Many periodontitis patients are not aware of their disease, even though it may have been progressing over many years. Only when pain and acute inflammatory symptoms appear do such patients seek out a dentist or dental hygienist.
Such emergency cases must be treated immediately. However, to avoid life-threatening incidents, a succinct general medical history must be taken, with particular attention to any medicines the patient may be taking (anticoagulants!) and an assessment of the necessity for infection prophylaxis (endocarditis, HIV etc.), as well as allergies and previous significant incidents.
Next, a clinical and radiographic examination should be performed for emergency patients; despite the pain, this is absolutely necessary before any treatment.
Included in the category “periodontal emergency situations and treatments” are:
Initial topical medicinal and mechanical treatment for acute NUG
Treatment of acute, suppurating pockets
Opening periodontal abscesses
Immediate extraction of hopelessly mobile teeth that cannot be maintained
Acute, combined endodontic-periodontal problems
Treatment of periodontal trauma following accidents
Acute ulcerative gingivoperiodontitis (acute NUG/NUP) is painful and progresses very rapidly. Careful instrumentation and application of topical agents generally bring relief within a few hours and a reduction of the acute situation.
Caution: Ulceration may be a symptom of HIV-seropositivity (opportunistic infection).
Active suppurating pockets generally are not painful if drainage is established at the gingival margin (exception: abscess). Such pockets represent an exacerbating inflammatory process, which leads to rapid attachment loss. They must be treated immediately with application of rinsing solutions or ointments; mechanical cleansing must also be initiated.
Periodontal abscesses are usually very painful. They must be drained immediately. This can usually be accomplished via probing from the gingival sulcus.
In the case of molars with deep pockets or furcation involvement, an abscess that penetrates the bone may develop subperiosteally. These cannot always be reached via the gingival margin, and must be drained by means of an incision.
Immediate extraction should be reserved for teeth that cannot be maintained or are highly mobile or which cause the patient undue discomfort. In the case of anterior teeth, for esthetic reasons, extractions should be avoided when possible, or an immediate temporary should be prepared.
Acute, endodontic/periodontal processes have a more favorable prognosis if the primary problem is of endodontic origin. The root canal should always be treated first, subsequently the pocket.
Periodontal trauma due to accident usually requires immediate splinting (following any necessary reimplantation or repositioning of the tooth).
462Emergency Situation: Acute Necrotizing Ulcerative Gingivitis (NUG)The severe pain in the acute stage permits only a very careful peripheral attempt at cleansing.Treatment of this acute condition involved gentle debridement with 3% hydrogen peroxide, and application of a disinfecting ointment containing anti-inflammatory and analgesic ingredients. The patient was told to rinse at home with a chlorhexidine solution.463After Emergency Treatment—Subacute StageSeveral days after gentle topical application of the medicaments and careful mechanical debridement, the signs of active NUG—especially the pain -subsided.Treatment by means of systematic subgingival scaling can now proceed. A gingivoplasty may be indicated subsequently in the normal course of treatment.464Emergency Situation—Localized Acute PocketTooth 31 is vital and should be maintained despite the 10 mm pocket. Very little pus has formed; drainage via the gingival margin appears possible. The tooth is slightly percussion sensitive. Prior to systematic mechanical treatment, the tooth is treated on an emergency basis with topical application of a medicament, and the pocket is disinfected.Right: Note the deep defect on the distal of tooth 31.465Emergency Treatment Using Local Medicament, and Follow-upAs an emergency measure the pocket was first rinsed thoroughly with chlorhexidine solution and then filled with achromycin ointment (3%). Once the acute symptoms subside, a thorough root planing can be performed.Right: Eight weeks after the emergency therapy, the gingiva has regained its resiliency and has shrunk somewhat. Probing depth is now only ca. 3 mm.466Emergency Situation: Pocket Abscess—Drainage After Probing From the Gingival MarginOriginating from a deep pocket mesial to tooth 11, a periodontal abscess has formed. Copious pus exudes when the pocket is probed.Left: The radiograph depicts the periodontal probe inserted to the base of the osseous defect.467Emergency Treatment Using Topical Medicament—Radiographic Follow-upThe abscess has opened via the gingival margin. The pocket is first thoroughly rinsed, then filled with an antibiotic-containing ointment. Once the acute symptoms have subsided, definitive therapy can be undertaken.Left: Radiograph 6 months after definitive therapy: New bone formation is apparent.468Emergency Situation: Periodontal Abscess Anticipates Drainage Through the GingivaOriginating from the deep, one-wall infrabony pocket mesial to the tipped but vital tooth 47, an abscess has developed. The buccal gingiva is distended as the abscess is about to penetrate through the mucosa.Tooth 47 is an abutment for a removable partial denture that is ill-fitting, but the patient wants to retain the partial denture.469Abscess—DrainageAs soon as the mucosa was touched the abscess opened and copious pus exuded.Left: In the radiograph one observes the deep mesial periodontal pocket with a hoe scaler in situ. Since the furcation appears not to be involved, it is possible to consider maintaining this tooth. The ensuing treatment included mechanical debridement and topical application of medicaments.470Emergency Situation in the Posterior Segment: Hopeless Molar (37)Pus exudes spontaneously from the deep distal pocket and the buccal furcation of tooth 37.The tooth is vital, highly mobile and painful to the slightest touch.471Radiograph of 37 Before Immediate ExtractionThe periodontal probe can be inserted almost to the root apex in the deep buccal pocket. Without clinical probing, such a defect at this location would be almost impossible to detect. The shape of the furcation is very unfavorable in terms of treatment; the two roots appear to fuse apically.Right: Highly infiltrated granulation tissue remains attached to the root after extraction.472Emergency Situation in the Anterior Area: Painful Tooth 11 is Hopeless—FistulaA fistula emanating from the deep pocket has developed. The non-vital tooth is highly mobile and sensitive to percussion. This tooth cannot be saved; it was extracted immediately.Right: The radiograph reveals that a probe can be carefully inserted far beyond the apex (endo-perio problem).473Immediate Extraction—Immediate TemporaryAn immediate temporary is necessary for esthetics. Following extraction the root was severed and the crown was used as a temporary. A wire and acid–etched resin secured the crown to the adjacent teeth. This type of temporary can usually be maintained until definitive reconstruction.Right: Radiographic view of the temporary replacement consisting of the patient’s own tooth crown.
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