ACUTE PERIODONTAL DISORDERS AND THEIR MANAGEMENT Flashcards
Define acute
Rapid onset and destruction of periodontal tissues in short span of time making early and swift diagnosis and treatment crucial.
list the treatment stages of acute conditions
- Initial control of infection and pain management,
- followed by management of pre-existing or residual lesions
The 1999 classification for abscesses in the periodontium includes which abscesses?
- Gingival,
- periodontal,
- peri-coronal
- peri-apical abscesses
Impact of 2018 periodontal disease classification
what is the reasons highlighted for the change in 2018:
- Differentiation between gingival and periodontal abscesses can be confusing.
- Abscess by definition is an acute lesion – hence chronic and acute terminology removed
- No peri-coronal abscess terminology
what is our diagnosis and management of acute perio dx based on?
2018 perio disease of disease classificatiom
Impact of 2018 periodontal disease classification
what are the 2 classification of perio abscesses?
- Perio abscesses in perio patients (pre-existing perio pocket)
- Perio abscess in non-perio patient (not madatory to have pre-existing perio pocket)
list the PERIODONTAL DISORDERS THAT MAY PRESENT IN ACUTE PHASE
*Periodontal abscess
Necrotising periodontal diseases (NPD)
Necrotising gingivitis / Necrotising periodontitis
Ulceration terminology removed as it is secondary to necrosis.
Primary herpetic gingivostomatitis
Definition of Periodontal Abscess
A localised purulent infection within the tissues adjacent to the periodontal pocket that may lead to destruction of the periodontal ligament and alveolar bone
Note: no longer called lateral periodontal abscess
Definition of Periodontal Abscess
Herrera et al 2013 –
Herrera et al 2013 – comprehensive definition ‘a lesion with an expressed periodontal breakdown occurring during a limited period of time, with easily detectable clinical symptoms, including a localised
Abscesses in the periodontium may be secondary to the followi
Pulp necrosis
Periodontal infections
Pericoronitis
Trauma or surgery
list the PERIODONTAL ABSCESS Microbiology
Aerobes:
S. viridans
Mainly gram negative anaerobes:
P. gingivalis
P. intermedia
F. nucleatum
C. rectus
Capnocytophaga spp
Tannerella forsythia
PERIODONTAL ABSCESS
Hypothesised aetiological factors
. Occlusion of pocket orifice
Furcation involvement
Systemic antibiotic therapy
Diabetes
describe factor -
Occlusion of pocket orifice
Reduced clearance of bacteria, accumulation of host cells
Tissue damage due to lysosomal enzymes released from neutrophils taking part in host defence
- How is pocket occluded?
- Incomplete removal of calculus
- Impaction of food
- foreign body
describe factor - Furcation involvement
Furcation is difficult to instrument and keep clean
Anatomical factor related to furcation eg enamel pearl
describe factor - Systemic antibiotic therapy
Superinfection with opportunistic organisms
describe factor - diabetes
If poorly controlled, may have increased susceptibility to abscess developing
FEATURES OF PERIODONTAL ABSCESS - CLINICAL
what are the General Clinical features
- Vital pulpal response
- Affected tooth will have deep pockets, attachment loss
FEATURES OF PERIODONTAL ABSCESS - CLINICAL
what are the Specific clinical features
- Vary according to stage of development of abscess
- Early stage, acute, pus not yet draining
- Pus draining, may become chronic
- Systemic involvement (lymphodenophathy, temperature, pulse rate) (can prescribe antibiotics for this)
List the clinical features of a perio abscess
- Ovoid elevation of gingiva on lateral aspect of root, Gingiva red & swollen with smooth & shiny surface
- Suppuration from pocket (gentle pressure)
- Mobile tooth
- May be slightly extruded
- May be painful to bite on, may have sensation of wanting to grind tooth
Note, discomfort eases when swelling points, pus discharges; abscess may become chronic
PERIODONTAL ABSCESS, PUS NOT DRAINING
describe the acute presentation
Possible swelling and redness at site of abscess, not well localised, pus not draining yet
Pain may be severe, throbbing
- Vital pulpal response
- Affected tooth will have deep pockets, attachment loss
May be slightly extruded from socket, high on bite
May have increased mobility
FEATURES OF PERIODONTAL ABSCESS - RADIOGRAPHIC
Radiographic
Cannot see a periodontal abscess on a radiograph!
Supporting evidence of periodontal involvement:
- Bone loss
- Furcation may be involved if molar tooth
Signs and symptoms depend on stage of development of abscess
What will diagnosis be based upon?
Clinical examination findings
special tests results:
- Radiographic examination
- Pulp vitality tests
What does management depend on?
- Stage of development of abscess
- Overall prognosis of tooth
- Patient’s medical history/ compliance and motivation
Management of acute periodontal abscess
May be an unplanned “emergency” and may interrupt treatment plan
What will this require?
Control of infection
Relief from pain
Assessment of prognosis/need for further therapy
what are the Proposed 4 therapeutic alternatives ?
- Incision and drainage and debridement of the abscess
- Tooth extraction
- Antimicrobials ?
- Surgery
describe the MANAGEMENT OF PERIODONTAL ABSCESS WITH PUS NOT DRAINING (1)
- Check no impacted material in pocket
- Relieving occlusion is advocated
- Although affected tooth may be slightly extruded, may be more comfortable to grind opposing tooth? Keep in mind not to be aggressive with this. - Advise hot salt mouthwashes to encourage drainage
- 1/2 teaspoon salt in cup of hot water
- rinse for 1 min; repeat until cup empty
- repeat several times daily for 2-3 days
describe the MANAGEMENT OF PERIODONTAL ABSCESS WITH PUS NOT DRAINING (2)
Advise pain killers
e.g. ibuprofen (2 x 200mg three to four times daily) or paracetamol (2 x 500mg every 4-6 hours)
If not possible to achieve drainage and severe pain is present and risk of spread of infection:
- Systemic antibiotic may be prescribed, for example: (refer SDCEP guidelines and BNF)
- Preferred first line of antibiotic - Phenoxymethyl penicillin 500mg 4 times a day – due to narrow spectrum
- Metronidazole 400mg three times per day for 5 days.
Review patient after a few days
What is included in the review stage?
Review signs and symptoms
After acute phase, assess prognosis
- Is it a recurrent abscess?
- Is further periodontal therapy indicated?
- Is extraction indicated?
describe the MANAGEMENT OF PERIODONTAL ABSCESS WITH PUS TO DRAIN
Achieve drainage
- Local gentle debridement in the pocket
- Remove any impacted material
- Incision and drainage if indicated
Advise hot salt mouthwashes
Relieve occlusion
Advise pain killers as appropriate
Review in a few days
describe the PERIODONTAL ABSCESS WITH SYSTEMIC INVOLVEMENT
Occasionally see evidence of associated systemic involvement:
Extraoral swelling
Lymphadenopathy
Rarely cellulitis
Malaise
Raised temperature
MANAGEMENT OF PERIODONTAL ABSCESS WITH SYSTEMIC INVOLVEMENT
Acute phase as for abscess with pus to drain, plus:
- Incision and drainage if appropriate
- Systemic antibiotics (consider if severe systemic involvement or immunocompromised situations such as uncontrolled diabetic)
- Antibiotic sensitivity ideal
- Phenoxymethyl penicillin q.i.d for 5 days (recent update – June 2021 SDCEP), amoxicillin if patient is not compliant
- eg Metronidazole 400 mg t.i.d. 5 days
- Re evaluation after 24 to 48 hours.
What do we need to consider in a differential diagnosis?
Need to consider relevant findings from history, examination, signs, symptoms, results of special tests
For periodontal abscess, what may differential diagnosis include?
- Gingival abscess – not anymore as per the new classification 2018
- Pericoronal abscess - not anymore as per the new classification 2018
- Periodontic-endodontic lesion
- Periapical abscess
describe a gingival abcess
- Localised purulent infection that involves the marginal or interdental papilla
- Localised, painful, rapidly expanding
- Acute inflammatory response to foreign agents - Red, shiny, smooth
- Fluctuant within 24 – 48 hours
- Points and discharges spontaneously
describe pericoronal abscess
Localised purulent infection within tissue surrounding crown of partially erupted tooth
- Mandibular third molar common site
- Red and swollen gingival flap
- Infection may spread
- Possible systemic involvement
PERIODONTAL-ENDODONTIC LESIONS
what may be aetiology be?
Primary periodontal, secondary endodontic
- ie necrotic pulp as consequence of periodontal involvement
Often, poor/hopeless prognosis
Primary endodontic, secondary periodontic
- ie periodontium is involved after pulpal necrosis
describe periapical abcess
Pulpal necrosis eg carious pulpal involvement on heavily restored tooth
Non-vital (confirm with pulp test)
Periapical tissues involved (periapical periodontitis)
Periodontal tissue involvement NOT a key feature
Tooth Tender To Percussion (TTP), may be acutely painful
NECROTISING PERIODONTAL DISEASES (1999 classification)
- Necrotising ulcerative gingivitis (NUG) and
- Necrotising ulcerative periodontitis (NUP)
be collectively called “Necrotising periodontal
diseases” as may be different stages of same infection
describe specific features of NECROTISING PERIODONTAL DISEASES (NPD)
- painful, interdental necrosis, bleeding gingivae
- necrotic ulcers affecting interdental papillae
- “punched out” appearance
- ulcers painful, covered by grey slough
- gingival bleeding with little provocation
- possible halitosis, “foetor oris”
- possible lymph nodes – involvement
- NB there is not a “chronic” form of NPD – can recur tho’
AETIOLOGY OF NPD (NECROTISING PERIODONTAL DISEASES)
Fusiform-spirochaete bacterial infection
- Selenomonas sp., Fusobacteria sp., P. intermedia
- spirochaetes, Treponema sp
4 zones in gingival lesion
Bacterial zone
- Neutrophil rich zone
- Necrotic zone
- Spirochaetal infiltration zone
list the NPD PREDISPOSING FACTORS
Stress
Immune suppression (may be feature of HIV infection)
Smoking
Poor diet or malnutrition
Pre-existing gingivitis, poor oral hygiene, previous history of NPD
MANAGEMENT NPD - local measures
- remove gross deposits plaque and calculus
- ultrasonic scaler useful
- oxidising mouthwash (hydrogen peroxide; Bocasan)
- gentle oral hygiene + 0.2% chlorhexidine rinse to aid plaque control, help prevent secondary infection
MANAGEMENT NPD - systemic measures
metronidazole 200 (or 250 mg) t.i.d. for 3 days
MANAGEMENT NPD - after “acute” phase
Periodontal therapy
- OHI
- Scale and polish/ root surface debridement
- Advise stop smoking
- Other predisposing factors eg stress management
Some minor regeneration of papillae possible
RECURRENCE / PROGRESSION OF NPD
NPD:
- May become “recurrent”
Necrotising periodontitis:
- May involve the necrosis of gingival tissues, periodontal ligament, alveolar bone
Necrotising stomatitis:
- Necrotising process below / apical to mucogingival junction
describe PRIMARY HERPETIC GINGIVOSTOMATITIS
- Caused by herpes simplex virus type 1.
- Primary contact
- Essentially disease of childhood
- Becoming more common in older ages
- Immunity to virus develops
- Lowered resistance may lead to herpes labialis - “cold sore” (30% population)
describe the DIAGNOSIS OF PRIMARY HERPETIC GINGIVOSTOMATITIS (1)
Acute onset
Fever
Malaise
Cervical lymphadenopathy
Gingivae very acutely inflamed
- very red
- swollen
Vesicles:
- painful, any part of oral mucosa
- often hard palate, dorsum tongue, gingiva
- 2-3mm, dome shaped
- rupture leaves circular shallow ulcers with yellowish or grey floors and red margins
- smears show ballooning degeneration of viral damaged cells
Rising titre of antibodies to virus
describe the MANAGEMENT OF PRIMARY HERPETIC GINGIVOSTOMATITIS as a viral infection
- It will run its course in 7-18 days
- Antibiotics are NOT indicated! it is viral infection!
- Anti-viral therapy acyclovir would need to be used early to be effective
describe the MANAGEMENT OF PRIMARY HERPETIC GINGIVOSTOMATITIS
supportive treatment
Soft diet and plenty of fluids
Analgesics for control of pain and fever
Bed rest if necessary
Chlorhexidine rinse/gentle swab can
- relieve soreness
- control secondary infection
- may hasten healing
CAUTION: PRIMARY HERPETIC GINGIVOSTOMATITIS
Very infectious, via close contact
Transmissable via saliva
Caution when treating patients with virus - infection from vesicle or saliva:
potential for painful “herpetic whitlow” of digit
vesicles and crusting resemble herpes labialis
