ACUTE PERIODONTAL PROBLEMS
vast majority or periodontal conditions are non-acute in nature and typically
are not associated with pain. However, acute periodontal conditions do
arise, either in patients with an underlying periodontitis, or in otherwise
periodonatlly uncompromised patients. The differential diagnosis of such
conditions is an essential prerequisite for the appropriate and immediate
management of acute periodontal problems.
two most common forms of acute periodontal problems are the periodontal
abscess and acute necrotising ulcerative gingivitis (ANUG). This practice
information sheet will focus predominantly on the diagnosis and management
on the diagnosis and management of these conditions.
A periodontal abscess is
defined as: "An acute, destructive process in the periodontium resulting
in localised collections of pus communicating with the oral cavity through
the gingival sulcus or other periodontal sites and not arising from the
tooth pulp". (International Conference on Research in the Biology of Periodontal
The majority of periodontal
abscesses occur in a pre-existing periodontal pocket. If the pocket is
occluded, then infectious materials within the pocket can accumulate and
the build-up of a purulent discharge can result in the formation of the
clinical signs and symptoms of a periodontal abscess. Occlusion of pockets
can be caused by the impaction of a foreign body such as a seed lodged
within the gingival sulcus.
Drainage of a pocket may
also be blocked following healing of the coronal gingival tissues, while
debris and bacteria remain at the base of a deep pocket. This may be evident
when a patient has had a "scale and clean", without adequate instrumentation
to clean the base of a deep periodontal pocket or a furcation area. Periodontal
abscesses can also arise following secondary infection of lateral periodontal
cysts or as a result of` trauma to the periodontium, for example perforation
of a root canal.
Compromised host immune response
may predispose a patient to the formation of periodontal abscesses. The
presence of multiple periodontal abscesses is typically seen in poorly
controlled diabetic patients. Examination of the microbial factors involved
in the formation of acute periodontal abscesses has revealed the predominance
of` gram negative anaerobic rods , and the presence of fungi resembling
Candida species (assumed to be secondary invaders in the area of pre-existing
Factors influencing microbial
virulence may trigger the formation of a periodontal abscess. One of the
most common of these is the formation of resistant bacterial species following
the use of systemic antibiotics. Bacterial samples, taken from patients
with multiple periodontal abscesses which developed 1-3 weeks after penicillin
or tetracycline therapy,revealed the presence of` resistant strains to
antibiotics in 55 percent of samples.
The most common symptom
of a periodontal abscess is pain. The tissues surrounding the painful tooth
or teeth are usually swollen, varying from a small localised enlargement
to diffuse swelling involving the gingival, alveolar mucosa and oral mucosa.
The tissues often appear to be red or a deep red-blue in colour. Facial
or neck cellulitis are rare, although lymphadenopathy and fever may be
The affected tooth, and often
the adjacent teeth, are usually tender to bite on and sensitive to clinical
percussion. The tooth is usually mobile and high in the occlusion. Periodontal
probing usually reveals the presence of a deep pocket, through which a
purulent discharge can be drained. There may also be evidence of a sinus
tract draining the abscess.
Radiographs are often
useful in confirming the diagnosis, revealing the presence of a radiolucent
area along the lateral aspect of the tooth involved. However, if the abscess
is located on the buccal or palatal aspects of the tooth, then no radiographic
evidence may be detected.
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
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.
is an acute infection occurring around the crown of a partially erupted
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.
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
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 (ANUG) is defined as "a rapidly destructive, non-communicable,
gingival infection of complex 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;
There are a number of predisposing
factors that appear to precipitate the onset of the disease. These include:
poor oral hygiene
plaque retentive factors such
as overhangs, crowded teeth and calculus
systemic diseases affecting
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.
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
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
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
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
This material has been
compiled with the assistance of Dr Louise Brown, Lecturer in Periodontics
at the University of Melbourne.