DENT 267: LO6 LS2- Abscesses of the Periodontium: Pericoronal & Periodontal Abscesses

Pericoronitis/Pericoronal Abscess

-inflammation surrounding the crown of a completely or incompletely erupted tooth

-aka operculitis

-most common in 3rd and 2nd mand molars

-may be acute of chronic

operculum

-flap of tissue that covers the occlusal surface of a tooth either partially or fully erupted

signs & symptoms of pericoronitis

-operculum

-swelling and redness

-bleeding

-ulcerated or traumatized

-pain, tenderness, pus

-trismus

-foul breath & taste

-lymphadenopathy (enlarged lymph nodes)

-fever, malaise

-toxic systemic complications

-referred pain to ear & throat

radiographic signs/histopathology of pericoronitis

-area of radiolucency or bone loss

-gingival pocket

-increase in tissue fluids

-cellulitis

etiology of pericoronitis

-biofilm, food debris and mechanical irritation from occlusion

-when treated early, tissues may return back to normal but long-range prognosis depends on elimination of the operculum

-extraction may be required as tooth position & anatomical limitations may prevent successful results after removal of operculum

prognosis of pericoronitis

-untreated pericoronitis can lead to a severe infection w/ systemic complications and loss of periodontium

-condition may recur

care plan for pericorontis

-determine extent of involvement

-gentle debridement

-irrigation w/ warm water (saline)

-incision and drainage may be required

-systemic antibiotic therapy if toxic systemic involvement

-home care procedures (warm saline rinses/irrigation)

-analgesics/anti-inflammatory

-within 72 hrs of first appt, re-eval and debride again

-within 24 hrs of second appt, after infection subsides, decide on whether ext or perio surgery to remove operculum is required

client education/prevention: pericoronitis

-early removal of opercula prior to pericoronitis and early removal of partially erupted teeth (3rd molars) as required

-adequate biofilm control around erupting teeth

-explain etiology to client & effective biofilm control

post extractions of 8s

-deep pockets on the 7s (especially mand, sometimes max)

-be aware & refer to periodontist if necessary

-surgery needed, maybe bone grafting if deep pockets

periodontal abscess

-localized collection of pus within the periodontium

-can be acute or chronic

-in clients w/ deep perio pockets

periodontal abscess: can be caused by

-bacteria that have become established in the tissues

-trauma

-advancing disease

-incomplete scaling & root planning

acute periodontal abscess

-gingiva is enlarged, red-blue, tender, with a smooth shiny surface

-has mobility

-can point and drain through the tissue or drain through the pocket opening

-percussion tender, pus from pocket

-perio pocket is deep and communicates w/ abscess

-tooth feels high bc the tooth may be extruded

-external features may appear distant from affected tooth

-microflora is predominantly gram - anaerobic

chronic periodontal abscess

-usually asymptomatic but may become acute

-painless bc drain into oral cavity through fistula or pocket

-exudate through sinus tract of pocket

-reg gingiva

radiographic signs of a perio abscess

-radiolucent area lateral to the root

-possibly no evident radiographic changes due to position of abscess

-extensive bone loss in advanced stages of a perio abscess

perio abscess: histopathology/pathogenesis

-local accumulation of inflammatory cells w/ a fibrous CT capsule

-in acute stage, predominant cell is PMN

-in chronic stage, principal cell is lymphocyte

-osteoclastic resorption of the surrounding alveolar bone is evident

perio abscess: etiology

-blockage of a pocket, partially or completely by calc, biofilm, food debris or foreign objects (toothpick trauma)

-incomplete calculus removal making drainage of inflammatory products impossible (usually a deep probing depth where calculus has been removed at most coronal aspect)

-theory is that the removal of coronal deposits allows the GM to tighten like a drawstring pouch, preventing drainage of bacterial toxins, resulting in an abscess

-pus cannot drain, therefore an abscess occurs

-bifurcations, trifurcations and deep infrabony pockets are common sites

-clients w/ poorly controlled diabetes mellitus may be more susceptible to perio abscess formation bc of a lower resistance to infection

perio abscess: prognosis

-depends on amount of type and bone loss, position of bone and abscess and mobility

-prognosis for bone regeneration may be better following an acute abscess than a chronic one

perio abscess: care plan

-correct diagnosis by clinician, radiographic and pulp testing (to rule out perio abscess)

-typically, the bone loss does not involve the apex and the tooth is vital

-reduce abscess w/ anesthesia, local antimicrobials, debridement

-establish drainage by scaling/curetting in the pocket or incising the abscess (extraction will also provide drainage)

-systemic antibotics if fever and enlarged lymph nodes

-warm saltwater rinses, rest, fluids, analgetics/anti-inflammatory

-reduce pocket (f/u tx) through flap surgery or ext later to treat the periodontal defect

-occlusal adjustment or temporary splinting, depending on mobility

abscess of the periodontium

-vital pulp

-bone loss does not involve root apex

-localized constant pain

endodontic abscess

-non-vital pulp

-bone loss involves root apex

-intermittent pain that is difficult to localize

education/prevention: perio abscess

-explain cause & mechanism of condition to client

-early medical & perio therapy for diabetics

-biofilm control & CC for clients w/ perio pockets

-pocket elimination or reduction & relief from occlusal trauma done prior to formation of a perio abscess