ACUTE PERIODONTAL LESIONS

Acute periodontal infections are more frequently seen is often the reason a person seeks Dental care. The treatment of acute periodontal infections entails the alleviation of the acute symptoms and prevent spread of infection

Periodontal abscess Gingival abscess Pericoronitis Primary herpetic gingivostomatitis Recurrent herpetic gingivostomatitis Necrotizing periodonal lesions

PERIODONTAL ABSCESS Definition Periodontal abscess is a localized purulent inflammation of the periodontal tissues Classification Based on location - Gingival abscess - Periodontal abscess -Pericoronal abscess Course of disease Acute Chronic

Based on number Single Multiple Based on etiological criteria Periodontitis related abscess Non-Periodontitis related abscess

Prevalence of periodontal abscess is relatively high Accounts for 6% - 14% of all dental emergencies Third most common dental emergency

PERIODONTITIS RELATED ABSCESS Found in patient with untreated periodontitis Associated with moderate to deep periodontal pocket, furcations and bone loss

The abscess formation is due to marginal closure of deep periodontal pocket (& lack of proper drainage)

Presence of deep pocket / tortuous pocket and deep concavity associated with furcation may lead to abscess formation

Characteristics of periodontal abscess

Usually occurs on lateral aspect of tooth Appears edematous red and shiny May have dome like appearance or come to a distinct point

Based on the course of the disease PD abscess can be acute or chronic

Acute periodontal abscess - lesion with expressed periodontal breakdown - Occurs over a limited period of time - frequently associated with preexisting PD disease - Predisposing factors Pocket depth, furcation involvement and tortuous pocket anatomy (predispose to the occlusion of pocket orifice).

- Pus can drain through pocket / orifice

Mechanism behind the formation of PD abscess

Exacerbation of a chronic lesion

Post therapy periodontal abscess

Post surgical periodontal abscess

Post antibiotic PD abscess

Microbiology of PD abscess

Harbor approximately 74% of gram negative rods Non motile and strict anaerobic

P. gingivalis Prevotella intermedia Bacteroides forsythus Fusobacterium nucleatum A.A Capnocytophaga ochraccus Eikenella corrodins Comphylaobacter recta

Signs and symptoms of acute periodontal abscess

Abscess appear shiny red, raised and rounded masses Deep red to bluish colour of affected tissues Throbbing and radiating pain Sensitivity of tooth and gingival in palpation Tooth mobility Cervical lymphadinopathy

Systemic symptoms of fever and malaise

Purulent exudate

Non-Periodontitis related abscess Impaction of foreign body in gingival sulcus / P.D pocket

may be related to oral hygiene practice (tooth brush trauma, tooth pick etc)

Orthodontic devices / food particles etc

Tooth perforation / fracture

Diagnosis Based on

Patients chief complaint

Overall evaluation Clinical and R/G signs Lab finding - elevated number of blood leukocyte

- Increased in blood neutrophils and monocytes

Differential diagnosis Periapical abscess Lateral periodontal cyst Vertical root fracture Endo-periodontal abscess Osteomyelitis

Gingival abscess Occurs in gingival It occurs in otherwise healthy gingiva and is found in the absence of periodontal infections of the teeth. Most frequently involves the marginal gingival and interdental tissue Localized, acute inflammatory lesion that may arise from a variety of sources, Including

Microbial plaque
Infection Trauma Foreign body impaction

Signs and symptoms Painful

Red, smooth
Often fluctuant swelling (pus filled)

Treatment Treatment of PD abscess includes 2 stages - Resolving the acute lesion - Followed by management of the resulting chronic condition

Treatment options for periodontal abscess

Drainage through pocket or incision Scaling and root planning Periodontal surgery Systemic antibiotics Tooth removal

Drainage through pocket Anaesthesia with topical / local anesthesia Pocket wall is gently retracted with probe / curette Gentle digital pressure is applied Irrigation may be used to express exudates and clear the pocket If lesion is small and good access scaling and R.P may be undertaken If lesion is large and drainage cant be established - use of systemic antibiotic with short term high dose regimens is recommended

Drainage through external incision Local anaesthesia

Abscess dried, isolated with gauze sponge

A vertical incision done through the most fluctuant centre of the abscess with # 15 blade

Tissue lateral to the incision separated with periosteal elevator / curette

Light digital pressure applied with moist gauze pad

In patient with abscess with marked swelling, tension and pain it is recommended to use systemic antibiotics as the only initial treatment in order to avoid damage to healthy periodontium

Post treatment instruction

- Frequent rinsing with warm salt water - Periodic application of chlorhexidine gluconate (either rinsing / locally with a cotton tipped) - Reduce exertion and increase fluid intake - Analgesic for patient comfort

Indications for antibiotic therapy in patient with acute abscess Cellulites (non localized, spreading infection) Deep, inaccessible pocket Fever regional lymphadinopathy

Immunocompromised patient
Antibiotic options for periodontal infections Amoxicillin Clindamycin Azithromycin

Pericoronitis
Definition Inflammation of the gingivla in relation to the crown of an incompletely erupted tooth - In early part of 20th century it was also known as folliculitis - Later Kay, described this condition as pericoronitis

- Develops at any age, more common between 16-24 yrs of age

Operulum-The flap of tissue that either completely or partially covers the associated tooth The space between the crown of the tooth and the overlying flap of tissue is the ideal location for food debris to collect and bacteria to grow

As the bacteria increasingly infect the area. The tissue responds by becoming extremely inflamed and painful
Even in patient with no clinical signs and symptoms the gingival flap is often chronically inflamed and infected and has varying degree of ulceration along its inner surface Acute inflammatory response is a constant possibility and may be exacerbated by trauma from occlusion or foreign body trapped underneath the tissue flap

Predisposing factors - Emotional stress, fatigue, upper respiratory tract infections, - pregnancy and menstruation - Impinging of maxillary molars - associated osteitis, distal bony pocket increases the infection

Signs and symptoms of acute pericoronitis Extreme pain (radiating to ear, throat and floor of mouth) Swelling of the operculum and gingiva Purulent exudates Foul taste Swelling of the cheek

Cervical lymphadenopathy
Trismus Systemic complication fever, leucocytosis and malaise. The tissue may be so swollen that it interferes with the mastication and is easily traumatized during eating

Clinical features Pericoronitis may be acute, subacute / chronic Acute phase Patient aware of the eruption of teeth and discomfort Patient experiences severe throbbing and radiating pain Development of some degree of restricted mouth opening Enlarged regional submandibular lymphnodes Halitosis

Pyrexia associated with tachycardia, leucocytosis and malaise Intraorally swelling and purulent discharge
Dysphagia indicates that the infection has spread to sublingual and paraphryngeal spaces

Subacute phase
Systemic feature become less acute Patient experience continuous dull pain, persistence of intra oral swelling, jaw stiffness and regional lymphadenopathy pus discharge from follicular space Ulceration of the operculum become more pronounced

Chronic phase

Complete absence of systemic features except during acute exacerbation

Dull pain with unpleasant taste in oral cavity

IOPAR may reveal crater like bony defect around third molar

Diagnosis

History
Clinical examination Special investigation include radiographic examination,total and differential count of leucocyte

Differential diagnosis

During early state pulpitis and periodontitis

In later stage due to limitation of mouth opening with jaw stiffness can mimic TMJ dysfunction

If swelling is diffuse liable to confuse with tonsillitis

Management Depends on

severity of case,
Weather it is recurrence and possible systemic complication

Local treatment Topical anesthesia The infected area is debrided, usually be gentle flushing with warm water / diluted hydrogen perioxide

After irrigation, a drop of astringent like Talbos solution of Iodine can be applied Prescribe antibiotic if patient is febrile / cervical lymphadenopathy Traumatic occlusion if any be relieved (grinding maxillary third molar)

After acute condition has resolved appropriate decision must be taken as to weather IIIrd molar must be removed / to be retained after pericoronal flap excision

Complications

Pericoronal abscess

Peritonsillar abscess
Pterygomandibular and submassetric abscess Involvement of submaxillary, posterior cervical, deep cervical and retropharyngeal lymp nodes Cellulitis Ludwigs angina