset of symptoms. The major descriptor of pain of lateral periodontal abscess in 20 (80.0%) patients was severe, spontaneous, throbbing, radiating, or nonradiating pain associated with sleep disturbance, aggravated by drinks of extreme temperature and mastication but temporarily relieved by analgesics. Teeth involved in the abscess were 16 molars (64.0%), 5 premolars (20.0%), 1 canine (4.0%), and 3 incisors (12.0%). Incision and drainage with analgesics, antibiotics, vitamins prescriptions, and warm saline mouth bath instruction resolved the periodontal abscess in 10 (32.0%) patients; 7 (28.0%) patients had pus drainage through curettage of the periodontal pocket and 2 (8.0%) patients had incision and drainage and root canal treatment in addition. One patient refused treatment (4.0%) and a few patients, i.e. 6 (24.0%) were subjected to tooth extraction. One patient who had root canal treatment eventually had the tooth extracted. Of the patients, 9 (36.0%) and 8 (32.0%) had three and four drug combinations, respectively, in their prescriptions. The interval for review after the patients received treatment was varied, with 14 (56.0%) having the initial recall appointment within 7 days [Table 3].
| Discussion|| |
Periodontal abscess is a frequent periodontal condition in which periodontal tissues may be rapidly destroyed. It requires urgent care because of the consequences on the prognosis of the affected tooth and the possibility of the infection spreading., In this study, the prevalence of periodontal abscess was low. The reported value in this study was lower than the values reported in the literature, which were obtained from the dental clinic as a whole and not restricted specifically to periodontology. The high nonadherence to long-term periodontal maintenance care among Nigerians because of the already established symptomatic dental visit preference may be an explanation, as periodontal abscess is essentially prevalent in patients with periodontal maintenance.
The older age group is affected by periodontal abscess, as can easily be seen by the high prevalence of this condition in this age group; periodontitis increases the predisposition to periodontal abscess with aging, which can then become complicated by periodontal abscess due the restriction of periodontal pocket drainage. In this study, there were more males who had periodontal abscess than females. The higher tendency among males to experience periodontal disease is due to the low attention they pay to their oral self-care than females; this explains the difference in periodontal disease between both the genders. Tobacco use, alcohol consumption, and cleaning of teeth less than twice daily that are risk factors for periodontal disease were commoner among the male patients in this study. Although oral hygiene was predominantly fair, the nonadherence to the recommended mouth cleaning twice daily increased the risk of the development and progression of periodontal disease.
The presence of medical problems impairs immunity, more specifically that of DM against invaders, thereby increasing the predisposition to abscess formation. Hypertension was a significant medical problem among the patients that can be explained by the high proportion of the older age group, an established risk factor for hypertension. Further study of any link between hypertension and predisposition to periodontal abscess is suggested.
Partial edentulism resulting from tooth extraction prior to periodontal abscess presentation indicates low oral health awareness, lack of comprehensive dental care, or treatment default. This calls for preventive oral health education and motivation in every encounter between a dentist and his/her patients.
The major descriptor of pain of lateral periodontal abscess in the majority of patients was severe, spontaneous, throbbing, radiating, or nonradiating pain associated with sleep disturbance, aggravated by drinks of extreme temperature and mastication but temporarily relieved by analgesics. This is a classic description of acute periodontal abscess that is considered a periodontal emergency, as substantiated by the predominance of visits within 7 days of the onset of symptoms.
The periodontal abscess occurred in relation to a greater portion of posterior teeth, specifically molars. The anatomy and morphology of posterior teeth like their complex anatomy and root concavities that increase their predisposition to periodontitis and subsequently periodontal abscess explained the high prevalence of the abscess in relation to posterior teeth. This is confirmed by the reported higher prevalence of periodontal pocket in the molars of Nigerians. More than half (56.0%) of the patients had abscess on the right side, 36.0% on the left side, and 8.0% on both sides. The lateralization of oral lesions has been reported in the literature. Although handedness was not assessed, it has been reported that the worse oral health status is usually seen on the right side in right-handed individuals. Hence, further study on handedness and periodontal abscess is suggested. Multiple periodontal abscesses encountered in this study occurred in known DM patients.
The management of acute lesions includes establishing drainage through the periodontal pocket, incision to establish drainage and irrigation, flap surgery, or even extraction of hopeless teeth. Antibiotics are prescribed in medically compromised patients, in the presence of systemic symptoms in affected persons, and also to prevent the development of systemic symptoms. Incision and drainage or curettage with analgesics, antibiotics, vitamins prescriptions, and warm saline mouth bath instruction resolved the periodontal abscess; a few patients were subjected to tooth extraction. This means that with accurate diagnosis and adequate treatment, the longevity of affected teeth can be prolonged in selected cases. However, it is justifiable to state tooth loss as a complication or consequence of periodontal abscess, as 24.0% of the studied cases were subjected to tooth extraction. It was noted that the interval for initial review after treatment of patients varied in this study, justifying the need for a protocol to be laid down for initial review after treatment for periodontal abscess.
This study is limited by the small number of studied cases, its retrospective nature, and nonassessment of pain severity using the visual analogue scale. However, using self-rating in dental clinical practice is considered the global standard and therefore, this study will serve as a reasonable baseline information upon which further studies can improve.
| Conclusion|| |
In conclusion, the overall prevalence of periodontal abscess that affected predominantly older males of the lower social class with systemic diseases and complete dentition in a Nigerian specialist periodontology clinic was low. Curettage or incision and drainage with drugs adequately resolved majority of the cases.
| References|| |
Marquez IC. How do I manage a patient with periodontal abscess? J Can Dent Assoc 2013;79:d8.
Vályi P, Gorzó I. Periodontal abscess: Etiology, diagnosis and treatment. Fogorv Sz 2004;97:151-5.
Herrera D, Roldán S, Sanz M. The periodontal abscess: A review. J Clin Periodontol 2000;27:377-86.
Medeiros R Jr, Catunda Ide S, Queiroz IV, de Morais HH, Leao JC, Gueiros LA. Cervicofacial necrotizing fasciitis following periodontal abscess. Gen Dent 2012;60:316-21.
Sevinc A, Bayindir Y, But A. The knocked-out erythrocyte sedimentation rate: Periodontal abscess. Clin Lab 2008;54:15-8.
Silva GL, Soares RV, Zenóbio EG. Periodontal abscess during supportive periodontal therapy: A review of the literature. J Contemp Dent Pract 2008;9:82-91.
Herrera D, Roldán S, González I, Sanz M. The periodontal abscess (I). Clinical and microbiological findings. J Clin Periodontol 2000;27:387-94.
Topoll HH, Lange DE, Müller RF. Multiple periodontal abscesses after systemic antibiotic therapy. J Clin Periodontol 1990;17:268-72.
Becker T, Neronov A. Orthodontic elastic separator-induced periodontal abscess: A case report. Case Rep Dent 2012;2012:463903.
Sousa D, Pinto D, Araujo R, Rego RO, Moreira-Neto J. Gingival abscess due to an unusual nail-biting habit: A case report. J Contemp Dent Pract 2010;11:085-91.
Yegin Z, Ileri Z, Tosun G, Sener Y. Treatment of periodontal abscess caused by occlusal trauma: A case report. J Pediatr Dent 2013;1:50-2.
Laversanne S, Guyot L, Brignol L, Thiéry G. Tooth abscess: Management in the field. Med Trop (Mars) 2011;71:215-6.
Azodo CC, Ololo O. Toothache among dental patients attending a Nigerian secondary healthcare setting. Stomatologija 2013;15:135-40.
Gray JL, Flanary DB, Newell DH. The prevalence of periodontal abscess. J Indiana Dent Assoc 1994;73:18-20, 22-4.
Arowojolu MO. Prevalence of periodontal pocketing and tooth mobility according to tooth types in Nigerians-a pilot study. Afr J Med Med Sci 2002;31:119-21.
Yorita GJ, Melnick M. Cleft lip and handedness: A study of laterality. Am J Med Genet 1988;31:273-80.
[Table 1], [Table 2], [Table 3]