emergencies Flashcards
symptoms that might lead pt to present
PAIN swelling pus bleeding mobility ulceration
abscesses types x4
periapical
gingival
periodontal
pericoronal
differential diagnoses - irreversible pulpitis
poorly localised
constant, dull throbbing
unlikely to see anything radiographically - pulp not necrosed, no bone destruction
differential diagnoses - reversible pulpitis
pain triggered by stimulus - hot/cold, not constant - resolves
as it gets more established triggered by sweet
unlikely to see anything radiographically - pulp not necrosed, no bone destruction
heightened response to sensibility testing
differential diagnoses - periapical periodontitis
TTP
no response to sensibility testing (if caused by pulp necrosis extension)
pain to biting
might see bone loss radiographically (takes 3m to show)
differential diagnoses - pericoronal abscess
PE tooth, usually L8s
Periodontal abscess
a localised accumulation of pus within the gingival wall of a PD pocket resulting from the destruction of the collagen fibre attachment and the loss of nearby alveolar bone
active period of PD breakdown which occurs whilst there is marginal closure of the deep PD pocket occluding drainage
non-draining infection of a PD pocket
PD abscess S + S
+ to sensibility testing
mobility
likely to see lat lesion on radiograph (but may not see anything)
pain and tenderness
swelling of gingiva
bleeding
deep pocket depth
may have suppuration
PD abscess - what to do if tooth is unrestorable
extract
SDCEP tx of a PD abscess
- subgingival instrumentation short of base of pocket to avoid iatrogenic damage, LA?
- if pus present - drain by incision or through the PD pocket
- recommend optimal analgesia
- don’t prescribe ABs unless signs of spreading infection or systemic involvement
- 0.2% CHX MW until acute symptoms subside
- review within 10 days and carry out definitive PD instrumentation and recall interval
PD abscesses in non-periodontitis pts - possible cause
impaction of foreign bodies
harmful habits- nail biting
alteration of root surface e.g. perforation, root fracture etc
what is ANUG now called?
necrotising gingivitis
necrotising periodontitis
- (chronically/severely compromised or temporarily/moderately compromised)
necrotising stomatitis
NG presentation
acute onset of severe pain
marginal gingival ulceration and craters
punched-out appearance
loss of ID papilla
slough
rapidly destructive
necrosis locally
may have local lymphadenopathy/systemically unwell
halitosis
bleeding
if NG not treated and controlled rapidly?
may leave significant gingival recession
NG microbiology
anaerobic bacteria with fusiform and spirochetes species in a compromised host
NG risk factors
neglected mouth - poor OH
smoking
stress
malnutrition
lack of sleep
prev NP
younger pts
immunosuppression/ immunocompromised
HIV infection
NG tx SDCEP
- debridement - LA, ultrasonic
- MW until acute symptoms subside (0.2% CHX / 6% Hydrogen peroxide)
- review within 3-5 days and do definitive instrumentation as required, recall interval
- address risk factors - OH, smoking etc
- if no resolution, review general health and consider referral to specialist
- ABs if spreading infection/systemic involvement or local measures are incomplete at initial presentation
- metronidazole 400mg x3 daily for 3 days
secondary herpes
- often reactivated post-PD surgery esp palatally
- often not painful
- can be confused clinically with other bullous conditions and if uncertain refer to oral med
- self-limiting - 10 days
- analgesic , CHX MW
- if doesn’t resolve/recurrent refer to oral med
chemical trauma e.g. from etch/bleaching agent
- acute onset, painful
- manage conservatively and prevent infection and tissue loss if possible
- irrigate lots
- reassure should heal in 2 weeks
-
CHX MW and avoid brushing site until it heals
- to prevent gingival recession
primary herpetic gingivostomatitis spread and causative agent
- highly infectious, spread through contaminated saliva
- Herpes simplex virus HSV1
- usually in kids 2-5 yo
primary herpetic gingivostomatitis S + S
acute onset usually but not always children
+/- systemic (potentially serious if present) - dehydration/encephalitis
painful ulceration preceded by fragile vesicles which are only rarely visible
affects gingival tissue, tongue, lips, cheeks and roof of mouth
primary herpetic gingivostomatitis tx
- usually managed symptomatically as self-limiting over 5-7 days
- attention to fluid intake
- paracetamol
- reassurance
- consider aciclovir: shortens duration of symptoms, more rapid healing and helps to establish eating/drinking again earlier
primary herpetic gingivostomatitis long term effect
may result in recurrent lesions at other sites, around 40% of individuals
primary herpetic gingivostomatitis SDCEP tx
symptomatic relief: local measures
- avoid dehydration
- soft diet
- analgesics
- antimicrobial MW
if immunocompromised/severe infection
- aciclovir 200mg x5 daily for 5 days
acute leukaemia
rare
presenting as severe hyperplastic gingivitis
hyperplastic tissue is full of leukaemic infiltrate
acute or slower onset over a few weeks
likely systemic S+S to aid diagnosis
- bone pain
- fever
- freq infections
- freq or severe nosebleeds
- lymphadenopathy
- pallor
-
SOB
can also see ulceration of inner surface of lip due to acute neutropenic changes
urgent referral via GMP/ oral med as soon as potential diagnosis is considered
gingival abscess
- a localised purulent infection that involves the marginal gingiva or ID papillae
- peridontally healthy
gingival abscess S + S
localised swelling
may have suppuration
usually painful and TTP
what is a gingival abscess often due to?
subgingivally impacted foreign objects, tend to occur in a prev healthy gingiva
e.g. piece of nail due to a nail biting habit
gingival abscess management
incise, drain and irrigate
may need mechanical debridement to mitigate aetiology
0.2% CHX MW/saline rinse
review
SDCEP periodontitis associated with endo lesions - definition
clinical AL and also a tooth with necrotic/partially necrotic pulp
perio endo lesions S+S
swelling
suppuration
TTP
may have generalised PDD with localised pain
deep pocketing to root apex with BOP
negative response to sensibility tests
SDCEP perio endo lesion tx
endo tx of tooth (get drainage?)
recommend optimal analgesia
no ABs unless signs of spreading infection or systemic involvement
0.2% CHX MW until acute symptoms subside
review within 10 days and PD instrumentation, recall
perio endo lesion
- communication between PD lesion and pulp
- deep pocket around a non-vital tooth
origin
- the infection may arise primarily from pulpal inflammatory disease expressed through the PDL or the alveolar bone to the oral cavity,
- or it may be initiated from a PD pocket communicating to the pulp apically or through accessory canals
prognosis of primary endo lesions
often respond well to RCT alone
prognosis of primary perio/truly combined lesions
often poor
prognosis of endo perio lesions associated with trauma and iatrogenic factors e.g. perforation
usually poor as affect tooth structure
