Acute perio conditions

Question 1

What is an endo-perio lesion?

Answer 1

Occur when a patient has CAL and a necrotic/ partially necrotic pulp/ pulpitis.
Originate in either the periodontal or pulpal tissues.
Result of a communication between perio pocket and pulp.

Question 2

What is the definition of an abscess?

Answer 2

Inflammatory response to bacteria/ infection where inflammatory exudate is contained within a vesicle - has to be supparation.
The area is generally swollen and inflamed.

Question 3

What are possible routes of communication for an endo-perio lesion?

Answer 3

Lateral accessory canals
Furcal canals
Apical foramen
Perforation
Exposed dentinal tubules
Developmental grooves - dens in dente

Question 4

How does the 2017 world workshop broadly classify endo-perio lesions?

Answer 4

Endo-perio lesion with root damage

Endo-perio without root damage

Question 5

What is the grading for endo-perio lesions under 2017 world workshop classification (in perio and non-perio patients)?

Answer 5

Grade 1 - narrow deep periodontal pocket in 1 tooth surface

Grade 2 - wide deep perio pocket in 1 tooth surface

Grade 3 - deep perio pockets in more than 1 tooth surface

Question 6

What symptoms might someone experience if they have an endo-perio lesion?

Answer 6

Systemic factors - fever, swelling, general malaise
Pain
TTP
Bad taste in mouth
Tooth mobility
Halitosis
Suppuration

Question 7

What is the emergency treatment for an endo-perio lesion according to SDCEP?

Answer 7

Assess overall prognosis of the tooth and consider whether tooth retention is possible or desirable
Carry out endo tx. of affected tooth
Following endo tx., manage perio tissues surgically or non-surgically - supra and sub-gingival pmpr
Do not prescribe antibiotics unless signs of systemic involvement

Question 8

What is the prescription of CHX mouthwash?

Answer 8

0.2% CHX
10ml 2x daily for 2 weeks - or until acute symptoms subside

Question 9

What are the 4 types of abscess?

Answer 9

Gingival abscess
Periodontal abscess
Peri-coronitis/ peri-coronal abscess
Perio-endo lesion/ abscess

Question 10

Define a gingival abscess?

Answer 10

Localised discharging infection that involves the marginal gingiva or interdental papillae

Question 11

Define a periodontal abscess?

Answer 11

Localised accumulation of pus within gingival wall of a periodontal pocket resulting in the destruction of the collagen fibre attachment and the loss of nearby alveolar bone

Question 12

Define a peri-coronal abscess?

Answer 12

Localised accumulation of pus within the overlying gingival flap surrounding the crown of an incompletely erupted tooth

Question 13

What is the aetiology of gingival abscesses?

Answer 13

Often associated with sub-gingivally impacted foreign objects and tend to occur in previously healthy gingivae

Question 14

Presentation of a periodontal abscess?

Answer 14

Painful
Presence of an ovoid elevation in the gingiva along lateral part of root - most prominent sign.
Deep perio abscess may be less obvious
Tender to touch
Usually associated with deep perio pocket
Bleeding
Tenderness on probing
Supparation
Patient may report occlusion feeling high

Question 15

Aetiology of a periodontal abscess?

Answer 15

Changes in composition of subgingival microbiome only, or combined with decreased host defence
e.g.
Following debridement - calculus may dislodge and pushed into perio tissues
Acute exacerbation of periodontitis
After surgical therapy

Question 16

Aetiology of peri-coronal abscess?

Answer 16

Partially erupted/ impacted M3M most frequently involved site.
Bacteria and debris harboured underneath operculum

Question 17

State some of the key differences between the ulcers in necrotising gingivitis and acute herpetic gingivostomatitis?

Answer 17

NG - located in interdental papillae, marginal gingivae. Punched-out, covered in white slough, readily bleed

Acute herpetic gingivostomatitis - located throughout entire oral mucosa, multiple vesicles that coalesce and are shallow, no tendency to bleed, regular shaped ulcers

Question 18

What causative agents are involved in a periodontal abscess?

Answer 18

Biofilm gets trapped in the pockets
Increased tissue tone following periodontal treatment so the biofilm cannot get out

Question 19

What should be prescribed first-line for necrotising gingivitis and periodontitis?

Answer 19

Metronidazole tablets 400mg
Send 9 tablets
1 tablet 3x/day for 3 days

Question 20

What is treatment for necrotising gingivitis?

Answer 20

• Establish if any underlying contributing risk factors that could be better controlled e.g. smoking
• OHI - don’t brush for 2 days to allow for mechanical healing
• Supra and sub-gingival pmpr full-mouth (LA may be needed and done in stages dependant on pain tolerance)
• MW - either hydrogen peroxide 6%
  CHX 0.2% - send 300ml, rinse 10ml 2x per day until acute symptoms subside
• Antibiotic prescription if required (systemic/ spreading infection)
• Review in 3-5 days and carry out further supra and sub gingival pmpr
• If no resolution - blood testing/ further investigation/ referral to secondary care

Question 21

Clinical signs/ symptoms of necrotising gingivitis?

Answer 21

Punched-out papillae
Grey/ white slough
Bad smell
Bad taste
Extreme pain
Crater-like ulcerated appearance

Systemic factors may be present:
Malaise
Lymphadenopathy
Fever

Question 22

Risk factors for necrotising gingivitis/ periodontitis?

Answer 22

Stress
Immunocompromised - HIV/ AIDS/ leukaemia
Smoking
Malnutrition
Poor OH
Young
Low socio-economic status

Question 23

First line anti-biotic prescription for necrotising gingivitis?

Answer 23

Metronidazole tablets 400mg
Send 9 tablets
1 tablet 3x per day for 3 days

Question 24

What patient group are contra-indicated for metronidazole prescription and what should be prescribed for them instead for necrotising gingivitis?

Answer 24

Alcohol-dependant and patients on warfarin

Amoxicillin capsules 500mg
9 capsules
1 capsule 3x per day for 3 days

Question 25

How to differentiate between periodontal abscess and periapical abscess?

Answer 25

Perio
Pt. generally describes general area rather than single tooth
Localised swelling, tenderness in affected gum area, may have tooth mobility
Radiograph - PDL space widening, larger bone destruction

Periapical
Pt. can more easily localise where the pain is coming from
Severe toothache, swelling of adjacent gum, may be TTP
Radiograph - radiolucency at tooth apex

Question 26

Why is it important to differentiate between periodontal and periapical abscesses?

Answer 26

The treatment differs depending on the lesion

Question 27

What type of bacteria is metronidazole effective against?

Answer 27

Anaerobic bacteria

Question 28

What is the treatment for a phosphoric acid burn?

Answer 28

Symptomatic relief
CHX 0.2% 10ml 2x/day for 2 weeks
Benzydamine spray
Benzocaine topical gel
Warm salty mouth rinse

Question 29

Name some conditions that often have desquamative gingivitis presentation associated? (not a diagnosis)

Answer 29

Mucous membrane pemphigoid
Pemphigus vulgaris
Oral lichen planus - when confined to gingival tissues

Question 30

What is the gingival clinical presentation of acute leukaemia?

Answer 30

Gingival hyperplasia - will feel puffy like a water cushion - lots of immune cell infiltrate
Infiltrated margins will be inflamed
Painful
Erythematous
Sensitivity to acidic/ spicy food etc.
Halitosis

Question 31

What is the management for a periodontal abscess?

Answer 31

Establish that abscess is of perio origin and not combined endo-perio lesion
Careful subgingival pmpr just short of base of perio pocket to avoid iatrogenic damage (+/- LA - likely required)
If pus present, drain by incision or through the perio pocket
Recommend optimal analgesia
ONLY IF SYSTEMIC prescribe antibiotics
metronidazole 400mg, TDS for 5 days