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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
Usually occurs on lateral aspect of tooth Appears edematous red and shiny May have dome like appearance or come to a distinct point
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
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)
Diagnosis Based on
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
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
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
A vertical incision done through the most fluctuant centre of the abscess with # 15 blade
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
- 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
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
Diagnosis
History
Clinical examination Special investigation include radiographic examination,total and differential count of leucocyte
Differential diagnosis
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