Acute periodontitis clinic diagnostics. I. Acute periodontitis. Additional examination methods include

Periodontitis in dentistry is the inflammatory process that occurs in the tissues surrounding the root of the tooth in the apex area. Periodontitis is a complication of dental caries and pulpitis, and in turn can itself lead to complications such as the appearance of granuloma, jaw cyst, fistula, maxillary abscess, osteomyelitis, phlegmon, etc.

External symptoms of periodontitis are severe toothache, increasing with pressure on the affected tooth, tooth mobility, swelling and swelling of the gums, increased body temperature, enlarged regional lymph nodes.

The periodontium becomes infected through root canals, and the treatment practice chosen by the dentist depends on two factors - the type of disease and the stage in which it is currently located.

Only a doctor can determine what type of disease is developing in a patient, since all types of disease can cause the following symptoms:

• aching pain that increases in the evening, intensifying if you knock on a tooth or bite it;
• the serous inflammatory process gradually develops into a purulent stage - the pain becomes stronger, changing from aching to throbbing, and the duration of the pain syndrome increases;
• Flux forms at the base of the tooth, and the area near the root swells;
• the tooth may lose stability and become mobile;
• The temperature rises, and the pain prevents you from falling asleep.

Periodontitis can be treated, and this is a “plus”, but only if treatment is started on time. The prognosis for therapy is positive, allowing one to avoid the spillover of inflammation into chronic stage, the appearance of abscesses and fistulas, sepsis. Periodontitis is especially dangerous for pregnant women. Another useful topic:

Apical periodontitis and its causes

The first, simplest and easiest to treat form of periodontitis is apical periodontitis - an inflammatory process in the periodontium, localized near the root apex. The disease is diagnosed by examination and X-ray examination; in addition, the patient’s complaints are taken into account. By the way, this form occurs in 30% of patients who go to the dentist, whose age ranges from 21 to 60 years.

The causes of apical periodontitis can be divided into three conditional categories - infectious, drug and traumatological. The most common cause of periodontitis is caries, during which the root canals become infected with various bacteria.

It can also be caused by untreated pulpitis, an inflammatory process in the gums that occurs due to the appearance of tartar, trauma (provided that the patient already has infectious pulpitis), as well as improper treatment or dental prosthetics, poor-quality materials, especially if We are talking about arsenic-based drugs.

Chronic and acute form periodontitis

Acute apical periodontitis occurs without characteristic pathologies in dental, dental and jaw tissue. But at the same time, purulent exudate appears, flowing out when pressing on the tooth outward. If the problem is not solved in time, the focal infection will progress to the chronic stage, which is characterized by the appearance of a neoplasm in the form of a capsule located near the canals of the tooth.

The capsule can develop into a fistula or cyst, which is complicated by purulent abscesses penetrating into the bone-jaw tissue, osteomyelitis and phlegmon, which cause bad breath.

Granulating periodontitis and its features

Granulating periodontitis is a simple and highly treatable form of the disease. All pathologies are reversible, if, of course, you consult a doctor in time.

The disease is characterized by pain syndrome, which manifests itself when biting or hitting tooth on tooth, as well as a feeling of swelling of the gums with periodic appearance of fistulas on it.

Granulomatous periodontitis and its features

The granulomatous form is the most dangerous form disease, since it occurs without characteristic symptoms. But at this time the tooth itself, and possibly the bone to which it is attached, is destroyed, and cysts and granulomas appear on the roots, disrupting the shape of the gums, so if you do not regularly preventive examination, you can lose a tooth, which is called “out of the blue.”

Fibrous periodontitis and its features

This form of periodontitis is difficult to diagnose, since most patients do not have any symptoms characteristic of the disease, and those that appear may indicate not only periodontitis, but also the presence of pulpitis in the form of gangrene. The only thing that can guide doctors to a correct diagnosis is the localization of focal inflammation.

Treatment of periodontitis is carried out according to different schemes, they depend on the form of the disease. Sometimes periodontitis can pass without pronounced symptoms, and then inaction is fraught with the development of complications such as:

• Dental granuloma is a round inflammatory formation that occurs in the root apex area. Outwardly it appears as a round bump on the gum.
• A cyst is a neoplasm in the form of a cavity filled with liquid or mushy contents (dead cells, bacteria, etc.) in the bone tissue of the jaw, arising in response to inflammation of the apex of the tooth root.
• The fibrous form of periodontitis is chronic. The main feature of this form is that the elastic, mobile collagen-containing periodontal tissue is gradually replaced by rough connective tissue.
• Gingival fistula is a neoplasm in the form of a canal connecting the surface of the tooth and the source of infection.

Treatment of dental periodontitis is a long and complex process that takes place over several visits to the dentist. Chronic periodontitis is especially difficult to treat; here you need to be patient for several months. Acute periodontitis will require at least two visits to the doctor. The treatment regimen will depend on the form of periodontitis, the area of ​​its spread and the degree of neglect.

Treatment of periodontitis should be a complex process, including medicinal and instrumental treatment methods, as well as physical therapy, if there are existing indications.

The main objectives of treatment are:

• cupping inflammatory process to prevent it from flowing into more complex shape and to other areas of the gums;
• restoration of affected tissues to return the periodontal tissue to the ability to perform all necessary loads.

To complete the tasks, instrumental treatment is performed, which consists of opening the tooth cavity and removing the affected tissue, during which the root apex can be partially or completely amputated and the cyst removed from the gum. Tooth extraction occurs only when traditional treatment does not give the expected result.

Along with this treatment, the patient is prescribed antibiotics, which will stop the infectious process, rinses based on mineral waters, herbal infusions and antiseptic drugs, which will clean the wound of pathogenic bacteria. But the main physiotherapeutic methods in this case are UHF, Sollux, laser exposure per tooth

When the infection process is stopped, the roots are sealed and the tooth is closed with a filling. In some cases, the tooth is replaced with a crown.

In the initial stages, it is possible to treat periodontitis using conservative methods. The following stages of therapeutic treatment can be distinguished:

1. Carrying out pain relief. Local injection anesthesia is used, which is quite sufficient for painless treatment.
2. Canal treatment. For quality treatment The root canals must be thoroughly cleaned and expanded using a special tool. These measures serve to remove infected dentin layers and make it possible to remove purulent exudate through the root canal, thereby cleaning the resulting cavities. Cleansing and removal of exudate takes place in several stages under constant supervision and with the help of a wide range of endodontic instruments.
3. Treatment of the canals continues with their antiseptic treatment using antiseptic solutions– hydrogen peroxide, chlorhexidine, sodium hypochloride, etc. High-quality canal treatment is the key to the absence of relapses.
4. Injection of disinfectants into the area of ​​the root apex for their further distribution into surrounding tissues to suppress microbial infection. Bandages with medicinal drugs are worn for a certain number of days, after which you can begin filling the canals.
5. Filling of the canals is carried out using gutta-percha pins and filling fillers containing antimicrobial components. Quality control of canal filling is carried out using targeted radiography.
6. After filling the canal, a glass ionomer gasket is applied to its mouth, then the tooth cavity is closed with a composite filling or ceramic inlay.

Often for more effective treatment periodontitis, especially if there are neoplasms (granuloma, cyst, fibrous formations) in addition to drug therapy Physiotherapeutic treatment is added. It promotes rapid resorption of formations, reduces inflammation, and accelerates the processes of periodontal tissue regeneration. Among the physical treatment methods, the most effective are:

• Electrophoresis;
• Laser therapy;
• Magnetotherapy;
• Paraffin applications.

Acute granulating and granulomatous periodontitis: treatment features

The granulomatous form takes the longest possible time to treat and requires special professionalism from the dentist, since he must clean the tooth of dead and diseased tissue and prescribe the correct drug treatment, expand the channels in order to disinfect them. The dentist must then open the apex to allow the infiltrate to drain out of the roots.

On the first visit, a temporary filling is installed - this is necessary to check how thoroughly the tissue cleaning operation was performed. On the second visit, a permanent filling is placed if the inflammatory process has already stopped. By the way, if there is a cyst, it is carried out surgery for its removal. After a period of time (approximately six months), a follow-up examination is carried out.

Granulating periodontitis also involves performing the measures described above, but at the same time, drugs that restore bone tissue, and before installing a permanent filling, insulating spacers are inserted into the tooth cavity.

Chronic periodontitis and its treatment during exacerbation

In the event that chronic periodontitis has worsened, the doctor must assess the patient’s condition, since there is no specific, precise treatment method. Therapy should depend on how the chronic process proceeds, how severe the pain syndrome is, how the tissues are affected, and whether there are complications in the form of a cyst-forming process.

But, regardless of the treatment regimen, therapeutic measures are aimed at curing damaged areas (macro- and microcanals, periodontal gap), easing the pain syndrome, and disinfecting adjacent areas, removing foci of inflammation. Instrumental operations are combined with the use of broad-spectrum antibiotics that can kill the infection and prevent it from developing further.

If tooth tissue can be restored, specialists should try to activate the natural regenerative process, which will restore the normal shape of the gums and bone tissue.

The method of treating periodontitis is chosen by the doctor based on complex diagnostic measures, giving an accurate understanding of what type of periodontitis we are talking about.

Used in advanced cases when there is a threat of deeper spread of infection. Among the surgical methods used are the following:

• Resection of the apex of the tooth root (removal of the apex of the root along with the one present on it);
• Coronoradicular separation - dissection of a multi-rooted tooth;
• Cystomy – removal of a cyst;
• Removal of a tooth.

In the event that gradual, conservative methods do not give the expected effect, and this happens quite often, the dentist transfers the patient to the hands of surgeons, who remove all affected and injured tissues. This allows you to stop the development of infection and prevent it from spreading to other areas of the gum.

The operation is carried out under conditions outpatient treatment under local anesthesia, and after the operation, the patient must take antibiotics and antiseptics, which will completely destroy the infection.

When a tooth is a source of danger to the integrity of the dentition, and surgery is not advisable due to total tissue damage, the tooth is removed.

Surgical treatment can be carried out only if the tooth canals are obturated along their length, which guarantees that the process will not lead to remission.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2015

Acute apical periodontitis of pulpal origin (K04.4)

Dentistry

general information

Short description

Recommended
Expert advice
RSE at the RVC "Republican Center"
healthcare development"
Ministry of Health
And social development
Republic of Kazakhstan
dated October 15, 2015
Protocol No. 12

Protocol name: Acute periodontitis

Acute periodontitis- spicy inflammatory disease periodontal tissues.

Protocol code:

ICD-10 code(s):
K04.4 Acute apical periodontitis of pulpal origin

Abbreviations used in the protocol:
EDI - electroodontodiagnosis
EOM - electroodontometry
EDTA - ethylenediaminetetraacetate
GIC - glass ionomer cement

Date of protocol development/revision: 2015

Protocol users: dentist-therapist, dentist general practice, Dentist.

Assessment of the degree of evidence of the recommendations provided.

Table - 1 Level of evidence scale:

Classification

Clinical classification apical periodontitis (MMSI, 1987) :

1. Acute apical periodontitis:
a) intoxication phase;
b) exudation phase: serous, purulent

2. Chronic apical periodontitis:

A) fibrous;
b) granulating;
c) granulomatous;

Clinical picture

Symptoms, course

Diagnostic criteria for diagnosis[ 2, 3, 4, 5, 7 ]

Complaints and anamnesis[ 2, 3, 4, 5, 7 ] :
The main symptom of acute apical periodontitis is constant localized pain. Clinical manifestations are determined by the phase of acute periodontitis. In acute periodontitis, the transition from the intoxication phase to the exudation phase occurs very quickly.

Table - 2. Survey data

Physical examination:

Table - 3. Physical examination data

Diagnostics

List of basic and additional diagnostic measures:

Basic (mandatory) and additional diagnostic examinations carried out on an outpatient basis:

1. collection of complaints and anamnesis
2. general physical examination (external examination and examination itself oral cavity probing of the carious cavity, percussion of the tooth, palpation of the gums and transitional folds)
3. determination of the tooth’s reaction to temperature stimuli
4. EDI
5. X-ray of the tooth.

Minimum list of examinations that must be carried out when referring for planned hospitalization: no

Basic (mandatory) diagnostic examinations carried out at the inpatient level (in case of emergency hospitalization, diagnostic examinations not carried out at the outpatient level are carried out): no

Diagnostic measures carried out at the emergency stageemergency care: No

Instrumental studies:

Table - 4. Data instrumental studies

Indications for consultation with specialists: according to indications - consultation with a dental surgeon for periostotomy

Laboratory diagnostics

Laboratory research(according to indications): No.

Differential diagnosis

Differential diagnosis.

We carry out differential diagnosis with acute purulent pulpitis, acute odontogenic osteomyelitis, acute sinusitis (if the causative tooth is localized in the upper jaw), exacerbation of chronic periodontitis, as well as acute apical periodontitis in the intoxication phase with acute apical periodontitis in the exudation phase.

Table - 5 Differential diagnostic signs of acute periodontitis

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:

· pain relief;
· stop the development of the pathological process;
· prevention of complications;
· restoration of the anatomical shape and function of the tooth;
· restoration of dental aesthetics.

Treatment tactics[ 6, 7, 8, 9, 10, 11, 12 ] :

Treatment is carried out on an outpatient basis.
The following treatment methods are used:
1) Conservative method;
2) Surgical methods treatment (if indicated - periostotomy).
Premedication is administered according to indications.

Table - 6 Treatment of acute periodontitis in the intoxication phase

Table - 7 Treatment of acute periodontitis in the exudation phase.

*The number of visits depends on the choice of filling material for obturation of the root canal.

Treatment in one visit.
The indication for the treatment of acute periodontitis in one visit is to perform a periostotomy in a single-rooted tooth.

Drug treatment:

Table - 8

Other types of treatment: No

Surgical intervention:

Surgical intervention provided on an outpatient basis: periostotomy

Surgical intervention provided in an inpatient setting: No

Indicators of treatment effectiveness.
· satisfactory condition;
· absence of pain;
· high-quality obturation of root canals;
· restoration of the anatomical shape and function of the tooth.

Drugs ( active ingredients), used in the treatment

Hospitalization

Indications for hospitalization: No

Prevention

Preventive actions:
· training in oral hygiene,
· professional oral hygiene,
· timely sanitation of the oral cavity (treatment of dental caries and pulpitis),
· fluoridation of drinking water,
· use of fluoride-containing toothpastes (for fluoride deficiency in drinking water);
· carrying out remineralizing therapy,
· preventive sealing of fissures and blind pits,
· comprehensive prevention of major dental diseases,
normalization of the regime and nutritional pattern,
rational prosthetics and orthodontic treatment,
· dental education.

Further management: observation after 1; 3; 6 months.

Information

Sources and literature

1. Minutes of meetings Expert Council RCHR MHSD RK, 2015
   1. List of used literature: 1. Order of the Ministry of Health of the Republic of Kazakhstan No. 473 dated 10.10.2006. “On approval of the Instructions for the development and improvement clinical guidelines and protocols for the diagnosis and treatment of diseases.” 2. Therapeutic dentistry: Textbook for students of medical universities / Ed. E.V. Borovsky. - M.: “Medical Information Agency”, 2011.-798 p. 3. Therapeutic dentistry: Textbook / Ed. Yu.M. Maksimovsky. – M.: Medicine, 2002. -640 p. 4. Nikolaev A.I., Tsepov L.M. Practical therapeutic dentistry: Tutorial– M.: MEDpress-inform, 2008. – 960 p. 5. Periodontitis. Clinic, diagnosis, treatment: Textbook. Zazulevskaya L.Ya., Baibulova K.K. and others - Almaty: Verena, 2007. -160 pp. 6. Nikolaev A.I., Tsepov L.M. Phantom course of therapeutic dentistry. Textbook. M.: “MEDpress-inform”. 2014. –430 p. 7. Antanyan A.A. Effective endodontics. Moscow. 2015. 127 p. 8. Martin Troup. A guide to endodontics for general dentists. – 2005. – 70 p. 9. Lutskaya I.K., Martov V.Yu. Medicines in dentistry. – M.: Med.lit., 2007. -384 p. 10. Steven Cohen, Richard Burns. Endodontics.-S-P.- 2000.- 693 p. 11. Krasner P, Rankow HJ. Anatomy of the pulp chamber floor. Journal of Endodontics (JOE) 2004;30(1):5 12. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod 2008;34:1171-6. 13. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol J Endod 2004;196-2004. 14. Friedlander LT, Cullinan MP, Love RM. Dental stem cells and their potential role in apexogenesis and apexification. Int Endod J 2009;42:955-62.

Information

List of protocol developers with qualification information:
1. Esembaeva Saule Serikovna - Doctor of Medical Sciences, Professor - Director of the Institute of Dentistry of the Kazakh National Medical University named after S.D. Asfendiyarov;
2. Bayakhmetova Aliya Aldashevna - Doctor of Medical Sciences, Professor, Head of the Department of Therapeutic Dentistry of the Kazakh National Medical University named after S.D. Asfendiyarov;
3. Sagatbaeva Anar Dzhambulovna - Candidate of Medical Sciences, Associate Professor of the Department of Therapeutic Dentistry of the Kazakh National Medical University named after S.D. Asfendiyarov;
4. Smagulova Elmira Niyazovna - candidate of medical sciences, assistant at the department of therapeutic dentistry, Institute of Dentistry, Kazakh National Medical University named after S.D. Asfendiyarov;
5. Tuleutaeva Raikhan Yesenzhanovna - candidate of medical sciences, acting associate professor of the department of pharmacology and evidence-based medicine State Medical University of Semey.

Disclosure of no conflict of interest: No

Reviewers:
1. Zhanalina Bakhyt Sekerbekovna - Doctor of Medical Sciences, Professor of the Western Kazakhstan State University medical University them. M. Ospanova, head of the department of surgical dentistry and pediatric dentistry;
2. Mazur Irina Petrovna - Doctor of Medical Sciences, Professor of the National medical academy postgraduate education named after P.L. Shupika, professor of the Department of Dentistry, Institute of Dentistry.

Indication of the conditions for reviewing the protocol: revision of the protocol after 3 years and/or when new diagnostic and/or treatment methods with more high level evidence.

Attached files

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Alas, it is not an uncommon sight: a dentist comes to work in the morning, and the first sufferer is already waiting for him near the office - sleep-deprived, red eyes, mouth slightly open, holding his jaw with his hand - all the signs of severe pain are evident. These are the manifestations of acute periodontitis.

Acute periodontitis, as its name suggests, is an acute inflammation of the tissues surrounding the apex of the tooth root, the periodontium.

The periodontium is a connective tissue structure designed to hold the tooth in the bone socket, as well as to transmit chewing load to the jawbone.

Normal, healthy periodontium of all teeth of both jaws has a huge margin of strength and is able to withstand pressure tens of times greater than the capabilities of all masticatory muscles.

Video: periodontitis

Kinds

Serous

Serous periodontitis is the first phase of an acute reaction of the periodontium to irritation, be it an infection, injury or any other impact.

In this case, first small and then large areas of changes in the periodontium appear. The lumen of blood capillaries increases, and the permeability of their walls increases. Serous fluid appears with an increased content of leukocytes.

The waste products of microorganisms, as well as the decay products of various cells, irritate sensitive nerve endings. This leads to constant pain, slight at first, but constantly intensifying.

The pain intensifies significantly when the tooth is tapped, although in some cases prolonged pressure on the tooth may provide some relief from the pain. The tissues surrounding the tooth are not yet involved in the inflammatory process, so no external changes are observed on their part.

Acute purulent periodontitis

In the absence of timely treatment, serous inflammation turns purulent.

Small purulent foci, microabscesses, unite into a single focus of inflammation. Purulent discharge, consisting of the breakdown of cells of various periodontal tissues and blood cells (mainly leukocytes) creates excess pressure.

The symptoms of acute periodontitis are very clear. The fixation of the tooth in the socket worsens, and a temporary, reversible appearance of tooth mobility is possible. The pain becomes sharp, tearing, radiating to adjacent teeth or even to the opposite jaw.

Any touch to the tooth is extremely painful; with normal closing of the mouth, the impression of premature occlusion is created only on the diseased tooth; a “feeling of a grown tooth” appears, although no real movement of the tooth from the socket is observed.

Causes

Complication of pulpitis

Most common cause of this disease is any form of pulpitis, especially acute. In this case, the inflammation passes beyond the apical foramen, spreading to the periodontal tissue.

Video: what is pulpitis

Poorly sealed canals

In the presence of untraversed canals, as well as in the case of resorption of the root filling, foci of intracanal inflammation arise that can involve pathological process and postapical tissues.

Therefore, it is extremely important for any endodontic intervention to achieve complete and permanent obturation of the root canals along their entire length.

Marginal

Less commonly, the entry points for infection in periodontal tissue are periodontal pockets. With their significant depth, as well as in the presence of abundant deposits (or in the case of acute trauma to the marginal periodontium), a marginal onset of acute periodontitis is possible.

In this case, the gums around the tooth will have inflammatory changes, often with profuse suppuration.

Pain due to active drainage of the inflammation site will not be as pronounced as with the apical localization of the pathological process.

Traumatic

With a strong short-term impact on the tooth (for example, during a blow), traumatic changes occur in the periodontium, from mild sprains to long-term ruptures of ligaments.

Depending on the degree of damage, pain of varying severity is observed, significantly increasing from touching the tooth, as well as its mobility.

With prolonged, constant exposure to the tooth, a restructuring of periodontal tissue can occur, expressed in an increase in the periodontal gap, as well as destruction of both periodontal ligaments and lysis of the walls of the bone socket, leading to loosening of the tooth.

Medication

Drug-induced periodontitis occurs when exposure to periodontal tissue various drugs, either mistakenly introduced into the root canals, or used in violation of treatment technologies.

The most common variant of drug-induced periodontitis is “arsenic periodontitis,” which occurs either when there is an overdose of devitalizing drugs, or when they remain inside the tooth for longer than the recommended time.

A marginal onset of arsenic periodontitis is also possible in the case of cervical localization of the tooth cavity and a leaky temporary filling.

Treatment consists of removing the toxic drug and treating the inflamed tissue with an antidote, for example, a unithiol solution.

Development mechanism

During the development of a focus of inflammation in the periodontium, a successive change of several stages occurs.

• In the first of them, periodontal, the focus (one or several) is delimited from other areas of the periodontium.
• As the main focus of inflammation increases (and when several merge), a large part of the periodontium is gradually involved in inflammation. Symptoms are increasing.
• Under the influence of increased pressure in the closed space of the periodontium, the exudate seeks a way out and usually finds it, breaking through either through the marginal area of ​​the periodontium into the oral cavity, or through the internal compact bone plate of the tooth socket into the bone spaces of the jaw.
• In this case, the exudate pressure decreases sharply, the pain significantly weakens and the patient experiences significant relief. Unfortunately, in the absence of proper treatment, the spread of inflammation does not stop there; it passes under the periosteum.
• The subperiosteal stage of development of acute periodontitis is manifested by the appearance of periostitis, that is, gumboil. The periosteum bulges into the oral cavity, hiding purulent discharge underneath.
• Since the periosteum is a dense connective tissue formation, it is able to restrain the pressure of exudate for some time. At this time, patients complain of the appearance of significant, painful swelling in the area of ​​​​the projection of the apex of the tooth root.
• After the periosteum breaks through, the exudate enters under the oral mucosa, which is unable to provide any long-term resistance.

Subsequently, a fistula forms, the outflow of pus is established, and the patient’s complaints sharply weaken until they almost completely disappear.

But that's only external changes, in fact, the inflammatory process with the appearance of an outflow tract continues to function and is capable of further increase and complications, up to the appearance of osteomyelitis.

However, in some cases, fistula formation makes it possible to significantly subside the first phase of periodontal inflammation and its transition to chronic periodontitis.

Diagnostics

Diagnosis is not difficult.

The presence in the past of throbbing pain, intensifying at night (history of pulpitis) or a significant defect in the crown of the tooth, painless on probing, speaks in favor of acute periodontitis.

Severe pain that intensifies when you touch the tooth allows you to verify the correctness of this diagnosis.

Differential diagnosis should be carried out with:

• Acute pulpitis. With pulpitis, the pain pulsates, has a paroxysmal character and does not change with percussion; with periodontitis, strong, tearing and continuous, aggravated by touching the tooth;
• Exacerbation of chronic periodontitis. The best way– X-ray, with acute periodontitis there are no changes in the periodontal area;
• Osteomyelitis. The lesion is extensive, covering the roots of several teeth. Therefore, severe pain occurs when percussion occurs on several adjacent teeth.

Treatment

Endodontic

Treatment of acute periodontitis begins after examination, diagnosis and receipt informed consent patient.

First of all, you should take care of high-quality pain relief, since the inflamed periodontium reacts extremely painfully to the slightest touch to the tooth, as well as to vibration, which is inevitable during preparation.

Photo: Treatment of acute periodontitis requires the use of anesthesia

If there is a defect in the crown part of the tooth, it is necessary to prepare it within healthy tissues.

Old fillings, if any, must be removed. Then, under the cover of an antiseptic solution (chlorhexidine digluconate or sodium hypochlorite), the orifices of the root canals should be found and opened. If they have been filled previously, the root fillings are removed.

If the canals are being treated for the first time, it is necessary to remove their infected contents and perform mechanical treatment of the walls, excising non-viable tissue, as well as increasing the lumen of the canals necessary for further treatment and filling.

When treating acute apical periodontitis after obtaining sufficient outflow of exudate through the root canals, the doctor’s actions should be aimed at achieving three goals (the principle of triple action according to Lukomsky):

• Fighting pathogenic microflora in the main root canals.
• Fights infection in root canal branches and root dentinal tubules.
• Suppression of inflammation in the periodontium.

To achieve success in these areas, many methods have been proposed, among which the most effective are:

• Electrophoresis with antiseptic solutions;
• Ultrasonic diffusion enhancement(penetration) of medicinal preparations into the root canals;
• Laser treatment of root canals. In this case, the bactericidal effect is achieved both from the radiation itself and from the release of atomic oxygen or chlorine when the laser acts on special solutions.

Upon completion of the mechanical and antiseptic treatment of the canals, the tooth should be left open for 2–3 days, the patient being prescribed an antibacterial drug and hypertonic rinses.

If there are signs of periostitis, it is necessary to make an incision along the transitional fold in the area of ​​​​the projection of the root apex (with mandatory dissection of the periosteum). The resulting wound should be stream washed with an antiseptic solution, leaving elastic drainage.

On the second visit, if an incision has been made and there are practically no complaints, permanent root canal filling is possible.

Otherwise, the canals should be filled temporarily for approximately 5–7 days (with calcium hydroxide or post-apical therapy paste). Then the installation of a permanent root filling and restoration of the crown of the tooth are postponed to the third visit.

In case of obstruction of the root canals or if endodontic treatment is unsuccessful, the tooth must be removed. After extracting the tooth, it is recommended to place antibacterial drug and stop the bleeding.

The patient is given recommendations: do not rinse your mouth or eat food for several hours, do not allow the socket to warm up and beware of large physical activity. The next day, it is advisable to carry out a control inspection of the outer part of the hole.

In the absence of complaints and signs of alveolitis, further healing of the socket usually does not require medical intervention. Otherwise, the hole should be freed from the remaining coagulated blood and loosely tamponed with a strip of bandage sprinkled with iodoform. Repeat the procedure after 1–2 days.

Forecast

When carrying out high-quality treatment of acute apical periodontitis, the prognosis is favorable.

In most cases, the periodontium becomes an asymptomatic state of chronic fibrous periodontitis and does not require further treatment. In the case of an increase in symptoms, as a rule, a diagnosis of “exacerbation of chronic periodontitis” is made and appropriate treatment is carried out.

If a person does not apply for qualified assistance to a specialist or treatment is carried out without achieving the required result, further events can develop in one of two directions:

Deterioration of the condition with the development of acute purulent complications, such as periostitis, abscess and/or phlegmon. Osteomyelitis may also develop.

Reducing the severity of inflammation (complaints and clinical manifestations), transition of periodontal inflammation to chronic course, most often with the formation of granulomas and cysts, with rare or frequent exacerbations.

Prevention

The best prevention is to prevent the occurrence or timely treatment of caries and its complications - pulpitis. It is necessary to avoid overloading the periodontium, especially during prosthetics and correction of malocclusions.

You should also strictly adhere to existing technologies for treating diseases of the oral cavity in order to avoid the occurrence of drug-induced periodontitis.

Acute periodontitis- acute periodontal inflammation.

Etiology. Acute purulent periodontitis develops under the influence of mixed flora, where streptococci predominate (mainly non-hemolytic, as well as viridian and hemolytic), sometimes staphylococci and pneumococci. Possible rod-shaped forms (gram-positive and gram-negative), anaerobic infection, which is represented by obligate anaerobic infection, non-fermenting gram-negative bacteria, veillonella, lactobacilli, yeast-like fungi. In untreated forms of apical periodontitis, microbial associations number 3-7 types. Pure cultures are extremely rarely isolated. With marginal periodontitis, in addition to the listed microbes, there is a large number of spirochetes, actinomycetes, including pigment-forming ones. Pathogenesis. An acute inflammatory process in the periodontium primarily occurs as a result of the penetration of infection through an opening in the apex of the tooth, or less often through a pathological periodontal pocket. Damage to the apical part of the periodontium is possible due to inflammatory changes in the pulp, its necrosis, when the abundant microflora of the tooth canal spreads into the periodontium through the apical opening of the root. Sometimes the putrefactive contents of the root canal are pushed into the periodontium during chewing, under the pressure of food.

Marginal, or marginal, periodontitis develops as a result of infection penetration through the gum pocket due to injury or contact with the gum medicinal substances, including arsenic paste. Microbes that have penetrated into the periodontal gap multiply, form endotoxins and cause inflammation in periodontal tissues. Great importance in the development of the primary acute process in the periodontium, they have some local features: lack of outflow from the pulp chamber and canal (presence of an unopened pulp chamber, filling), microtrauma during active chewing load on a tooth with an affected pulp. They also play a role common reasons: hypothermia, past infections, etc., but most often the primary effect of microbes and their toxins is compensated by various nonspecific and specific reactions of periodontal tissues and the body as a whole. Then an acute infectious-inflammatory process does not occur. Repeated, sometimes prolonged exposure to microbes and their toxins leads to sensitization, and antibody-dependent and cellular reactions develop. Antibody-dependent reactions develop as a result of immune complex and IgE-mediated processes. Cellular reactions reflect allergic reaction delayed type hypersensitivity. The mechanism of immune reactions, on the one hand, is due to a violation of phagocytosis, the complement system and an increase in polymorphonuclear leukocytes; on the other hand, by the proliferation of lymphocytes and the release of lymphokines from them, causing destruction of periodontal tissue and resorption of nearby bone. Various cellular reactions develop in the periodontium: chronic fibrous, granulating or granulomatous periodontitis. Violation of protective reactions and repeated exposure to microbes can cause the development of an acute inflammatory process in the periodontium, which in essence is an exacerbation of chronic periodontitis. Clinically, they are often the first symptoms of inflammation. The development of pronounced vascular reactions in a fairly closed periodontal space, an adequate protective response of the body, as a rule, contributes to inflammation with a normergic inflammatory reaction.

The compensatory nature of the response of periodontal tissues during a primary acute process and exacerbation of a chronic one is limited by the development of an abscess in the periodontium. It can be emptied through the root canal, gum pocket when opening a periapical lesion or removing a tooth. In some cases, under certain general and local pathogenetic conditions purulent focus is the cause of complications of odontogenic infection, when purulent diseases develop in the periosteum, bone, and perimaxillary soft tissues.

Pathological anatomy. During an acute process, the main phenomena of inflammation appear in the periodontium - alteration, exudation and proliferation. Acute periodontitis is characterized by the development of two phases - intoxication and a pronounced exudative process. In the intoxication phase, migration of various cells occurs - macrophages, mononuclear cells, granulocytes, etc. - into the zone of microbial accumulation. In the phase of the exudative process, inflammatory phenomena increase, microabscesses form, periodontal tissue melts and a limited abscess is formed. On microscopic examination, in the initial stage of acute periodontitis, one can see hyperemia, swelling and a small leukocyte infiltration of the periodontal area around the root apex. During this period, perivascular lymphohistiocytic infiltrates containing single polynuclear cells are detected. As the inflammatory phenomena further increase, leukocyte infiltration intensifies, capturing larger areas of the periodontium. Separate purulent lesions form - microabscesses, and periodontal tissue melts. Microabscesses connect with each other, forming an abscess. When a tooth is removed, only individual remaining areas of sharply hyperemic periodontium are revealed, and throughout the rest of the root the root is exposed and covered with pus.

An acute purulent process in the periodontium causes changes in the tissues surrounding it (bone tissue of the alveolar walls, periosteum of the alveolar process, maxillary soft fabrics, tissues of regional lymph nodes). First of all, the bone tissue of the alveoli changes. In the bone marrow spaces adjacent to the periodontium and located over a considerable extent, swelling is noted bone marrow and varying degrees of pronounced, sometimes diffuse, infiltration of it by neutrophilic leukocytes. In area cortical plate in the alveoli, lacunae filled with osteoclasts appear, with predominant resorption (Fig. 7.1, a). Restructuring of bone tissue is observed in the walls of the socket and mainly in the area of ​​its bottom. The predominant resorption of bone leads to the expansion of the holes in the walls of the socket and the opening of the bone marrow cavities towards the periodontium. There is no necrosis of the bone beams (Fig. 7.1, b). Thus, the restriction of the periodontium from the alveolar bone is broken. In the periosteum covering the alveolar process, and sometimes the body of the jaw, in the adjacent soft tissues - gums, peri-maxillary tissues - signs of reactive inflammation are recorded in the form of hyperemia, edema, and inflammatory changes are also observed in the lymph node or 2-3 nodes, respectively, of the affected periodontium of the tooth . Inflammatory infiltration is observed in them. In acute periodontitis, the focus of inflammation in the form of abscess formation is mainly localized in the periodontal fissure. Inflammatory changes in the alveolar bone and other tissues are reactive, perifocal in nature. And it is impossible to interpret reactive inflammatory changes, especially in the bone adjacent to the affected periodontium, as its true inflammation.

Clinical picture. In acute periodontitis, the patient indicates pain in the causative tooth, which intensifies when pressing on it, chewing, and also when tapping (percussion) on the chewing or cutting surface. The feeling of “growing” or lengthening of the tooth is characteristic. With prolonged pressure on the tooth, the pain subsides somewhat. Subsequently, the pain intensifies, becoming continuous or with short light intervals. They are often pulsating. Thermal effects, the patient taking a horizontal position, touching the tooth, and biting increase the pain. Pain spreads along the branches trigeminal nerve. The general condition of the patient is satisfactory. On external examination, as a rule, there are no changes. Observe enlargement and pain associated with the affected tooth lymph node or nodes. Some patients may have mildly expressed collateral edema of the perimaxillary soft tissues adjacent to this tooth. Percussion is painful in both vertical and horizontal directions. The mucous membrane of the gums, alveolar process, and sometimes the transitional fold in the projection of the tooth root is hyperemic and swollen. Palpation of the alveolar process along the root, especially corresponding to the opening of the apex of the tooth, is painful. Sometimes, when pressing with an instrument on the soft tissues of the vestibule of the mouth along the root and transitional fold, an impression remains, indicating their swelling.

Diagnostics based on the characteristic clinical picture and examination data. Temperature stimuli and electrical odongometry data indicate a lack of pulp response due to its necrosis. On an x-ray during an acute process of pathological changes in the periodontium, it is possible not to detect or to detect an expansion of the periodontal fissure, blurred cortical plasticity of the alveoli. With an exacerbation of the chronic process, changes characteristic of granulating, granulomatous, and rarely fibrous periodontitis occur. As a rule, there are no changes in the blood, but in some patients leukocytosis (up to 9-10 9 /l), moderate neutrophilia due to band and segmented leukocytes are possible; ESR is often within normal limits.

Differential diagnosis. Acute periodontitis is differentiated from acute pulpitis, periostitis, osteomyelitis of the jaw, suppuration of the root cyst, acute odontogenic sinusitis. Unlike pulpitis, in acute periodontitis the pain is constant, and in diffuse inflammation of the pulp it is paroxysmal. In acute periodontitis, in contrast to acute pulpitis, inflammatory changes are observed in the gum adjacent to the tooth; percussion is more painful. In addition, electrical odontometry data helps in diagnosis. Differential diagnosis of acute periodontitis and acute purulent periostitis of the jaw is based on more pronounced complaints, feverish reaction, the presence of collateral inflammatory edema of the peri-maxillary soft tissues and diffuse infiltration along the transitional fold of the jaw with the formation of a subperiosteal abscess. Percussion of the tooth during periostitis of the jaw is less painful, unlike acute periodontitis. For the same, more pronounced general and local symptoms, differential diagnosis acute periodontitis and acute osteomyelitis of the jaw. Acute osteomyelitis of the jaw is characterized by inflammatory changes in the adjacent soft tissues on both sides of the alveolar process and the body of the jaw. In acute periodontitis, percussion is sharply painful in the area of ​​one tooth, in osteomyelitis - in several teeth. Moreover, the tooth that was the source of the disease reacts to percussion less than neighboring intact teeth. Laboratory data - leukocytosis, ESR, etc. - allow us to distinguish between these diseases.

Purulent periodontitis should be differentiated from suppuration of a perihilar cyst. The presence of limited bulging of the alveolar process, sometimes the absence of bone tissue in the center, and displacement of teeth, in contrast to acute periodontitis, characterize a suppurating perihilar cyst. An x-ray of a cyst reveals a round or oval area of ​​bone resorption.

Acute purulent periodontitis must be differentiated from acute odontogenic inflammation maxillary sinus, in which pain may develop in one or more adjacent teeth. However, congestion of the corresponding half of the nose, purulent discharge from the nasal passage, headache, and general malaise are characteristic of acute inflammation of the maxillary sinus. Violation of the transparency of the maxillary sinus, revealed on an x-ray, allows you to clarify the diagnosis.

Treatment. Therapy for acute apical periodontitis or exacerbation of chronic periodontitis is aimed at stopping the inflammatory process in the periodontium and preventing the spread of purulent exudate into the surrounding tissues - the periosteum, perimaxillary soft tissues, bone. Treatment is predominantly conservative and is carried out according to the rules set out in the corresponding section of the textbook “Therapeutic Dentistry” (2002). Conservative treatment is more effective with infiltration or conduction anesthesia with 1-2% solutions of lidocaine, trimecaine, ultracaine.

A more rapid subsidence of inflammatory phenomena is facilitated by a blockade - the introduction of an infiltration anesthesia type of 5-10 ml of a 0.25-0.5% solution of an anesthetic (lidocaine, trimecaine, ultracaine) with lincomycin into the area of ​​the vestibule of the mouth along the alveolar process, respectively, to the affected one and 2-3 neighboring teeth. The anti-edematous effect is provided by the introduction of the homeopathic remedy “Traumel” in the amount of 2 ml along the transitional fold or external dressings with ointment of this drug.

It must be borne in mind that without the outflow of exudate from the periodontium (through the tooth canal), blockades are ineffective and often ineffective. The latter can be combined with an incision along the transitional fold to the bone, with perforation of the anterior wall of the bone using a bur, corresponding to the peri-apical part of the root. This is also indicated in case of unsuccessful conservative therapy and an increase in inflammatory phenomena, when it is not possible to remove the tooth due to some circumstances. If ineffective therapeutic measures and increasing inflammation, the tooth should be removed. Tooth extraction is indicated when there is significant destruction, obstruction of the canal or canals, or the presence of foreign bodies in the channel. As a rule, tooth extraction leads to rapid subsidence and subsequent disappearance of inflammatory phenomena. This can be combined with an incision along the transitional fold to the bone in the area of ​​the root of the tooth affected by acute periodontitis. After tooth extraction during a primary acute process, curettage of the hole is not recommended, but should only be washed with a solution of dioxidine, chlorhexedine and its derivatives, gramicidin. After tooth extraction, pain may intensify and body temperature may rise, which is often due to the traumatic nature of the intervention. However, after 1-2 days, these phenomena, especially with appropriate anti-inflammatory drug therapy, disappear.

To prevent complications after tooth extraction, you can inject anti-staphylococcal plasma into the dental alveolus, wash it with streptococcal or staphylococcal bacteriophage, enzymes, chlorhexidine, gramicidin, leave an iodoform swab and a sponge with gentamicin in the mouth. General treatment acute or exacerbation of chronic periodontitis consists of the oral administration of pyrazolone drugs - analgin, amidopyrine (0.25-0.5 g each), phenacetin (0.25-0.5 g each), acetylsalicylic acid(0.25-0.5 g each). These drugs have analgesic, anti-inflammatory and desensitizing properties. Some patients are prescribed sulfonamide drugs according to indications (streptocide, sulfadimezin - 0.5-1 g every 4 hours or sulfadimethoxine, sulfapyridazine - 1-2 g per day). However, the microflora, as a rule, is resistant to sulfa drugs. In this regard, it is more advisable to prescribe 2-3 pyrosolone medicines(acetylsalicylic acid, analgin, amidopyrine) /4 tablets of each, 3 times a day. This combination of drugs gives an anti-inflammatory, desensitizing and analgesic effect. In weakened patients burdened with other diseases, especially of cardio-vascular system, connective tissue, kidney diseases are treated with antibiotics - erythromycin, kanamycin, oletethrin (250,000 units 4-6 times a day), lincomycin, indomethacin, voltaren (0.25 g) 3-4 times a day. Foreign specialists, after tooth extraction due to an acute process, necessarily recommend treatment with antibiotics, considering such therapy also as a prevention of endocarditis and myocarditis. After tooth extraction in acute periodontitis, in order to stop the development of inflammatory phenomena, it is advisable to use cold (an ice pack on the soft tissue area corresponding to the tooth for 1-2-3 hours). Next, warm rinses, sollux are prescribed, and when the inflammatory phenomena subside, others are prescribed. physical methods treatment: UHF, fluctuarization, electrophoresis of diphenhydramine, calcium chloride, proteolytic enzymes, exposure to helium-neon and infrared lasers.

Exodus. With correct and timely conservative treatment in most cases of acute and exacerbation of chronic periodontitis, recovery occurs. (Insufficient treatment of acute periodontitis leads to the development of a chronic process in the periodontium.) It is possible for the inflammatory process to spread from the periodontium to the periosteum, bone tissue, peri-maxillary soft tissues, i.e. Acute periostitis, osteomyelitis of the jaw, abscess, phlegmon, lymphadenitis, inflammation of the maxillary sinus may develop.

Prevention is based on sanitation of the oral cavity, timely and proper treatment pathological odontogenic foci, functional unloading of teeth using orthopedic treatment methods, as well as carrying out hygienic and health measures.

The periodontium is a complex of tissues that connects the tooth root and the alveolar plate. The main functions of the periodontal ligament: fixation of teeth in the alveolus, uniform redistribution of the load on the tooth and alveolar tissues during chewing, nutrition of the cement of the tooth and alveoli. The inflammatory process leads to dysfunction of the periodontium and causes acute throbbing pain. Lack of timely treatment can cause tooth loss and the development of complications such as phlegmon, abscess, and periostitis.

Causes of the disease

The causes of acute periodontitis can be infectious or non-infectious. The first include:

1. An advanced form of caries and, as a result, pulpitis. From the pulp through the root canal, pathogenic bacteria penetrate into periodontal tissue, provoking the occurrence of an inflammatory process and the development of periodontitis.
2. Poor quality root canal treatment in the treatment of pulpitis. If the patient has not had all root canals treated, the infection remains in the tooth tissue and exists high risk its further spread.
3. Gum diseases, which are accompanied by inflammatory processes. The infection penetrates through the periodontal pockets, often accompanied by discharge large quantity pus.

Non-infectious causes of acute periodontitis are:

Symptoms

Due to the fact that acute periodontitis does not manifest itself in any way at the initial stage, the disease is difficult to diagnose. The only symptom is the occurrence of minor painful sensations when pressing on the affected tooth. As inflammation develops, the following symptoms appear:

• sharp or aching pain local in nature, which intensify with thermal or physical influence;
• slight swelling and redness of the gums in the area of ​​inflammation;
• inflammation of the lymph nodes.

The transition of the disease to the next stage is accompanied by intoxication and the appearance of additional symptoms:

Forms of acute periodontitis

There are two main forms of acute periodontitis:

1. Acute serous periodontitis is initial stage inflammatory process can affect not only “living” teeth, but also teeth with the nerve removed during treatment. The disease develops rapidly, from the moment of onset to the appearance of the first symptoms, less than a day passes. Serous periodontitis is indicated by the presence pain while biting and chewing food. There is swelling and tenderness of the gums in the affected area. The serous form of the disease is classified according to location. Highlight the following types diseases: apical (the source of inflammation is located in the upper third of the tooth root), marginal (tissues located along the ligamentous apparatus are affected), diffuse (the infection spreads to the entire root).
2. Purulent periodontitis appears if the previous stage, serous, was not treated in time. Characterized by severe pain, which is accompanied by the penetration of purulent masses under the root of the tooth. May be observed painful sensations in the area of ​​the ears, eyes and in the temporal zone, general weakness, malaise, general increase in temperature and enlarged lymph nodes.

The development of acute purulent periodontitis occurs in several stages:

• periodontal (the appearance of a microabscess in the area of ​​the periodontal fissure, the appearance of a subjective sensation of an enlarged tooth);
• endosseous (penetration of pus into bone tissue);
• subperiosteal (accumulation of pus under the periosteum, formation of flux);
• submucous (entry of purulent masses into soft tissues, accompanied by a decrease in pain and an increase in swelling of the face).

Diagnostics

To diagnose the disease, the dentist conducts a survey and visual examination of the patient. The presence of pronounced symptoms (pulsating pain that increases with pressure, swelling of the gums, a defect in the crown of the tooth, discoloration of the tooth enamel) indicates the presence of acute periodontitis.

The following methods can be used for additional diagnostics:

1. X-ray. An image of an inflamed tooth with a purulent form shows an expansion of the periodontal fissure, and the cortical alveolar plate is poorly visible. X-rays for acute periodontitis, at the serous stage, make it possible to find out the etiology of the disease and determine the optimal treatment regimen.
2. Electroodontometry - checking the reaction to electricity to determine tissue sensitivity indicators. With purulent periodontitis, the readings will be above 100 μA ( healthy tooth responds to 2-5 µA).
3. Thermal test. Periodontitis is characterized by increased sensitivity to hot irritants, but no reaction to cold; however, in the serous form of the disease, the test result is negative.
4. General blood analysis. There may be an increased number of white blood cells and a change in the erythrocyte sedimentation rate.

Treatment methods

Treatment of acute periodontitis is aimed at stopping the inflammatory process, preventing the spread of purulent masses into the surrounding tissues and the penetration of infection into the blood, and restoring the damaged tooth. The standard treatment regimen includes two main stages:

1. Opening and widening the canal to drain pus and accumulated fluid. Then processing is carried out disinfectants To disinfect purulent particles, an antiseptic bandage is applied to the damaged area.
2. Root canal filling. In case of serous periodontitis, a root filling can be installed at the first visit to the dentist after thorough disinfection of the canal.

Treatment includes taking antibiotics (Tsiprolet, Sulfadimethoxin), antihistamines (Diazolin, Suprastin), rinsing the mouth with warm antiseptic solutions (Rivanol, Furacillin). If necessary, the patient can be prescribed analgesics (Ketorol, Analgin).

If periodontal damage is caused by improper use of medications, careful treatment of the canal using an antidote is necessary. A single injection into the mucous membrane of a drug that reduces the effect of toxins on the body may be required. Then a sealed bandage is applied. After the pain disappears and in the absence of exacerbations, the canals are treated and filled. Acute traumatic periodontitis involves treatment aimed at eliminating the consequences of mechanical damage to the tooth and subsequent restoration of the dental unit.

Prevention and prognosis

Regular visits to the dentist and timely healing procedures- the main preventive measure to prevent the development of acute periodontitis. To maintain the health of the dentition, it is necessary to carefully observe oral hygiene and carry out periodic cleaning of tartar and plaque (once every six months).

Eating large quantities of foods high in sugar and carbohydrates contributes to the destruction of tooth enamel and the appearance of caries. To prevent dental disease, the diet should include unprocessed vegetables and fruits, and dairy products.

If, despite everything preventive measures If acute serous or purulent periodontitis occurs, immediate treatment must be started. In the absence of timely or poor quality medical care There are two possible scenarios:

1. The patient's condition will deteriorate significantly, complications with purulent discharge (periostitis, abscess, phlegmon, osteomyelitis) may develop.
2. Acute periodontitis will develop into chronic form, with periodic exacerbations. The formation of granulomas and cysts is possible.