Acute gingival and periodontal conditions **The University of Western Australia** Dr Emma Perry | BDSc, AssocDeg DH, GradCert HPEd Lecturer (Clinical Dentistry) | UWA Dental School Content courtesy of Dr Anna Hughes and Dr Tina Choo  **The University of Western Australia** Dr Emma Perry | BDSc, AssocDeg DH, GradCert HPEd Lecturer (Clinical Dentistry) | UWA Dental School Content courtesy of Dr Anna Hughes and Dr Tina Choo Cartoon illustration of a crying molar tooth with inflamed red gums. Two green, angry-looking bacteria characters are positioned on top of the tooth, appearing to cause pain or infection. The image visually represents acute gingival and periodontal conditions. # Acknowledgement of country On **Noongar** land. Our university is located alongside the Derbal Yerrigan (Swan River) on Whadjuk Noongar Boodja (land). The University of Western Australia acknowledges that we are situated on Noongar land and that Noongar people remain the spiritual and cultural custodians of their land and continue to practise their values, languages, beliefs and knowledge. Artist: Dr Richard Barry Walley OAM  Acknowledgement of country On **Noongar** land. Our university is located alongside the Derbal Yerrigan (Swan River) on Whadjuk Noongar Boodja (land). The University of Western Australia acknowledges that we are situated on Noongar land and that Noongar people remain the spiritual and cultural custodians of their land and continue to practise their values, languages, beliefs and knowledge. Artist: Dr Richard Barry Walley OAM Indigenous artwork depicting a stylized black swan head with a yellow beak and eye. The swan is positioned inside concentric circular rings featuring patterns of white ovals, blue curves, and gold lines. The artist credit 'Artist: Dr Richard Barry Walley OAM' is visible in the bottom left corner. **Everyone is welcome** THE UNIVERSITY OF WESTERN AUSTRALIA 3    **Everyone is welcome** Illustration of a diverse group of people including individuals with disabilities (wheelchair user, prosthetic leg), LGBTQ+ symbols (rainbow flag, heart on shirt), and various ethnicities. Context: Part of an inclusivity message under 'Everyone is welcome'. Horizontal rainbow stripe graphic representing LGBTQ+ pride or diversity. Includes a small geometric pattern on the left end. Context: Visual separator between two illustrations supporting the theme of inclusion. Large illustration showing a diverse crowd of people waving, including elderly person with walker, child, various ethnicities, and gender expressions. Context: Reinforces the inclusive theme 'Everyone is welcome' from OCR text. **Learning outcomes** * Diagnose and classify the most common acute gingival and periodontal conditions by recognising risk factors and clinical presentation * Explain the aetiology of acute gingival and periodontal conditions * Describe the rationale and methods for management of the most common acute gingival and periodontal conditions THE UNIVERSITY OF WESTERN AUSTRALIA **Learning outcomes** - Diagnose and classify the most common acute gingival and periodontal conditions by recognising risk factors and clinical presentation - Explain the aetiology of acute gingival and periodontal conditions - Describe the rationale and methods for management of the most common acute gingival and periodontal conditions University of Western Australia logo featuring a shield with a swan and text. # Lecture outline **Necrotising periodontal diseases** - **Necrotising gingivitis** (NG) - **Necrotising periodontitis** (NP) - **Viral lesions** - **Abscesses of the periodontium** - **Gingival abscess** - **Pericoronitis** - **Periodontal abscess** - **Other less common conditions** - **Endo-perio lesions** covered in dedicated lecture from **DENT4212 endodontics module** Lecture outline **Necrotising periodontal diseases** - **Necrotising gingivitis** (NG) - **Necrotising periodontitis** (NP) - **Viral lesions** - **Abscesses of the periodontium** - **Gingival abscess** - **Pericoronitis** - **Periodontal abscess** - **Other less common conditions** - **Endo-perio lesions** covered in dedicated lecture from **DENT4212 endodontics module** University of Western Australia logo featuring a shield with a swan and the university name. # Acute characteristics - **Rapid onset** - **Pain or discomfort** - **Tissue destruction +/- infection** - **Patients usually seek urgent care (pain)** It is important to identify and eliminate predisposing factors to prevent recurrence 6 - **Rapid onset** - **Pain or discomfort** - **Tissue destruction +/- infection** - **Patients usually seek urgent care (pain)** It is important to identify and eliminate predisposing factors to prevent recurrence.  A labelled diagram titled 'CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASES AND CONDITIONS 2017'. The diagram is structured into two main sections: 'Periodontal Diseases and Conditions' and 'Peri-Implant Diseases and Conditions', each subdivided into categories such as 'Periodontitis', 'Necrotizing Periodontal Diseases', 'Systemic diseases or conditions affecting the periodontal supporting tissues', and 'Peri-Implant Mucositis'. Specific references to consensus reports (e.g., Papapanou et al. 2018) are included within the boxes. **Treatment plan** **THE UNIVERSITY OF WESTERN AUSTRALIA** **PERIODONTAL TREATMENT PLAN** **EMERGENCIES PHASE OF PERIODONTAL TREATMENT** Item Proposed Item Completed **RISK MANAGEMENT PHASE OF PERIODONTAL TREATMENT (step1)** Item Proposed Item Completed **FUNDAMENTAL PHASE OF PERIODONTAL TREATMENT (step1&2)** Item Proposed Item Completed **RE-EVALUATION PHASE OF PERIODONTAL TREATMENT (step3)** Item Proposed Item Completed **CORRECTIVE PHASE OF PERIODONTAL TREATMENT (step3)** Item Proposed Item Completed **MAINTENANCE PHASE (step4)** Item Proposed Item Completed **PROPOSED MAINTENANCE INTERVAL** **3 Months** **6 Months** **12 Months** **Other** Student Signature Tutor Signature   **PERIODONTAL TREATMENT PLAN** **EMERGENCIES PHASE OF PERIODONTAL TREATMENT** Item Proposed Item Completed **RISK MANAGEMENT PHASE OF PERIODONTAL TREATMENT (step1)** Item Proposed Item Completed **FUNDAMENTAL PHASE OF PERIODONTAL TREATMENT (step1&2)** Item Proposed Item Completed **RE-EVALUATION PHASE OF PERIODONTAL TREATMENT (step3)** Item Proposed Item Completed **CORRECTIVE PHASE OF PERIODONTAL TREATMENT (step3)** Item Proposed Item Completed **MAINTENANCE PHASE (step4)** Item Proposed Item Completed **PROPOSED MAINTENANCE INTERVAL** - 3 Months - 6 Months - 12 Months - Other Student Signature Tutor Signature Screenshot of a digital 'Periodontal Treatment Plan' form interface. The layout lists sequential phases of treatment including 'Emergencies Phase', 'Risk Management Phase (step1)', 'Fundamental Phase (step1&2)', 'Re-evaluation Phase (step3)', 'Corrective Phase (step3)', and 'Maintenance Phase (step4)'. Each phase includes checkboxes for 'Item Proposed' and 'Item Completed'. At the bottom, there are fields for 'Proposed Maintenance Interval' with radio buttons for timeframes, signature boxes for Student and Tutor, and action buttons. Zoomed-in view of the top navigation bar and header section of the Periodontal Treatment Plan form. Visible tabs include 'Clin II', 'Clin III', 'Clin IV', 'Radiography Report', 'Perio Diag I', 'Perio Diag II', 'Risk Assessment', and an active tab labeled 'TP'. Below this is the title 'PERIODONTAL TREATMENT PLAN' followed by the first section header 'EMERGENCIES PHASE OF PERIODONTAL TREATMENT'. **Periodontal Treatment Step** **Step 0** **PREREQUISITE TO THERAPY** - Educate, classification, diagnosis, risk assess, care plan **Step 1** **RISK** - Risk factor control, OHI, adjuncts for GI, PMPR, supra-gingival scaling **Step 2** **INTERVENE** - Sub-gingival biofilm & calculus removal ± adjuncts **Step 3** **CHECK** - Non-responder sites: Re-RSD/surgery **Step 4** **EXIT** - plan longer-term care (above) **C** **Supportive care/rehabilitation** **E** The University of Western Australia 9  **Periodontal Treatment Step** **Step 0** **PREREQUISITE TO THERAPY** - Educate, classification, diagnosis, risk assess, care plan **Step 1** **RISK** - Risk factor control, OHI, adjuncts for GI, PMPR, supra-gingival scaling **Step 2** **INTERVENE** - Sub-gingival biofilm & calculus removal ± adjuncts **Step 3** **CHECK** - Non-responder sites: Re-RSD/surgery **Step 4** **EXIT** - plan longer-term care (above) **C** Supportive care/rehabilitation **E** A stepped diagram illustrating the periodontal treatment sequence (Step 0 to Step 4). Steps are color-coded: green for Step 0, blue for Step 1, purple for Step 2, pink for Step 3, and orange for Step 4. Each step includes a label (P, R, I, C, E) and a description of the clinical action required. **Necrotising periodontal diseases** • NG and NP appear to be the same disease but at different stages. • Differentiated by: • Severity • Extent of tissue destruction Glick et al 1994, Robinson et al 1998  - NG and NP appear to be the same disease but at different stages. - Differentiated by: - Severity - Extent of tissue destruction Glick et al 1994, Robinson et al 1998 Illustration of the Grim Reaper standing in a graveyard with tombstones and candles under a full moon. Contextually represents 'Necrotising periodontal diseases' and the severity of tissue destruction mentioned in the slide text. NG, necrotizing gingivitis; NP, necrotizing periodontitis; NS, necrotizing stomatitis <sup>a</sup>Mean plasma and serum concentrations of retinol, total ascorbic acid, zinc, and albumin markedly reduced, or very marked depletion of plasma retinol, zinc, and ascorbate; and saliva levels of albumin and cortisol, as well as plasma cortisol concentrations, significantly increased <sup>b</sup>Living in substandard accommodations, exposure to debilitating childhood diseases, living near livestock, poor oral hygiene, limited access to potable water and poor sanitary disposal of human and animal fecal waste <sup>c</sup>Measles, herpes viruses (cytomegalovirus, Epstein-Barr virus-1, herpes simplex virus) chicken pox, malaria, febrile illness  NG, necrotizing gingivitis; NP, necrotizing periodontitis; NS, necrotizing stomatitis ^a^ Mean plasma and serum concentrations of retinol, total ascorbic acid, zinc, and albumin markedly reduced, or very marked depletion of plasma retinol, zinc, and ascorbate; and saliva levels of albumin and cortisol, as well as plasma cortisol concentrations, significantly increased ^b^ Living in substandard accommodations, exposure to debilitating childhood diseases, living near livestock, poor oral hygiene, limited access to potable water and poor sanitary disposal of human and animal fecal waste ^c^ Measles, herpes viruses (cytomegalovirus, Epstein-Barr virus-1, herpes simplex virus) chicken pox, malaria, febrile illness A structured table titled 'Necrotising periodontal diseases' from The University of Western Australia. The table is organized into four columns: Category, Patients, Predisposing conditions, and Clinical condition. It classifies necrotizing periodontal diseases into two main categories: 'Necrotizing periodontal diseases in chronically, severely compromised patients' (affecting adults and children) and 'Necrotizing periodontal diseases in temporarily and/or moderately compromised patients' (affecting gingivitis and periodontitis patients). Rows detail specific predisposing conditions such as HIV/AIDS, malnourishment, extreme living conditions, severe infections, stress, smoking, and local factors like root proximity. The clinical condition column lists outcomes including NG (necrotizing gingivitis), NP (necrotizing periodontitis), NS (necrotizing stomatitis), Noma, and possible progression pathways. # Necrotising periodontal diseases <b>Aetiology</b> • Opportunistic / dysbiotic **microbiome** in a susceptible host • Fusiform bacteria, **Prevotella intermedia**, & spirochaetes • **Bacterial invasion** of soft tissues occurs • **Intense release** of cytokines and tissue destruction Falkler et al 1987, Stevens et al 1984  #### Aetiology - Opportunistic / dysbiotic **microbiome** in a susceptible host - Fusiform bacteria, **Prevotella intermedia**, & spirochaetes - **Bacterial invasion** of soft tissues occurs - **Intense release** of cytokines and tissue destruction Falkler et al 1987, Stevens et al 1984 Scanning electron micrograph (SEM) showing spirochaetes (helical bacteria) in a dysbiotic microbiome. The image features blue-green helical structures against a purple background of other bacterial cells and host tissue debris. # Necrotising periodontal diseases ## Risk Factors - Poor oral hygiene - Smoking - Insufficient sleep & Psychological STRESS – inability to cope with stress - HIV +ve patients & Immunosuppressed patients - Severe malnutrition - Developed countries - Young people (15-34yrs) - Developing countries - children Some wisdom 13  #### Risk Factors - Poor oral hygiene - Smoking - Insufficient sleep & Psychological STRESS – inability to cope with stress - HIV +ve patients & Immunosuppressed patients - Severe malnutrition - Developed countries - Young people (15-34yrs) - Developing countries - children Illustration showing a person smoking with the text 'QUIT SMOKING' at the bottom. This visual supports the 'Smoking' risk factor listed in the adjacent text. **Necrotising periodontal diseases** **THE UNIVERSITY OF WESTERN AUSTRALIA** **Epidemiology** * Unclear, but **low** in developed countries * Higher in developing countries - **5-25%** * Higher in children - **54-68%** are children <10 yrs * HIV +ve patients **2%** (**30%** if not on HAART) * Higher in military population * High during WWI & WWII 14  - Unclear, but **low** in developed countries - Higher in developing countries - **5-25%** - Higher in children - **54-68%** are children <10 yrs - HIV +ve patients **2%** (**30%** if not on HAART) - Higher in military population - High during WWI & WWII Illustration showing two soldiers in green uniforms and helmets carrying rifles, standing near a rock formation. This visual corresponds to the epidemiology point regarding 'Higher in military population'. # Necrotising gingivitis * **Sudden Onset**- Rapid development and painful, more common to affect anterior teeth * Starts with ulceration of interdental papilla, leading to papillary necrosis * "Punched out" papillae appearance * Fibrinous pseudomembrane * +/- Fever, lymphadenopathy, malaise * No bone loss * Bleeding * Malodour **Fig. 19-7** Necrotizing gingivitis in a 22-year-old woman: bleeding, necrosis, and pseudomembrane can be observed.  - **Sudden Onset** - Rapid development and painful, more common to affect anterior teeth - Starts with ulceration of interdental papilla, leading to papillary necrosis - "Punched out" papillae appearance - Fibrinous pseudomembrane - +/- Fever, lymphadenopathy, malaise - No bone loss - Bleeding - Malodour Clinical photo showing the anterior teeth and gums of a patient with necrotizing gingivitis. The image demonstrates the key features described in the text: redness and inflammation of the gum tissue (erythema), ulceration between the teeth (interdental papilla) giving a 'punched out' appearance, and the presence of a whitish/yellowish fibrinous pseudomembrane covering the necrotic areas. **Necrotising gingivitis** <b>The University of Western Australia</b> **Fig. 19-9** Healing of necrotizing gingivitis lesions in the upper anterior sextant. (a) Active lesions with necrosis the interdental papillae. (b) Complete resolution after 60 days. (Source: Courtesy of Dr. Nidia Castro dos Santos and Dr. Mauro Santamaria.) 16   **Fig. 19-9** Healing of necrotizing gingivitis lesions in the upper anterior sextant. (a) Active lesions with necrosis the interdental papillae. (b) Complete resolution after 60 days. (Source: Courtesy of Dr. Nidia Castro dos Santos and Dr. Mauro Santamaria.) Clinical photo labeled (a) showing active necrotizing gingivitis lesions in the upper anterior sextant. The image displays inflamed, red gingival tissue and necrosis affecting the interdental papillae between the teeth. Clinical photo labeled (b) showing the complete resolution of necrotizing gingivitis lesions in the upper anterior sextant after 60 days. The gingiva appears healthy and pink compared to the initial state. # Necrotising gingivitis ## Essential clinical features * Lesions are painful * Lesions are gingival ulcers, punched-out crater-like affecting the interdental papilla and may involve marginal gingiva * Gingival ulcers bleed spontaneously or readily * The acute condition may occur from an existing chronic gingival condition or de novo ## Non-essential clinical features * "Pseudomembrane" of sloughed necrotic debris & bacteria covering the ulcerated area * Bad breath * Fever, malaise * Lymphadenopathy – (submandibular & cervical) #### Essential clinical features - Lesions are painful - Lesions are gingival ulcers, punched-out crater-like affecting the interdental papilla and may involve marginal gingiva - Gingival ulcers bleed spontaneously or readily - The acute condition may occur from an existing chronic gingival condition or de novo #### Non-essential clinical features - "Pseudomembrane" of sloughed necrotic debris & bacteria covering the ulcerated area - Bad breath - Fever, malaise - Lymphadenopathy – (submandibular & cervical) University of Western Australia logo. **Necrotising periodontitis** * Lesions extend into alveolar bone * Exposed bone, gingival recession, tooth mobility * Malodour, lymphadenopathy, fever and malaise * Severe pain and spontaneous bleeding * Exfoliation of teeth within months of onset of NP **Fig. 19-8** Necrotizing periodontitis: presence of necrosis/ulcer of the interdental papillae. (Source: Courtesy of Dr. Mauro Santamaria.) **THE UNIVERSITY OF WESTERN AUSTRALIA** 18  - Lesions extend into alveolar bone - Exposed bone, gingival recession, tooth mobility - Malodour, lymphadenopathy, fever and malaise - Severe pain and spontaneous bleeding - Exfoliation of teeth within months of onset of NP **Fig. 19-8** Necrotizing periodontitis: presence of necrosis/ulcer of the interdental papillae. (Source: Courtesy of Dr. Mauro Santamaria.) Clinical photograph showing severe periodontal disease. It depicts multiple teeth with significant brown calculus deposits and gingival recession. There is a visible ulceration or necrosis of the interdental papilla between the central incisors, consistent with the caption describing necrotizing periodontitis. Necrotising periodontitis   Clinical photo showing necrotising periodontitis. The image displays a close-up of teeth with significant gingival recession and exposed root surfaces. A large piece of necrotic tissue or debris is visible at the base of one tooth, surrounded by inflamed pink gum tissue. Clinical photo viewed through a dental mirror showing necrotising periodontitis. The image highlights a tooth with dark discoloration on the crown and severe gingival recession exposing the root structure. The surrounding soft tissues appear inflamed. # Necrotising periodontitis 20    Text heading: 'Necrotising periodontitis' indicating the subject of the slide. Dental radiograph (X-ray) showing teeth with restorations and surrounding bone structure. The image is framed by a blue border. Dental radiograph (X-ray) showing similar dental anatomy as the first image. This image is framed by a yellow border. NG and NP management - Needs **urgent** treatment - Disease can progress rapidly (necrotic bone & soft tissue) - If left untreated: NG → NP  - Needs **urgent** treatment - Disease can progress rapidly (necrotic bone & soft tissue) - If left untreated: NG → NP A simple medical symbol consisting of a blue cross inside a circle. # NG and NP management * **Gentle debridement** with ultrasonic (with LA) to remove slough, plaque & necrotic tissues, saline irrigation * Rx metronidazole 400mg 12-hourly for 3-5 days, pain management, OHI (gentle) * Mouthwash for 2-3 weeks, 2 x daily for 1 min * CHX 0.2% * **OR** * **H2O2 1.5%** * Stop smoking! * Review 2-3 days later - further Rx may be needed Robinson et al 1998     - **Gentle debridement** with ultrasonic (with LA) to remove slough, plaque & necrotic tissues, saline irrigation - Rx metronidazole 400mg 12-hourly for 3-5 days, pain management, OHI (gentle) - Mouthwash for 2-3 weeks, 2 x daily for 1 min - CHX 0.2% - **OR** - **H2O2 1.5%** - Stop smoking! - Review 2-3 days later - further Rx may be needed Robinson et al 1998 Product packaging for Curasept ADS 220 Chlorhexidine oral rinse. Bottle of Curasept mouthwash. Bottle of Colgate Peroxyl Hydrogen Peroxide Oral Hygiene Mouth Rinse. Packaging and blister strip for Flagyl (Metronidazole) 400mg tablets. **NG and NP management** Access by University of Western Australia (CAUL) Therapeutic Guidelines > Oral and Dental > Necrotising periodontal disease Necrotising periodontal disease metronidazole 400 mg orally, 12-hourly for 3 to 5 days. If pain and inflammation restrict oral hygiene practices, recommend short-term use of a mouthwash to reduce plaque formation; use: 1 hydrogen peroxide 3% solution 5 mL, mixed with 5 mL of warm water, rinsed in the mouth for 1 minute then spat out, 12-hourly until pain has reduced OR 1 hydrogen peroxide 1.5% solution 10 mL, rinsed in the mouth for 1 minute then spat out, 12-hourly until pain has reduced OR 2 chlorhexidine 0.2% mouthwash 10 mL rinsed in the mouth for 1 minute then spat out, 8- to 12-hourly until pain has reduced [**Note 1**] OR 2 chlorhexidine 0.12% mouthwash 15 mL rinsed in the mouth for 1 minute then spat out, 8- to 12-hourly until pain has reduced [**Note 1**]   Access by University of Western Australia (CAUL) Therapeutic Guidelines > Oral and Dental > Necrotising periodontal disease **Necrotising periodontal disease** metronidazole 400 mg orally, 12-hourly for 3 to 5 days. If pain and inflammation restrict oral hygiene practices, recommend short-term use of a mouthwash to reduce plaque formation; use: 1. hydrogen peroxide 3% solution 5 mL, mixed with 5 mL of warm water, rinsed in the mouth for 1 minute then spat out, 12-hourly until pain has reduced OR 1. hydrogen peroxide 1.5% solution 10 mL, rinsed in the mouth for 1 minute then spat out, 12-hourly until pain has reduced OR 2. chlorhexidine 0.2% mouthwash 10 mL rinsed in the mouth for 1 minute then spat out, 8- to 12-hourly until pain has reduced [**Note 1**] OR 2. chlorhexidine 0.12% mouthwash 15 mL rinsed in the mouth for 1 minute then spat out, 8- to 12-hourly until pain has reduced [**Note 1**] Clinical photograph of a medication box and blister pack for Flagyl (Metronidazole) 400 mg. The box is pink with white text indicating the brand name 'Flagyl', dosage '400mg', and generic name '(Metronidazole)', along with manufacturer 'SANOFI'. A blister pack containing yellow tablets is placed next to it. Screenshot from Therapeutic Guidelines showing recommended mouthwash procedures for Necrotising periodontal disease. It lists specific instructions for using hydrogen peroxide solutions (3% or 1.5%) and chlorhexidine mouthwashes (0.2% or 0.12%), including volumes, rinsing duration, frequency, and conditions for use until pain has reduced. # NG and NP management The University of Western Australia **Response to treatment is diagnostic** At 1-2 week review: * **Subgingival debridement** if necessary (earlier may hinder regenerative potential of tissues) and treat chronic disease if present * **Reinforce oral hygiene** * **Review again** - maintenance or needs surgery? * **Failure to resolve** may be due to incomplete debridement/ stress/ malnutrition/ smoking/ immunological conditions * Regimen shown to have **94% resolution within 1 week** & **100% within 1 month** * If not resolved, you need to rule other non-infective conditions that resemble **NG**, e.g. desquamative gingivitis Robinson et al 1998 24   **Response to treatment is diagnostic** At 1-2 week review: - **Subgingival debridement** if necessary (earlier may hinder regenerative potential of tissues) and treat chronic disease if present - **Reinforce oral hygiene** - **Review again** - maintenance or needs surgery? - **Failure to resolve** may be due to incomplete debridement/ stress/ malnutrition/ smoking/ immunological conditions - Regimen shown to have **94% resolution within 1 week** & **100% within 1 month** - If not resolved, you need to rule other non-infective conditions that resemble **NG**, e.g. desquamative gingivitis Robinson et al 1998 A close-up photograph of a set of periodontal curettes (scaling instruments) with multi-colored handles resting on a dark surface. A clinical intraoral photograph showing teeth and gingiva being treated with a dental scaler or brush, demonstrating the subgingival debridement procedure mentioned in the text. # # NG and NP management ## Longer term management * Review at 1 month * If resolved, place on 3/12 maintenance, (may need periodontal surgery if deformities present) * If no resolution, refer to periodontist or oral medicine specialist, (blood test, microbiological sample & biopsy -> histopathology investigations) * Up to 30% of patients will experience recurrence within 2 years * Maintenance of meticulous OH and scaling/debridement 25  #### Longer term management - Review at 1 month - If resolved, place on 3/12 maintenance, (may need periodontal surgery if deformities present) - If no resolution, refer to periodontist or oral medicine specialist, (blood test, microbiological sample & biopsy -> histopathology investigations) - Up to 30% of patients will experience recurrence within 2 years - Maintenance of meticulous OH and scaling/debridement Illustration showing a person looking at a calendar with question marks, representing long-term management and recurrence timelines. # NG and NP management **THE UNIVERSITY OF WESTERN AUSTRALIA** Image courtesy of Dr Anna Hughes 26  Image courtesy of Dr Anna Hughes Clinical photograph showing a frontal view of the anterior teeth and gingiva. The image displays significant inflammation of the gingival tissue (redness and swelling) along the gumline, consistent with the 'NG and NP management' context (likely Gingivitis or Non-Plaque Induced Gingivitis). There is visible plaque accumulation at the cervical margins of the lower incisors. IPD-P03848 Eng-Patent (27)  IPD-P03848 Eng-Patent (27) Clinical intraoral photograph showing the anterior dentition. The image displays the maxillary and mandibular central incisors, lateral incisors, and canines in occlusion. Notable features include significant gingival recession on the lower left central incisor, exposing a substantial portion of the root surface. The upper central incisors appear slightly proclined. The title 'NG and NP management' is visible above the image. # NG and NP management 28  Clinical intraoral photograph showing a patient's upper dental arch with visible gingival inflammation and potential periodontal disease. The image is relevant to the slide title 'NG and NP management'. NG and NP management **Image courtesy of Dr Anna Hughes**  Image courtesy of Dr Anna Hughes Clinical intraoral photograph showing the maxillary arch. The image displays the upper teeth and gingiva, demonstrating the anatomical structures relevant to NG (nasal) and NP (palatal) management. **Acute herpetic gingivostomatitis** * **Herpes Simplex virus** * **70-80% of population exposed** * **Less in developed countries** * **Young adults & children** * **Affects whole mouth & gingiva** * **1-2mm blisters that rupture to form small, shallow, painful & irregular ulcers, 7-10 days** * **Ulcers covered by a yellowish-gray center & surrounded by a red halo** </img>  - **Herpes Simplex virus** - **70-80% of population exposed** - **Less in developed countries** - **Young adults & children** - **Affects whole mouth & gingiva** - **1-2mm blisters that rupture to form small, shallow, painful & irregular ulcers, 7-10 days** - **Ulcers covered by a yellowish-gray center & surrounded by a red halo** Clinical photo showing a mouth affected by acute herpetic gingivostomatitis. The image displays the upper and lower teeth with significant inflammation of the gums (gingiva) and inner cheeks. There are visible redness, swelling, and ulceration consistent with the text description of 'small, shallow, painful & irregular ulcers' that rupture from blisters. # Acute herpetic gingivostomatitis **THE UNIVERSITY OF WESTERN AUSTRALIA** * Ulcers may take up to 2 weeks to heal * Heal with no scarring * Rare to get gingival recession * Sore to touch, food & drinks * Worse with salty, acidic, hard foods * Fever & malaise * Ddx recurrent apthous ulcers? * These are not seen on keratinised tissues 31  - Ulcers may take up to 2 weeks to heal - Heal with no scarring - Rare to get gingival recession - Sore to touch, food & drinks - Worse with salty, acidic, hard foods - Fever & malaise - Ddx recurrent apthous ulcers? - These are not seen on keratinised tissues Clinical photograph showing the oral cavity affected by acute herpetic gingivostomatitis. The image displays significant erythema (redness) and inflammation of the gingiva (gums). Multiple small, shallow ulcers are visible on the inner mucosal surfaces of the cheeks and lips, as well as on the tongue. **Acute herpetic gingivostomatitis** **Table 4. Differences in clinical features of necrotizing ulcerative gingivitis (NUG) and acute herpetic gingivostomatitis (AHG)** **Site of ulcers** NUG: Interdental papilla, Marginal gingival AHG: Gingiva, no predilection for interdental papilla; Entire oral mucosa **Character of ulcers** NUG: Punched-out, crater-like; Covered by yellow/white/gray slough; Bleed readily or spontaneously; Painful on stimulation AHG: Multiple vesicles that coalesce and form shallow, fibrin-covered, regular-shaped ulcers; No marked tendency to bleed; Not specially tender **Fever** NUG: Doubtful or slight only AHG: 38 °C (or more) **Symptoms** NUG: Painful gums, ‘dead-feeling teeth’ AHG: Sore mouth **Duration of ulcers and discomfort** NUG: Short-lived (1–3 days), with appropriate therapy AHG: More than 1 week, even with therapy  **Table 4. Differences in clinical features of necrotizing ulcerative gingivitis (NUG) and acute herpetic gingivostomatitis (AHG)** **Site of ulcers** NUG: Interdental papilla, Marginal gingival AHG: Gingiva, no predilection for interdental papilla; Entire oral mucosa **Character of ulcers** NUG: Punched-out, crater-like; Covered by yellow/white/gray slough; Bleed readily or spontaneously; Painful on stimulation AHG: Multiple vesicles that coalesce and form shallow, fibrin-covered, regular-shaped ulcers; No marked tendency to bleed; Not specially tender **Fever** NUG: Doubtful or slight only AHG: 38 °C (or more) **Symptoms** NUG: Painful gums, 'dead-feeling teeth' AHG: Sore mouth **Duration of ulcers and discomfort** NUG: Short-lived (1–3 days), with appropriate therapy AHG: More than 1 week, even with therapy Comparison table comparing Necrotizing Ulcerative Gingivitis (NUG) and Acute Herpetic Gingivostomatitis (AHG). Columns are labeled NUG and AHG. Rows compare Site of ulcers (Interdental papilla vs Gingiva), Character of ulcers (Punched-out crater-like with slough vs Multiple vesicles coalescing into shallow ulcers), Fever (Doubtful/slight vs 38°C or more), Symptoms (Painful gums/dead-feeling teeth vs Sore mouth), and Duration of ulcers and discomfort (Short-lived 1-3 days vs More than 1 week). **Acute herpetic gingivostomatitis** **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** **Management** * Pain relief: analgesics & topical anaesthetics rinses * Advice to have adequate fluid intake & food * Use of antiviral medication **questioned: ACYCLOVIR**, only if started immediately * Inform - AHG is **CONTAGIOUS!** * Review in 2wks to confirm correct diagnosis * Recurrence can occur- dental tx, stress, fever, trauma #### Management - Pain relief: analgesics & topical anaesthetics rinses - Advice to have adequate fluid intake & food - Use of antiviral medication **questioned: ACYCLOVIR**, only if started immediately - Inform - AHG is **CONTAGIOUS!** - Review in 2wks to confirm correct diagnosis - Recurrence can occur - dental tx, stress, fever, trauma **Reactivation of viruses** **Herpes simplex virus** **Cold sores** **Varicella Zoster** **Shingles (from chicken pox)** **Fig. 20.4 Herpetic vesicles recurred in the lip. (A) Early stage. (B) Late stage, showing brownish, crusted lesions. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. ed2, St Louis, 2002, Mosby.)** **Fig. 20.5 Recurrent intraoral herpetetic vesicles are seen (A) in the palate and (B) in the gingiva. The latter location is rare. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology, ed 2, St Louis, 2002, Mosby.)** 34 **The UNIVERSITY OF WESTERN AUSTRALIA**   **Herpes simplex virus** **Cold sores** **Varicella Zoster** **Shingles (from chicken pox)** **Fig. 20.4** Herpetic vesicles recurred in the lip. (A) Early stage. (B) Late stage, showing brownish, crusted lesions. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. ed2, St Louis, 2002, Mosby.) **Fig. 20.5** Recurrent intraoral herpetetic vesicles are seen (A) in the palate and (B) in the gingiva. The latter location is rare. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology, ed 2, St Louis, 2002, Mosby.) Composite figure illustrating Herpes simplex virus reactivation. Panel A shows early-stage herpetic vesicles on the lip. Panel B shows a late-stage lesion with brownish, crusted appearance. Panel C displays recurrent intraoral herpetetic vesicles in the palate. Panel D shows vesicles in the gingiva. Clinical photograph of Varicella Zoster (Shingles) presenting as an intraoral lesion. White arrowheads point to the affected area showing mucosal changes. Abscesses of the periodontium **THE UNIVERSITY OF WESTERN AUSTRALIA**  Clinical photograph showing a periodontal abscess on the gingiva adjacent to an upper right third molar tooth. The tooth appears discolored with calculus deposits and shows signs of extrusion and mobility as described in the caption. • **Classified based on aetiology** <table> <tr> <td><strong>Periodontal abscess in periodontitis patients (in a pre-existing periodontal pocket)</strong></td> <td>Acute exacerbation</td> <td>Untreated periodontitis</td> <td></td> </tr> <tr> <td></td> <td></td> <td>Non-responsive to therapy periodontitis</td> <td></td> </tr> <tr> <td></td> <td></td> <td>Supportive periodontal therapy</td> <td></td> </tr> <tr> <td></td> <td>After treatment</td> <td>Post-scaling</td> <td></td> </tr> <tr> <td></td> <td></td> <td>Post-surgery</td> <td></td> </tr> <tr> <td></td> <td></td> <td>Post-medication</td> <td>Systemic antimicrobials</td> </tr> <tr> <td></td> <td></td> <td></td> <td>Other drugs: nifedipine</td> </tr> <tr> <td><strong>Periodontal abscess in non-periodontitis patients (not mandatory to have a pre-existing periodontal pocket)</strong></td> <td>Impaction</td> <td></td> <td>Dental floss, orthodontic elastic, toothpick, rubber dam, or popcorn hulls</td> </tr> <tr> <td></td> <td>Harmful habits</td> <td></td> <td>Wire or nail biting and clenching</td> </tr> <tr> <td></td> <td>Orthodontic factors</td> <td></td> <td>Orthodontic forces or a cross-bite</td> </tr> <tr> <td></td> <td>Gingival overgrowth</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Alteration of root surface</td> <td>Severe anatomic alterations</td> <td>Invaginated tooth, dens evaginatus or odontodysplasia</td> </tr> <tr> <td></td> <td></td> <td>Minor anatomic alterations</td> <td>Cemental tears, enamel pearls or developmental grooves</td> </tr> <tr> <td></td> <td></td> <td>Iatrogenic conditions</td> <td>Perforations</td> </tr> <tr> <td></td> <td></td> <td>Severe root damage</td> <td>Fissure or fracture, cracked tooth syndrome</td> </tr> <tr> <td></td> <td></td> <td>External root resorption</td> <td></td> </tr> </table> 36  **Classified based on aetiology** **Periodontal abscess in periodontitis patients (in a pre-existing periodontal pocket)** - Acute exacerbation - Untreated periodontitis - Non-responsive to therapy periodontitis - Supportive periodontal therapy - After treatment - Post-scaling - Post-surgery - Post-medication - Systemic antimicrobials - Other drugs: nifedipine **Periodontal abscess in non-periodontitis patients (not mandatory to have a pre-existing periodontal pocket)** - Impaction - Dental floss, orthodontic elastic, toothpick, rubber dam, or popcorn hulls - Harmful habits - Wire or nail biting and clenching - Orthodontic factors - Orthodontic forces or a cross-bite - Gingival overgrowth - Alteration of root surface - Severe anatomic alterations - Invaginated tooth, dens evaginatus or odontodysplasia - Minor anatomic alterations - Cemental tears, enamel pearls or developmental grooves - Iatrogenic conditions - Perforations - Severe root damage - Fissure or fracture, cracked tooth syndrome - External root resorption A detailed classification table of periodontal abscesses categorized by aetiology. The table is divided into two main sections: 'Periodontal abscess in periodontitis patients' and 'Periodontal abscess in non-periodontitis patients'. It lists specific causes such as acute exacerbation, impaction, harmful habits, orthodontic factors, gingival overgrowth, alteration of root surface (including severe anatomic alterations, minor anatomic alterations, iatrogenic conditions, severe root damage, and external root resorption), and post-medication factors like systemic antimicrobials or other drugs like nifedipine. **Abscesses of the periodontium** • Pericoronal Abscess (Pericoronitis) • Gingival Abscess • Periodontal Abscess • Combined perio-endo abscess • Other acute abscesses  - Pericoronal Abscess (Pericoronitis) - Gingival Abscess - Periodontal Abscess - Combined perio-endo abscess - Other acute abscesses Clinical intraoral photograph showing the lower anterior teeth with a visible periodontal abscess. A metal dental instrument is probing a swollen, purulent gingival lesion located on the gum tissue between the mandibular central and lateral incisors. # Abscesses of the periodontium ## Pericoronitis * **Easy to diagnose as can see partially** **erupted tooth with inflamed gum flap** * **Gingiva in 3rd molar area appear red &** **swollen, infection may be due to** **biofilm, trauma, food debris** * Infection may spread posteriorly into the oropharyngeal area and medially to the base of the tongue and involve the regional lymph nodes, may have difficulty swallowing * Patients may have a history of pericoronitis * Gram-negative anaerobic pathogens **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** 38  - **Easy to diagnose as can see partially erupted tooth with inflamed gum flap** - **Gingiva in 3rd molar area appear red & swollen, infection may be due to biofilm, trauma, food debris** - Infection may spread posteriorly into the oropharyngeal area and medially to the base of the tongue and involve the regional lymph nodes, may have difficulty swallowing - Patients may have a history of pericoronitis - Gram-negative anaerobic pathogens Clinical photo showing a mouth with pericoronitis. The image displays an inflamed gum flap overlying a partially erupted tooth in the posterior region (likely a mandibular third molar). The gingiva appears red and swollen, consistent with infection due to biofilm or food debris. **Abscesses of the periodontium** **Pericoronitis** 39  Panoramic dental radiograph showing the full dentition of a patient. The image displays both maxillary and mandibular arches with visible teeth, including third molars (wisdom teeth). Some teeth show restorations (fillings) as bright white areas. The surrounding bone structure is also visible. This radiograph is likely used to demonstrate pericoronitis or other periodontal abscesses mentioned in the context. # Abscesses of the periodontium ## Pericoronitis 40     Main title text: 'Abscesses of the periodontium' Subheading text: 'Pericoronitis' Page number: '40' Medical diagram illustrating the progression of pericoronitis. It shows three sequential cross-sectional views of teeth and surrounding tissue. The first panel shows a partially erupted tooth with gingival tissue covering the crown. The second panel shows inflammation (greenish-yellow discoloration) at the gum margin. The third panel shows severe inflammation (red swelling) extending over the tooth crown. Arrows indicate the progression from left to right. # Abscesses of the periodontium ## Management * **Acute phase and initial Treatment:** * debride & irrigate under the pericoronal flap * Rx. Antibiotics if systemic involvement (fever, lymphadenopathy), warm salt water mouthwash * Manage underlying condition: * operculectomy * distal debridement * extract third molar(s)  #### Management - **Acute phase and initial Treatment:** - debride & irrigate under the pericoronal flap - Rx. Antibiotics if systemic involvement (fever, lymphadenopathy), warm salt water mouthwash - Manage underlying condition: - operculectomy - distal debridement - extract third molar(s) Medical illustration demonstrating the surgical management of pericoronitis. The sequence shows: (A) clinical presentation of an impacted tooth with inflamed tissue; (B) occlusal view of the area; (C) elevation of a pericoronal flap using a dental elevator; (D) irrigation and debridement under the flap; and (E) final position after tissue removal or suturing. # Abscesses of the periodontium 42     Clinical photo showing a periodontal abscess on the gingiva above a molar tooth, labeled 'Before'. Clinical photo showing the same site after treatment with healthy gingival tissue and no visible abscess, labeled 'After'. Clinical photo showing another periodontal abscess on the gingiva near a molar, labeled 'Before'. Clinical photo showing the resolved site with normal gingival appearance, labeled 'After'. # Abscesses of the periodontium ## Gingival abscess - Localised purulent infection - smooth, red, painful swelling - Confined to marginal gingival tissue, often at previously non-diseased sites - Usually an acute inflammatory response (1-2 days) to plaque, trauma or foreign substances forced into the gingiva (Piksters, dental floss, food) - If left untreated, lesion may ruptres spontaneously - Diagnosis - find & retrieve the offending foreign material if applicable - Treatment: debride & irrigate pocket - Localised purulent infection - smooth, red, painful swelling - Confined to marginal gingival tissue, often at previously non-diseased sites - Usually an acute inflammatory response (1-2 days) to plaque, trauma or foreign substances forced into the gingiva (Piksters, dental floss, food) - If left untreated, lesion may ruptre spontaneously - Diagnosis - find & retrieve the offending foreign material if applicable - Treatment: debride & irrigate pocket The University of Western Australia logo located in the top right corner. **Abscesses of the periodontium** **Gingival abscess** 44  Clinical photograph showing a gingival abscess on the gum tissue adjacent to a tooth. The image displays localized swelling and inflammation (erythema) with a visible pustule or collection of pus, characteristic of a gingival abscess. **Abscesses of the periodontium** **Periodontal abscess** * **3rd** most common emergency in general practice (UK data) * **8-14%** of all dental emergencies * More common in patients with untreated gum disease (60%) vs patients undergoing active periodontal treatment (13.5%) * Patients in maintenance – 38% (5-29yrs follow up) * Usually around molars & lower incisors  - **3rd** most common emergency in general practice (UK data) - **8-14%** of all dental emergencies - More common in patients with untreated gum disease (60%) vs patients undergoing active periodontal treatment (13.5%) - Patients in maintenance – 38% (5-29yrs follow up) - Usually around molars & lower incisors Clinical photograph showing a periodontal abscess. The image displays an inflamed gingival margin with significant swelling and redness surrounding a molar tooth exhibiting signs of decay or discoloration. Abscesses of the periodontium **Periodontal abscess** • Rapid destruction of periodontal tissues, with a negative effect on the prognosis of the affected tooth. Bacterial invasion of soft tissues ulceration of the PE occurs. • May lead to tooth loss • During SPT, main reason for tooth extraction • Teeth with repeated abscess formation – prognosis considered "hopeless" • Severe systemic consequences can occur Herrara et al 2018   - Rapid destruction of periodontal tissues, with a negative effect on the prognosis of the affected tooth. Bacterial invasion of soft tissues ulceration of the PE occurs. - May lead to tooth loss - During SPT, main reason for tooth extraction - Teeth with repeated abscess formation – prognosis considered "hopeless" - Severe systemic consequences can occur Herrara et al 2018 Clinical photo of the lower anterior teeth showing severe periodontal disease. The gingiva is inflamed and swollen. A wooden probe or cotton stick is inserted into a deep periodontal pocket on the left side, demonstrating significant tissue destruction. Periapical radiograph of the lower anterior teeth showing severe vertical bone loss (periodontitis). A thin metallic instrument (probe) is visible in the interproximal space between the central incisors, indicating a deep pocket. There is also a large radiopaque restoration visible on one of the premolars. **Abscesses of the periodontium** **Periodontal abscess** 47 <img>Diagram of a periodontal abscess showing tissue layers and cellular infiltration: Normal oral epithelium, inflammatory cell infiltrate, granular debris, necrotic connective tissue, and ulcerated pocket epithelium; tag badge for Western Australia university<br/><img>  Labelled diagram of a periodontal abscess showing tissue layers and cellular infiltration: Normal oral epithelium, inflammatory cell infiltrate, granular debris, necrotic connective tissue, and ulcerated pocket epithelium. **Abscesses of the periodontium** **Periodontal abscess**  Labelled medical diagram illustrating a periodontal abscess. The image displays two side-by-side panels depicting the progression of bacterial infection in the gingival tissues. Labels include 'Tooth enamel', 'Gingival epithelium', 'Bacteria' (represented as black dots), 'Leukocyte' (blue cells), 'Junctional epithelium', 'Gingival connective tissue', 'Inflammation', 'Osteoclas', and 'Alveolar bone'. The visual shows bacteria penetrating the epithelium, triggering leukocyte response and inflammation leading to bone destruction. **Abscesses of the periodontium** The University of Western Australia **Periodontal abscess - why?** * Untreated periodontitis * Poor access/residual calculus - anatomical difficulties in furcations, vertical defects, root concavities * Non-inflammatory- root fractures/ perforations * Systemic antimicrobial intake, without subgingival debridement * Poorly controlled diabetics - higher risk 49  #### Periodontal abscess - why? - Untreated periodontitis - Poor access/residual calculus - anatomical difficulties in furcations, vertical defects, root concavities - Non-inflammatory - root fractures/perforations - Systemic antimicrobial intake, without subgingival debridement - Poorly controlled diabetics - higher risk Clinical photograph showing multiple extracted teeth with periodontal abscesses and residual calculus. The image displays various anatomical sites such as furcations, vertical defects, and root concavities where calculus is trapped (indicated by blue arrows). This visual supports the slide's discussion on 'poor access/residual calculus' as a cause for periodontal abscesses. Abscesses of the periodontium **Periodontal abscess** Microbial composition similar to periodontitis Most prevalent bacterial species were Porphyromonas gingivalis (50-100%), Prevotella intermedia, Prevotella melaninogenica, Fusobacterium nucleatum, Tannerella forsythia, Treponema species, Campylobacter species, Capnocytophaga species, Aggregatibacter actinomycetemcomitans or gram-negative enteric rods Herrara et al 2018 50  #### Periodontal abscess Microbial composition similar to periodontitis Most prevalent bacterial species were Porphyromonas gingivalis (50-100%), Prevotella intermedia, Prevotella melaninogenica, Fusobacterium nucleatum, Tannerella forsythia, Treponema species, Campylobacter species, Capnocytophaga species, Aggregatibacter actinomycetemcomitans or gram-negative enteric rods Herrara et al 2018 Scientific diagram comparing bacterial proportions across three states: Health, Gingivitis, and Periodontitis. Each state is represented by a pie chart divided into segments labeled 'Rods' (anaerobic) and 'Cocci' (aerobic/facultative). A legend distinguishes between 'Aerobic and facultative organisms' (light grey) and 'Anaerobic organisms' (dark grey). The visual progression demonstrates an increasing shift from aerobic to anaerobic bacteria as the condition worsens. **Abscesses of the periodontium** **Periodontal abscess** * Confined to marginal gingival tissue * Ovoid swelling in gum * Gingiva is oedematous & red, with a smooth, shiny surface * Very common - Pus may be expressed from the gingival margin by gentle digital pressure, or by probing * Uncommon - Fistula  #### Periodontal abscess - Confined to marginal gingival tissue - Ovoid swelling in gum - Gingiva is oedematous & red, with a smooth, shiny surface - Very common - Pus may be expressed from the gingival margin by gentle digital pressure, or by probing - Uncommon - Fistula Clinical photograph demonstrating a Periodontal abscess. The image shows the marginal gingival tissue of upper anterior teeth exhibiting an ovoid swelling. The gingiva is visibly oedematous and red with a smooth, shiny surface characteristic of acute inflammation. **Abscesses of the periodontium** **Periodontal abscess** • Symptoms vary from a slight discomfort, tender gums, to severe pain & swelling, or tooth “elevation” • Increased tooth mobility, TTP or soreness with chewing • Extra-oral uncommon – swollen face (3.6%) • Lymphadenopathy, fever & malaise (7-40%) **THE UNIVERSITY OF WESTERN AUSTRALIA** 52  #### Periodontal abscess - Symptoms vary from a slight discomfort, tender gums, to severe pain & swelling, or tooth "elevation" - Increased tooth mobility, TTP or soreness with chewing - Extra-oral uncommon – swollen face (3.6%) - Lymphadenopathy, fever & malaise (7-40%) Clinical photograph showing a periodontal abscess on a tooth. The image displays inflamed gingival tissue with erythema and swelling adjacent to the tooth structure, consistent with the condition described in the slide text. **Abscesses of the periodontium** **Periodontal abscess diagnosis** • Deep probing depths >5mm (7-9mm on average) • Positive response to pulp vitality test • Radiographs – no apical radiolucency or endodontic lesion, but bone loss observed **THE UNIVERSITY OF WESTERN AUSTRALIA** 53   #### Periodontal abscess diagnosis - Deep probing depths >5mm (7-9mm on average) - Positive response to pulp vitality test - Radiographs – no apical radiolucency or endodontic lesion, but bone loss observed Clinical photo showing a dental probe inserted into a periodontal pocket between teeth to demonstrate deep probing depths (>5mm) mentioned in the diagnosis text. Radiograph (X-ray) of teeth showing bone loss observed in the context of a periodontal abscess diagnosis, with no apical radiolucency or endodontic lesion present. # Abscesses of the periodontium ## Periodontal abscess * Can occur in patients undergoing perio tx, during maintenance, or untreated perio patients * Usually in patients with a history of periodontitis & smokers * May occur post scaling due to remaining subgingival calculus on root surface - deep periodontal pockets, furcations, & intrabony defects * May occur when antibiotics Rx without debridement in patients with periodontal disease  #### Periodontal abscess - Can occur in patients undergoing perio tx, during maintenance, or untreated perio patients - Usually in patients with a history of periodontitis & smokers - May occur post scaling due to remaining subgingival calculus on root surface - deep periodontal pockets, furcations, & intrabony defects - May occur when antibiotics Rx without debridement in patients with periodontal disease Clinical photograph showing the anterior maxillary dentition. There is a distinct, localized, erythematous (red) swelling on the gingiva above the central incisors, consistent with a periodontal abscess as described in the accompanying text. Abscesses of the periodontium **Periodontal abscess - management** * Drain abscess by debriding through the pocket or an incision & removing plaque, calculus, & other irritants * Occlusal adjustment * CHX mouthwash * Rx. Analgesics * Resolution 2-7 days * Recurring abscess – surgery to access site to find other cause for abscess 55 #### Periodontal abscess - management - Drain abscess by debriding through the pocket or an incision & removing plaque, calculus, & other irritants - Occlusal adjustment - CHX mouthwash - Rx. Analgesics - Resolution 2-7 days - Recurring abscess – surgery to access site to find other cause for abscess **Abscesses of the periodontium** **Periodontal abscess - management** *Rarely needed!* *Only if spreading locally + mild systemic involvement* *Phenoxymethylpenicillin 500mg x4 daily for 5 days or Amoxycillin 500mg tds for 5 days ( plus metronidozole 400mg bds 5 days) TG* *PENICILLIN ALLERGY: CLINDAMYCIN 300mg tds for 5 days* *If severe systemic + spreading- immediate referral to a hospital!!*   #### Periodontal abscess - management *Rarely needed!* *Only if spreading locally + mild systemic involvement* - Phenoxymethylpenicillin 500mg x4 daily for 5 days or Amoxycillin 500mg tds for 5 days (plus metronidazole 400mg bds 5 days) TG - **PENICILLIN ALLERGY: CLINDAMYCIN 300mg tds for 5 days** - If severe systemic + spreading - immediate referral to a hospital!! Photo of a hand holding a box of 'Augmentin Duo forte' prescription-only medicine. The packaging indicates it contains amoxicillin and clavulanic acid tablets. A visual representation of the cover of the 'Therapeutic Guidelines: Oral and Dental 2012 Version 2'. The cover features a purple background with white text for the title and version number. Below the text is an image of a clown figurine with a colorful outfit (orange, green, blue) and a red nose, appearing to shout or sing. # Abscesses of the periodontium ### Periodontal abscess - without treatment… * Tooth loss * Spread of infection to other parts of the body – bacteraemia, lung infection, brain abscess 57   #### Periodontal abscess - without treatment… - Tooth loss - Spread of infection to other parts of the body – bacteraemia, lung infection, brain abscess Clinical photo showing a child with facial swelling consistent with an abscess. Illustration of the Grim Reaper holding a scythe in a graveyard setting, symbolizing death. **Differential diagnosis** <table> <caption>Differentiation of Necrotizing Ulcerative Gingivitis, Chronic Desquamative Gingivitis, and Chronic Periodontal Disease</caption> <thead> <tr> <th>Necrotizing Ulcerative Gingivitis</th> <th>Desquamative Gingivitis</th> <th>Chronic Destructive Periodontal Disease</th> </tr> </thead> <tbody> <tr> <td>Bacterial smears show fusospirochetal complex</td> <td>Bacterial smears reveal numerous epithelial cells and few bacterial forms</td> <td>Bacterial smears vary</td> </tr> <tr> <td>Marginal gingiva affected</td> <td>Diffuse involvement of marginal and attached gingivae and other areas of oral mucosa</td> <td>Marginal gingiva affected</td> </tr> <tr> <td>Acute history</td> <td>Chronic history</td> <td>Chronic history</td> </tr> <tr> <td>Painful</td> <td>May or may not be painful</td> <td>Painless if uncomplicated</td> </tr> <tr> <td>Pseudomembrane</td> <td>Patchy desquamation of gingival epithelium</td> <td>Usually no desquamation, but purulent material may appear from pockets</td> </tr> <tr> <td>Papillary and marginal necrotic lesions</td> <td>Papillae do not undergo necrosis</td> <td>Papillae do not undergo noticeable necrosis</td> </tr> <tr> <td>Affects adults of both genders and occasionally affects children</td> <td>Affects adults, most often women</td> <td>Usually found in adults, occasionally found in children</td> </tr> <tr> <td>Characteristic fetid odor</td> <td>No odor</td> <td>Some odor but not strikingly fetid</td> </tr> </tbody> </table>  **Differentiation of Necrotizing Ulcerative Gingivitis, Chronic Desquamative Gingivitis, and Chronic Periodontal Disease** | Necrotizing Ulcerative Gingivitis | Desquamative Gingivitis | Chronic Destructive Periodontal Disease | |---|---|---| | Bacterial smears show fusospirochetal complex | Bacterial smears reveal numerous epithelial cells and few bacterial forms | Bacterial smears vary | | Marginal gingiva affected | Diffuse involvement of marginal and attached gingivae and other areas of oral mucosa | Marginal gingiva affected | | Acute history | Chronic history | Chronic history | | Painful | May or may not be painful | Painless if uncomplicated | | Pseudomembrane | Patchy desquamation of gingival epithelium | Usually no desquamation, but purulent material may appear from pockets | | Papillary and marginal necrotic lesions | Papillae do not undergo necrosis | Papillae do not undergo noticeable necrosis | | Affects adults of both genders and occasionally affects children | Affects adults, most often women | Usually found in adults, occasionally found in children | | Characteristic fetid odor | No odor | Some odor but not strikingly fetid | A structured comparison table titled 'Differentiation of Necrotizing Ulcerative Gingivitis, Chronic Desquamative Gingivitis, and Chronic Periodontal Disease'. The table is organized into three columns representing the conditions: Necrotizing Ulcerative Gingivitis, Desquamative Gingivitis, and Chronic Destructive Periodontal Disease. Rows compare features such as bacterial smear findings (fusospirochetal complex vs. epithelial cells), affected areas (marginal gingiva vs. diffuse involvement), history (acute vs. chronic), pain level, presence of pseudomembrane or desquamation, necrosis patterns, patient demographics, and odor characteristics. 59 ## Other less common conditions **Acute Candida infection in a cancer patient receiving chemotherapy**  **Acute Candida infection in a cancer patient receiving chemotherapy** Clinical photo: An intraoral view showing the upper and lower anterior dentition. The gingival tissues appear erythematous (red) and inflamed. There are white, adherent patches visible on the mucosal surfaces, consistent with acute Candida infection (thrush). The teeth show signs of dental plaque accumulation. # Other less common conditions ## Desquamative gingivitis in a patient with auto-immune disease NB The image of the mouth has a slight red and inflamed appearance, consistent with the text presented in the image. The image includes a picture of the mouth with the teeth and gums visible.  #### Desquamative gingivitis in a patient with auto-immune disease Clinical photo showing the oral cavity with teeth and gums. The gums appear red and inflamed, consistent with desquamative gingivitis as described in the OCR context. Other less common conditions **Desquamative gingivitis** in a patient with auto-immune disease 61   **Desquamative gingivitis** in a patient with auto-immune disease Clinical photo showing desquamative gingivitis on the lower teeth and gum line, with visible tissue sloughing or peeling. OCR context: Desquamative gingivitis in a patient with auto-immune disease. Clinical photo showing inflamed gums (gingivitis) on upper teeth, with redness and possible ulceration. OCR context: Desquamative gingivitis in a patient with auto-immune disease. **Other less common conditions** **THE UNIVERSITY OF WESTERN AUSTRALIA** 62  Clinical photograph showing an intraoral view of the posterior mouth. The image features the tongue on the left side and the right cheek on the right. A significant finding is a reddish, raised lesion (neoplasm) located near the molar region between the teeth and the soft tissue. A dental instrument is visible retracting the cheek to expose the area. Other less common conditions Allergic reactions   Allergic reactions Clinical photo showing a severe allergic reaction in the oral cavity. The image displays significant erythema and edema of the lips and perioral skin, with yellowish crusting visible on the outer lip surface. Two coins are placed adjacent to the mouth for scale reference. Clinical photo demonstrating an allergic reaction localized to the gingiva. The gums exhibit diffuse redness (erythema) and swelling (edema), particularly affecting the interdental papillae between the anterior teeth. Reading **Chapter 14** **Non-Plaque-Induced Gingival Diseases** **Palle Holmstrup**¹ and **Mats Jontell**² ¹ Department of Periodontology, School of Dentistry, University of Copenhagen, Copenhagen, Denmark ² Oral Medicine and Pathology, Institute of Odontology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden **Chapter 19** **Abscesses, Necrotizing Lesions of the Periodontium,** and **Endo-Periodontal Lesions** **David Herrera**¹ and **Magda Feres**² ¹ ETEP (Etiology and Therapy of Periodontal and Peri-Implant Diseases) Research Group, Complutense University of Madrid, Madrid, Spain ² Department of Periodontology, Dental Research Division, Guarulhos University, Guarulhos, São Paulo, Brazil and The Forsyth Institute, Cambridge, MA, USA The University of Western Australia  **Chapter 14** **Non-Plaque-Induced Gingival Diseases** **Palle Holmstrup**¹ and **Mats Jontell**² ¹ Department of Periodontology, School of Dentistry, University of Copenhagen, Copenhagen, Denmark ² Oral Medicine and Pathology, Institute of Odontology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden **Chapter 19** **Abscesses, Necrotizing Lesions of the Periodontium,** and **Endo-Periodontal Lesions** **David Herrera**¹ and **Magda Feres**² ¹ ETEP (Etiology and Therapy of Periodontal and Peri-Implant Diseases) Research Group, Complutense University of Madrid, Madrid, Spain ² Department of Periodontology, Dental Research Division, Guarulhos University, Guarulhos, São Paulo, Brazil and The Forsyth Institute, Cambridge, MA, USA The University of Western Australia A photograph of the book 'Lindhe's Clinical Periodontology and Implant Dentistry', Seventh Edition. The cover is dark purple and includes microscopic images of periodontal tissue on the front and spine. Questions? **emma.perry@uwa.edu.au** Images in presentation not otherwise credited are licence-free from https://www.freepik.com/ 65  Questions? **emma.perry@uwa.edu.au** Images in presentation not otherwise credited are licence-free from https://www.freepik.com/ Portrait photo of presenter Emma Perry with short hair and glasses, used for identification during the Q&A session. 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