Periodontal

Emergencies In
General Practice

By - S.AARTHI
INTERN
INTRODUCTION

A periodontal emergency arises when an

acute condition invovling the periodontium
causes pain, forcing the patient to seek
urgent care.

Timely management is the key in

preventing further damage to the
periodontium as well as improving the
patient's physical and psychological
well-being.

2
 ABSCESS ULCERATION INJURIES

GINGIVAL ABSCESS ANUG/ANUP PHYSICAL

ACUTE HERPETIC
PERIODONTAL ABSCESS THERMAL
GINGIVOSTOMATITIS

PERIO-ENDO CHEMICAL
LESION/ABSCESS

PERICORONAL ABSCESS
GINGIVAL ABSCESS

A gingival abscess is 'a localised purulent infection that involves

the marginal gingiva or interdental papillae'.
Clinical Features

In its early stages, it appears as a red swelling with a smooth,

shiny surface.

Within 24-48 hrs, the lesion usually becomes fluctuant and

pointed, with a surface orifice from which a purulent exudate
maybe expressed.
Aetiology

Results from bacteria carried deep into the tissues when a foreign
substance. [ eg., toothbrush bristle, piece of apple core etc ] is
forcefully embedded into the gingiva.
Emergency Management

The abscess should be incised, drained and irrigated with

saline to relieve the acute symptoms.
Mitigation of the aetiology is an important consideration and
mechanical debridement may help with this.
Short�term use of chlorhexidine mouthwash (0.2%) or warm
saline rinses is often recommended, especially if the area is
too tender to brush.
Long-term Management

A follow-up appointment should be arranged to check for

resolution.
PERIODONTAL ABSCESS

A periodontal abscess is 'a localised accumulation of pus within

the gingival wall of a periodontal pocket resulting in the
destruction of the collagen fibre attachment and the loss of
nearby alveolar bone.'
Clinical Features

1. Acute periodontal abscess

They are associated with preexisting periodontal disease. They

may occur around any tooth when the periodontal pocket
becomes occluded, often as a result of a foreign object.

An exacerbated inflammatory reaction then occurs. If the

pocket can drain through a sulcus or a fistula (opening in the
tissue), the infection can stabilize and be considered in a
chronic state.
There is marked swelling of the
periodontal tissues. Clinically, the tissue
appears shiny, reddened, and raised.

Associated with a central incisor with a

large fistulous tract.
2. Chronic periodontal abscess

The chronic periodontal abscess exhibits suppuration that

exudes into the oral cavity on digital pressure through the pocket
or sinus tract. The associated gingival tissue is red and swollen.
Aetiology

It may represent disease exacerbation of existing

periodontitis in the presence of complex pocket
morphology, furcation involvement or a vertical defect.

Changes in the composition of the subgingival microbiota,

with an increase in bacterial virulence, or a decrease in the
host defence, may also result in a diminished capacity to
drain the increased suppuration.
Following debridement – calculus fragments may become
dislodged and pushed into the periodontal tissues.
After surgical therapy – associated with the presence of
foreign bodies such as membranes or sutures.
Acute exacerbation of periodontitis.
Systemic antimicrobial intake without subgingival debridement in
severe periodontitis (related to an overgrowth of opportunistic
bacteria).
Emergency Management

The first phase of treatment involves control of the acute condition

to arrest tissue destruction and management of acute symptoms.
If the tooth can be saved, drainage needs to be established
(through the pocket or with an external incision) and the periodontal
pocket should be thoroughly debrided.
Occlusal adjustment may also be help to provide immediate relief.
Long-term Management

Periodontal therapy should be evaluated after resolution of the

acute phase. In cases where the patient has not been treated
previously, the appropriate periodontal treatment should be
provided.

If the patient is already within the active phase of therapy, the

periodontal therapy should be completed once the acute lesion
has been treated.
PERIO-ENDO LESION/ABSCESS

Combined periodontal/endodontic lesions are localised, circumscribed

areas of infection originating in the periodontal and/or pulpal tissues. They
are essentially a result of a communication between the periodontal
pocket and the pulp.
Clinical Features

The abscess will be associated with a deep

pocket surrounding a non-vital tooth.

The pocket may circumscribe a large part

of the tooth or be a localised narrow deep
lesion.

A smooth, shiny swelling of the gingiva or

mucosa will be present. The swelling may
have purulent exudate or fistula and will be
tender to palpation.
Aetiology

The infection may arise primarily from pulpal inflammatory

disease expressed through the periodontal ligament or the
alveolar bone to the oral cavity, or it may be initiated from a
periodontal pocket communicating to the pulp apically or
through accessory canals.
Emergency Management

Drainage by debriding the pocket and/or extirpating the pulp.

The abscess may be incised if it is fluctuant and pointing.
Other treatments may include limited occlusal adjustment,
the administration of antimicrobials if there are signs of
spreading infection and management of patient comfort.
Long-term Management

Primary endodontic lesions often respond well to root canal

therapy alone. If the lesion is primary periodontal or truly
combined, there is often a very poor prognosis and this is
usually a good indication for extraction in single rooted teeth.

In multi-rooted teeth, root resection may be a possible

consideration following endodontic therapy. It is also
necessary to ensure that there has not been a vertical
fracture, since this may often render a tooth unsavable.
PERICORONAL ABSCESS
Pericoronitis is ‘inflammation of the soft tissues surrounding the
crown of a partially erupted tooth.’

A peri-coronal abscess is the ‘localised accumulation of pus

within the overlying gingival flap surrounding the crown of an
incompletely erupted tooth'.
Clinical Features

Red, swollen, possibly suppurative lesion that is painful to

touch. Swelling of the cheek at the angle of mandible, trismus
and a radiating pain to ear are common.
The patient may also experience systemic complications such
as lymphadenopathy, fever and general malaise.
Aetiology

The partially erupted and impacted mandibular third molar is

the site most frequently involved.

The overlying operculum is an excellent harbour for the

accumulation of debris and bacteria.

In addition, insult to the operculum is often produced by

trauma from an opposing tooth.
Emergency Management

Following anaesthesia, the operculum should be irrigated to

remove any debris.
In some cases, it may be necessary to excise the operculum
and possibly also perform some occlusal adjustment on the
opposing tooth to eliminate any sources of trauma.
Antibiotics are only indicated if there are systemic signs or
spreading infection.
 Long-term Management

Once the acute phase of the infection has subsided, a decision

needs to be made on whether the tooth requires extraction.

The evidence suggests that ‘the first episode of pericoronitis,

unless particularly severe, should not be considered as an
indication for surgery. Second or subsequent episodes should be
considered appropriate indication for surgery.’

Extraction might also be indicated if the tooth is associated

with extensive caries or root resorption.
NECROTIZING PERIODONTAL DISEASES

These include necrotising gingivitis (NG) and necrotising

periodontitis (NP).

NG describes a scenario where only the gingival tissues are

affected.

In NP, the necrosis progresses into the periodontal ligament and

alveolar bone, leading to attachment loss.
Clinical Features

The mandibular anterior teeth are most commonly affected. NG

will be associated with necrosis and ulcers in the free gingiva.

These lesions start at the interdental papilla and typically have a

‘punched out’ appearance. Marginal erythema may be present,
and necrotic lesions can progress to the marginal gingiva.

A pseudo-membrane may form over the necrotic area. When

this ‘membrane’ is removed, the underlying connective tissue
becomes exposed and bleeds.
In severe cases, bone sequestration may occur. In patients
with NG, there may be associated risk factors such as high stress
levels, heavy smoking and poor nutrition.

Both NG and NP may be associated with untreated HIV/AIDS or

other diseases and drugs that may, directly or indirectly, have an
immunosuppressant effect, such as chemotherapy or
anti�rejection medication in transplant patients.
Aetiology

Knowledge of the pathogenesis of this condition is limited but the

spirochetes and fusiform bacteria described in the necrotic lesions
have been shown to have the capacity to invade the epithelium and
connective tissue, as well as release endotoxins, which may cause
periodontal tissue destruction through modification of the host
response.
Emergency Management

Superficial debridement to remove soft and mineralised deposits

should be carefully performed.

Ultrasonic rather than hand instruments are recommended to

ensure minimum pressure over the ulcerated soft tissue.

The patient should be advised to use chemical plaque control

agents, such as chlorhexidine mouthwash (0.2% twice daily).

Other agents, such as 3% hydrogen peroxide diluted in 1:1 warm

water and other oxygen-�releasing agents, provide an additional
antibacterial effect against anaerobes through the release of oxygen.
.
If there is no improvement in the periodontal condition following
debridement, the use of systemic antimicrobials should be considered.

Metronidazole (400 mg three times a day for five days) is usually the first
choice, due to its action against strict anaerobes.

Long-term Management

Oral hygiene measures should be enforced and debridement should

be completed where necessary. Once the acute phase has been
controlled, treatment of any pre�existing periodontal disease and
control of systemic risk factors should be addressed.
 Management may also occasionally involve attempts to try to
disguise soft tissue asymmetry, which may be present following
resolution of lesions. However, not all cases (eg. class IV recession
defects) will be amenable to predictable soft tissue augmentation.
ACUTE HERPETIC GINGIVOSTOMATITIS

Most common viral infection of the oral mucosa.

Characterised by small ulcers with elevated margins that may

be dispersed throughout the mouth on both attached and
unattached mucosal surfaces.
 Systemic signs such as lymphadenopathy, fever and malaise may
also be present. Lesions normally last for 7–10 days and heal without
scarring. This condition is more frequently observed in children aged
two to five years of age.
Emergency Management

As the condition is self-limiting, no treatment is usually indicated beyond

hydration and management of symptoms.

Therapy to relieve pain must be initiated to allow the patient to eat and
drink. Paracetamol is commonly used and the recommended dosage
for a child aged two to four years is 180 mg every 4-6 hours.

If the condition is severe and presents in immune-compromised patients,

referral to hospital is advised as they may require intravenous antiviral drug
treatment.
ACUTE PHYSICAL, CHEMICAL OR THERMAL INJURY

Physical injuries may appear as erosions or ulcers and can be associated with
gingival recession. Less frequently they can present as hyperkeratosis, vesicles or
bullae.
If the physical trauma is limited but continuous over time, the lesion may be
hyperkeratotic.
If the trauma is more aggressive, superficial laceration may occur.
The lesion may be either asymptomatic or cause an intense localised pain in the
area of the lesion.
Thermal injury is usually painful for the patient and the appearance of the gingival
tissues may be erythematous, desquamated and occasionally associated with
vesicles, erosions or ulcers.

Chemical lesions may appear after direct contact of the agent over the mucosa,
leading to maculae, vesicles, erosions or ulcers, depending on the causal agent and
the duration of contact.
Aetiology

Physical injuries are most commonly caused by inappropriate

oral hygiene habits, traumatic injuries or parafunction.

Common causes of chemical trauma are oral bleaching

agents, either due to inappropriate use by the patient or
poorly fitting trays.

Thermal injury is commonly related to burns caused by very hot food

or drinks.
Emergency Management

Therapeutic intervention will depend upon the diagnosis and cause.

As well as clinical examination, an accurate patient history will be
important in determining the source of the trauma.

Treatment will include elimination of the initiating factor

(if required) and symptomatic management of the pain.
Long-term Management

Lesions usually heal without further intervention, but on

some occasions additional treatment may be required.

It is important to distinguish this group from lesions related to

mucocutaneous diseases where there may not be a clear initiating
factor, hence it may be necessary to withhold mechanical oral
hygiene procedures, supplemented by the use of chemical plaque
control, to help establish aetiology.
 SUBGINGIVAL ROOT FRACTURE

A fracture of a tooth extending from the supragingival oral environment in

an apical direction subgingivally can give rise to acute pain and
periodontal infection.
Magnification and good illumination can help to visualise
fracture lines. A ‘Tooth Slooth’ or similar device may also aid
diagnosis by applying occlusal loads to individual cusps.

Fractures may be vertical along the root axis, or at an angle

with varying degrees of root involvement.
Aetiology

The patient may or may not be aware of a specific traumatic

event during chewing. Heavily restored teeth without cuspal
coverage and bruxism are key risk factors. This is also not
uncommon in patients with a reduced periodontium due to an
unfavourable crown:root ratio.
Emergency Management
Management depends on the vitality of the tooth as well
as the location and extent of the fracture. It may be
necessary to remove existing restorations followed by
careful assessment of the tooth to confirm diagnosis.
A periodontal flap can be useful in visualising the
fracture.
Crown lengthening can help to expose the most apical
extent of the fracture. Initial care to relieve acute pain
may involve endodontic treatment. In some cases, the
tooth will be deemed untreatable and will require
extraction.
Long-term Management

Endodontic treatment should be followed by a full

coverage restoration if the tooth is restorable.