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ACUTE PERIODONTAL LESIONS
Acute periodontal infections are more frequently seen is often the reason a person seeks Dental care. The treatment of acute periodontal infections entails the alleviation of the acute symptoms and prevent spread of infection
Periodontal abscess
Gingival abscess
Pericoronitis
Primary herpetic gingivostomatitis
Recurrent herpetic gingivostomatitis
Necrotizing periodonal lesions
PERIODONTAL ABSCESS
Definition
Periodontal abscess is a localized purulent inflammation of the periodontal tissues
Classification
Based on location
- Gingival abscess - Periodontal abscess
-Pericoronal abscess
Course of disease
Acute
Chronic
Based on number
Single Multiple
Based on etiological criteria
Periodontitis related abscess
Non-Periodontitis related abscess
•Prevalence of periodontal abscess is relatively high
•Accounts for 6% - 14% of all dental emergencies
•Third most common dental emergency
PERIODONTITIS RELATED ABSCESS
Found in patient with untreated periodontitis
Associated with moderate to deep periodontal pocket, furcations and bone loss
The abscess formation is due to marginal closure of deep periodontal pocket (& lack of proper drainage)
Presence of deep pocket / tortuous pocket and deep concavity associated with furcation may lead to abscess formation
•Usually occurs on lateral aspect of tooth
•Appears edematous red and shiny
•May have dome like appearance or come to a distinct point
Characteristics of periodontal abscess
Based on the course of the disease PD abscess can be acute or chronic
Acute periodontal abscess
- lesion with expressed periodontal breakdown
- Occurs over a limited period of time
- frequently associated with preexisting PD disease
- Predisposing factors – Pocket depth, furcation involvement and tortuous pocket anatomy (predispose to the occlusion of pocket orifice).
- Pus can drain through pocket / orifice
Mechanism behind the formation of PD abscess
Exacerbation of a chronic lesion
Post therapy periodontal abscess
Post surgical periodontal abscess
Post antibiotic PD abscess
Microbiology of PD abscess
•Harbor approximately 74% of gram negative rods•Non motile and strict anaerobic
P. gingivalisPrevotella intermediaBacteroides forsythusFusobacterium nucleatumA.ACapnocytophaga ochraccusEikenella corrodinsComphylaobacter recta
Signs and symptoms of acute periodontal abscess
Abscess appear shiny red, raised and rounded masses
Deep red to bluish colour of affected tissues
Throbbing and radiating pain
Sensitivity of tooth and gingival in palpation
Tooth mobility
Cervical lymphadinopathy
Systemic symptoms of fever and malaise
Purulent exudate
Non-Periodontitis related abscess
Impaction of foreign body in gingival sulcus / P.D pocket
may be related to oral hygiene practice (tooth brush trauma, tooth pick etc)
Orthodontic devices / food particles etc
Tooth perforation / fracture
Based on
Patients chief complaint
Overall evaluation
Clinical and R/G signs
Diagnosis
Lab finding
- elevated number of blood leukocyte
- Increased in blood neutrophils and monocytes
Differential diagnosis
Periapical abscess
Lateral periodontal cyst
Vertical root fracture
Endo-periodontal abscess
Osteomyelitis
Gingival abscess
Occurs in gingival
It occurs in otherwise healthy gingiva and is found in the absence of periodontal infections of the teeth.
Most frequently involves the marginal gingival and interdental tissue
Localized, acute inflammatory lesion that may arise from a variety of sources, Including
•Microbial plaque
•Infection
•Trauma
•Foreign body impaction
Painful
Red, smooth
Often fluctuant swelling (pus filled)
Signs and symptoms
Treatment
Treatment of PD abscess includes 2 stages
- Resolving the acute lesion
- Followed by management of the resulting chronic condition
Treatment options for periodontal abscess
Drainage through pocket or incision
Scaling and root planning
Periodontal surgery
Systemic antibiotics
Tooth removal
Drainage through pocket
Anaesthesia with topical / local anesthesia
Pocket wall is gently retracted with probe / curette
Gentle digital pressure is applied
Irrigation may be used to express exudates and clear the pocket
If lesion is small and good access – scaling and R.P may be undertaken
If lesion is large and drainage cant be established - use of systemic antibiotic with short term high dose regimens is recommended
Drainage through external incision
Local anaesthesia
Abscess dried, isolated with gauze sponge
A vertical incision done through the most fluctuant centre of the abscess with # 15 blade
Tissue lateral to the incision separated with periosteal elevator / curette
Light digital pressure applied with moist gauze pad
In patient with abscess with marked swelling, tension and pain it is recommended to use systemic antibiotics as the only initial treatment in order to avoid damage to healthy periodontium
Post treatment instruction
- Frequent rinsing with warm salt water
- Periodic application of chlorhexidine gluconate (either rinsing / locally with a cotton tipped)
- Reduce exertion and increase fluid intake
- Analgesic for patient comfort
Indications for antibiotic therapy in patient with acute abscess
•Cellulites (non localized, spreading infection)
•Deep, inaccessible pocket
•Fever
•regional lymphadinopathy
•Immunocompromised patient
Antibiotic options for periodontal infections
Amoxicillin
Clindamycin
Azithromycin
Pericoronitis
Definition
Inflammation of the gingivla in relation to the crown of an incompletely erupted tooth
- In early part of 20th century it was also known as folliculitis
- Later Kay, described this condition as pericoronitis
- Develops at any age, more common between 16-24 yrs of age
Operulum-The flap of tissue that either completely or partially covers the associated tooth
The space between the crown of the tooth and the overlying flap of tissue is the ideal location for food debris to collect and bacteria to grow
As the bacteria increasingly infect the area. The tissue responds by becoming extremely inflamed and painful
Even in patient with no clinical signs and symptoms the gingival flap is often chronically inflamed and infected and has varying degree of ulceration along its inner surface
Acute inflammatory response is a constant possibility and may be exacerbated by trauma from occlusion or foreign body trapped underneath the tissue flap
Predisposing factors
- Emotional stress, fatigue, upper respiratory tract infections,
- pregnancy and menstruation
- Impinging of maxillary molars
- associated osteitis, distal bony pocket increases the infection
Signs and symptoms of acute pericoronitis
Extreme pain (radiating to ear, throat and floor of mouth)
Swelling of the operculum and gingiva
Purulent exudates
Foul taste
Swelling of the cheek
Cervical lymphadenopathy
Trismus
Systemic complication – fever, leucocytosis and malaise.
The tissue may be so swollen that it interferes with the mastication and is easily traumatized during eating
Clinical features
Pericoronitis may be acute, subacute / chronic
Acute phasePatient aware of the eruption of teeth and discomfort
Patient experiences severe throbbing and radiating pain
Development of some degree of restricted mouth opening
Enlarged regional submandibular lymphnodes
Halitosis
Pyrexia associated with tachycardia, leucocytosis and malaiseIntraorally – swelling and purulent discharge
Dysphagia indicates that the infection has spread to sublingual and paraphryngeal spaces
Subacute phase
Systemic feature become less acute
Patient experience continuous dull pain, persistence of intra oral swelling, jaw stiffness and regional lymphadenopathy
pus discharge from follicular space
Ulceration of the operculum become more pronounced
Chronic phase
Complete absence of systemic features except during acute exacerbation
Dull pain with unpleasant taste in oral cavity
IOPAR may reveal crater like bony defect around third molar
Diagnosis
History
Clinical examination
Special investigation – include radiographic examination,total and differential count of leucocyte
Differential diagnosis
During early state – pulpitis and periodontitis
In later stage – due to limitation of mouth opening with jaw stiffness can mimic TMJ dysfunction
If swelling is diffuse – liable to confuse with tonsillitis
Management
Depends on
severity of case,
Weather it is recurrence and
possible systemic complication
Local treatment
Topical anesthesia
The infected area is debrided, usually be gentle flushing with warm water / diluted hydrogen perioxide
After irrigation, a drop of astringent like Talbo’s solution of Iodine can be applied
Prescribe antibiotic if patient is febrile / cervical lymphadenopathy
Traumatic occlusion if any be relieved (grinding maxillary third molar)
After acute condition has resolved –
appropriate decision must be taken as to weather IIIrd molar must be
removed / to be retained after pericoronal flap excision
Complications
Pericoronal abscess
Peritonsillar abscess
Pterygomandibular and submassetric abscess
Involvement of submaxillary, posterior cervical, deep cervical and retropharyngeal lymp nodes
Cellulitis
Ludwig’s angina