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Acute periodontal conditions

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Brief description of the conditions

The main acute periodontal conditions are: necrotising periodontal diseases (necrotising ulcerative gingivitis and necrotising ulcerative periodontitis); periodontal abscess; and combined endodontic-periodontal lesions.

Necrotising periodontal diseases are severe inflammatory conditions of the gingiva (gum) caused by pathogenic bacteria (Fusiform bacteria and Spirochetes) and are more common in immunocompromised patients, patients who smoke and those with inadequate oral hygiene. Both involve the same disease process. Necrotising ulcerative gingivitis relates to lesions limited to gingival tissue. Necrotising ulcerative periodontitis involves loss of attachment.

A periodontal abscess is a localised accumulation of pus located within the gingival wall of the periodontal pocket/sulcus, resulting in significant tissue breakdown. In a patient with periodontitis this usually relates either to acute exacerbation of untreated periodontitis or occurs after professional mechanical plaque removal (PMPR). Other factors can influence the formation of a periodontal abscess, such as impaction of food or other foreign bodies, trauma from flossing, or anatomical changes (e.g. root perforation, cemental tears or fractures). Recurrent periodontal abscesses may also be a sign of undiagnosed Type II diabetes.

Combined endodontic-periodontal lesions occur where a patient not only has clinical attachment loss but also a tooth with a necrotic, or partially necrotic, pulp. 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 gingival tissue
  • Loss of gingival papillae
  • Loss of attachment/bone (in necrotising ulcerative periodontitis)
  • 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

Endodontic-periodontal lesion:

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

Initial management

Determine if the airway is compromised. Symptoms include: difficulty breathing; high pitched breathing sound (stridor); difficulty swallowing (dysphagia); hoarse or muffled sounding voice (dysphonia).

If the airway is compromised, send the patient immediately to emergency medical care at the nearest emergency department or call 999.

If the airway is not compromised:

  • Recommend optimal analgesia (see Analgesia).
  • Do not prescribe antibiotics unless there are signs of spreading infection, systemic infection, or for an immunocompromised patient if there are signs of necrotising disease.
  • Advise the patient to seek urgent dental care.

Subsequent care

For all acute periodontal conditions:

Arrange appropriate therapy with a dental hygienist, dental therapist, dentist or specialist.

Carry out professional mechanical plaque removal (PMPR) as effectively as symptoms allow. Local anaesthesia may be required.

Consider recommending the use of chemical plaque control (e.g. hydrogen peroxide or chlorhexidine mouthwash).

For Necrotising ulcerative gingivitis and Necrotising ulcerative periodontitis, also:

Provide oral hygiene instruction and, if appropriate, smoking cessation advice.

Consider prescribing metronidazole if there is evidence of spreading infection or systemic involvement, or if local measures cannot be completed due to severe symptoms (see SDCEP Drug Prescribing for Dentistry guidance for dose).

For Periodontal abscess, also:

Ensure that PMPR stops short of the base of the periodontal pocket.

Drain any pus by incision or through the periodontal pocket.

Consider extraction if appropriate.

For Perio-endo lesions: (tend to be associated with a single tooth leading to abscess formation), also:

Consider root canal treatment or retreatment (prior to periodontal therapy), or extraction if the tooth prognosis is poor.

More detailed advice on the management of acute periodontal conditions is available in the SDCEP Prevention and Treatment of Periodontal Diseases in Primary Care guidance.