What is the recommended treatment for a patient presenting with parulis?

Treatment of Parulis (Gingival Abscess)

A parulis requires immediate dental referral within a few days for definitive treatment, which involves addressing the underlying pulpal necrosis through either endodontic therapy or extraction, combined with drainage of the abscess. 1

What is a Parulis?

A parulis is a gingival abscess or "gum boil" that appears on the gingiva adjacent to the root of an affected tooth, representing a visible sign of underlying pulpal necrosis with purulent drainage through a sinus tract. 1

Primary Management Algorithm

Immediate Actions

• Refer to a dentist within a few days for definitive treatment—this is the cornerstone of management, as the parulis is merely the visible manifestation of deeper pathology requiring dental intervention. 1
• The underlying cause is pulpal necrosis (dead tooth pulp), which cannot resolve without addressing the source through either root canal therapy or extraction. 1

Definitive Dental Treatment Options

The dentist will determine the appropriate intervention based on:

• Endodontic therapy (root canal) if the tooth is salvageable and the patient desires preservation. 2
• Extraction if the tooth is non-restorable, near exfoliation (in primary teeth), or the patient prefers removal. 1
• Drainage establishment through the existing sinus tract or surgical incision if needed, combined with subgingival scaling, root planing, and curettage of inflamed tissue. 2

Role of Antibiotics

Systemic antibiotics are NOT routinely indicated for an isolated parulis in an otherwise healthy patient without systemic symptoms. 2

When to Consider Antibiotics

Antibiotics should be reserved for specific circumstances:

• Systemic symptoms present: fever, malaise, tachycardia, or altered mental status indicating systemic spread. 2
• Immunocompromised patients: those at higher risk for systemic dissemination. 2
• Extensive facial or gingival swelling: beyond the localized parulis, suggesting cellulitis or deeper space infection. 1
• Preventive measure for systemic disease: in patients with cardiac conditions or other risk factors for bacteremic complications. 2

Antibiotic Selection (When Indicated)

• Amoxicillin/clavulanate provides coverage for oral flora including anaerobes and beta-lactamase producers. 1
• Penicillin V is an alternative for simple infections without beta-lactamase concerns. 3, 4, 5
• Duration: typically 5-7 days if antibiotics are deemed necessary. 1, 3

Critical Pitfalls to Avoid

• Do not treat with antibiotics alone without dental referral—this only temporarily suppresses symptoms while the underlying necrotic pulp remains, guaranteeing recurrence. 1, 2
• Do not delay dental referral thinking the parulis will resolve spontaneously—it represents established pulpal necrosis requiring definitive intervention. 1
• Do not confuse with periodontal abscess—while both present as gingival swelling, a parulis originates from pulpal pathology (endodontic origin), whereas a periodontal abscess arises from the periodontal pocket itself and requires different management. 2

Red Flags Requiring Urgent/Emergency Referral

• Fever >38°C or systemic toxicity: suggests spread beyond the local site. 6, 7
• Rapidly progressive swelling: especially if involving facial planes or causing airway compromise. 6, 7
• Severe pain out of proportion to examination: raises concern for deeper infection or necrotizing process. 6, 7
• Trismus or difficulty swallowing: indicates potential deep space involvement. 8

Patient Education Points

• The parulis is a drainage pathway for infection from a dead tooth—it will recur until the tooth is definitively treated. 1
• Maintain oral hygiene but avoid aggressive brushing of the affected area. 1
• Warm saline rinses may provide symptomatic relief but do not substitute for dental treatment. 1
• Follow up with the dentist even if the parulis temporarily disappears, as this indicates the sinus tract has closed but the underlying infection persists. 1