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A 7-year-old boy was referred to the paediatric clinic with a swollen cheek since one day. Intraoral examination revealed erythematous and swollen gingivae in the right upper quadrant. The consulted maxillofacial surgeon diagnosed him with a canine fossa abscess. The patient recovered quickly after incision and drainage, followed by antibiotic therapy.

Odontogenic orbital abscess with intracranial and pulmonary involvement

A 58-year-old woman presented to the emergency department with left ptosis and complete ophthalmoplegia. Imaging demonstrated a left orbital abscess. Her past medical history included cavitatory lung disease and "aseptic" meningitis 2 months previously. An anaerobic organism and commensal of the oral flora, Peptostreptococcus sp., was cultured from the orbital abscess. The patient was found to have a carious upper molar with chronic buccal abscess, which was extracted. This case presents an uncommon pathogen arising from an odontogenic infection as the etiology for orbital abscess, cavitatory lung disease, and meningitis in one patient.

Acute periodontal lesions

This review provides updates on acute conditions affecting the periodontal tissues, including abscesses in the periodontium, necrotizing periodontal diseases and other acute conditions that cause gingival lesions with acute presentation, such as infectious processes not associated with oral bacterial biofilms, mucocutaneous disorders and traumatic and allergic lesions. A periodontal abscess is clinically important because it is a relatively frequent dental emergency, it can compromise the periodontal prognosis of the affected tooth and bacteria within the abscess can spread and cause infections in other body sites. Different types of abscesses have been identified, mainly classified by their etiology, and there are clear differences between those affecting a pre-existing periodontal pocket and those affecting healthy sites. Therapy for this acute condition consists of drainage and tissue debridement, while an evaluation of the need for systemic antimicrobial therapy will be made for each case, based on local and systemic factors. The definitive treatment of the pre-existing condition should be accomplished after the acute phase is controlled. Necrotizing periodontal diseases present three typical clinical features: papilla necrosis, gingival bleeding and pain. Although the prevalence of these diseases is not high, their importance is clear because they represent the most severe conditions associated with the dental biofilm, with very rapid tissue destruction. In addition to bacteria, the etiology of necrotizing periodontal disease includes numerous factors that alter the host response and predispose to these diseases, namely HIV infection, malnutrition, stress or tobacco smoking. The treatment consists of superficial debridement, careful mechanical oral hygiene, rinsing with chlorhexidine and daily re-evaluation. Systemic antimicrobials may be used adjunctively in severe cases or in nonresponding conditions, being the first option metronidazole. Once the acute disease is under control, definitive treatment should be provided, including appropriate therapy for the pre-existing gingivitis or periodontitis. Among other acute conditions affecting the periodontal tissues, but not caused by the microorganisms present in oral biofilms, infectious diseases, mucocutaneous diseases and traumatic or allergic lesions can be listed. In most cases, the gingival involvement is not severe; however, these conditions are common and may prompt an emergency dental visit. These conditions may have the appearance of an erythematous lesion, which is sometimes erosive. Erosive lesions may be the direct result of trauma or a consequence of the breaking of vesicles and bullae. A proper differential diagnosis is important for adequate management of the case.

Oral lesions you can't afford to miss

Being able to promptly recognize and diagnose oral lesions is critical to heading off several potentially serious conditions. This article and photo guide can help.

Pediatric intraoral high-flow arteriovenous malformation: a diagnostic challenge

Arteriovenous malformations (AVMs) are rarely reported in the dental pediatric literature. They may develop adjacent to primary molars and can be life-threatening due to their potential for massive bleeding. The most common symptom associated with documented cases of AVMs is spontaneous gingival bleeding. Other clinical signs include pain, erythematous gingiva, resorption and mobility of teeth, soft tissue discoloration, facial swelling, and asymmetry. Radiographically, AVMs are osteolytic lesions. The purpose of this report was to describe the challenge of diagnosis of a high-flow arteriovenous malformation located in the primary maxillary molar region, which was misdiagnosed as a dentoalveolar abscess adjacent to previously treated primary molars. A decision to extract a tooth with gingival swelling and associated spontaneous bleeding should be made after the differential diagnosis of a vascular malformation has been ruled out.

Streptococcal lung abscesses from a dental focus following tocilizumab: a case report

Patients suffering from dental infections and concurrently using immunosuppressive medication are at increased risk of developing systemic streptococcal infections. Tocilizumab is a novel therapeutic agent targeting interleukin-6. We describe a case of streptococcal lung abscesses from a dental focus after use of tocilizumab for treatment of Takayasu arteritis.

Myofibroma of the mandible: a case report

This report describes the case of a male aged 28 years who presented with a chief complaint of discomfort and swelling in the mandibular right molar area. An incisional biopsy was performed with a preliminary differential diagnosis of periodontal abscess, fibrotic lesion, or odontogenic tumor. Subsequent excision of the lesion was performed and histologic analysis confirmed the diagnosis of myofibroma.

Comparing the risk identification and management behaviors between oral health providers for patients with diabetes

PURPOSE

Evidence supporting the link between periodontal disease and systemic disease continues to grow. To date, little is known about how dental professionals incorporate this information into managing diabetic patients. This study examines the risk identification and practice behaviors regarding diabetic patients among dentists, hygienists and specialists.

METHODS

Responses were received from 383 currently practicing oral health professionals in Arkansas. The electronic survey consisted of 35 open and closed-ended or Likert-type items. Principal components factor analysis using varimax rotation was used to explore underlying dimensions of the questionnaire in order to provide a more parsimonious view of the outcomes. Logistic models were fitted to determine best practice outcome as a function of knowledge and professional and social norms.

RESULTS

Neither knowledge about diabetes (p<0.285) nor provider type (p<0.186) was a predictor of practice behavior. Professional and social norms (p<0.001) identified those practitioners who felt modifying their management strategies for their patients with diabetes was a necessary component of their practice behavior.

CONCLUSION

In general, risk assessment was lacking, irrespective of whether a clinician was a dentist or dental hygienist. Results indicate oral health professionals in Arkansas need to improve the treatment and management of patients with diabetes and periodontal disease.

Furcation lesion in a mandibular canine

Morphological changes can complicate dental treatment. This report presents a rare case of a furcation lesion in a mandibular canine with two roots. A 39-year-old man in general good health sought dental care for severe pain in his maxillary anterior teeth. The clinical examination showed localized swelling in the vestibular mucosa close to the mandibular left canine. Radiographic examination revealed two distinct roots and vertical bone resorption in the canine's mesial surface. Periodontal evaluation led to a diagnosis of periodontal abscess associated with furcation lesion. Despite the occurrence in an atypical location, the site of periodontal furcation received conventional therapy for initial decontamination, including tissue debridement and a combination of polyvinylpyrrolidone irrigation and antibiotics. To improve access, the decontamination was completed with surgical techniques and scaling and root planing. Early diagnosis of this rare morphological change helped to determine appropriate, timely treatment planning and optimal patient recovery.

[Tooth abscess: management in the field]

Tooth abscess can be diagnosed based solely on clinical findings. No additional studies are required. Abscess can be treated using a few basic instruments.

Primary extranodal non-Hodgkin lymphoma of the gingiva initially misdiagnosed as dental abscess

Oral non-Hodgkin lymphomas are uncommon, and those arising on the gingiva are rare. A case of non-Hodgkin lymphoma of the gingiva that was erroneously diagnosed and treated as a dental abscess is presented. Clinical examination showed a firm and ulcerated mass extending from the mandibular right first premolar region to the retromolar trigone. Resorption of the alveolar ridge was radiographically observed. Histologic analysis revealed a large B-cell non-Hodgkin lymphoma. No other evidence of the disease was found except in the mandible. The patient was treated with chemotherapy that resulted in complete regression. As primary non-Hodgkin lymphoma of the gingiva can be misdiagnosed as a trivial inflammatory lesion, a histologic examination should be mandatory in those cases in which symptoms do not subside after specific treatment.

Teaching dental pain with and without underlying oral physiology: learning implications

This study investigated whether teaching undergraduate dental students the diagnosis and management of acute dental pain alongside the underpinning oral physiology helped them to understand the topic better than teaching them acute dental pain as a separate entity. Each of three clinical years of dental students at the same dental school was taught in two groups. Each group was taught the signs/symptoms of five acute dental pain conditions by the same member of the staff. However, the teaching for one group of students in each year reminded the students about the physiology that underpinned the clinical symptoms. One week later, the students completed an open-ended questionnaire that required them to list signs/symptoms of the five dental pain conditions. For each year of dental students that was examined, the mean student marks were significantly higher (p<0.05) for those who were taught dental pain and the underlying physiology compared with students who were only taught dental pain as a stand-alone subject. This suggests that integrating biomedical science and clinical teaching is beneficial.

[Clinical and therapeutical considerations regarding odontogenic acute mediastinitis]

Odontogenic acute mediastinitis is an polymicrobial infections caused in most cases by gram negative and anaerobic germs. The odontogenic origin of the cases in this study was based on anamnestic inquiry of the patients, which reveales a dental treatment 7-15 days before the diagnosis of acute mediastinitis was established. Clinical features are often nonspecific at the debut of this affection; septic shock could appear suddenly associated with multiple systems and organs failure. This is the explication why, some of these patients presented septic shock when are diagnosed. In this situations, when acute mediastinitis is suspected, based on clinical and imaging findings, it must be confirmed by surgical exploration and perioperative bacteriological evaluations. Positive diagnosis is based on clinical features associated with labs and imaging studies. Surgery plays an important role in therapy of acute mediastinitis: debridement and drainage of mediastinum with subsequently lavage of it, using antiseptic solutions. Broad spectrum antibiotherapy should be administrated immediately, before antibiogram is ready.

Periodontal abscess during supportive periodontal therapy: a review of the literature

AIM

The aim of this review is to present the current status of the occurrence and management of a periodontal abscess during supportive periodontal therapy (SPT).

BACKGROUND

A periodontal abscess depicts typical features and has been described in patients under SPT in clinical trials. Common periodontal pathogens have been observed in this lesion and some etiologic factors may be responsible for its recurrence. This condition can be isolated or associated with factors that can change the prognosis of affected teeth.

REVIEW RESULTS

Although it has been frequently noticed in untreated periodontitis, the periodontal abscess can also occur in patients under SPT and has been regarded as one of the possible complications of SPT. Patients with a high susceptibility to periodontal disease lost more teeth than those with a healthy periodontium.

CONCLUSION

Early diagnosis and appropriate intervention for periodontal abscesses in patients under SPT are extremely important for the management of the periodontal abscess since this condition can lead to loss of the involved tooth. A single case of a tooth diagnosed with periodontal abscess that responds favorably to adequate treatment does not seem to affect its longevity.

CLINICAL SIGNIFICANCE

An accurate diagnosis and adequate treatment can preserve the longevity of affected teeth.

Management of odontogenic infection of pulpal and periodontal origin

The dental biofilm is a complex bacterial ecosystem that undergoes evolution, maturing and development, and thus leads to odontogenic infection. The infection is normally located in the tissues of the dental organ itself, and follows a chronic course of evolution. However, bacterial pathogens express virulence factors in the biofilm, and this together with changes in host immunity, may cause clinical exacerbations and spread of infection to other areas of the body. Odontogenic infection management should take into consideration the fact that therapeutic success lies in the control of the infectious aetiologic agent, using mechanical-surgical debridement and/or antimicrobial therapy. Debridement techniques have a fundamentally quantitative effect (by reducing the size of the inoculum) and therefore if these techniques are used alone to control infection, despite an initial clinical improvement that is sometimes prematurely considered as therapeutic success, odontopathogens may persist and the process may recur or become chronic. Microbiological examination may be helpful in defining therapeutic success in a more reliable way, it could define the prognosis of recurrence more precisely, and could enable the most appropriate antibiotic to be selected, thus increasing therapeutic efficacy. Antimicrobial therapy brings about a quantitative and qualitative change in the bacterial composition of the biofilm, in addition to being able to act on sites that are inaccessible through mechanical debridement. However, incorrect antimicrobial use can lead to a selection of resistant bacterial species in the biofilm, in addition to side effects and ecological alterations in the host. In order to minimise this risk, and obtain maximum antimicrobial effect, we need to know in which clinical situations their use is indicated, and the efficacy of different antibiotics with regard to bacteria isolated in odontogenic infection.

Bedside ultrasound of the soft tissue of the face: A case of early Ludwig’s angina

A case is reported of a 38-year-old man presenting with early Ludwig's angina. It is difficult to differentiate superficial from deep infections of the face and neck by physical examination alone. The diagnosis of this condition with bedside soft tissue ultrasound of the face is described. Ludwig's angina is an uncommon infection of the deep tissues of the face and neck that usually evolves from more superficial infections such as dental abscesses.

Mandibular fracture caused by periodontal abscess: Radiological, US, CT and MRI findings

Mandibular fracture is a rare but possible outcome of a periodontal abscess. A case of complete fracture of the mandible with abscess infiltrating the surrounding soft tissues is described. The patient reported nor trauma, nor locoregional surgery. Ultrasonography and orthopantomography revealed the fracture of the mandible and the abscess at the masseter muscle. Further preoperative diagnostic examinations included CT and MRI. CT revealed the complete fracture line more clearly; MR the extension of the abscess.

Undifferentiated Malignant Neoplasm Involving the Interdental Gingiva: A Case Report

BACKGROUND

Metastases to the gingiva are uncommon. They can be a diagnostic challenge clinically because of their rarity and tendency to mimic benign lesions. In this report, we present a case of an undifferentiated malignant neoplasm of unknown origin presenting as benign inflammatory gingival lesions and we review the literature on metastases to the gingiva.

METHODS

A 44-year-old female patient was referred by a local periodontist for evaluation of multiple painless gingival lesions that clinically resembled pyogenic granulomas or periodontal abscesses, but with an uncharacteristic multifocal presentation in the background of good oral hygiene. Her medical history was unremarkable except for recent weight loss. Periapical radiographs were obtained, as well as two incisional biopsies, one placed in formalin for routine histology and immunohistochemistry, the other in phosphate buffered saline for flow cytometry.

RESULTS

Radiographic findings were non-contributory for hard tissue pathoses. Histopathological findings were consistent with a poorly differentiated malignancy, suggestive of metastatic disease. Immunohistochemical studies and flow cytometry were unsupportive in delineating any tumor differentiation. The patient subsequently developed multiple tumors throughout the body with similar histopathological findings, yet no primary tumor was identified and a definitive diagnosis could not be rendered. She was discharged one month later in poor condition with the principal diagnosis of hemorrhage/ pancytopenia, and a secondary diagnosis of metastatic head and neck cancer.

CONCLUSION

This case of malignant metastatic tumor of unknown origin presenting as benign gingival lesions illustrates the importance of thorough patient evaluation, which should include a biopsy when necessary for definitive diagnosis.

[Periodontal abscess: etiology, diagnosis and treatment]

The periodontal abscess is an acute destructive process in the periodontium resulting in localized collections of pus communicating with the oral cavity through the gingival sulcus or other periodontal sites and not arising from the tooth pulp. The prevalence of periodontal abscess is relatively high and it affects the prognosis of the tooth. Periodontal abscesses can develop on the base of persisting periodontitis but can also occur in the absence of periodontitis. The cause of the development of periodontal abscess originating from chronic periodontitis is the marginal closure of a periodontal pocket, or the pocket lumen might be too tight to drain the increased suppuration due to changes in the composition of subgingival microflora, alteration of bacterial virulence or host defenses. Diagnosis of a periodontal abscess is based on medical and dental history as well as oral examination (pocket depth, swelling, suppuration, mobility, sensibility of the tooth). The most prevalent group of bacteria: P. gingivalis, P. intermedia, B. forsythus, F. nucleatum and P. micros. Previous studies have suggested that the complete therapy of the periodontitis patients with acute periodontal abscess has to do in two stages: the first stage is the management of acute lesions, then the second stage is the appropriate comprehensive treatment of the original and/or residual lesions. The management of acute lesions includes establishing drainage via pocket lumen, subgingival scaling and root planing, curettage of the lining pocket epithelia and seriously inflamed connective tissue, compressing pocket wall to underlying tooth and periodontal support, and maintaining tissue contact. Some authors recommend the incision or to establish drainage and irrigation, or a flap surgery, or even extraction of hopeless teeth. We recommend the use of systemic antibiotics as a preventive measure of systemic disease or in case of systemic symptoms.

A lot of clot

A 37-year-old man presented with fever and a red, painful right eye. He had proptosis, conjunctival chemosis, and ophthalmoplegia OD. The patient had extremely poor dentition and had self decompressed a dental abscess prior to admission. Magnetic resonance imaging of the brain and orbital revealed extraocular muscle engorgement and a dilated superior ophthalmic vein OD. Orbital echography revealed a lack of flow in the right superior ophthalmic vein. An extensive hematologic evaluation for infection and inflammation was negative. A chest radiograph showed a lung abscess for which he received intravenous antibiotics. Over time, the periorbital erythema, ophthalmoplegia, proptosis, and pain resolved. Repeat MRI showed resolution of the orbital findings and repeat chest x-ray showed resolution of the left upper lobe abscess.

[Quantitative analysis of contrast enhanced MRI of the inferior alveolar nerve in inflammatory changes of the mandible]

PURPOSE

To evaluate the role of contrast enhanced MRI in quantifying signal changes of the inferior alveolar nerve following inflammatory changes of the mandible.

MATERIAL AND METHODS

30 patients with inflammatory changes of the mandible underwent MRI of the face. Both sides of the mandible, the affected as well as the unaffected healthy side were evaluated retrospectively. Regions of interest were placed at 5 defined places on both sides to assess signal intensity before and after intravenous application of paramagnetic contrast agent. The results of the measurements were compared between the healthy and the affected side (t-test, p < 0.05) and correlated with clinical findings (t-test, p < 0.05).

RESULTS

All patients with hypesthesia of the inferior alveolar nerve in areas of the lips or chin (n = 4) showed a marked increase in signal intensity from 35 % to 83 % distal to the inflammatory process. Patients without sensitivity disorders showed less increase in signal intensity with a maximum of 51 % distal to the inflammatory process. In nearly all patients no contrast enhancement was observed distal to the first molar on the unaffected side.

CONCLUSIONS

Quantitative analysis of contrast enhanced MRI of the neurovascular bundle is able to show pathologic mandibular lesions. In case of inflammatory changes of the mandible the neurovascular bundle is able to show pathologic mandibular lesions. In case of inflammatory changes of the mandible, the neurovascular bundle shows a significant increase in signal intensity distal to the lesion compared to the unaffected healthy side of the mandible.

[The adverse effect of gas formation on prognosis in a patient with deep neck infection]

A seventy-one-year-old woman was hospitalized with a suspicion of deep neck infection and poor general health. She had been receiving treatment for hepatitis, diabetes mellitus, and cardiac failure and had a history of tooth ache and severe neck pain lasting for the past 10 days. She had been admitted to another center where she had received antibiotic treatment for five days for widespread swelling in the neck and lower extremities, fatigue, and difficulty in breathing and swallowing. Upon admission, computed tomography showed gas formation in the neck and facial regions. Prompt abscess drainage was performed and intense treatment with antibiotics was continued. Despite all efforts, the patient died on the second day of hospitalization from cardiopulmonary arrest. This case emphasizes how urgent drainage is when gas formation is detected in deep neck infections, with inevitable poor prognosis with antibiotic treatment alone.

Dental screening of pediatric cardiac surgical patients

Dental screenings were completed on 209 pediatric patients six months and older that were scheduled for cardiac surgery from two different geographical locations. The screening involved an educational session on bacterial endocarditis and preventive dentistry followed by a dental examination. We found that sixty-two (30 percent) patients had seen a dentist regularly, ninety-three (44 percent) practiced daily oral hygiene and thirty-seven (18 percent) knew about bacterial endocarditis. Local dentists performed invasive procedures on seventy-one (34 percent) patients and thirty-four (48 percent) received antibiotic prophylaxis. Only twenty-three (68 percent) of the thirty-four patients received the then current American Heart Association antibiotic regimen. Dental disease was diagnosed in 175 (84 percent) of the 209 patients: 164 (78 percent) gingivitis; sixty (29 percent) caries; six (7 percent) dental abscess; three (1 percent) periodontal abscess; five (2 percent) periocornitis. Cardiac surgery was postponed in twenty-four (12 percent) patients. We conclude that parents lacked knowledge about bacterial endocarditis even after being informed during their routine cardiology visit, there appears to be a deficiency of knowledge among dentists regarding the indications and antibiotic regimen required to prevent bacterial endocarditis, and all cardiac surgical patients should have a dental exam and preventive dental program implemented prior to six months of age and dental screening prior to their cardiac surgery.

Increasing frequency of dental patients in the urban ED

This study examined the spectrum and frequency of dental disorders presenting to an urban ED. Data were retrospectively collected on all patients presenting with dental complaints between January 1, 1987 and December 31, 1995. Data included age, date and time of presentation, diagnosis, triage acuity and disposition. Of the 3,943 charts reviewed, 1,892 (48%) patients required emergent oral surgery management and 2,051 (52%) emergency physician management only. The frequency of dental patients increased from 4.4/1,000 total ED patients in 1987 to 11.5/1,000 in 1995 (P < .05). The rate of emergent dental trauma, emergent nontraumatic dental care, and nonemergent nontraumatic dental care increased similarly during the study period. There was no significant difference by day of week, but a significantly greater number of nonemergent patients presented between 7:00 a.m. and 3:00 p.m. (72%). The incidence of dental patients presenting to the ED increased significantly between 1987 and 1995. Approximately one-half did not require specialist consultation and could potentially have been managed by a primary care dental practitioner.

The swollen face. Severe odontogenic infections

Owing to the widespread availability of preventive dental care and the development of effective antibiotics for the treatment of orofacial infection, the incidence of serious odontogenic infections has decreased dramatically over the past 50 years. Serious dental infections still occur, however, and their occasionally severe complications or even mortality warrant serious study of the clinical presentation, anatomy, and pathophysiology of orofacial infections. The goal of this review is to provide the emergency practitioner with a concise description of the clinical presentation, relevant anatomy, and treatment principles of odontogenic infection in the patient who presents to the ED with a swollen face or difficulty in opening the mouth widely. Prompt institution of surgical therapy for the infection, aided by appropriate antibiotic therapy enables the healthcare professions to continue their remarkable progress in treating these once-dreaded infections.

The periodontal abscess: a review

BACKGROUND/AIMS

The periodontal abscess is a frequent periodontal condition in which periodontal tissues may be rapidly destroyed. Its importance is based on the possible need of urgent care, the affectation of tooth prognosis, and the possibility of infection spreading. There is scant information in the scientific literature regarding this condition and most of it has been published as case reports and text books, where conclusions are not evidence-based, but rather empirical observations made by recognised clinicians. The aim of this review was to critically analyse all available information on this subject in the dental and medical literature, including information on its prevalence, proposed etiologies and pathogenesis, diagnosis, microbiology and treatment alternatives.

SUMMARY

The periodontal abscess is the 3rd most frequent dental emergency, and it is specially prevalent among untreated periodontal patients and periodontal patients during maintenance. Different etiologies have been proposed, and 2 main groups can be distinguished, depending on its relation with periodontal pockets. In the case of a periodontitis-related abscess, the condition may appear as an exacerbation of a non-treated periodontitis or during the course of periodontal therapy. In non-periodontitis related abscesses, impaction of foreign objects, and radicular abnormalities are the 2 main causes. The abscess microflora seems to be similar to that of adult periodontitis, and it is dominated by gram-negative anaerobic rods, including well-known periodontal pathogens. Complications and consequences include tooth loss and the spread of the infection to other body sites. Diagnosis and treatment is mainly based on empiricism, since evidence-based data are not available. The role of systemic antibiotics, in the treatment of periodontal abscesses, is especially controversial.

The periodontal abscess (II). Short-term clinical and microbiological efficacy of 2 systemic antibiotic regimes

BACKGROUND/AIMS

The aim of this short-term open parallel longitudinal clinical study was to compare the clinical and microbiological efficacy of 2 different antibiotic regimes in the treatment of acute periodontal abscesses.

METHOD

After patient selection, a clinical examination was carried out recording the following variables: pain, edema, redness, swelling, bleeding on probing, suppuration, tooth mobility, lymphadenopathy, and probing pocket depth. Microbiological samples were taken from the lesion and the patient was randomly assigned to one of two antibiotic regimes: azithromycin or amoxicillin/clavulanate. Clinical variables were recorded, and microbiological samples were taken, at 3-5 days, 10-12 days and 30 days. Additional mechanical treatment (debridement and scaling) was performed in the third visit (10-12 days). Blood and urine samples were collected at baseline and after 10-12 days. Microbiological samples were processed by anaerobic culturing, and isolated periodontal pathogens were tested for antibiotic susceptibility by means of the spiral gradient endpoint methodology.

RESULTS

15 patients took azithromycin, and 14 amoxicillin/clavulanate. Subjective clinical variables demonstrated statistically significant improvements with both antibiotic regimes, which lasted for at least 1 month (p<0.01). Objective clinical variables also showed clear improvements, being statistically significant after 30 days with probing pocket depth in the azithromycin group (p<0.01). Microbiologically, short-term reductions were detected with both antibiotics, however fast recolonization occurred after the third visit. No significant differences were found between both treatment regimes. Antibiotic susceptibilities demonstrated no resistances for amoxicillin/clavulanate, while 2-3 strains of each studied pathogen were resistant to azithromycin.

CONCLUSIONS

However, both antibiotic regimes were effective in the short-term treatment of periodontal abscesses in periodontitis patients.

The periodontal abscess (I). Clinical and microbiological findings

BACKGROUND/AIMS

Little information is available regarding the diagnosis and microbiology of periodontal abscesses. The aim of this descriptive clinical and microbiological study was to provide more information in order to help in the characterisation of the periodontal abscess associated to periodontitis.

METHOD

29 consecutive patients with a periodontal abscess were studied by the assessment of clinical variables, including both subjective (pain, edema, redness and swelling) and objective (bleeding on probing, suppuration, probing pocket depth, tooth mobility and cervical lymphadenopathy) parameters. Microbiological samples were taken for anaerobic microbiology and processed by means of culture. Systemic involvement was also studied through the analysis of blood and urine samples using conventional laboratory standards.

RESULTS

62% of the abscesses affected untreated periodontitis patients, and 69% were associated with a molar tooth. More than 75% of the abscesses had moderate-severe scores related to edema, redness and swelling, and 90% of the patients reported pain. Bleeding occurred in all abscesses, while suppuration on sampling was detected in 66%. Mean associated pocket depth was 7.28 mm, and 79% of teeth presented some degree of mobility. Cervical lymphadenopathy was seen in 10% of patients, while elevated leucocyte counts were observed in 31.6%. The absolute number of neutrophils was elevated in 42% of the patients. High prevalences of putative periodontal pathogens were found, including Fusobacterium nucleatum, Peptostreptococcus micros, Porphyromonas gingivalis, Prevotella intermedia and Bacteroides forsythus.

CONCLUSIONS

The periodontal abscess has clear clinical characteristics and is usually associated with severe periodontal destruction. This condition may cause systemic involvement and the lesion generally has a large bacterial mass with a high prevalence of well-recognised periodontal pathogens.

Parameter on acute periodontal diseases. American Academy of Periodontology

The American Academy of Periodontology has developed the following parameter on the treatment of acute periodontal diseases. Patients should be informed about the disease process, therapeutic alternatives, potential complications, expected results, and their responsibility in treatment. Consequences of no treatment should be explained. Failure to treat acute periodontal diseases appropriately can result in progressive loss of periodontal supporting tissues, an adverse change in prognosis, and could result in tooth loss. Given this information, patients should then be able to make informed decisions regarding their periodontal therapy.

Non-Hodgkin's lymphoma and periodontitis. A case report

BACKGROUND

We describe an unusual case of extra-nodal non-Hodgkin's lymphoma that developed in the maxillae associated with localized severe periodontitis in a 64-year-old Caucasian male. The lymphoma was diagnosed less than 2 years following routine periodontal surgery and 8 weeks after the extraction of hopeless teeth in the associated area.

METHODS

Two months following the extractions, the patient experienced pain and swelling in the maxillary right edentulous area mimicking an abscess, and reported for emergency care. An expansile lesion measuring 2.0 x 2.5 cm in diameter was noted on radiographic examination to extend into the right maxillary sinus. A definitive biopsy diagnosis of high-grade, small, non-cleaved, diffuse non-Hodgkin's lymphoma of the right posterior maxillae was established. The patient was subsequently treated by a combination of radiation, chemotherapy, and bone marrow transplantation.

RESULTS

The maxillary tissues healed uneventfully, and the patient has been closely observed for approximately 5 years without symptoms or recurrence of the lymphoma.

CONCLUSIONS

This case highlights the need for careful debridement of extraction sockets associated with severe periodontitis and argues for the routine submission of extracted teeth with adjacent soft tissue for microscopic analysis, to assist in the early diagnosis of potentially life-threatening malignancies.

Direct detection of Prevotella intermedia and P. nigrescens in suppurative oral infection by amplification of 16S rRNA gene

A specific 16S rDNA PCR and subsequent hybridisation reaction was designed to discriminate between strains of Prevotella intermedia (n = 15) and P. nigrescens (n = 15). This technique was then used to detect the presence of these two bacterial species in acute suppurative oral infection. A total of 36 pus samples aspirated from 26 peri-apical abscesses, three root canals, three periodontal abscesses, two cases of refractory periodontitis, one cyst and one haematoma was examined. A portion of the pus sample was processed by PCR and the remainder of the specimen was subjected to routine culture. The PCR-based technique gave an identical pattern of detection of P. intermedia or P. nigrescens to that obtained by culture for 30 of the 36 specimens. Either P. intermedia or P. nigrescens was present in 14 samples and neither species was detected in 16 samples. In the remaining six samples the PCR method indicated the presence of one (n = 3) or both (n = 3) of the Prevotella species but neither or only one species was isolated by culture. It is concluded that the presence of P. intermedia and P. nigrescens in pus can be detected rapidly and specifically by direct PCR amplification of 16S rDNA. P. nigrescens was detected more frequently than P. intermedia in suppurative peri-apical infection both by culture and PCR.

[Clinical studies on the pathophysiology of odontogenic abscesses]

In 26 patients with abscesses in the maxillofacial area, the electrolyte concentrations, pH and osmotic and hydrostatic pressures of the pus fluid were measured and calculated. The main cations identified were sodium (134 +/- 38 mmol/l) and potassium (37 +/- 16 mmol/l) and as anions chloride (183 +/- 46 mmol/l) and bicarbonate (10 +/- 4 mmol/l). The pH value of the pus liquid was 6.164 +/- 0.233. The calculated mean osmotic pressure of the pus liquid was 7910 +/- 1455 mm Hg, whereas the measured physical pressure inside the abscess was 49 +/- 13 mm Hg. Both pressure types show time-dependent pressure curves. With time, the real pressure inside the abscess cavity increases, whereas the osmotic pressure decreases. There was no relationship between the two pressure types and the different species of microorganisms responsible for the inflammation. The results of the study reveal that abscesses can be regarded as osmotically active systems, and the mechanism by which the abscess is formed might be as follows. After penetration of virulent microorganisms into the tissue space, the area of acute inflammation is walled off by the collection of inflammatory cells. Destruction of tissue by products of the polymorphonuclear leucozytes takes place and results in liquefactive necrosis and a hypertonic abscess cavity. The inwards-directed flow of tissue fluids into the cavity via the abscess membrane causes volume expansion and generates pressure, two facts that can explain the swelling dynamics and typical symptoms of abscesses in the maxillofacial area.

[Diagnostic and therapeutic concepts of canine fossa abscess. Evaluation of a multicenter study of 55 German-speaking departments of oromaxillofacial surgery]

A possible complication of fossa canina infections is reactive thrombosis of the vena angularis, which can lead to cavernous sinus phlebothrombosis. According to the literature there are different opinions about the treatment protocol of fossa canina abscesses. Therefore a multicentre study was undertaken in which 55 departments of oral surgery were interviewed using a standardized questionnaire about their procedures. The basis of diagnosis consists of clinical examination (100%), antibiogram (77.1%) and radiography (97.1%). A total of 28.6% use additional imaging procedures. Sonography is used by 20.0% and is found to be helpful in the diagnosis of vena angularis thrombosis. The painful palpation of the medial angle of the eye is of major diagnostic importance (100%) although anatomic variations of the vena angularis have to be considered. Extraoral incisions are not used in most cases (25.7% in exceptional cases) as well as ligations of the vena angularis in case of thrombosis (8.6% in exceptional cases). There is an agreement in the use of antibiotics (elective administration in 14.3%, obligatory administration in 85.7%); 77.1% don't use heparin to treat thrombosis of the vena angularis. In heparin therapy risks such as bleeding complications and thrombocytopenia have to be considered.

[The time characteristics of the exacerbation of chronic periodontitis and of odontogenic perimaxillary abscesses]

Time course of some laboratory values and clinical manifestations of inflammatory process is studied in 52 patients with exacerbations of chronic periodontitis and 284 patients with odontogenic perimaxillary abscesses. Routine laboratory studies (clinical and biochemical analyses of the blood and urine) were carried out. Acute odontogenic inflammations are characterized by an intermittent course with periodicity of about a week. The end of the first week from the disease onset coincided with recovery in exacerbation of chronic periodontitis and with the beginning of stabilization of inflammatory process in abscess. Recovery after abscess was observed 2 weeks after disease onset. These regularities may be useful for specifying the pathogenesis, terms of check-ups, and duration of treatment.

[Odontogenic pyogenic infections. 10-year analysis]

All patients of the Department of Oral and Maxillofacial Surgery at the Erfurt Hospital with odontogenic pyogenic infections have been analyzed in a retrospective study over a period of 10 years, from 1987 to 1997. This included questions concerning frequency, seriousness and treatment of these infections, social changes in the environ prove effects about the referral behaviour and the course. Odontogenic pyogenic infections are mixed infections. Aerobic agents such as hemolytic streptococcuses and staphylococcuses as well as anaerobic bacteria and fungi can be involved. Cephalosporine, aminobenzylpenicillin in combination with beta-lactamase inhibitor, alcylaminopenicillin and lincosamide are recommended based on analysis of infection resistance as first choice medications with carbapeneme as a reserve antibiotic.

A five-year-old with a dental abscess: a case study

Dental caries remain one of the most common disorders of childhood in the United States. Often nurse practitioners (NPs) will see children who are suffering from the complications of a dental carie, such as a dental abscess and/or cellulitis. This article describes the case of a 5-year-old girl who presented at an evening clinic with tooth pain, fever, and facial swelling. Three treatment choices are discussed: (1) 400 mg of amoxicillin (Augmentin), by mouth, with comfort measures, and return to the clinic in the morning; (2) 2 g of ceftriaxone by injection, with comfort measures, and return to the clinic in the morning; (3) or hospitalize via emergency department for intravenous fluids and antibiotics. The treatment that was chosen not only takes into account the disease process, but also the impact of this choice on the family. A model for the progression of dental caries in low-income groups with recommendations for prevention is also presented.

Perineural fibrous thickening within the dental pulp in type 1 neurofibromatosis: a case report

A case of type 1 neurofibromatosis is presented that illustrates oral manifestations and their role in the diagnosis of this condition. The oral lesions may be overlooked in the diagnosis of intraoral swellings. This case documents the finding of perineural fibrous thickening within the dental pulp. Such changes may indicate pulpal involvement in neurofibromatosis and the effect of a genetically transmitted disorder upon the pulp.

Surgical treatment of central epithelial ghost cell tumor

A surgical treatment for central epithelial odontogenic ghost cell tumor is described. A brief review of the literature is given, and histopathology is discussed. The rationale for conservative treatment is presented, along with an illustrative case report.

Contemporary management of deep neck space infections

Deep neck infections continue to be seen despite the wide use of antibiotics. These infections follow along fascial planes to create deep neck space abscesses. The clinical presentation often points to the space involved. Understanding the regional anatomy gives the surgeon the ability to treat these grave infections. The records of 24 patients with a diagnosis of deep neck space abscess admitted to Hermann Hospital between 1988 and 1993 were reviewed. Fifty percent of the patients had received antibiotics for an infection of the ear, nose, or throat before the development of a neck space abscess. Ten patients had parapharyngeal abscesses, seven had retropharyngeal abscesses, six had submandibular space abscesses, and one had parotid space abscess. Thirty-five organisms were isolated in 18 cases (1.9 isolates per patient). The most common organism cultured was Streptococcus (13 of 18), followed by Staphylococcus (6 of 18), Bacteroides (5 of 18), Micrococcus (2 of 18), and Neisseria (2 of 18). One case each of Candida, Enterobacter, Enterococcus, Peptostreptococcus, Proteus, Proprionobacter, and Pseudomonas was cultured. Six patients had no growth on culture but did have organisms found on Gram's stain. The operative techniques and antibiotics used are discussed. The main complications of jugular vein thrombosis, carotid artery rupture, and mediastinitis are described, as well as an unusual case of meningitis from a large retropharyngeal-parapharyngeal abscess.