Perio

‫بسم الله الرحمن الرحيم‬

ACUTE PERIODONTAL CONDITIONS U noticed that most of the periodontal cases treated in the clinic are chronic cases (chronic marginal gingivitis, chronic periodontitis) even aggressive periodontitis is a chronic case. But also we have acute periodontal conditions, what does that mean? It means the emergency cases that come to the clinic as a periodontal problem. If u remember the treatment plan in your examination sheet, the first step of phase 1 is the emergency treatment. Acute periodontal conditions are divided into:  Abscesses of the Periodontium.  Necrotizing Periodontal Diseases.  Gingival Diseases of Viral Origin-Herpesvirus.  Recurrent Aphthous Stomatitis.  Allergic Reactions.

Abscesses of the Periodontium 1. Gingival Abscess: A localized purulent infection that involves the marginal gingiva or the interdental papilla. Slide 5: a well defined gingival abscess. There is neither destruction to the periodontal tissues nor severe gingival inflammation but the pt comes complaining from a swelling in the gingiva not related to an endo problem, so, what is the etiology of the gingival abscess? Acute inflammatory response to foreign substances forced into the gingiva, or response to trauma to this specific part of the gingival tissue. Usually tooth brushing causes gingival abscesses caused by the tooth brush bristles that will resolve without noticing a problem.

Clinical Features: 1. Localized swelling of marginal gingiva or papilla: if it is extended to the apex, then I'll suspect an apical problem & if it's associated with deep pocket then I suspect a periodontal tissue problem. 2. A red, smooth, shiny surface. 3. May be painful and appear pointed. 4. Purulent exudates may be present. 5. No previous periodontal disease. •

Treatment: 1. Elimination of foreign object. 2. Drainage through sulcus with probe or light scaling; cz it's obvious that this abscess is filled with fluid. 3. Follow-up after 24-48 hours. •

First line treatment for any acute abscess is drainage -----------------------------------------------------------------------

2. 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. It's more sever condition than gingival abscess & usually a pre-existing chronic periodontitis is present. Purulent: associated with pus formation.

As the periodontal condition is associated with a periodontal abscess, we conclude that there is more destruction to the periodontal ligaments & alveolar bone. Slide 9: periodontal abscess is bigger in size, filled with pus & on x-ray, it’s associated with sever bone resorbtion.

•

Factors associated with abscess development:

1. Occlusion of pocket orifice (by healing of marginal gingiva following supragingival scaling): when we do scaling for a chronic periodontitis case, we must remove every calculus residuals in the pocket, otherwise, the small particles of calculus left behind will close the orifice of the periodontal pocket while it's in an active stage (inflammation, pus formation …) so the pus will accumulate in the pocket forming the abscess. 2. Furcation involvement. 3. Systemic antibiotic therapy (allowing overgrowth of resistant bacteria). 4. Diabetes Mellitus: multiple periodontal abscesses in uncontrolled patients. Clinical Features: 1. Smooth, shiny swelling of the gingiva. 2. Painful, tender to palpation. 3. Purulent exudates. 4. Increased probing depth. 5. Mobile and/or percussion sensitive. 6. Tooth usually vital. •

The abscess position may confuse us with a periapical one, so how can we differentiate between them?  Periodontal Abscess: – Vital tooth. – No caries. – Pocket. – Lateral radiolucency. – Mobility (tenderness). – Percussion sensitivity variable. – Sinus tract opens via keratinized gingiva.  Periapical Abscess: – Non-vital tooth. – Caries.

No pocket. – Apical radiolucency. – No or minimal mobility. – Percussion sensitivity. – Sinus tract opens via alveolar mucosa. But some of the features may overlap, ex: a carious tooth with a periodontal abscess. So the most important feature to distinguish between them is the tooth vitality. Non vital: periapical abscess vital: periodontal abscess. –

Treatment: 1. Anesthesia. 2. Establish drainage: Via sulcus is the preferred method » Surgical access for debridement » Incision and drainage » Extraction So when doing drainage, we do simple root planning just one stroke to remove any particles that might be closing the pocket orifice, so we get the drainage from the periodontal pocket. If we can't get the drainage from the pocket, we do a simple surgical incision on the abscess on the most purulent part of it. We don't finish the first emergency visit unless the abscess is drained. 3. Limited occlusal adjustment: the tooth might be under extrusion forces due to the pus accumulation. 4. Antimicrobials. 5. Culture and sensitivity. •

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. ------------------------------------------------------------–

3. 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. Slide 17: Pericoronal abscess on a partially impacted third molar. Under the flap, we find food debris with bacterial accumulation that ends with a Pericoronal abscess associated with pus formation & purulent infection. Clinical Features: 1. Operculum (soft tissue flap). 2. Localized red, swollen tissue. 3. Area painful to touch. 4. Tissue trauma from opposing tooth common. 5. Purulent exudates, trismus, lymphadenopathy, fever, and malaise may be present. •

Treatment Options: 1. Debride/irrigate under Pericoronal flap. 2. Tissue recontouring (removing tissue flap): after 2448 hours from the first visit. 3. Extraction of involved and/or opposing tooth. 4. Antimicrobials (local and/or systemic as needed). 5. Culture and sensitivity. 6. Follow-up. •

Before beginning the treatment, we should evaluate the tooth, if it's expected not to erupt in a correct position & alignment, we simply extract it.

Necrotizing Periodontal Diseases 1. Necrotizing Ulcerative Gingivitis (NUG): An infection characterized by gingival necrosis presenting as “punched-out” papillae, with gingival bleeding and pain. It might be the only gingival condition associated with pain. Slide 22: NUG, with punched out papillae; the papillae looks like a crater (‫)فوهة البركان‬. Also, we can see white pale areas that are the necrotic tissue. Historical terminology: 1. Vincent’s disease. 2. Trench mouth. (‫)خندق‬ 3. Acute necrotizing ulcerative gingivitis (ANUG)…this terminology changed in 2000. •

• Points related to NUG: 1. Necrosis limited to gingival tissues. 2. Estimated prevalence 0.6% in general population. 3. Young adults (mean age 23 years). 4. More common in Caucasians. 5. Bacterial flora: -Spirochetes (Treponema sp.). -Prevotella intermedia. -Fusiform bacteria.

•

Clinical Features: 1. Gingival necrosis, especially tips of papillae. 2. Gingival bleeding. 3. Pain.

4. Fetid breath: unpleasant odor from the patient's mouth. 5. Pseudomembrane formation: white tissue formation. •

Predisposing factors: 1. Emotional stress. 2. Poor oral hygiene. 3. Cigarette smoking. 4. Poor nutrition. 5. Immunosuppression. Necrotizing Periodontal diseases are common in Immunocompromised patients, especially those who Are HIV (+) or have AIDS.

-----------------------------------------------------------------2. Necrotizing Ulcerative Periodontitis (NUP): An infection characterized by necrosis of gingival tissues, periodontal ligament, and alveolar bone. So it's more sever & for sure found in HIV (+) patients. Slide 28: NUP: very ugly & sever condition. In the picture, the necrotizing slough area is found between the two centrals in the bony resorbed area. The first thing we do in treatment, is to bring a gauze soacked in saline & clean the slough area, the patient will feel immediate relief. •

Clinical Features: 1. Clinical appearance of NUG. 2. Severe deep aching pain. 3. Very rapid rate of bone destruction. 4. Deep pocket formation not evident: due to the sever destruction & necrosis, we don't find any pockets.

Treatment: 1. Local debridement: •

Most cases adequately treated by debridement and scaling/root planning. » Anesthetics as needed. » Consider avoiding ultrasonic instrumentation due to risk of HIV transmission. So we have to be gentle; simple & very mild scaling if necessary (to remove heavy calculus) & cleaning of the slough area. 2. Oral hygiene instructions: we tell the patient to brush his teeth even though it will be painful to him so we advise him to use an ultra soft tooth brush… why? Cz u can't tell the patient not to brush his teeth, but we tell him to tolerate the pain & brush gently to prevent more plaque accumulation. 3. Oral rinses – (frequent, at least until pain subsides allowing effective OH): » Chlorhexidine gluconate 0.12%; 1/2 oz 2 x daily. » Hydrogen peroxide/water: 3% concentration, more than that will cause by itself tissue necrosis. Very effective rinse, cz most of the bacteria is gram –ve anaerobes, so by introducing (H2O2) with oxygen, it will kill the bacteria. » Povidone iodine. 4. Pain control. 5. Antibiotics (systemic or severe involvement): » Metronidazole/ amoxicillin. » Avoid broad spectrum antibiotics in AIDS patients. 6. Modify predisposing factors. 7. Follow-up: » Frequent until resolution of symptoms. » Comprehensive periodontal evaluation following acute phase!!!! »

We follow up the patient after 1-2 days when the acute infection stage has subsided, and then we treat the case as any other periodontal case: scaling, root planning….. Etc. The dr didn't talk about the remaining slides, cz we have already taken them in a previous lecture.

How to write a prescription? The dr started this part with a Disclaimer (announcement): This presentation is not intended to replace common pharmaceutical knowledge about drugs and their indications or contra-indications. It is the responsibility of each dentist to be up to date in regard to medications, patients medical history, and whether the patient could receive a certain medication or not. Writing a prescription steps: 1. Write clearly: understandable names & abbreviations. 2. Preferably use scientific name: why? To give the patient the chance to choose from multiple brands, Help reducing the cost for the patient & it's more professional. – Use brand name if you really want a certain brand or if the only available med is from that brand: if the dr prefers a certain type of drug for a specific condition, he can write the brand of the drug.

–

Examples:

Paracetamol (analgesic): Revanin®, Panadol®, Jopamol®, Panadol Actifast® 2. Ibuprofen: brufen®, balqabrofen®, remofen®, doloraz®… 1.

3.

Write the form of medication: a. Oral Route: Capsules, syrup, tablets… b. Intra-oral topical use: Rinses, lozenges*, ointment, gel. Lozenge: small sweet or medical tablets to be dissolved in the mouth.

c. External use: ointment, gel, cream… d. Injections: intra-muscular (IM), intravenous (IV), subcutaneous (SC). Don't leave this to the pharmacist to decide, u should specify the form in the prescription sheet. 4. Write the quantity of the medication: to avoid drug abuse, so we write how many pills for ex. The patient needs. Specially in restricted medications For pain medications (30 tab, 20 caps)… Know the proper dosage to know the proper quantities: Example: Amoxicillin is prescribed for intraoral infections for one week, three times daily……..7 X 3 = 21 capsules. Children syrup: know the concentration per ml. and the child weight. 5. Write the method of application. 6. Write the duration of intake: how many days. 7. Write the doze. 8. Write the precautions or certain instructions. 9. Use accurate abbreviations: we should know every abbreviation, its meaning & how to use correctly.

Abbreviations commonly used:

b.i.d.: used twice daily (every 12 hours). • t.i.d.: three times daily (every 8 hours). • q.i.d.: four times daily. • h.s.: at bed time. • Stat.: immediately. • d.: once daily. • p.c.: after meal. • p.r.n.: when needed. • Caps: capsules. • Tab: tablets. We should know all of these abbreviations. As a dentist am interested in mouth washes, analgesics & antibiotics. •

Examples:

Amoxicillin: Prescribed for adults as 250 mg and 500 mg capsules. So the prescription should be: Amoxicillin 500 mg caps (22 caps) 2 stat then 1 x 3 x 7 p.c. OR; 2 stat then 1 t.i.d. p.c. 7 days. But why 22 capsule? Cz the first dose, the patient will take 2 capsules (1 gm), an extra capsule in the first day. 2. Ibuprofen: ● Syrup (for children). ● Tablets (200, 400, 600, 800 mg), or gelcap (Doloraz 400). ● Maximum dose per day for healthy adult: 2400 mg per 24 hours. ● Prescribed t.i.d. ● Post surgery: depending on severity 400-800 t.i.d. p.c. cz it's an analgesic with anti inflammatory action. 1.

●

In prescription:

Ibuprofen 400 mg tabs 30 1-2 tab t.i.d. p.r.n. p.c. (so the pt takes 1-2 tablets when needed after meals) Or; 1-2 tab x 3 p.r.n. p.c. 3. Paracetamol (acetomenophin): ● Children: syrup, suppository (‫)تحاميل‬. ● Adults: tablets 250, 500, 1000 mg, effervescent tablets. ● Could come with caffeine or combination of aspirin and caffeine (Tylenol preps, USA). ● New fast release: Panadol Actifast (500 mg). ● Maximum dose per day for healthy adult: 4 grams per 24 hours. ● Helpful for patients with gastric irritation, asthma, contraindications for NSAIDs. ● In prescription: Paracetamol 500 mg tabs 40 1-2 tab q.i.d. p.r.n. p.c. Or, 1-2 x 4 x 3 then p.r.n. 4. Chlorhexidine gluconate mouthwash (mouth rinse): European preps (BP, 0.2%), US preps (USP, 0.12%). Prescribed post-surgical, for patients with challenging oral cavity conditions, severe inflammation, physically-impaired patients, nifedipine-induced gingival enlargement and patients with poor mechanical ability to remove calculus; so we don't prescribe it to every pt. The duration and frequency of use not agreed upon (days depend on indication). Common prescription in our clinic is b.i.d. rinse.

In prescription: Chlorhexidine 0.2% mouthwash 1 bottle. Rinse 2 minutes, 30 minutes after brushing. 10 ml x 2x 14. The dr prefers this prescription in words in order to let the pharmacist explain the instructions to the pt. Also it’s important not to eat after 30 minutes from rinsing with chlorhexidine, to minimize the staining. (Notice the spelling of chlorhexidine). 5. Antibiotics: Periodontics: aggressive periodontitis only: For adults: amoxicillin 500 mg caps (2 stat) and Metronidazole 250 mg tabs, each given (t.i.d. p.c. 7 days). Or Doxycycline 100 mg (2 stat then 1X1X20) (So total num of days is 21 with 22 caps: only 2 capsules in the first day, then 1 capsule/ day for 20 days.). Next semester, the first two quizzes will be about writing prescriptions….. 6. ANUG: - American school: Amoxicillin (250-500 mg caps, 2 stat then 1x3x7). - Euro countries: Metronidazole 250-500 mg tab (1x 3x 7) p.c. 7. Augmentin/ Amoclan: - Amoxicillin and clavulonic acid combination in one tablet. - Post implant or surgery involving bone and soft tissue… grafts, regenerative therapy, sinus elevation other. - Presentations for adults tab (375 mg, 625 mg: 1 x3 x 7 pc). Or, 1 gram b.i.d. (better compliance for more sever cases involving bone surgery).

- We prefer long acting drugs; so the pt will take the drug 1-2 times/ day rather than 3-4 times/ day. 8. Clarithromycin (2nd generation of erythromycin): - Macrolide. - For adults, post surgery involving bone. - 500 mg tabs 1 x2x7 p.c. (good compliance). - Slide 18: in this pic, dr. hayder along with dr. khaled did a sinus elevation: they elevated the sinus in order to provide enough space for an implant. There are drugs that the pharmacist will not give them to the patient unless the pt has a prescription for them, these drugs are named as Restricted and classified medications, such as: Narcotics, sedatives and addictive medications mostly for severe pain (examples; Tramadol, diazepam (valium), pethidine, codiene containing preparations). • Only prescribed by specialists and for restricted indications and limited, well-profiled patients. • Prescriptions Written in 2 copies and stamped, so the pharmacist will keep a copy for inspection done on the pharmacy. • Please do not take lightly and be responsible.

The End Done by: Rawan M. Atallah