Gingival Abscess

A gingival abscess is a localised, acute, painful collection of pus confined to the gingival soft tissue (the marginal gum or interdental papilla), arising from bacterial infection after a foreign body or trauma has broken the gingival surface. It does not involve the periodontal ligament or the supporting bone, which distinguishes it from a periodontal abscess.

• Common causes: impaction of food fragments (popcorn husks, fish bones, seeds, nuts), toothbrush bristles, dental floss or toothpicks, fragments of dental impression material or orthodontic wire, and trauma from hard food or a poorly fitting appliance.
• It follows existing gingivitis in many patients, because inflamed tissue is easily penetrated.
• It can occur at any age and in people with healthy periodontal support; the incidence is higher with poor plaque control, diabetes and smoking.
• Left alone it may drain spontaneously, but it can extend to a periodontal or spreading soft tissue infection.

• Rapid onset (hours to days) of a painful, red, smooth, shiny swelling of the marginal gum or papilla, often dome shaped and fluctuant, with a pustule at the surface.
• Tenderness on touch or biting, with sometimes a bad taste from pus discharge.
• Teeth are firm, not mobile, vital, and not tender to percussion; probing depths are normal apart from the swelling.
• Usually no fever or facial swelling; regional lymph nodes may be tender.
• Red flags: facial swelling, trismus, difficulty swallowing or breathing, fever above 38 degrees Celsius, floor of mouth swelling, or spread beyond the gingiva.

• Clinical examination with a mirror, light and periodontal probe: localised gingival swelling without deep pocketing.
• Pulp vitality testing (cold test or electric pulp test) and percussion of nearby teeth to exclude a periapical abscess; periapical radiograph to exclude bone loss, a root lesion, or a retained foreign body (a radiograph may show a radio opaque foreign body).
• Check temperature and look for lymphadenopathy.
• Blood glucose or HbA1c if recurrent or in people with risk factors.
• Differentials: periodontal abscess (deep pocket, bone loss, tooth mobility), periapical abscess (non-vital tooth, percussion tenderness), pericoronitis, necrotising gingivitis, pyogenic granuloma, epulis, mucocele, and tumour (persisting swelling).

Local treatment (the definitive step)

• Remove the cause: gently irrigate under the gum margin with warm saline to dislodge impacted material; remove any foreign body with a probe or curette.
• Drain: if fluctuant, incise at the most dependent point with a number 11 or 15 blade under topical or infiltration anaesthesia (for example lidocaine 2 percent with adrenaline 1 in 80 000, 1.8 mL), then express pus and irrigate with saline.
• Smooth, debride and polish the root surfaces of the adjacent teeth once the acute stage has settled.

Home care

• Rinse with warm salt water (half a teaspoon of salt in a glass of warm water) every 2 hours for 2 to 3 days.
• Chlorhexidine gluconate 0.2 percent mouthwash 10 mL twice daily for 1 minute for up to 1 to 2 weeks.
• Gentle brushing of the area with a soft toothbrush and cleaning between teeth; soft diet; avoid hard food on that side.
• Analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g daily), with ibuprofen 400 mg orally every 8 hours with food for 2 to 3 days (children: paracetamol 15 mg/kg every 6 hours, ibuprofen 10 mg/kg every 8 hours).

Antibiotics (not routinely needed after drainage)

• Use only if there is fever, spreading cellulitis, lymphadenopathy, immunosuppression, or poorly controlled diabetes:
  • Amoxicillin 500 mg orally three times daily for 3 to 5 days (children: 40 mg/kg/day in three divided doses, maximum 500 mg a dose), with metronidazole 400 mg orally three times daily for 3 to 5 days added for severe infection.
  • Penicillin allergy: clarithromycin 500 mg orally twice daily for 5 days, or metronidazole 400 mg three times daily for 5 days alone.
• Admit for intravenous antibiotics and surgical drainage if there is facial swelling, trismus, dysphagia, or systemic toxicity.

Follow up

• Review in 48 hours and again at 1 to 2 weeks; confirm resolution, then treat underlying gingivitis with scaling and oral hygiene instruction.
• Refer to a dentist if the swelling recurs, persists beyond 2 weeks, or is not clearly of gingival origin, and biopsy any lesion that does not resolve.