Acute Periodontal Lesions and Mucogingival conditions Flashcards
Acute
Periodontal
Lesions
(3)
*Periodontal Abscesses
*Necrotizing periodontal
diseases
*Endo Perio lesions
Frequent
Dental
Emergency
A. –% of all emergency
patients, 3rd most common
B. –% of untreated
periodontal patients
C. –% of patients in
active periodontal treatment
D. –% of patients in
periodontal maintenance
7‐14
60
13.5
37
Periodontal Abscess
Localized accumulation
of pus located within the
gingival wall of the
periodontal pocket, with
an expressed periodontal
breakdown occurring
during a limited period of
time, and with easily
detectable clinical
symptoms.
Periodontal Abscess
Etiology
(6)
Pulp necrosis,
Periodontal infections
Pericoronitis
Trauma
Surgery
Foreign body impaction
Sequence of events leading to
abscess formation:
(8)
- Occlusion of existing periodontal
pocket. - Bacterial invasion of soft tissue
wall. - Leukocytic infiltration (neutrophils).
- Vascular thrombosis.
*5. Edema and swelling.
*6. Tissue necrosis & liquefaction.
*7. Collagenolysis & bone resorption.
*8. Production of purulent exudate.
Acute Periodontal Disease
*Most common symptoms in order of decreasing frequency:
(4)
*1. Pain
*2. Swelling and Edema
*3. Lymphadenopathy
*4. Fever
Periodontal Abscess
*Multiple abscess formation is often a manifestation of:
(3)
*Diabetes (Uncontrolled or undiagnosed): most of the
cases have this as a cause.
*AIDS (compromised immune system)
*Depressed Immune System (steroid therapy,
chemotherapy)
Microbiology
- 65% of the microbial flora is
Gram‐Negative and anaerobic. - Bacteria that produce
proteinases, as P. gingivalis and
P. intermedia are important in
the pathogeneses of the
periodontal abscess since they
increase the availability of
nutrients, and thereby increase
the number of bacteria within
the abscess environment.
*Treponema (spirochetes)
*Fusobacterium nucleatum
*Prevotella intermedia
*Porphyromonas gingivalis
*Peptostreptococcus micros
*Tannerella forysthia
*Candida albicans
Histopathology of Abscess
(5)
Acute inflammatory infiltrate
Vascular hyperemia and thrombosis
Lysis of the collagen matrix in the lamina propria and the gingival fibers
Ulceration and apical proliferation of JE
Osteoclastic mediated bone resorption
Periodontal Abscess in periodontitis patients
(3)
*Periodontal abscess could represent a period of disease exacerbation( due
to the presence of a tortuous pocket, furcation involvement, or vertical
defect)
*Composition of microflora
*Decreased host defense
Periodontal Abscess in periodontitis patients
Acute Exacerbation:
(3)
*In untreated periodontitis
*Non‐responsive to
periodontal therapy
*Patients on supportive
periodontal therapy
Periodontal Abscess in periodontitis patients
After treatment
(3)
*Post‐Scaling
*Post‐surgery
*Post‐medication
Antimicrobials
Nifedepine
Periodontal abscess in non periodontitis
patients
(5)
*Impaction of foreign bodies
*Harmful habits
*Orthodontic factors
*Gingival enlargement
*Alteration of the root surface including
*Alteration of the root surface including
(5)
Dens invaginatus
cemental tears or enamel pearls
Iatrogenic conditions such as perforations
Severe root damage: Vertical root fracture or
cracked tooth syndrome
External root resorption
Periodontal Abscess
(Clinical Signs)
(10)
- Pain
- Localized swelling and fluctuence
- Purulent exudate
- Deep periodontal pocket
- Tooth exhibits vital pulp
- May present with a fistula
- Tooth mobility
- Sensitivity to percussion
- Low grade fever
- Lymphadenopathy
Periodontal Abscess
(Differential Diagnosis)
(6)
1.
Periapical
abscess
2. Acute
pulpitis
3. Tooth
or root fracture
4.
Pericoronitis
5. Lateral
periodontal cyst
6.
Gingival cyst
Abscess
Complications
(3)
Tooth loss (up to 45% of teeth with
periodontal abscesses in maintenance
are extracted)
Bacteremia following abscess
treatment
Chronic or episodic bacteremia from
untreated periodontal disease
Abscess
Treatment
(5)
Non‐surgical drainage and debridement
with local anesthetic
Surgical Drainage for large abscess
Surgical Therapy with flap reflection,
debridement with ultrasonic, sutures
Antibiotics if systemic infection indicated
by fever or lymphadenopathy
Reevaluation and any further needed
therapy
*Diagnosis
(5)
*Health history and medications
*Dental history
*Current periodontal status
*Current status of affected tooth
*Periapical radiographs
Health history and medications
(2)
*Diabetes
*Systemic antibiotics
Current status of affected tooth
(2)
*Cold and EPT tests vital
*Pain on percussion
Clinical exam
(4)
*Redness
*Swelling
*Purulent discharge
*Lymphadenopathy
Determine etiology
(6)
*Calculus fragments from recent cleaning
*Systemic antibiotic treatment without subgingival debridement
*Acute exacerbation of untreated periodontitis
*Foreign body impaction
*Endodontic perforation
*Cemental tear
Treatment
*Closed approach
(2)
*Incision and drainage through the pocket
*Root planning to depth of sulcus
Treatment
*Open approach
(3)
*Sulcular incisions and full thickness flap
*Remove all visible soft and hard deposits from root and adjacent bone
*Replace flap and suture closed
Treatment
*Thorough —
*Consider —
irrigation
systemic antibiotics (usually not needed)
Postoperative Therapy
(4)
*Home care
*Prescribe analgesics
*Re‐evaluation
*Frequently monitor radiographically and clinically at maintenance appointments for evidence of periodontal disease.
Acute
Periodontal
Diseases
(4)
Acute Pericoronitis
Acute Herpetic Gingivostomatitis
(Acute) Periodontal Abscess
(Acute) Necrotizing Ulcerative Gingivitis
Role of Keratinized Gingiva
Highly debated over many years
Possible to maintain periodontal health in the absence of keratinized gingiva.
All surfaces with less then — mm of keratinized gingiva exhibit clinical inflammation even in the absence of plaque.
When a narrow band of keratinized gingiva is present, sites with a — phenotype has a greater tendency to progress
2.0
thinner
Keratinized gingiva
*How much is enough?
*Bowers 63: normal varies from —
*Lang and Loe 72: need — keratinized, 1mm attached
*Maynard and Wilson 79: — keratinized needed for restorative with — attached
*Dorfman and Kennedy 80: less than 1 mm is adequate if inflammation is controlled
*Freedman et al 99: 18 year study, less than — is adequate if inflammation is controlled
1‐9mm
2 mm
5mm
3 mm
1 mm
Periodontal Phenotype
*Based on Anatomic characteristics
(3)
A. Gingival Phenotype
Keratinized tissue width ‐Avg 5.72 mm for thick biotype and 4.15 mm for thin phenotype
Gingival Thickness‐ranged from 0.63mm‐1.24 mm.
B. Bone Morphotype ( BM) – mean 0.34 mm for thin biotype and 0.754 for thick/Avg phenotype
C. Tooth Position
Gingival recession by definition is
apical migration of the gingival margin with concomitant exposure of the root surface.
Gingival recession by definition is apical migration of the gingival margin with concomitant exposure of the root surface.
This condition affects
a large population irrespective of Oral Hygiene.
Gingival Recession
*Estimated prevalence:
*—% of young adults
*—% Middle aged‐Elderly adults suffer from Gingival recessions with an average prevalence of —%
54.5
100, 78.6
Gingival Excess
(4)
Pseudo pocket
Inconsistent gingival margin
Excessive gingival display
Gingival enlargement
Changes in Color
Normal.
Physiologic pigmentation
Subtle changes in color,
contour and consistency
CEJ STEP DESCRIPTORS
Class A
Class A
Class B
Class B
‐ CEJ detectable without step
+ CEJ detectable with step
‐ CEJ undetectable without step
+ CEJ undetectable with step
Most common mucogingival
defects in Daily practice
(2)
- Gingival Recessions
- Inadequate Zone of keratinized gingiva
Predisposing Factors:
(5)
*1. Periodontal Biotype and
attached Gingiva
*2. The impact of tooth brushing
*3. The impact of cervical
restorative margins
*4. The impact of orthodontics
*5. Other conditions
Diagnostic
considerations
(3)
*Recession Depth and Gingival thickness.
*Modern Recession classification ( CAIRO et al 2011)
*Recession Type (RT) 1
‐Gingival Recession with No loss of interproximal attachment. Interproximal CEJ was not detected either on the mesial or distal aspect of the tooth.
Recession Type (RT) 2
‐ Gingival recession associated with loss
of interproximal attachment. The amount of interproximal
attachment loss was less or equal to the buccal attachment
loss.
Recession Type (RT) 3‐
Gingival recession with the loss of interproximal
attachment. Interproximal attachment loss is greater than the buccal
attachment loss.
Cairo Classification for
gingival recession
Treatment oriented
RT 1 ( Miller Class I and II) :
Cairo RT 2 ( overlapping Miller Class III):
Mixed results
Cairo RT 3 (Overlapping Miller Class IV):
100% root coverage can be predicated
Mixed results
Full root coverage is not achievable
Comparison on treated and untreated sites
*18‐35 year follow‐up
*47 patients with 64 sites
*83% of the 64 treated sites showed recession reduction, while 48% of
the 64 untreated sites experienced increased recession
*Number of increases in recession was limited
*Thin gingival biotypes augmented by grafting remained stable over
time compared to untreated areas with thin biotypes.
*Untreated areas also showed a tendency to develop new recession.
