Acute perio conditions Flashcards
What is an endo-perio lesion?
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.
What is the definition of an abscess?
Inflammatory response to bacteria/ infection where inflammatory exudate is contained within a vesicle - has to be supparation.
The area is generally swollen and inflamed.
What are possible routes of communication for an endo-perio lesion?
Lateral accessory canals
Furcal canals
Apical foramen
Perforation
Exposed dentinal tubules
Developmental grooves - dens in dente
How does the 2017 world workshop broadly classify endo-perio lesions?
Endo-perio lesion with root damage
Endo-perio without root damage
What is the grading for endo-perio lesions under 2017 world workshop classification (in perio and non-perio patients)?
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
What symptoms might someone experience if they have an endo-perio lesion?
Systemic factors - fever, swelling, general malaise
Pain
TTP
Bad taste in mouth
Tooth mobility
Halitosis
Suppuration
What is the emergency treatment for an endo-perio lesion according to SDCEP?
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
What is the prescription of CHX mouthwash?
0.2% CHX
10ml 2x daily for 2 weeks - or until acute symptoms subside
What are the 4 types of abscess?
Gingival abscess
Periodontal abscess
Peri-coronitis/ peri-coronal abscess
Perio-endo lesion/ abscess
Define a gingival abscess?
Localised discharging infection that involves the marginal gingiva or interdental papillae
Define a periodontal abscess?
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
Define a peri-coronal abscess?
Localised accumulation of pus within the overlying gingival flap surrounding the crown of an incompletely erupted tooth
What is the aetiology of gingival abscesses?
Often associated with sub-gingivally impacted foreign objects and tend to occur in previously healthy gingivae
Presentation of a periodontal abscess?
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
Aetiology of a periodontal abscess?
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
Aetiology of peri-coronal abscess?
Partially erupted/ impacted M3M most frequently involved site.
Bacteria and debris harboured underneath operculum
State some of the key differences between the ulcers in necrotising gingivitis and acute herpetic gingivostomatitis?
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
What causative agents are involved in a periodontal abscess?
Biofilm gets trapped in the pockets
Increased tissue tone following periodontal treatment so the biofilm cannot get out
What should be prescribed first-line for necrotising gingivitis and periodontitis?
Metronidazole tablets 400mg
Send 9 tablets
1 tablet 3x/day for 3 days
What is treatment for necrotising gingivitis?
- 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
Clinical signs/ symptoms of necrotising gingivitis?
Punched-out papillae
Grey/ white slough
Bad smell
Bad taste
Extreme pain
Crater-like ulcerated appearance
Systemic factors may be present:
Malaise
Lymphadenopathy
Fever
Risk factors for necrotising gingivitis/ periodontitis?
Stress
Immunocompromised - HIV/ AIDS/ leukaemia
Smoking
Malnutrition
Poor OH
Young
Low socio-economic status
First line anti-biotic prescription for necrotising gingivitis?
Metronidazole tablets 400mg
Send 9 tablets
1 tablet 3x per day for 3 days
What patient group are contra-indicated for metronidazole prescription and what should be prescribed for them instead for necrotising gingivitis?
Alcohol-dependant and patients on warfarin
Amoxicillin capsules 500mg
9 capsules
1 capsule 3x per day for 3 days
How to differentiate between periodontal abscess and periapical abscess?
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
Why is it important to differentiate between periodontal and periapical abscesses?
The treatment differs depending on the lesion
What type of bacteria is metronidazole effective against?
Anaerobic bacteria
What is the treatment for a phosphoric acid burn?
Symptomatic relief
CHX 0.2% 10ml 2x/day for 2 weeks
Benzydamine spray
Benzocaine topical gel
Warm salty mouth rinse
Name some conditions that often have desquamative gingivitis presentation associated? (not a diagnosis)
Mucous membrane pemphigoid
Pemphigus vulgaris
Oral lichen planus - when confined to gingival tissues
What is the gingival clinical presentation of acute leukaemia?
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
What is the management for a periodontal abscess?
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
