Dr.

Azza Abushama
OVERVIEW
• Abscesses of the Periodontium
• Necrotizing Periodontal Diseases
• Gingival Diseases of Viral Origin-Herpesvirus
• Recurrent Aphthous Stomatitis
• Allergic Reactions
 Abscesses of the Periodontium
• Gingival Abscess

• Periodontal Abscess

• Pericoronal Abscess
 Gingival Abscess
A localized purulent infection that involves the
marginal gingiva or interdental papilla.
 Gingival Abscess
• Etiology:
– Acute inflammatory response to foreign substances
forced into the gingiva
• Clinical Features:
– Localized swelling of marginal gingiva or papilla
– A red, smooth, shiny surface
– May be painful and appear pointed
– Purulent exudate may be present
– No previous periodontal disease
• Treatment
– Elimination of foreign object
– Drainage through sulcus with probe or light scaling
– Follow-up after 24-48 hours
 Periodontal Abscess

A localized purulent infection within the tissues

adjacent to the periodontal pocket that may lead to the
destruction of periodontal ligament and alveolar bone.
 Periodontal Abscess

• Usually pre-existing chronic periodontitis present!!!

• Factors associated with abscess development

– Occlusion of pocket orifice (by healing of marginal
gingiva following supragingival scaling)
– Furcation involvement
– Systemic antibiotic therapy (allowing overgrowth
of resistant bacteria)
– Diabetes Mellitus
 Periodontal Abscess

• Clinical Features:
– Smooth, shiny swelling of the gingiva
– Painful, tender to palpation
– Purulent exudate
– Increased probing depth
– Mobile and/or percussion sensitive
– Tooth usually vital
Periodontal Vs. Periapical Abscess
Periodontal Abscess Periapical Abscess
Vital tooth Non-vital tooth
No caries Caries
Pocket No pocket
Lateral radiolucency Apical radiolucency
Mobility No or minimal mobility
Percussion sensitivity Percussion sensitivity
variable
Sinus tract opens via Sinus tract opens via
keratinized gingiva alveolar mucosa
 Periodontal Abscess
• Treatment:
– Anesthesia
– Establish drainage
• Via sulcus is the preferred method
• Surgical access for debridement
• Incision and drainage
• Extraction
• Other Treatment Considerations:
– Limited occlusal adjustment
– Antimicrobials
– Culture and sensitivity

 A periodontal evaluation following resolution of acute

symptoms is essential!!!
 Periodontal Abscess
• Antibiotics:
if indicated due to fever, malaise, lymphadenopathy,
or inability to obtain drainage
– Without penicillin allergy
• Penicillin
– With penicillin allergy
• Azithromycin
• Clindamycin

 Alter therapy if indicated by culture/sensitivity

 Pericoronal Abscess
A localized purulent infection within the tissue
surrounding the crown of a partially erupted tooth.
Most common adjacent to mandibular third molars
in young adults; usually caused by impaction of
debris under the soft tissue flap
 Pericoronal Abscess
• Clinical Features:
– Operculum (soft tissue flap)
– Localized red, swollen tissue
– Area painful to touch
– Tissue trauma from opposing tooth common
– Purulent exudate, trismus, lymphadenopathy, fever,
and malaise may be present
• Treatment Options:
– Debride/irrigate under pericoronal flap
– Tissue recontouring (removing tissue flap)
– Extraction of involved and/or opposing tooth
– Antimicrobials (local and/or systemic as needed)
– Culture and sensitivity
– Follow-up
Necrotizing Ulcerative Gingivitis
An infection characterized by gingival necrosis
presenting as “punched-out” papillae, with
gingival bleeding and pain.
 Necrotizing Ulcerative Gingivitis
• Historical terminology:
– Vincent’s disease
– Trench mouth
– Acute necrotizing ulcerative gingivitis (ANUG) up to 2000.

• Eitology & Bacterial flora

– Spirochetes (Treponema sp.)
– Prevotella intermedia
– Fusiform bacteria
 Necrotizing Ulcerative Gingivitis
• Clinical Features:
– Estimated prevalence 0.6% in general population
– Young adults (mean age 23 years)
– More common in Caucasians
– Necrosis limited to gingival tissues
– Gingival necrosis, especially tips of papillae
– Gingival bleeding
– Pain
– Fetid breath
– Pseudomembrane formation
 Necrotizing Ulcerative Gingivitis

• Predisposing Factors:
– Emotional stress
– Poor oral hygiene
– Cigarette smoking
– Poor nutrition
– Immunosuppression

 Necrotizing Periodontal diseases are common in

immunocompromised patients, especially those who
are HIV (+) or have AIDS
 Necrotizing Ulcerative periodontitis

An infection characterized by necrosis of gingival

tissues, periodontal ligament, and alveolar bone
 Necrotizing Ulcerative periodontitis

• Clinical Features:
– Clinical appearance of NUG
– Severe deep aching pain
– Very rapid rate of bone destruction
– Deep pocket formation not evident
• Treatment
– Local debridement
– Oral hygiene instructions
– Oral rinses
– Pain control
– Antibiotics
– Modify predisposing factors
– Proper follow-up
 Necrotizing Periodontal Diseases
 Local debridement
– Most cases adequately treated by debridement and sc/rp
– Anesthetics as needed
– Consider avoiding ultrasonic instrumentation due to risk of
HIV transmission
 Oral hygiene instructions:
- Very important step.
 Oral rinses:
– frequent, at least until pain subsides allowing effective OH:
• Chlorhexidine gluconate 0.12%; 1/2 oz 2 x daily
• Hydrogen peroxide/water
• Povidone iodine
 Necrotizing Periodontal Diseases

 Pain control:
systemically or locally
 Antibiotics
– systemic or severe involvement:
• Metronidazole
• Avoid broad spectrum antibiotics in AIDS patients
– Modify predisposing factors
– Follow-up frequent until resolution of symptoms

 Comprehensive periodontal evaluation following

acute phase!!!!
 Gingival Diseases of Viral Origin

Acute manifestations of viral infections of the oral mucosa, characterized by redness and
multiple vesicles that easily rupture to form painful ulcers affecting the gingiva.
Include :
•Primary Herpetic Gingivostomatitis
•Recurrent Oral Herpes
•Recurrent Aphthous Stomatitis
 Primary Herpetic Gingivostomatitis
• Classic initial infection of herpes simplex type 1
• Mainly in young children
Primary Herpetic Gingivostomatitis
• Clinical Features:
– Painful severe gingivitis with ulcerations, edema,
and stomatitis
– Vesicles rupture, coalesce and form ulcers
– Fever and lymphadenopathy are classic features
– Lesions usually resolve in 7-14 days
Primary Herpetic Gingivostomatitis
• Treatment
– Bed rest
– Fluids
– Nutrition
– Antipyretics
– Pain relief
• Viscous lidocaine
• Benadryl elixir
• 50% Benadryl elixir/50% Maalox
– Antiviral medications
• Immunocompromised patients
 Recurrent Oral Herpes
• “Fever blisters” or “cold sores”
• Oral lesions usually herpes simplex virus type 1
• Recurrent infections in 20-40%
• Herpes labialis common
• Recurrent infections less severe than primary
Recurrent Oral Herpes

• Clinical Features:
– Lesions start as vesicles, rupture and leave
ulcers
– A cluster of small painful ulcers on attached
gingiva or lip is characteristic
– Can cause post-operative pain following dental
treatment
Recurrent Oral Herpes
• Virus reactivation:
– Fever
– Systemic infection
– Ultraviolet radiation
– Stress
– Immune system changes
– Trauma
– Unidentified causes
Recurrent Oral Herpes
• Treatment:
– Palliative
– Antiviral medications
• Consider for treatment of immunocompromised
patients, but not for periodic recurrence in healthy
patients
 Recurrent Aphthous Stomatitis
• “Canker sores”
• Etiology unknown
• Prevalence 10 to 20% of general population
• Usually begins in childhood
• Outbreaks sporadic, decreasing with age
• Predisposing Factors
– Trauma
– Stress
– Food hypersensitivity
– Previous viral infection
– Nutritional deficiencies
Recurrent Aphthous Stomatitis
• Clinical features:
– Affects mobile mucosa
– Most common oral ulcerative condition
– Three forms
• Minor
• Major
• Herpetiform
Recurrent Aphthous Stomatitis
• Clinical features of Minor Aphthae:
• Most common
• Small, shallow ulcerations with
slightly raised erythematous
borders
• Central area covered by
yellow-white
pseudomembrane
• Heals without scarring in 10 –
14 days
Recurrent Aphthous Stomatitis
• Clinical features of Major Aphthae
• Usually larger than 0.5cm
in diameter
• May persist for months
• Frequently heal with
scarring
Recurrent Aphthous Stomatitis
• Clinical features of Herpetiform Aphthae
• Small, discrete crops of
multiple ulcerations
• Lesions similar to
herpetic stomatitis but no
vesicles
• Heal within 7 – 10 days
without scaring
Recurrent Aphthous Stomatitis
• Treatment
- Palliative treatment
– Pain relief - topical anesthetic rinses
– Adequate fluids and nutrition
– Corticosteroids
– Oral rinses (Chlorhexidine has been anecdotally
reported to shorten the course of apthous stomatitis)
– Chemical or Laser ablation of lesions
 Allergic Reactions
• Intraoral occurrence uncommon
– Higher concentrations of allergen required for
allergic reaction to occur in the oral mucosa
than in skin and other surfaces
Allergic Reactions
• Examples:
– Dental restorative materials
• Mercury, nickel, gold, zinc, chromium, and
acrylics
– Toothpastes and mouthwashes
• Flavor additives (cinnamon) or preservatives
– Foods
• Peanuts, red peppers, etc.
Allergic Reactions
• Clinical Features:
– Variable
– Resemble oral lichen planus or leukoplakia
– Ulcerated lesions
– Fiery red edematous gingivitis

• Treatment
– Comprehensive history and interview
– Lesions resolve after elimination of offending agent
 SUMMARY

 Abscesses of the Periodontium

 Necrotizing Periodontal Diseases
 Gingival Diseases of Viral Origin
 Recurrent Aphthous Stomatitis
 Allergic Reactions