The signs and symptoms of a periodontal abscess - pain, swelling,
colour changes, formation of pus, extrusion of the tooth and
radiolucency - are not always present, nor are they unique to a
periodontal abscess. Other conditions that may cause similar signs
to those observed with periodontal abscess are:
Periapical abscess: this occurs in the presence of a pulpless infected
root canal, and hence the response to pulp vitality testing will be
negative. It is worth remembering, however, that the status of`the
pulp may be difficult to ascertain if the patient is in severe pain,
and has taken analgesics in an attempt to dull the pain.
Acute pulpitis: this lacks most of the signs and symptoms of a
periodontal abscess, except pain. The pain is diffuse, and can be
affected by thermal changes.
Tooth or root fracture: inflammation, pocketing and/or suppuration
may be the presenting signs of a vertical root fracture. The
presence of a narrow pocket along the root of a root-filled tooth
may indicate a root fracture.
Pericoronitis: this is an acute infection occurring around the
crown of a partially erupted tooth.
Periodontal cyst: a periodontal cyst appears radiographically as a
well defined oval radiolucency on the lateral surf`ace of a root. It
most commonly occurs in the mandibular canine-premnolar region. The cyst can become infected, and develop into a
periodontal abscess.
Treatment:
Once a periodontal abscess has been diagnosed, emergency
treatment needs to be provided to resolve the infection. Drainage
is usually achieved through the pocket as part of the root planing
procedure to clean the plaque and calculus deposits from the
root surfaces. After adequate anaesthesia has been achieved,
drainage can be started by inserting a sharp curette to the base of
the abscess.
Antibiotics are only indicated if systemic symptoms
are present, or if the patient is medically compromised. The
patient should be advised to use a chlorhexidine mouthwash.
Review appointments should be scheduled after 2-4 days, and
then after one week, to monitor the resolution of the abscess.
If
the root surface has been difficult to debride due to the presence
of anatomical features such as furcations or deep grooves,
periodontal surgery may be required in order to minimise the
risk of recurrence of the abscess.
ACUTE NECROTISING ULCERATIVE GINGIVITIS
Acute necrotising ulcerative gingivitis (ANUG) is defined as "a
rapidly destructive, non-communicable, gingival infection of
complex aetiology".
TO TOP
Aetiology:
Although it is accepted that bacteria play a causative role in the
aetiology of ANUG, the specific aetiology is yet to be established.
The role of the immune response in the pathogenesis of ANUG
has received some attention ,with research indicating that the
neutrophil may play an important role. More recently, it has been
suggested that ANUG shares many features with super-antigen
related staphylococcal; streptococcal infections.
There are a number of predisposing factors that appear to
precipitate the onset of the disease. These include:
Local factors:
- poor oral hygiene
- plaque retentive factors such as overhangs, crowded teeth
and calculus
- cigarette smoking
Systemic factors:
- emotional stress
- poor nutrition
- hormonal imbalance
- systemic diseases affecting immune responsiveness
Clinical features:
The clinical features of ANUG characteristically include necrosis
of the crest of the marginal gingival tissues, usually commencing
at the interdental papillae. The destruction of tissue is rapid, and
is associated with spontaneous bleeding, halitosis and pain. It is
usually self-limiting, but it may spread laterally and apically to
involve the entire gingival complex.
It is sometimes seen in
recurrent forms. The gingival alteration seen in ANUG is
characterised by punched-out and cratered depression in the
interdental sites, with the surfaces of the lesions covered with a
grey or greyish-yellow pseudomembrane. Patients often comment
on having a "metallic" taste. In severe cases, there can be systemic
symptoms including high fever, malaise and lymphadenopathy.
Differential diagnoses:
The diagnosis of ANUG is usually straight forward, given its
characteristic presentation. However, there are several other oral
mucosal lesions that may be confused with ANUG. These include
acute herpetic gingivostomatitis, desquamative gingivitis, HIV-
related periodontitis, streptococcal gingivostomatitis, advanced
marginal gingivitis, apthous stomatitis, acute leukaemia, and
dermatoses (including pemphigus, benign mucous membrane
pemphigoid, lichen planus and erythema multiforme).
Treatment:
Due to the pain associated with ANUG, emergency treatment can
sometimes pose a challenge. However, the principles of
management of any infection still hold - that is, it is important to
remove bacteria and local factors. This can be achieved by
anaesthetising the area, and gently debriding the supra- and
subgingival surfaces with ultrasonic and hand instruments. The
patient should be instructed to use a chlorhexidine mouthwash,
and the adjunctive use of antibiotics (Metronidazole 200mg tid
for 5 days; or Tinidazole 2g stat) is usually recommended.
Healing should be checked after one week, and additional
cleaning and oral hygiene instruction provided at that visit.
Depending on the amount of soft tissue damage caused by the
infection, gingivoplasty may be required in order to recontour
the gingival defects.
SUMMARY
Acute periodontal problems require an accurate diagnosis, so
that appropriate emergency care can be provided to relieve the
patient's symptoms of pain. Careful follow-up of the affected
areas is essential for the avoidance of recurrent problems, which
can lead to further soft and/or hard tissue destruction