chapter 9 Flashcards
Characteristics of acute periodontal diseases
sudden onset, rapid course of progression, accompanied by pain and discomfort, may be unrelated to preexisting gingivitis or periodontitis, lesion may be localized or more widespread in mouth, may present with systemic involvement
Abscesses of the periodontium
Circumscribed (abscess is localizd to specific site) fluctuant collection of pus localizedé within gingival wall of periodontal pocket. Pus (whitish, yellow, milky exudate consisting of dead and dying neutrophils, bacteria, cellular debris and fluid leaked from blood vessels. Precise bacterial etioly of abscess = unclear, most lesions contain microflora that are predominantly gram negative and anaerobic.
Implications of untreated abscesses
- Common dental emergency
- Can initiate rapid periodontal destruction and lead to premature tooth loss
- Possible link between abscesses of periodontium and systemic diseases
Characteristics of an abscess of the periodontium
- Acute abscess: constant, localized pain
- Chronic abscess: no pain or dull pain
- Circumscribed
- Possible increase in tooth mobility
- Radiographic loss of alveolar bone not involving tooth apex
- Tooth usually has vital pulp
- Fever may occur (serious) not common
- If delayed treatment, pus may drain through sinus tract
Causes of abscesses of the periodontium
- Blockage of orifice of pocket
- Accidentaly forcing foreign object into tissues
- incomplete calculus removal in periodontal pocket
Comparaison of periodontal abscesses and pulpal abscesses
- Vitalitity test results: PA(usually,vital pulp), PuA(usually, no vital pulp)
- Radiographic appearance: PA(bone loss present and an angular deflect and/or furcation radiolycency), PuA(bone loss at tooth root apex)
- Symptoms: PA(localized, constant pain), PuA(difficult to localize, intermittent pain
Classification of abscesses of the periodontium by course of the lesion
Acute abscess: rapid onset characterized by pain/discomfort, primarily caused by exacerbation of chronic inflammatory periodontal lesion
Chronic abscess: grows slowly and is not typically associated with pain, forms after spread of infection controlled by spontaneous drainage host response or therapy
Gingival abscess: primarily limited to gingival margin or interdental papilla without involvement of deeper structures of periodontium
Periodontal abscess: abscess of periodontium that affects deeper structures of periodontium as well as gingival tissues, usually occurs in site with preexisting periodontal disease invluding preexisting periodontal pockets, usually affects deeper structures of periodontium
Pericoronal abscess: involves tissues around crown of partially erupted tooth
Pericoronitis: soft tissue inflammation associated with abscess
Signs and symptoms of a pericoronal abscess
- Pain at site
- swelling of perculum
- Possible trismus
- Possible elevated body temperature
- Possible lymphadenopathy
Management of patients with abscesses of the periodontium
- Fundamental treatment steps: establishment of path of drainage for pus, thorough periodontal instrumentation of affected tooth surfaces in area of abscess, pain relief
Steps in treatment of a gingival or periodontal abscess
- Administer local anaesthesia
- Drain pus
- Perform thorough periodontal instrumentation
- Adjust occlusion, if needed
- Prescribe antibiotics, if needed
- Recommend warm saline rinses
- Prescribe pain meds if needed
- Establish follow-up appointments
Treatment of pericoronal abscess
Fundamental treatment steps: Establishment of path of drainage for pus, irrigation of undersurface of operculum, thorough periodontal instrumentation of tooth surfaces in area of abscess, relief of pain
Common steps in treatment of patient with pericoronal abscess
- Admisister local anesthesia
- drain pus
- Perform thorough periodontal instrumentation
- Irrigate under operculum
- prescribe antibiotics, if need
- Recommend warm saline rinses
- Prescribe pain medications if needed
- Evaluate for need for third molar extractions
- Establish follow-up appointments
- if pericoronal abscess reoccurs, reasses if surgical excision of operculum or extraction of offending tooth is warranted
Endodontic-Periodontal Lesions (EPL)
- Formerly known as combined periodontal-endodontic lesion
- Localized area of bacterial infection characterized by infection of pulp and periodontal tissues in same tooth
-Can originate from either dental pulp or periodontal tissues - Periodontlally derived lesion: Infection enters tooth via accessory canals and/or apical foremen of root, initialtes inflammatory changes in pulp-root canal complex
- Pulpally derived lesion: Infection escaped out of tooth of tooth, triggers secondary infection of periodontal tossues
Signs and symptoms of EPLs
- Deep pocketing that extends close to apex
- Negative or altered response to pulp sensitivity tests
- Bone resorption in apical or fungal regions of tooth
- Spontaneous pain
- Pain upon palpation or percussion
- Purulent suppuration
- Tooth mobility
- Presence of sinus tract
- gingival color alterations
Necrotizing periodontal disease (NPD)
Distinct characteristics: interdental tissue necrosis, intense gingival pain, spontaneous gingival bleeding
Secondary clinical characteristics: Fetid breath, pseudomembrane formation, systemic involvement
- Noncommunicable, destructive, inflammatory diseases
- Limited to interdental and marginal gingiva
- Historically called Vincent’s infection (no longer valid)
- Distinctive characteristic is tissue necrosis of gingiva
- Progression follows predictable course: interproximal gingival necrosis, causes punched out appearance, spreads to affect marginal gingiva
- Most often found in mandibular anterior region
Etiology of necrotizing gingivitis
- Late 19th cent, vincent identifies spirochètes and fusiforme deep in tissues
- Mid 20th cen Listgarden confirmed spirochetal invasion deep with tissues of NG lesions
- More recent testing revealed presence of diverse array of microorganisms deep within NG lesions
- Still debate wether invasion of specific bacteria species occurs before or after onset of NG
- Inflammatory response major contributing factor to development of NG
- HIV - positive individuals at higher risk of NG (may be indications of HIV infection)
Prevalence of NG
- Can affect subjects of any age, most common between ages of 20 - 30
- Lower prevalence in developed countries compared to developing countries
-95% of cases in north america occur in caucasians
Characteristics of NG
- necrosis and ulcers in interdental papilla
- Gingival bleeding
- Pain
- Pseudomembrane formation
- Halitosis
- Lymphadenopathy
- Fever
Treatment for NPD
Management should focus on:
- Reducing patient pain/discomfort
- arresting destructive progression of disease
- restoring form and function of involved periodontal tissues
- Preserving stability of periodontium following initial management
Stage 1: management of the Acute stage NPD
First day of treatment
- Remove pseudomembrane and soft and mineralized deposits and provide self-care regimen
Second day of treatment
- Initiate subgingival periodontal instrumentation and provide further instruction in self care to control systemic predisposing factors
Third visit
- Complete subgingival instrumentation, evaluate patient for resolution of symptoms, further counsel patient on predisposing factors and home care
Sever cases many require use of systemic antibiotics
Stages 2 & 3: management of acute stage of NPD
Stage 2: control preexisting conditions
- Comprehensive clinical assessment to identify and manage underlying periodontal disease
Stage 3: corrective surgical management
- May be required for some patient to reestablish natural contours of gingiva
Stage 4: maintenance phase (management of acute stage of NPD)
- Assess periodontal status
- reinforce self-care
- Control predisposing factors
-Perform any nessecary periodontal instrumentation
Factor in patient compliance levels
Necrtotizing periodontitis (NP)
- Same clinical features as necrotizing gingivitis but tissue necrosis spreads to underlying periodontal attachment apparatus
- Can lead to bone loss and clinical attachment loss
Typical treatment of Necrotizing periodontitis
- Similar to necrotizing periodontitis treatment, but may be more complex due to extensive, irreversible tissue destruction
- Referral to periodontist recommended
- Close collaboration with patient’s medical practitioner also warranted
