|Year : 2011 | Volume
| Issue : 1 | Page : 37-40
Multiple acute periodontal abscesses due to clenching
Krithiga Gurumoorthy, Babitha Ajjappa, Shobha Prakash
Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India
|Date of Web Publication||4-Mar-2011|
Department of Periodontics, College of Dental Sciences, Davangere, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This case report presents clenching as one of the etiological factors in the causation of multiple acute periodontal abscesses.
Acute inflammatory periodontal diseases often present diagnostic problems for the clinician. These are not numerous, but cannot be glossed over. Acute periodontal abscess is one such condition which requires timely intervention and management. The development of the acute exacerbation occurs from an alteration in the tissues immediately adjacent to the affected teeth. Occlusion of the orifice of the periodontal pocket, diabetes, and clenching or bruxism are factors that can cause such an alteration. Here, we report a rare case of multiple acute periodontal abscesses due to clenching in an adult male. A 19-year-old male patient reported to the Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India, with pain and swelling of left cheek and left lower back teeth region of 2 days duration associated with difficulty in mouth opening. Detailed history revealed forceful clenching of teeth during his sleep. He appeared toxic and febrile. There was a diffuse, tender extraoral swelling in the left cheek. The patient had trismus and intraoral examination revealed multiple periodontal abscesses from 34 to 37. The drainage of the abscesses was obtained through the pocket orifice. The root surface was thoroughly planed to remove the deposits and to enhance further drainage. Subgingival irrigation with 0.1% povidone iodine was done and systemic antibiotics were prescribed. The patient was explained regarding the cause of the disease and motivated to stop clenching again. Subgingival irrigation with povidone iodine was continued for the next 3 days and the area curetted after 1 week to prevent recurrence. The healing was uneventful. Clenching of teeth can be one of the etiological factors for the causation of multiple acute periodontal abscesses which can be managed with proper and timely intervention of periodontal therapy.
Keywords: Clenching, periodontal abscess, habits, occlusion, antibiotics, swelling
|How to cite this article:|
Gurumoorthy K, Ajjappa B, Prakash S. Multiple acute periodontal abscesses due to clenching. J Interdiscip Dentistry 2011;1:37-40
This case report presents clenching as one of the etiological factors in the causation of multiple acute periodontal abscesses.
Periodontal diseases are generally considered to be chronic. From the usual insidious course of the disease on a gross clinical level to the cellular infiltrate within the affected tissues, every feature seems to point to essential chronicity. There are, nevertheless, acute inflammatory periodontal diseases. These are not numerous and not very common as to create more than a small area of concern or to require more than simple treatment and are not comparable to the chronic lesion in importance. These pathoses often present diagnostic problems for the clinician. They are, however, not to be glossed over.
Here, we report a rare case of multiple acute periodontal abscesses due to clenching in an adult male.
| Case Report|| |
A 19-year-old male patient reported to the Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India, with pain and swelling in left cheek and left lower back teeth region of 2 days duration associated with difficulty in mouth opening. Detailed history of the patient revealed forceful clenching of teeth during his sleep following a nightmare after which he experienced moderate pain in lower left back tooth region. He kept clenching the teeth in the same region to alleviate the pain in the night. Next day he observed multiple swellings in left lower back tooth region. Later the condition worsened with the swelling in left cheek. There was no relevant medical history.
On examination, the patient had fever and left submandibular lymph node enlargement. He appeared toxic and febrile. There was a diffuse, tender extraoral swelling in the left cheek [Figure 1], extending horizontally from the angle of the mouth to tragus of the left ear and vertically the ramus of the mandible was obliterated and extended upwards to the lower border of the left eye. It was soft and painful on palpation with a smooth surface. The patient had trismus and intraoral examination revealed multiple periodontal abscesses, extending from lower left 1 st premolar to 2 nd molar on the buccal surface [Figure 2]. The swellings were diffuse involving the marginal gingiva, attached gingiva, and the oral mucosa of the buccal aspect extending from lower left 1 st premolar to 2 nd molar. The affected tissues were red in color, tender to palpation. Associated teeth were tender to percussion and there was Grade I tooth mobility in relation to 36. Probing pocket depth of 4-5 mm and purulent exudate were present from 34 to 37. OPG of the patient revealed no changes in relation to both PDL and alveolar bone as the abscesses were located on the facial surfaces of the teeth [Figure 3].
|Figure 2: Intraoral examination revealed multiple periodontal abscesses in relation to 34-37|
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The drainage of the abscesses was obtained through the pocket orifice by using a sharp curette. The root surface was thoroughly planed to remove the deposits and to enhance further drainage. Subgingival irrigation with 0.1% povidone iodine was done and systemic antibiotics were prescribed. Patient was treated with antibiotic (T. Tinimox - tinidazole 300 mg; amoxycillin 500mg, twice daily for 5 days), analgesic, and anti-inflammatory agents (T. Instrel - tramadol 37.5 mg; paracetamol 500 mg, twice daily for 3 days and T. Lyser forte 10 mg - serratiopeptidase, once daily for 3 days) along with povidone iodine mouth rinse and stolin gum paint for topical application. The patient was explained regarding the cause of the disease and motivated to stop clenching again. Subgingival irrigation with povidone iodine was continued for the next 3 days and the area curetted after 1 week to prevent recurrence. The healing was uneventful [Figure 4] and [Figure 5].
| Discussion|| |
Periodontal abscesses have been recognized as a distinct clinical entity since the latter part of the 19 th century. The International Conference on Research in the biology of Periodontal Disease in 1977 defined a Periodontal Abscess as "an acute, destructive process in the periodontium resulting in localized collection of pus communicating with the oral cavity through the gingival sulcus or other periodontal sites and not arising from the tooth pulp." 
A periodontal abscess is a localized accumulation of pus within the gingival wall of the periodontal pocket. It may be acute or chronic. The accepted view of an acute periodontal abscess is that it occurs when a common suppurating pocket is occluded, shutting of drainage. The explanation does not take into account the tendency of lesions in furcations to exacerbate, in pockets in patients with diabetes mellitus, or in pockets adjacent to teeth under the extremely heavy occlusal stress. These pockets are not always occluded, yet they have a tendency to acute exacerbation.
The periodontal abscess exhibits all the clinical signs of an acute infection, but whatever infection is present is endogenous to the oral cavity. The development of the acute exacerbation occurs from an alteration in the tissues immediately adjacent to the affected teeth. Occlusion of the orifice of the periodontal pocket, diabetes, and clenching or bruxism are factors that can cause such an alteration.  Conditions in which periodontal abscess not related to inflammatory disease include tooth perforation, tooth fracture, foreign body impaction, trauma to the tooth, and poorly controlled diabetes mellitus which has been considered as predisposing factors for periodontal abscess. 
Bruxism, clenching, and doodling induce parafunctional forces on the periodontal tissues. Clenching has been defined as the fluctuating and repetitive force exerted on teeth on opposing arches when the dentition is in a fixed or locked position.  It represents isometric contractures in the muscles of mastication. Bruxism is the repetitive grinding or gritting of the teeth that can occur both nocturnally and at daytime.  Doodling is the repetitive toying, tapping, or clenching on an isolated tooth or a group of teeth when the mandible is in the eccentric position. Clenching and doodling, due to their locked position, have their impact on the attachment apparatus. Bruxism, in addition to its effects on the periodontium, also causes tooth wear. Clenching is far more destructive of the periodontium and more difficult to palliate. 
It has been estimated that the total duration of tooth contact in a 24-hour period is 17.5 minutes made up of 9 minutes chewing contact and 8.5 minutes swallowing contact. Therefore normal functional tooth-tooth contact is occasional and transient and by itself unlikely to damage. Forces generated during mastication depend largely on the consistency of the food. Peak pressures on an adult molar have been estimated at 0.4-1.8 kg, but because of the powers of adaptation of the periodontal tissues it is impossible to define excessive occlusal stress in precise numerical terms. It is estimated that during clenching or grinding, the individual might impose a load of over 20 kg on a tooth over periods of 2.5 seconds at a time.  This is far in excess of normal functional stresses and causes flow within the viscoelastic periodontal ligament and distortion of the alveolar bone, from which the tissues are slow to recover. Furthermore, the excessive load tends to affect the proprioceptive nerve endings, which are either overridden or set at a higher tolerance level, thereby impairing the protective reflex mechanism. Muscle activity becomes abnormal. A large proportion of patients with periodontal disease indulge in this habit. Many patients are aware of clenching their teeth when under stress during the day but few people are aware of a night grinding habit unless complained of by someone else.
The usual response of soft tissue to such trauma is to swell. Because of the arrangement of tissue, any enlargement causes an extrusion of the tooth which aggravates the trauma. If there is a lesion of the attachment apparatus, the response can be acute exacerbation of the pocket and a resultant periodontal abscess. While it is likely true to some extent, the short-term response is the major concern. Occasionally, a patient may report with acute multiple periodontal abscesses in a number of widely separated teeth in more or less simultaneous exacerbation. In every patient with multiple abscesses massive trauma was present, usually because of heavy clenching of teeth or bruxism or both. 
The most common symptom is pain. The patient is often oblivious to most of the accompanying symptoms until pain becomes evident. Gingival/mucosal swelling/both are usually seen at the site of pain. Swelling may vary from a small enlargement of the gingival unit to a diffuse swelling involving the gingival, alveolar mucosa, oral mucosa, and may extend to the face and the neck. The acute periodontal abscess is accompanied by symptoms such as throbbing, radiating pain, exquisite tenderness of the gingiva to palpation, sensitivity of the tooth to palpation, tooth mobility, lymphadenitis, and less frequently systemic effects like fever, leukocytosis, and malaise. Occasionally the patient may have symptoms of an acute periodontal abscess without any notable clinical lesion or radiographic changes. Sometimes the periodontal lesions are combined with pulpitis and in that contingency the signs are equivocal. Percussion and palpation are the most reliable diagnostic aids.
The first objective in treating the acute lesion is to establish drainage. As with many acute pyogenic infections, the release of pressure through the evacuation of pus has a salutary effect on the lesion. Pain is relieved, swelling is resolved, the extruded tooth returns to normal, mobility is reduced, and in general the patient feels better. After the acute phase has subsided, a chronic inflammatory lesion is left and must be treated. Many fine clinicians believe that the sooner the lesion is treated definitely, the better the chances for a reversal of the loss of bone and attachment. Prichard  reported that there is a strong convincing clinical evidence that there is a certain advantage in treating the pocket promptly after the acute exacerbation has subsided.
The treatment of the pocket includes the usual standard methods of flap reflection, debridement to remove exuberant granulation tissue and all other accretions, plus the adequate preparation of the root surface and the bony walls within the pocket.
| Conclusion|| |
Clenching of teeth can be one of the etiological factors for the causation of multiple acute periodontal abscesses, which can be managed with proper and timely intervention of periodontal therapy.
One of the causes of multiple acute periodontal abscesses can be clenching of teeth. Detailed history and correct clinical diagnosis are required for an effective and accurate treatment.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]