Periodontal Emergencies (Acute Periodontal Conditions)

It seems that the Dr was using different slides than what I have received, for this reason I included the actual script (what the Dr said during the lecture) in a box, you can find it in page #7&8, the rest of this document is a copy of what was written in the slides. Acute conditions are: Characterized by a rapid onset and rapid course. Frequently accompanied by pain and discomfort. Not necessarily related to the presence of pre-existing gingivitis or periodontitis. Periodontal Emergencies includes: 1. 2. 3. 4. 5. Abscess of the Periodontium. Pericoronitis. Endo-perio lesion. Herpetic infections. Necrotizing periodontal diseases.

Abscess of the Periodontium

Abscess of the periodontium is an acute infection involving a localized collection of pus in the periodontium.

Symptoms of Abscess of the Periodontium: - The patient comes to the dental office complaining of pain and swelling of the gingiva. - The patient may also complain of difficulty in mastication or bad taste in the mouth. - Elevated body temperature is a sign that the abscess of the periodontium is spreading; so this is a serious sign if present. Clinical Examination reveals: - A circumscribed swelling of the soft tissue; may involve the gingiva only or may involve both the gingiva and the mucosa - Slight mobility. - Vital teeth.

In this picture abscess has broken through the tissue:

Causes of Abscess of the Periodontium: - Blockage of the opening of an existing periodontal pocket. - Forcing a foreign object into the supporting tissues of a tooth. - Incomplete calculus removal: Can occur in a site with deep pocket where calculus deposits are removed only in the most coronal aspects of the pocket near the gingival margin. Removal of only the more coronal calculus allows the gingival margin to heal and tighten around the tooth. Bacterial toxins are trapped in the pocket and bacteria can result in the formation of an abscess. Types of abscesses of the Periodontium: Can be either: - Gingival Abscess. - Periodontal Abscess.

Gingival Abscess
Characterized by: - Periodontally healthy mouth (normally is not associated with per-existing periodontal diseases). - Foreign object is forced into a healthy sulcus. - Limited to gingival margin. - Localized swelling. - Painful. - Purulent exudates may be present. So it involves the marginal gingiva or interdental papilla:

Gingival abscess treatment: - Elimination of foreign object. - Drainage through sulcus with probe or light scaling (make sure that the area is clean and no calculus in the sulcus). - Control of discomfort. - Follow-up after 24-48 hours. - Recommend warm saline rinses. Normally it heals without any complications.

Periodontal Abscess
- A localized purulent infection within the tissues adjacent to the periodontal pocket. - Occurs at a site with preexisting periodontal pockets. - Usually affects deeper structures of the periodontium (PDL and Bone destruction). - Not limited to the gingival margin. - Usually there is impaction or lodgment of a piece of calculus or any foreign body and there is no way for escape of the fluid from the tissue, so it will end with the tissue forming an abscess, and it may form fistula and you know that abscess in general follow the path of the weakest structures for drainage, most of the cases it can be treated and the condition is reversible.

Factors associated with abscess development: Occlusion of pocket orifice (by healing of marginal gingiva following supragingival scaling): So you have to be careful and make sure when you do scaling or root planning, you need to flush, especially with root planning, because if the calculus is detached from the root surface but stayed inside the periodontal pocket, sometimes healing occurs and the epithelium has tendency to close the pocket and there will be entrapment of this piece of calculus and there will be abscess. Furcation involvement: because of difficult instrumentation sometimes we left behind calculus or foreign body and it gives rise to formation of periodontal abscess. Long term treatment of systemic antibiotic (allowing overgrowth of resistant bacteria) Diabetes Mellitus: of course they have more tendencies for formation of periodontal abscesses and in general periodontal disease and periodontitis.

Periodontal Abscess
Clinical Features: Smooth, shiny swelling of the gingiva. Painful, tender to palpation. Purulent exudates. Increased probing depth. Mobile and/or percussion sensitive. Tooth usually vital.

Periodontal Vs. PeriapicalAbscess

Periodontal Abscess: Vital tooth No caries Pocket Periapical Abscess: Non-vital tooth Caries No pocket

Treatment of periodontal abscess Anesthesia Antibiotics Establish drainage: Incision and drainage Extraction

Pericoronitis
- Localized infection within the tissue surrounding the crown of a partially erupted tooth. - Mandibular third molars in young adults, usually caused by impaction of debris under the soft tissue flap.

Pericoronal Abscess: - An abscess of the periodontium that involves tissues around the crown of a partially erupted tooth. - Also referred to as Pericoronitis. - Most frequently seen around mandibular third molars. - The flap of tissue covers part of the occlusal surface (operculum).

Clinical Features Operculum (soft tissue flap). Localized red, swollen tissue . Area painful to touch. Tissue trauma from opposing tooth common. Purulent exudate, trismus, and fever. Treatment Options Debride/irrigate under pericoronal flap. Tissue recontouring (removing tissue flap).

 Extraction of involved and/or opposing tooth. Antimicrobials (local and/or systemic as needed). .

Endo-Perio Lesion

There are basically 3 ways of communication between the pulp and the connective tissue (PDL): 1- The apical foramen: when the abscess is formed from it it's called Periapical abscess or periodontal apical abscess, which results from the infection of the pulp, and later on may result in infection and resorption of the bone, and as you know the bone is considered as a part of the periodontal system. 2- Lateral and accessory canals: which are mostly available in the apical third, and maybe also in the Furcation area, lateral accessory canals are mostly present with the lateral incisor. 3- Dentinal tubules: which contains the odontoblasts and the nerve endings that maybe responsible for the patient hypersensitivity. so these maybe source of communication for the infection between the pulp and the periodontium, these ways are present in normal anatomy. There are other types for communication which are pathological: 1- Dental malformation. 2- Vertical root fracture and perforations: in vertical root fracture and in dental malformation (like grooves) there will be a line of radiolucency, here after you do RCT and the periodontal treatment you'll find the still there is radiolucency, so I may search for vertical root fracture or grooves, here the cone beam CT may be useful in detecting them. 3- Iatrogenic factors: which are caused by a mistake of the Dr. himself, mostly when the Dr causes a perforation in the canal during RCT, which will result in radiolucency after the treatment .

There are 5 types of Endo-perio lesions: 1- Primary endodontic disease: here the lesion starts from the pulp, the pulp here is not vital, this type is treated by RCT. 2- Primary periodontal disease: when it starts from the periodontium (like if we have deep pocket and attachment loss), the pulp here is mostly vital, this type is treated by scaling and root planing. In these 2 types we have problem in 1 of them only. 3- Primary endo and secondary perio: where the lesion starts in the pulp and spreads to the periodontium, it can spread either from the apex or from the accessory canals. 4- Primary perio and secondary endo: where a lesion from the periodontium reaches the apex and causes endo problem which can also spread either from the apex or from the accessory canals. It can be differentiated by horizontal bone loss, Periapical radiolucency and the crown is intact (no caries or restorations) and the vitality test gives negative results. 5- Combined lesion: where there are perio problem and in the same time endo problem, it can be advanced where there is a communication between them and huge destruction of the bone, or you can find it in a stage before this communication, we start the treatment with RCT then perio treatment. The type of bacteria is different between the pulp and the periodontium lesions, and here we have a synergistic effect to damage the bone and the soft tissue. The Dr talked about a picture and said: here we have a true combined lesion and mostly we have angular bone resorption and huge bone resorption from the two sides. When we want to differentiate between these lesions it's very important to check the vitality of the teeth, we also we use Periapical radiographs, percussion, palpation and probing for the pocket, also we can see if we have a sinus tract or whatever. If we have a periodontal abscess in primary periodontal disease the tooth usually would be vital. Important: when we have an endo-perio lesion usually we start the treatment with RCT, because I cannot stop the infection the periodontium and still I have an infection in the pulp, so after I start do initial removal of the calculus I go immediately and do RCT and then we go to the perio treatment.

Necrotizing Periodontal Diseases

- Necrotizing Ulcerative Gingivitis (NUG) - Necrotizing Ulcerative Periodontitis (NUP)

Necrotizing Ulcerative Gingivitis

Necrotizing Ulcerative Gingivitis is an infection characterized by gingival necrosis presenting as punched-out papillae, with gingival bleeding and pain. Distinguishing Characteristics: - Necrosis (death of the cells). - Ulceration. - Loss of the gingival epithelium. - Pseudomembrane (a gray-white layer covering the necrotic areas of the gingiva). - Punched out papillae (destruction of papillae).

Historical terminology: Vincents disease. Trench mouth. Acute necrotizing ulcerative gingivitis (ANUG). Necrotizing Ulcerative Gingivitis: - Necrosis limited to gingival tissues. - Estimated prevalence 0.6% in general population. - Young adults (mean age 23 years). - More common in Caucasians. - Bacterial flora: Spirochetes (Treponema sp.).

 Prevotella intermedia. Fusiform bacteria. Clinical Features: Gingival necrosis, especially tips of papillae. Punched out or cratered papillae. Pain. Extreme halitosis. Pseudomembrane formation (Gray-white). Bleeding upon slight manipulation. Swollen lymph nodes. Elevated body temperature.

Predisposing Factors: Emotional stress. Poor oral hygiene. Cigarette smoking. Poor nutrition. Immunosuppression. ***Necrotizing Periodontal diseases are common in immunocompromised patients, especially those who are HIV (+).

Necrotizing Ulcerative Periodontitis

An infection characterized by necrosis of gingival tissues, periodontal ligament ,and alveolar bone.

Clinical Features:

Clinical appearance of NUG. Severe deep aching pain. Very rapid rate of bone destruction. Deep pocket formation not evident.

Necrotizing Periodontal Diseases Treatment:

Local debridement: Most cases adequately treated by debridementand sc/rp. Anesthetics as needed. Consider avoiding ultrasonic instrumentation dueto risk of HIV transmission Oral hygiene instructions Oral rinses: frequent, at least until pain subsides allowing effective OH) Chlorhexidine gluconate 2 x daily. Hydrogen peroxide/water. Povidone iodine. Pain control Antibiotics (systemic or severe involvement): Metronidazole. Modify predisposing factors. Proper follow-up.

Another picture of necrotizing Ulcerative Gingivitis:

Typical Treatment of NUG: First appointment: Gentle removal of pseudomembrane. Limited supragingival instrumentation. Self-care restricted to removal of debris with soft toothbrushing. Chlorhexidine rinses twice daily. Alternatively, equal parts hydrogen peroxide andwarm water every 2 to 3 hours.

Second appointment: 2 days after initial appointment. Subgingival instrumentation. Further self-care instructions. Third appointment: 5 days after initial appointment. Complete subgingival instrumentation. Antibiotics may be necessary. Fourth appointment: Following infection resolution. Comprehensive clinical assessment. Identify any underlying chronic periodontal disease.

Herpetic Infections
Herpes Simplex Virus, Acute viral infection of the oral mucosa: - Redness. - Multiple vesicles. - Painful ulcers. - Fever. - One to Two weeks. Treatment: Bed rest. Fluids. Nutrition. Antipyretics. Anti-viral. Recurrent Herpetic Infections Virus reactivation:

Fever. Systemic infection. Ultraviolet radiation. Stress. Immune system changes. Trauma.