Acute purulent periodontitis. I

Pus is formed as a result of the absorption of microbes by white blood cells. They die - they degenerate into fat and turn into pus, which can dissolve the surrounding bone, causing inflammation.

Causes

Inflammation around the tooth root occurs under the following circumstances:

Tooth destruction with subsequent death of the pulp (nerve) and penetration of infection to the peri-root tissues (75% of all cases).
Penetration of microbes through the gingival margin in gum diseases (or).
The injury is immediate or chronic (due to overload of a single tooth or unsuccessful prosthetics), leading to displacement of the tooth in the socket.
Local inflammatory processes (sinusitis, sore throat, otitis media).
Common diseases in which infection penetrates into the periodontal gap through blood or lymphatic vessels.
Drug-induced periodontitis develops during the treatment of pulpitis when root canals are treated with potent drugs.

Acute periodontitis occurs in two forms:

serous, in which swelling and pain are observed;
purulent – with symptoms of intoxication.

Periodontitis becomes purulent when immunity decreases. Characteristic signs arise that force the patient to seek medical help.

Symptoms

Acute periodontitis has specific manifestations associated with the localization of the inflammatory process. Any inflammation is accompanied by tissue swelling due to blood flow to the site of the disease. Bone tissue is inflexible, it cannot sharply increase in volume, and the nerve endings located in it are compressed by edema. This causes severe pain.

Symptoms of purulent periodontitis:

Severe constant aching pain.
Due to irritation of the nerve endings, a person experiences diffuse pain over the entire half of the jaw.
The accumulating edematous exudate pushes the tooth out of its socket by a fraction of a millimeter, creating the sensation of an “overgrown tooth” that hurts to chew food.
Because of the fear of closing his teeth, a sick person keeps his mouth slightly open.
The gums around the diseased tooth become red and swollen.
In children and in some cases in adults, swelling of the cheek or submandibular area may occur.
Often acute periodontitis is accompanied by the appearance.

Is it possible to determine on your own that it is purulent periodontitis that has developed? Yes, this disease has distinctive signs:

due to purulent melting of tissues and irritation of nerves, pain becomes excruciating;
when the inflamed area is warmed, the pain increases;
when eating hot food, the pain becomes unbearable;
cold water taken into the mouth dulls the pain for a short time, so a person carries a bottle of cold water with him.

Possible complications

Without treatment, periodontitis never ends on its own. If the patient does not consult a doctor, then a gradual transition of acute inflammation into a chronic form is possible, giving periodic exacerbations.

The danger of a chronic lesion is that it is a source of infection for the occurrence of diseases of the kidneys, heart, joints, and liver.

The most harmless of all complications is periostitis - inflammation of the periosteum, colloquially called gumboil and requiring an incision in the gums with a scalpel to empty the abscess.

Severe complications in the form of osteomyelitis, phlegmon, thrombophlebitis of the facial veins, sepsis pose a threat to human health and sometimes even life, therefore in such cases treatment of the patient in a hospital is indicated.

Which doctor should I contact for purulent periodontitis?

If signs of periodontitis are detected, you should contact a specialist.

Usually, patients experiencing severe pain want to immediately get rid of it along with the causative tooth and therefore make an appointment immediately with a dental surgeon.

In fact, there are not many indications for tooth extraction for periodontitis., This:

Significant tooth destruction and, as a result, loss of its functional value.
Severely twisted roots, making therapeutic help inaccessible.
Threat of serious complications.

Therefore, the right decision would be to make an appointment with a dentist-therapist.

Diagnostics

To make a diagnosis of periodontitis, collecting complaints and instrumental examination is usually sufficient.

Complaints: constant pain, which intensifies when eating hot food and chewing. With periodontitis of the extreme molars, there may be complaints of difficulty opening the mouth and pain when swallowing. There is often a slight increase in temperature and mild malaise. The lymph nodes in the neck are slightly enlarged.

Upon examination, they are found:

a decayed tooth or a large filling on a darkened tooth;
swollen gums.

Characteristic data of instrumental examination:

Painful palpation (feeling) of the gums.
Painful percussion (tapping on the tooth).
Electroodontodiagnosis (determining the viability of tissues in and around the tooth) gives indicators of 100 μA and higher (a healthy tooth responds to a current of 2-5 μA).
Thermal test reveals increased sensitivity to hot in the absence of a reaction to cold stimuli.

Of the additional examination methods, X-ray diagnostics occupies the main place. However, it must be said that it may turn out to be uninformative in an acute process, because signs of bone melting appear on the image only after 10-14 days.

Very rarely, mainly to identify complications, a general blood test is performed, which in case of purulent periodontitis shows a slight increase in the number of leukocytes and ESR.

Treatment of purulent periodontitis

Treatment of purulent periodontitis consists of several successive stages:

The main task of the doctor is to ensure the free flow of pus through the root canals. To do this, the dentist removes the remains of the previous filling and putrefactive decay from the tooth, and cleans the narrow canals in the roots with small endodontic (intradental) instruments. As soon as the first drop of pus appears at the mouth of the canal, the patient experiences relief and the excruciating pain goes away.
The next stage of treatment is carried out to relieve inflammation in the area of the bone around the tooth. Medicinal effects are carried out through canals in the roots. In this case, the tooth remains open for several days, without a filling, so that the pus can flow freely through the canals.
When the pain completely subsides and the swelling of the gums subsides, the doctor checks for tightness - closes the tooth.
If the pain does not recur, then it is time to restore the anatomical shape of the tooth using a permanent filling.

For acute periodontitis, another treatment regimen is used, in which the tooth is filled on the first visit, but an incision is made in the gum to allow the edematous fluid to come out. For purulent periodontitis, this option is rarely used for fear of complications.

Prevention

To avoid the occurrence of purulent periodontitis, you need to:

Treat dental caries promptly.
Prevent injuries during sports activities by using protective mouth guards.
For and choose clinics with qualified personnel.
Monitor your health, preventing a decrease in immunity.

Many people think that the loss of 1-2 teeth is fully compensated by the remaining ones. This is why patients at dental clinics are so persistent in their demand to remove a diseased tooth. In fact, the loss of each tooth entails irreversible damage to the dental system and creates unnecessary problems. In modern conditions, purulent periodontitis is curable in most cases.

Useful video about the treatment of periodontitis

Purulent periodontitis is a type of periodontitis in which an inflammatory process occurs in the root membrane of the tooth and adjacent tissues, as well as the connective tissue surrounding the tooth root becomes inflamed.

Purulent periodontitis is divided into infectious, traumatic and drug-induced, and the disease is divided into four stages of development: periodontal, endosseous, subperiosteal and submucosal. First, a microabscess develops, then infiltration occurs - pus penetrates into the bone tissue, resulting in the formation of a flux (pus accumulates under the periosteum) and at the last stage the pus passes into the soft tissue, accompanied by facial swelling and pain. Purulent periodontitis is treated in three visits to the doctor. At the first visit, the tooth is opened to remove pus; the root canals are processed and opened, a turunda with an antiseptic is inserted into the canal and a temporary filling is placed; At the last visit, the root canals are treated with medication and a permanent filling is installed.

It is also necessary to remove a tooth if:

its significant destruction;
the presence of foreign bodies in the channels;
obstruction of the canals.

But radical methods are rarely resorted to. In most cases, medications can keep the tooth intact.

Anesthesia– infiltration, conduction, intraligamentary or intraosseous anesthesia is performed using modern anesthetics. However, sometimes with properly administered anesthesia, the chosen anesthetic and the selected dosage, complete analgesia does not occur.

This may be due to several reasons:

1. The pH in the area of the inflamed tooth is lower, which makes the anesthetic less effective;

2. increased blood circulation in the surrounding tissue promotes rapid removal of the anesthetic from the injection zone, etc.;

3. due to the accumulation of exudate in the periodontal fissure, the diffusion of the anesthetic is impaired.

Or fix the tooth with your fingers.

Preparation carious cavity or removal of an old filling.

The preparation of cavities is carried out in compliance with all stages. All carious dentin should be removed prior to the actual endodontic intervention to avoid iatrogenic (re-)infection of the root canal system;

Providing access to the dental cavity. The task of this stage is to create direct access of the instrument to the tooth cavity and to the mouths of the root canals. It is carried out through a carious cavity in cavities of class 1 according to Black, by removing the carious cavity onto the oral or chewing surface in carious cavities of classes 2-4 according to Black, or by trephination of chewing or oral surfaces in carious cavities of class 5.

Opening of the tooth cavity. The task of this stage is to create wide and convenient access for the instrument to the tooth cavity and to the mouths of the root canals. When opening a tooth cavity, it is necessary to take into account the specific topography of dental cavities depending on their group affiliation and the age of the patient.

When accessing root canals, the following principles must be adhered to:

1. Instruments should not encounter obstacles in the coronal part of the tooth when inserting them into the mouths of the root canals:

2. The pulp chamber overhangs must be removed;

3. The integrity of the bottom of the pulp chamber should not be compromised to maintain the funnel-shaped mouths of the root canals;

Expansion of root canal orifices for unhindered penetration of endodontic instruments into the root canal.

Evacuation of pulp decay from the root canal is carried out in stages (fragmentally), using a pulp extractor or files, starting from the coronal part. A drop of antiseptic is applied to the mouth of the root canal, then the instrument is inserted to 1/3 of the working length of the root canal, rotated 90 degrees and removed. Then, after cleaning the instrument, a drop of antiseptic is applied again and the instrument is inserted into the root canal, but already at 2/3 of its length. Then the instrument is cleaned again, a drop of antiseptic is applied and the instrument is inserted to the full working length of the root canal. Removal of pulp decay should be accompanied by abundant irrigation of the root canals (medicated root canal treatment), most often a 0.5-0.25% sodium hypochlorite solution is recommended for this. Solutions of proteolytic enzymes are used to liquefy the exudate.

There are two different approaches at this stage of treatment. Some authors recommend opening the apical foramen or expanding the apical constriction to create an outflow of exudate from the periapical tissues. The criterion for controlling the opening of the apical foramen is the appearance of exudate in the lumen of the root canal. If exudate is not obtained during the expansion of the apical constriction (duration of inflammation) in the presence of periostitis, at the same visit an incision is made along the transitional fold with subsequent drainage of the wound.

Recently, publications have begun to appear in which the authors have a negative attitude towards the opening of the apical foramen, citing the fact that we thereby destroy the apical constriction and in the future, when filling the root canal, there is a risk of removal of the filling material into the periodontium.

The tooth is left open for several days (usually 2-3).

This ends the first visit. Patients are recommended to take home: thorough rinsing with hypertonic solutions up to 6-8 times a day. Cover the carious cavity with a cotton swab when eating.

Second visit

Be sure to clarify the patient’s complaints, clarify the anamnesis, evaluate the objective status: the condition of the mucous membrane near the causative tooth, percussion data, the presence or absence of exudate in the root canal.

In the absence of complaints and satisfactory general and local condition, they begin instrumental treatment of the root canals using one of the well-known methods (most often the “Crown Down” method), alternating it with medicinal treatment. The optimal treatment result is achieved only with careful mechanical treatment of the root canals with excision of necrotic tissue from the canal walls and creation of a canal configuration acceptable for its complete obturation.

Tooling root canal examination is carried out after determining the working length of the root canal using one of the available methods (tables, x-rays, apex locator, radiovisiography). In this case, treatment is carried out until apical constriction. In order not to injure the periapical tissues with instruments during mechanical processing, it is recommended to set all instruments to the working length of the root canal using a stopper.

Instrumentation of root canals with an open apical foramen requires special attention. Care must be taken to ensure that neither the irrigation solution nor the canal contents enter the periapical tissues and that they are not injured by instruments during mechanical processing.

Further, after the elimination of pain, the absence of exudate from the root canal, with painless percussion of the tooth and palpation of the gums, a number of authors recommend filling the root canals using preparations based on calcium hydroxide at the same second visit. After X-ray control of the root canal filling, an insulating lining and a permanent filling are placed. This approach is more often used in the treatment of single-rooted teeth. In the event of the appearance of periosteal phenomena (that is, an exacerbation of the process - pain when biting), an incision is made along the transitional fold to create an outflow of exudate.

The tooth-periodontal system, or in the arms of a gentle but powerful

To understand what acute periodontitis is and why it develops, you should realize that the tooth is not firmly driven into the gum and jaw, not driven like a nail into a board, but has sufficient freedom of movement in these structures due to the presence of ligaments between the jaw socket and the surface of the tooth .

The ligaments have the necessary power to hold the tooth in place, preventing it from excessively swinging back and forth, left and right, or rotating around a vertical axis. At the same time, providing the tooth with the possibility of “springy squats” - up and down movements in the socket limited by the elasticity of the ligaments, they do not allow it to be pressed too much inward during chewing, preserving the jawbone from damage by this fairly hard formation.

In addition to the shock-absorbing and fixing role, periodontal structures also perform the following functions:

protective, because they represent a histohematic barrier;
trophic - ensuring communication with the body of the vascular and nervous systems;
plastic - promote tissue repair;
sensory - the implementation of all types of sensitivity.

In case of acute damage to the periodontium, all these functions are disrupted, which leads the patient to the door to the dentist’s office at any time of the day. The symptoms can be so acute that even the thought of “enduring” and “waiting it out” does not arise (unlike when the sensations are quite tolerable).

About the mechanics of the destructive process, its stages

For the occurrence of acute periodontitis, either a medicinal effect on periodontal tissue, as in the treatment of pulpitis, is necessary, or the infection itself must penetrate into the bowels of the tooth - into the pulp. For this to happen, an entrance is required for infection to enter the tooth cavity, the role of which is performed by:

apical canal;
a cavity machined or formed along the way of insufficient quality;
line of damage resulting from ligament rupture.

Infection can also enter through pathologically deep periodontal pockets.

From the damaged pulp, microbial toxins (or a drug in the “arsenical” genesis of the condition) seep through the dentinal tubules into the periodontal fissure, first causing irritation of its structures, and then their inflammation.

The inflammatory process manifests itself:

pain due to the reaction of nerve endings;
microcirculation disorder, manifested by stagnation in tissues, externally appearing as hyperemia and swelling;
the body’s general reaction to intoxication and other changes in its biochemistry.

The destructive process goes through a series of successive stages:

On periodontal stage a lesion (or several) appears, delimited from the intact periodontal zones. The lesion expands or merges into one smaller one, involving a large volume of periodontal tissue in the process. Due to the increase in tension in the closed volume, the exudate, looking for a way out, breaks either through the marginal zone of the periodontium into the oral cavity, or, having melted the compact plate of the dental alveolus, into the bowels of the jaw. At this moment, due to a sharp decrease in the pressure exerted by the exudate, the pain is greatly reduced. The process moves into the next phase - it spreads under the periosteum.
Subperiosteal (subperiosteal) the phase in which symptoms appear - with the bulging of the periosteum into the oral cavity, which, thanks to the density of its structure, restrains the pressure of the purulent exudate accumulated under it. Then, having melted the periosteum, the pus appears under the mucous membrane, which is not a serious obstacle to its breakthrough into the oral cavity.
At the third stage, due to emergence– anastomosis of the apical zone with the oral cavity, the pain can almost completely disappear or become insignificant, while the painful swelling in the projection of the apex disappears. The danger of this phase is that the inflammation does not end there, but continues to spread, capturing new areas, which can lead to serious consequences, including the development. Sometimes the formation of a fistula means the transition of an acute condition to a chronic one.

Clinical symptoms of the main forms

According to the composition of the exudate, acute periodontitis can be serous and purulent, and according to the mechanism of occurrence:

infectious;
traumatic;
medicinal.

Serous phase

Serous periodontitis corresponds to the initial stage of the process - an acute nervous reaction of periodontal structures to their irritation with the appearance of initially subtle, but then increasingly increasing changes.

Due to the increased permeability of the capillary walls, a serous effusion is formed, which then includes living and dead leukocytes, products of the vital activity of microbes, and the remains of dead cells. This entire complex of microorganisms, active chemically and enzymatically, acts on the sensory nerve endings, causing them irritation, perceived as pain.

It is permanent, being mild at first, but gradually and methodically increasing, becoming unbearable when beaten on the tooth. In some cases, prolonged and volitional pressing of a tooth by closing the jaws can lead to a reduction in pain (but without its complete resolution). There are no external manifestations in the environment of the affected tooth, because inflammation in this case does not reach its peak.

Purulent phase

If you manage to overcome the initial pain without seeking dental help, the process moves into the next phase of purulent melting, and accordingly periodontitis becomes purulent.

Foci of microabscesses form a single, accumulated pus creates excess tension in a closed volume, causing unforgettable and unbearable sensations.

Characteristic symptoms are acute pain of a tearing nature, which radiates to the nearest teeth and further, right up to the opposite jaw. Even a light touch to a tooth causes an explosion of pain, calmly closing the mouth gives the effect of the greatest pressure on the painful area, the symptom of an “overgrown tooth” is positive in the absence of the reality of its protrusion from the socket. The degree of fixation in the socket decreases, temporarily and reversibly increasing.

In the case where inadequately deep gingival pockets serve as the entry point for infection into periodontal tissues, we speak of a marginal form of periodontitis (as in acute damage to the marginal periodontium). , occasionally, the process is accompanied by copious discharge of pus up to suppuration with the corresponding smell of decomposition inherent in it.

Due to the active drainage, pain in general symptoms fades into the background than with.
Acute purulent periodontitis under x-ray:

Traumatic form

In the case of a short-term effect of great destructive force (as with a blow that can cause rupture of ligaments over a large area), the development of traumatic periodontitis is possible. The intensity of pain depends on the degree of destruction of periodontal structures, increasing significantly when touching the painful area.

Characterized by increased mobility. With chronic negative effects, periodontal tissues are capable of restructuring, resorption of the bone walls of the alveoli begins, destruction of the fixing ligaments occurs, which leads to the expansion of the periodontal gap and loosening of the tooth.

Medicinal form

A distinctive feature of the medicinal form of the disease is its occurrence due to the impact on periodontal structures of drugs introduced into the root canals by mistake, or due to violations during the use of therapeutic therapy.

Most often, the development of arsenic periodontitis is diagnosed, which develops both when the required dose of arsenic is exceeded and when it remains in the tooth cavity for an excessively long time. The most popular “scenario” for the development of this form of the disease is insufficient tightness - the toxic drug must be immediately removed and the tissues treated with an antidote (Unithiol).

About diagnosis and differentiation from other diseases

To make a diagnosis, it is usually enough to question the patient (signs in the past and significant pain in the tooth, sharply increasing from touch, in the present are especially important from a diagnostic point of view), plus objective research data (painlessness of probing and a specific picture of crown destruction).

It is necessary to differentiate acute periodontitis from:

in a state of exacerbation;

A sign of pulpitis is throbbing pain of a paroxysmal nature, its character and intensity does not change with percussion tapping, but with a tendency to intensify at night, while periodontitis manifests itself as pain that does not go away and is unbearable, tearing in nature and sharply increasing from touching the tissues.

Unlike chronic periodontitis, the data do not demonstrate changes in the acute periodontal process.

With osteomyelitis, the image shows the extent of the lesion, including the roots of adjacent teeth. The accuracy of the diagnosis is confirmed by the pain of several adjacent teeth during percussion.

Features of treatment

The treatment strategy for the acute phase of periodontitis involves two options: complete healing of all tooth cavities, cleaning them of infection and decay products, or, as a last resort, its removal along with all pathological contents.

After confirmation of the diagnosis, acute periodontitis is performed, for which the highest quality anesthesia is performed due to the extreme susceptibility of the inflamed tissues to touch and vibration.

First visit

At the first visit to the clinic, the defect in the tooth crown is eliminated by preparing to healthy tissue; if there are already installed fillings, they are removed.

The next stage is the detection and opening of the root canal orifices. In the case of their previous filling, the filling material is removed, and during the initial opening of the canals, the most thorough removal of detritus is carried out, the walls are treated mechanically with the excision of all non-viable tissues. At the same time, the lumen of the canals is expanded to a diameter sufficient for further passage and filling.

All procedures are carried out using an antiseptic solution (Sodium hypochlorite or).

Once a sufficiently reliable drainage has been created, treatment of the apical region involves three tasks:

destruction of painful flora in the main root cavities;
extermination of infection in all branches of the root canals up to the dentinal tubules;
suppression of periodontal inflammation.

The success of these activities is facilitated by the use of:

electrophoresis with one of the antiseptic solutions;
method of intensifying diffusion of medicinal products into root canals using ultrasound techniques;
treatment of root canals with laser irradiation (the effect is achieved by combining radiation with the bactericidal effect of atomic oxygen or chlorine released from specially used solutions under the influence of a laser).

The stage of mechanical treatment and antiseptic etching of the tooth canals is completed by leaving it uncovered for 2–3 days. The doctor gives recommendations to the patient regarding the dosage regimen and the use of rinses with medicinal solutions.

If there are signs, the cavity is opened with the obligatory dissection of the periosteum along the transitional fold in the area of the projection of the root apex, with mandatory jet rinsing with an antiseptic solution and closing the resulting wound with elastic drainage.

Second visit to the clinic

At the second visit to the dental clinic, if the patient is absent, either permanent or for a period of 5–7 days is performed using the post-apical space for treatment. In this case, the installation of a permanent root filling and crown reconstruction are postponed until the third visit.

In case of complications

In case of obstruction of the root canals or if endodontic treatment fails, the tooth is removed and the patient then follows the tactics of treating the alveoli at home.

When examined the next day (if necessary), the hole is cleaned of the remaining blood clots with loose tamponade with a bandage sprinkled with Iodoform, with the manipulation repeated after 1–2 days. If there are no symptoms, there is no need for additional manipulations.

The occurrence of “arsenic periodontitis” requires immediate removal of the toxic agent and treatment of the inflamed tissue with an antidote.

Possible consequences, regular visits to the dentist.

Preventing the development of caries and its constant companion pulpitis is possible only by following the norms of common sense in the chewing process, because only a healthy periodontium successfully withstands the loads developed by all groups of masticatory muscles.

In order to avoid the development of drug-induced periodontitis, strict adherence to standards and techniques in the treatment of oral diseases is necessary, as well as, should be done without excessive stress on the periodontium.

Any endodontic operation must be completed fully along its entire length. In the case of incompletely traversed canals or poor-quality filling, the development of pulpitis inexorably follows, followed by periodontitis.