Acute Periodontal Conditions

Acute Necrotising Ulcerative

Gingivitis - Clinical Features
 Sudden onset
 Red, shiny gingivae which bleed easily
 Ulceration of interdental papillae, with tissue
destruction
 Pseudomembranous slough
 Halitosis
 Metallic taste
 Very painful
 Submental/Submandibular lymphadenitis
 ANUG - Occurrence
 M=F
 Majority 18 - 30 years
 Rare in young children, middle-age and elderly
 Recurrent episodes common unless adequately
treated
 In deprived regions of Africa may spread to affect the
facial tissues - cancrum oris or noma
 ANUG - Aetiology
 Probably caused by opportunistic infection of the
gingival tissue by commensal micro-organisms
 Classically a fuso-spirochaetal complex, but more
recent studies suggest a mixed anaerobic infection
 Predisposing factors:
– Inadequate Oral Hygiene
– Smoking
– Mental Stress
– Underlying Systemic Disease esp. HIV
– Post-viral infection
 ANUG - Treatment

 Thorough debridement if not too painful with

ultrasonics
 In severe cases remove loose debris with cotton wool
pellets soaked in 3% hydrogen peroxide
 OHI - soft toothbrush
 Mouthwashes - sodium perborate (Bocasan) may be
helpful in dislodging the slough and have a direct
effect on the bacteria. Can also use CHX
 ANUG - Treatment (II)
 Systemic Treatment - if adequate debridement
impossible - Metronidazole 200mg tds 3 days.
Penicillin is an alternative

 Follow-up Care - OHI and monitor gingival healing

and contour. Severe destruction may need surgical
intervention
Acute Herpetic Stomatitis - Aetiology
 Systemic infection with Herpes simplex virus (usually
type 1) which manifests by widespread intraoral
vesicles and ulceration
 Often a disease of early childhood when dismissed as
“teething” - much more severe in adulthood
 Highly contagious
 Acute Herpetic Stomatitis -
Clinical Features
 Sudden onset with high fever, cervical
lymphadenopathy and pain in mouth and throat
 Gingivae may become acutely inflamed, oedematous
and tender
 Intra-epithelial vesicles form with 24 hours usually on
tongue, buccal mucosa, palate and gingivae
 Vesicles rupture early to give numerous small
round/irregular superficial greyish-yellow ulcers with a
red halo
 Pain may interfere with eating, drinking and swallowing
 Acute Herpetic Stomatitis -
Treatment
 Mainly supportive
 Includes soft diet with adequate fluid intake, bed rest
and analgesics
 Oral ulceration is managed with chlorhexidine
mouthwash
 Antiviral agents reserved for the
immunocompromised
 Re-activation
 Primary illness leads to infection of trigeminal
ganglion
 Subsequent re-activation of the virus may occur.
 Most commonly manifests as Herpes Labialis
 Intra-oral re-activation may occur following trauma
such as surgery or infiltration anaesthesia.
 Periodontal Abscess

 An infection where the gingival sulcus or periodontal

pocket is the point of entry of the causative organism
 An acute suppurative inflammatory lesion arising
from an acute exacerbation of chronic periodontitis
and/or trauma to the gingival sulcus/pocket lining
 Aetiology
 blockage of drainage from pocket may lead to the
accumulation of pus
 trauma, caused by toothbrush bristles or food impaction
 orthodontic or occlusal forces
 dental procedures such as scaling
 host defences compromised e.g. viral illness, diabetes
 imbalance in flora
 multiple perio abscesses suggests imbalance between
host and flora
Periodontal abscess - clinical features
 Sudden onset
 Pain on biting, percussion and may be continuous
 Swelling and tenderness of overlying gingiva
 Increased mobility
 Bone loss
 Usually drainage along root surface to pocket orifice
 Extra-oral swelling is uncommon
 Must be differentiated from periapical abscess
 Periodontal vs Periapical
 Factors which differentiate a periodontal abscess:

– tooth responds to vitality tests

– associated pocketing on affected tooth and other teeth
– in some cases get multiple periodontal abscesses
– different drainage pattern
– associated facial swelling does not normally occur
– pain usually less than periapical abscess
– bone loss pattern on radiographs may help to differentiate
Periodontal Abscess - Treatment
 Poor prognosis if a lot of bone destruction - XLA
 Drainage by dilating pocket orifice with blunt
instrument or incision
 Gentle subgingival scaling to remove plaque, calculus
or foreign objects, usually under LA
 Hot salty mouthwash at home
 Systemic antibiotics not used unless concern about
permanent destruction or systemic upset
 Review to check healing and carry out further
cleaning and OHI
 Pericoronitis
 A localised purulent infection within the tissue
surrounding the crown of partially-erupted tooth
 Most commonly lower 8’s
 Clinically:
– localised erythema and swelling, which is painful to the
touch
– maybe purulent exudate
– trismus
– lymphadenopathy
– fever and malaise
 Pericoronitis (II)
 Treatment:
– goal is to eliminate acute signs and symptoms
– irrigation using saline, CHX or iodine
– debridement, usually with LA
– antibiotics
– tissue re-contouring
– extraction of involved or opposing tooth
– review to determine satisfactory resolution and consider
further treatment e.g. extraction
 Acute Traumatic Lesions
 Damage due to toothbrushing
 Pattern of ulceration of papilla and gingival margin
 May be gingival recession and cervical abrasion

 Suggest patient uses CHX for a week until ulcers heal

 Re-educate
 Review
 Treat abrasion and sensitivity
 References
 Palmer & Floyd, A Clinical Guide to Periodontology,
BDJ Books 1996, Chapter 8
 American Academy of Periodontology, Parameter on
Acute Periodontal Disease, www.perio.org
 Carranza 9th Ed Chapters 45 & 46
 Jenkins & Allen, Periodontics: A Synopsis, Wright,
1999, Chapter 20
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