Clinical markers of acute periodontitis
Periodontal inflammation is characterized by constant aching pain that sharply intensifies under mechanical load, such as biting or simply touching the crown. Patients often keep their mouth half-open to protect the causal tooth.
In the purulent inflammation phase, concomitant symptoms join:
- Edema and hyperemia of the gingiva and transitional fold in the projection of the root apex;
- Periosteal thickening due to inflammatory infiltration, tenderness upon palpation;
- Tooth mobility (up to grade II);
- Regional lymphadenitis with moderate subfebrile temperature;
- Electric pulp testing (EPT) records the complete death of the neurovascular bundle, while radiographic bone destruction is not visualized (only edema of the periodontal ligament is noted).
Distinction from pulpitis and trigeminal neuralgia
Differentiating periodontitis from acute pulp and nerve trunk lesions is aided by the character of pain, reaction to stimuli, and probing data.
| Nosology | Character of pain | Triggering factors | Probing of the cavity floor | EPT |
|---|---|---|---|---|
| Periodontitis | Constant, aching, localized | Biting, percussion | Painless | Complete pulp necrosis |
| Acute pulpitis | Paroxysmal, nocturnal, radiating | Thermal and chemical stimuli | Sharply painful | Decreased pulp electrical excitability |
| Trigeminal neuralgia | Paroxysmal, shooting ("electric shock-like"), does not bother at night | Light irritation of trigger zones | No pathological reactions | Pulp is intact |
In neuralgia, the attack is accompanied by autonomic signs (lacrimation, salivation, facial flushing, twitching of facial muscles), and the pain attack is short, which rules out periodontitis.
Differentiation from purulent-inflammatory processes of the jaws
The spread of infection beyond the periodontium alters the local status and severity of intoxication:
- Acute purulent periostitis. Inflammation spreads to the periosteum: a subperiosteal abscess forms with the symptom of fluctuation and pronounced collateral edema of the soft facial tissues. At the same time, the severity of spontaneous pain in the tooth itself and tenderness upon its percussion significantly decrease or disappear.
- Acute odontogenic osteomyelitis. Proceeds with severe intoxication (high hyperthermia, chills, autonomic disorders). The main diagnostic sign is that the infiltrate encompasses the jaw from two sides (vestibular and lingual or palatal), and several neighboring teeth become mobile. Meanwhile, the causal tooth hurts less than the adjacent intact teeth.
- Alveolitis. Occurs strictly after a tooth extraction surgery. A gray coating or a disintegrating blood clot is visualized in the socket (in some cases, the socket is completely empty), and inflammation affects the alveolar margin.
Jaw cysts and maxillary sinus inflammation
- Suppuration of a radicular or follicular cyst. Characterized by local deformation—bulging of a jaw section with displacement of a group of teeth. When the bone thins, palpation reveals yielding or a bone defect. Endodontic opening of the apical foramen is accompanied by the outflow of abundant cystic content or pus, and the diagnosis is confirmed by radiography.
- Maxillary sinusitis. Pain is diffuse, aching, radiating along the upper jaw, and intensifies when biting on the group of posterior teeth on the corresponding side. Key markers are unilateral rhinorrhea (serous or purulent, worsening when tilting the head or lying on the opposite side) and nasal congestion. Sinus radiographs reveal homogeneous diffuse shadowing.
The rule of three signs: in periodontitis, the floor does NOT hurt (on probing), the nerve does NOT react (on EPT), and the tooth cannot tolerate touches (biting and percussion).
Class and exam questions
Why does percussion pain of the causal tooth subside during periostitis?
The reduction in pain is associated with the breakout of exudate from the confined periodontal space into the subperiosteum. Intraperiodontal pressure drops, thereby decreasing the tension in the ligament, and the symptoms shift to the soft tissues and periosteum.
How to distinguish periodontitis from acute pulpitis with similar painful percussion?
In acute pulpitis, the pain is paroxysmal, worsens at night, and is triggered by temperature changes; probing of the cavity floor is sharply painful, and the pulp partially retains vitality. In periodontitis, the pain is constant, probing of the carious cavity floor is painless, and EPT values confirm complete pulp necrosis.
What are the key features distinguishing periodontitis from osteomyelitis?
Periodontitis is limited to the area of a single causal tooth with slightly altered blood parameters. Osteomyelitis is accompanied by severe intoxication, high fever, mobility of several teeth, and an infiltrate on both sides of the jaw simultaneously (vestibular and lingual/palatal).
What else to study on this topic
- Clinical picture of serous and purulent stages of periodontal inflammation
- Specifics of facial nerve lesions and rules for prescribing analgesics
- Differential diagnosis of neuropathies and trigeminal neuralgia
- Laboratory and functional examination methods in maxillofacial surgery (EMG, masticaciography)
- Radiological criteria for maxillary sinusitis
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