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