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Acute periodontal conditions

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Brief description of the condition

The main acute periodontal conditions are (1) Necrotising periodontal diseases (necrotising ulcerative gingivitis and necrotising ulcerative periodontitis), (2) Periodontal abscess, and (3) Combined endodontic-periodontal (endo-perio) lesions.

Necrotising periodontal diseases are severe inflammatory conditions of the gingiva (gum) caused by pathogenic bacteria (Fusiform bacteria and Spirochetes) and are more common in immunocompromised patients. Both involve the same disease process. Necrotising ulcerative gingivitis relates to lesions limited to gingival tissue. Necrotising ulcerative periodontitis involves loss of attachment.

A periodontal abscess represents an active period of periodontal breakdown which occurs whilst there is marginal closure of the deep periodontal pocket occluding drainage. Such abscesses develop in deep periodontal pockets without external influence and are commonly seen in patients with untreated periodontitis or as a recurrent infection during a course of active treatment. Recurrent periodontal abscesses may also be a sign of undiagnosed Type II diabetes.

Endodontic and periodontal lesions (endo-perio lesions) may affect a single tooth coincidentally leading to abscess formation. Diagnosis requires radiographic examination and vitality tests and treatment of the combined lesion involves both endodontic and periodontal therapy.

Key signs and symptoms

Necrotising periodontal disease:

  • Pain (general or localised)
  • Swelling 
  • Bleeding
  • Halitosis
  • Ulcerated gingival tissue
  • Loss of gingival papillae
  • Loss of attachment/bone (in necrotising ulcerative periodontitis)
  • Malaise
  • Fever

Periodontal abscess:

  • Pain and tenderness of gingival tissue
  • Increased tooth mobility
  • Fever and swollen or enlarged regional lymph nodes
  • Presence of swelling on gingiva
  • Suppuration from the gingiva

Perio-endo abscess:

  • Generalised periodontal disease may be present with localised pain
  • Swelling with or without suppuration on palpation
  • Deep pocketing to root apex with bleeding on probing

Initial management

Determine if the airway is compromised: the patient is unable to swallow their own saliva or they are unable to push their tongue forward out of their mouth.

If the airway is compromised, send the patient immediately to emergency care via NHS 24 or call 999.

If the airway is not compromised:

  • Recommend optimal analgesia (see Appendix 2), hydration and rest.
  • Do not prescribe antibiotics unless there are signs of spreading infection, systemic infection, or for an immunocompromised patient if there are signs of necrotising disease.
  • Advise the patient to seek urgent dental care.

Subsequent care

For all acute periodontal conditions:

Arrange appropriate therapy with a hygienist, dentist or periodontist.

Carry out professional mechanical plaque removal (PMPR) as effectively as symptoms allow. Local anaesthesia may be required.

Consider prescribing chemical plaque control (e.g. 6% hydrogen peroxide or 0.2% chlorhexidine mouthwash).

In addition, for:

Necrotising periodontal diseases: Necrotising ulcerative gingivitis (relating to lesions limited to gingival tissue) and Necrotising ulcerative periodontitis (where loss of attachment has occurred).

Provide oral hygiene instruction and, if appropriate, smoking cessation advice.

Consider prescribing metronidazole if there is evidence of spreading infection or systemic involvement, or if local measures cannot be completed due to severe symptoms (see SDCEP ‘Drug Prescribing for Dentistry’ guidance for dose).

Periodontal abscess

Ensure that professional mechanical plaque removal (PMPR) stops short of the base of the periodontal pocket.

Consider irrigating the periodontal pocket.

Drain any pus by incision or through the periodontal pocket.

Consider extraction.

Perio-endo lesions: Tend to be associated with a single tooth leading to abscess formation.

Consider root canal treatment or retreatment, or extraction if the tooth prognosis is poor.

More detailed advice on the management of acute periodontal conditions is available in the SDCEP Prevention and Treatment of Periodontal Diseases in Primary Care guidance (available at https://www.periodontalcare.sdcep.org.uk/).