Periodontal abscess is a limited focus of purulent inflammation in periodontal tissues. Patients complain of intense pain syndrome, the appearance of swelling in the area of certain teeth. With periodontal abscess, pathological mobility of the teeth is observed. The general condition worsens, the temperature rises. The diagnosis is based on the data of the anamnesis of the disease, the results of clinical, radiological and laboratory research methods. Treatment is aimed at drainage and sanitation of the purulent focus, stabilization of bone height, prevention of complications, achievement of stable remission.
Meaning
Periodontal abscess is a complication that occurs with an exacerbation of the inflammatory and destructive process in periodontal tissues, characterized by a limited accumulation of purulent exudate. The formation of periodontal abscesses is facilitated by deep pathological pockets, solid subgingival deposits. In the prevailing majority of cases, acute periodontal abscesses occur. Cold (chronic) periodontal abscesses are extremely rare. Frequent relapses of exacerbations of chronic periodontitis are observed in 30% of periodontal patients. Both men and women suffer equally. The peak incidence occurs in the autumn-spring period.
Causes
The oral cavity is one of the most complex microorganisms in the ecosystem of the human body. The bacterial profile of the microflora is determined by a number of exogenous and endogenous factors. Frequent infectious diseases, diseases of the endocrine system, immunodeficiency conditions reduce resistance, which creates favorable conditions for the manifestation of conditionally pathogenic bacteria of their virulent properties.
Local factors contributing to the development of this disease include the preserved circular ligament of the tooth, deeply located dental deposits, insufficient outflow of purulent exudate. Disease is formed with exacerbation of chronic periodontitis of moderate or severe degree. The main role in the development of periodontal abscess belongs to the activation of periodontopathogenic microorganisms: Porphyromonas gingivalis, Treponema denticola, Prevotella intermedia, Bacteroides forsythus.
Due to damage to the dental-epithelial attachment, microcirculation is disrupted, periodontal tissue oxygenation decreases, which leads to a short-term spasm with longer vasodilation. Local hypoxia causes local acidosis, metabolic disorders at the molecular and cellular level, which ultimately contributes to the accumulation of lipid peroxidation products and free radicals. Along with dystrophic changes and perivascular edema in periodontal abscess, pronounced infiltration of periodontal tissues by polymorphonuclear leukocytes is observed. At the same time, osteoclastic resorption and destruction of the alveolar bone and the root of the tooth occur with a cyclic or erratic course of the process.
Classification
According to the nature of the course , periodontal abscesses are divided into 2 categories:
- Acute periodontal abscess. They are characterized by a pronounced clinic, a sharp increase in pain syndrome. Deep periodontal pockets, pathological mobility of teeth are detected in the oral cavity. The formation of acute periodontal abscesses is accompanied by a temperature reaction, malaise.
- Chronic (cold periodontal abscess). Proceed with erased symptoms. Patients are concerned about bleeding, gum soreness. On examination, edematous cyanotic mucosa is detected, the roots of the teeth are exposed, periodontal pockets are filled with purulent discharge, granulations. Chronic periodontal abscesses tend to worsen with the transition to acute forms.
According to the localization of the pathological focus in dentistry, periodontal abscesses formed in the apical part of the roots of the teeth, in the middle of the root and in the cervical area are distinguished.
Symptoms
With the formation of a periodontal abscess, patients complain of the appearance of pronounced spontaneous pain. In the oral cavity, painful swelling is detected in the area of the alveolar part of the gum. The mucosa is edematous, hyperemic. On examination, periodontal pockets filled with granulations are diagnosed. With periodontal abscesses, pathological mobility of teeth of 2-3 degrees is noted, which leads to a violation of the masticatory function, the development of traumatic occlusion. The roots of the teeth are exposed.
Periodontal abscess can be detected in the area of two teeth. With a severe degree of aggravated chronic generalized periodontitis, multiple periodontal abscesses are diagnosed. The opening of the mouth is not broken. Regional lymph nodes are enlarged, painful. When a periodontal abscess is spontaneously opened, a fistula forms near the gingival margin, through which purulent exudate is evacuated. When a periodontal abscess appears, signs of intoxication develop, the temperature rises, and the general condition worsens. Patients complain of headache, malaise.
Diagnostics
Diagnosis of periodontal abscess includes anamnesis collection, clinical examination, dental x-ray, as well as additional laboratory and instrumental research methods. Upon examination, a dentist-therapist or periodontist reveals the presence of painful swelling of the gums in the area of certain teeth against the background of edematous, hyperemic mucosa. The dental-epithelial connection in periodontal abscess is broken, the transitional fold is smoothed. Teeth are mobile (2-3 degrees). Horizontal percussion is positive. With periodontal abscess, the depth of periodontal pockets varies from 3 mm to 6 mm and above, the contents are represented by granulation tissue, purulent discharge. There is also a displacement of teeth, which leads to the development of traumatic occlusion.
Radiographically, periodontal abscess reveals the expansion of the periodontal fissure, the destruction of the cortical plate with uneven vertical resorption of the spongy substance of the interdental septa, the formation of intraalveolar pockets and diffuse osteoporosis of the preserved spongy substance. The hygiene index of the approximal surfaces of teeth in the formation of periodontal abscess is unsatisfactory. The papillary-marginal-alveolar index (PMA) exceeds 50%, which indicates a pronounced inflammatory process involving the interdental papillae, the marginal margin and the alveolar part of the gum. The gingival sulcus bleeding index (SBI) in the development of periodontal abscess sharply exceeds the norm.
In the blood test of patients with periodontal abscess, changes appear that are characteristic of a nonspecific inflammatory process. There is an increase in leukocytes, an increase in ESR, a shift of the leukocyte formula to the left. With the help of molecular genetic research (quantitative PCR), it is possible to identify the qualitative and quantitative composition of the anaerobic microflora of the periodontal pocket. The results of the analysis indicate the prevalence of such bacteria as Porphyromonas gingivalis, Prevotella intermedia, Bacteroides forsythus in periodontal abscess among other periodontal pathogens, the relative content of which in the total bacterial mass steadily increases by more than 100 times.
With the help of cytological examination, along with a variety of microflora, a large number of destroyed neutrophil granulocytes are detected. The phenomena of phagocytosis in the formation of periodontal abscess are not pronounced. The study of saliva by chemiluminescence confirms the activation of lipid peroxidation processes, which indicates an exacerbation of inflammation. Periodontal abscess should be differentiated with acute periodontitis or exacerbation of chronic periodontitis, suppuration of the maxillary cyst, periostitis, osteomyelitis. A consultation with a dental surgeon is required.
Treatment
Treatment of periodontal abscess begins with the elimination of acute inflammation. To create an adequate outflow of purulent exudate, the pathological focus is washed with antiseptic solutions under pressure. In the absence of positive dynamics, the periodontal abscess is opened with a semilunar or point incision (the incision line passes in the area of maximum mucosal protrusion). After curettage of the acute period, periodontal pockets are curetted. Excise granulations, pathologically altered cement, epithelial strands, smooth the surface of the root. A muco-periosteal flap is formed, its reposition is performed, stitches are applied. Surgical intervention in periodontal abscess is carried out under constant irrigation of the surgical field with substances having antimicrobial activity. Periodontal dressing is used for 10 days.
Patients who have a periodontal abscess are diagnosed with dental plaque removal, treatment of caries and its complications. Oral rinsing with antiseptics from the groups of detergents, oxidants, nitrofuran and imidazole derivatives is shown. Antimicrobial drugs immobilized on biopolymer matrices are also widely used in the complex therapy of periodontal abscess, which contributes to the prolongation of the therapeutic effect. The general etiotropic treatment of patients with periodontal abscess includes antibiotic therapy, the appointment of anti-inflammatory, antiprotozoal agents. The most effective against anaerobic bacteria in periodontal abscess are lincosamides, macrolides. The use of fluoroquinolones in the acute stage accelerates the treatment of periodontal abscess and prolongs persistent remission. The method of antibacterial photodynamic therapy using a laser is highly effective.
With timely treatment and complex treatment, the pathological process can be stopped. However, since periodontitis is accompanied by irreversible destruction of bone tissue, the risk of re-exacerbation, accompanied by the formation of a periodontal abscess, is quite high.
Literature
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