Management of Acute Dental Problems

Brief description of condition

The main acute periodontal conditions are (1) Necrotising gingivitis and Necrotising periodontitis, (2) Periodontal abscess, and (3) Perio-endo lesions.

Necrotising gingivitis and Necrotising periodontitis are severe inflammatory conditions of the gingival (gum) caused by pathogenic bacteria (Fusiform bacteria and spirochetes) and often associated with a degree of immunocompromisation. Both involve the same disease process. Necrotising gingivitis relates to lesions limited to gingival tissue. Necrotising periodontitis involves loss of attachment.

A periodontal abscess represents an active period of periodontal breakdown which occurs whilst there is marginal closure of the deep periodontal pocket occluding drainage. Such abscesses develop in deep periodontal pockets without external influence and are commonly seen in patients with untreated periodontitis or as a recurrent infection during a course of active treatment.

Perio-Endo Abscesses (Endodontic and periodontal lesions) may affect a single tooth coincidentally leading to abscess formation. Diagnosis requires radiographic examination and vitality tests and treatment of the combined lesion involves both endodontic and periodontal therapy.

Key signs and symptoms

Necrotising Periodontal Disease:

• Pain (general or localised)
• Swelling
• Bleeding
• Halitosis
• Ulcerated and gingival tissue
• Loss of attachment
• Malaise
• Fever.

Periodontal Abscess:

• Pain and tenderness of gingival tissue
• Increased tooth mobility
• Fever and swollen or enlarged regional lymph nodes
• Presence of swelling on gingiva
• Suppuration from the gingiva.

Perio-Endo Abscess:

• Generalised periodontal disease may be present with localised pain
• Swelling with our without suppuration on palpation
• Deep pocketing to root apex with bleeding on probing.

Initial management

Determine if the airway is compromised: the patient is unable to swallow their own saliva or they are unable to push their tongue forward out of their mouth.

If the airway is compromised:

Send the patient immediately to emergency medical care via NHS 24 or call 999.

If the airway is not compromised:

Recommend optimal analgesia

Do not prescribe antibiotics unless there are signs of spreading infection, systemic complications, or for an immunocompromised patient if signs of necrotising disease

Advise the patient to seek urgent dental care.

Subsequent care

For all acute periodontal conditions, consider:

• Arranging appropriate therapy with a hygienist, dentist or periodontist
• Scaling teeth as effectively as symptoms allow. Local anaesthesia may be required
• Prescribing chemical plaque control (hydrogen peroxide and 0.2% chlorhexidine mouthwash).

Necrotising Periodontitis:

Necrotising gingivitis (relating to lesions limited to gingival tissue) and Necrotising periodontitis (where loss of attachment occurred).

Also consider giving oral hygiene instruction and, if appropriate, smoking cessation advice.

Prescribe metronidazole (see SDCEP Drug Prescribing for Dentistry guidance for dose).

Periodontal Abscess:

Also consider:

• Scaling and irrigating the periodontal pocket.
• Extraction.

Perio-endo lesions:

Tend to be associated with a single tooth leading to abscess formation.

Also consider root canal treatment or retreatment.

References

1. American Academy of Periodontology. Parameter on acute periodontal diseases, Journal of Periodontology 2000; 71 (5 Suppl): 863–6.
2. SDCEP. Drug prescribing for dentistry: dental clinical guidance, 2nd edition. Dundee: Scottish Dental Clinical Effectiveness Programme; 2011.
3. Sutherland S, Matthews DC. Emergency management of acute apical periodontitis in the permanent dentition: a systematic review of the literature. Journal of the Canadian Dental Association 2003; 69: 660.