Aveneu Park, Starling, Australia

INTRODUCTION: gingivitis, acute herpetic gingivostomatitis etc. elicit


pain is the most common cause of visit to dental clinics for immediate
relieve and treatment. Most cases of dental pain are easily diagnosed but on
rare occasion it becomes a challenge for the clinicians to establish the cause
of pain and treatment.

We Will Write a Custom Essay Specifically
For You For Only $13.90/page!

order now

among the numerous causes, pain of pulpal origin , gingivitis and some acute
gingival disease or condition eg. Acute Necrotising ulcerative gingivitis,
acute herpetic gingivostomatitis etc. elicit acute pain symptoms in patients.

Gingivitis is fairly common and is present
in majority of the population. Gingivitis may progress to periodontitis if left

Chronic periodontitis is the most prevalent
form of periodontitis. It  is a common
disease characterized by a painless, slow progression. It may occur in most age
groups, but is most prevalent among adults and seniors worldwide, with
approximately affected by at least one site with clinical attachment level (CAL)
? 3 mm and probing depth (PD) ? 4 mm.2 It is generally considered to
be a slowly progressing disease. It can be clinically diagnosed by the
detection of chronic inflammatory changes in the marginal gingiva, presence of
periodontal pockets, and loss of clinical attachment. It is diagnosed
radiographically by evidence of bone loss. 3

Localized and generalized chronic
periodontitis are usually considered to be two clinical expressions of the same
disease. In both cases, there are similar signs of inflammation (e.g. redness,
swelling, bleeding on probing) associated with moderate to heavy deposits of
plaque and calculus. They also share slow rates of progression, affect similar
populations (e.g. age range, gender), and are associated with similar genetic
and environmental risk factors. 4

A complete examination should include PD,
CAL, bleeding on probing (BOP), plaque index/score, furcation involvement,
suppuration, mobility, occlusal trauma, open contact areas, and radiographic
interpretation of bone levels. A combined evaluation of these parameters is
essential for a proper periodontal evaluation and diagnosis. Without these
measures, it is difficult to establish a proper diagnosis and therefore, proper
treatment of the patient. 5

Because chronic periodontitis is usually
painless, patients may be totally unaware that they have the disease and may be
less likely to seek treatment.

Further the presence of acute pain
manifestation in chronic periodontitis cases has been scarcely reported in
literature. Hence the purpose of this case report is to highlight the possible
occurrence of acute pain in patient with sign and symptoms of chronic



A 34 year old female came to the Department
of Periodontology with the chief complaint of pain in upper right back tooth
region for last 2 months. She stated that the pain was sudden in onset, sharp in
nature, radiating to head and was relieved on taking analgesics which she was
taking continuously for the past 2 months. She gave previous dental history of
her visit to multiple dental clinics where the cause of pain could not be
established, though she was prescribed antibiotics, analgesics as well as sedatives
for pain control. Despite all these her pain persisted and she was than
referred to the department of Periodontology.

Patient was visibly apprehensive at the
time of examination and after detail counselling clinical examination could be
started. Whereby , one peculiar finding was observed that the patient was not
even allowing to measure CAL/Pocket depth without Local Anesthesia. Slight
touching of probe with mild pressure provoked pain that radiated to her head
region making her feel distressed and uncomfortable. Upon repetitive counselling,
reassurance & with topical LA spray, probing depths and clinical attachment
levels were measured which revealed generalised loss of clinical attachment and
presence of probing pocket depths.

Radiographic examinations with IOPAs &
OPG revealed generalised loss of bone especially in upper posterior molar
region. Pattern of bone destruction was vertical as well as horizontal  in nature.

Hence on the basis of clinical and
radiographic examination a provisional diagnosis of chronic generalised
periodontitis was made and decision was made to treat the patient.

Phase-I therapy was completed in two visits
with interval of 2 weeks in between where the patient was managed with oral
hygiene instructions, thorough scaling and root planing , analgesics and use of
0.2% chlorhexidine gluconate mouthwash.

On subsequent visit there was decrease in
patient apprehension. After four weeks of periodontal therapy, even though
there was no change in probing depth or CAL but pain and clinical symptoms were
resolved.  It was decided to proceed with
surgical therapy for reconstruction of lost periodontal support. An open flap
debridement using Kirkland flap was done and patient was put on supportive
periodontal therapy.



Chronic periodontitis is more prevalent
than the general population recognizes. 1 It is a common disease
characterized by a painless, slow progression, loss of periodontal attachment
support (clinical attachment level) bone resorption, eventually resulting in
tooth mobility and loss. 2

Generally, chronic periodontitis is not
the chief complaint of a patient when he/she seeks dental treatment as it
progresses painlessly and slowly. 6

A study reported that the most common
chief complaint reported by chronic periodontitis subjects is: “I was told I
have gum disease”. The second most common chief complaint reported is: “I would
like to save my teeth”. Neither of these chief complaints are true chronic
periodontitis symptoms, such as bleeding gums. Only 6.2% of the subjects
reported having painful gingiva. 7

The various cause of dental pain for which
patient seeks dental treatment are pain of pulpal origin, pain due to
neuralgia, pain because of acute gingival conditions such as acute necrotising ulcerative
gingivitis, acute herpetic gingivostomatitis, acute pericoronitis and
gingival/periodontal abscess. However the presence of acute pain symptoms in
chronic periodontitis has been scarcely reported in the literature.

The peculiarity in the present case is the
presence of acute pain symptoms in the absence of attributable cause of origin
of the pain based upon the diagnosis made in various dental clinics for which
patient had been prescribed antibiotics, analgesics and even some sedatives .
Pain of pulpal origin and neuralgic pain were ruled out on the basis of
clinical and radiographic examination. Provisional diagnosis of generalised
chronic periodontitis was made on the basis of presence of pocket depth and
generalised loss of clinical attachment level clinically and generalised loss
of bone confirmed radiographically. With the consent of the patient, it was
decided to treat the patient with Non surgical and surgical periodontal

Non surgical therapy was completed in 2
visits which included thorough scaling and root planing, oral hygiene
instructions, analgesics and with use of 0.2% chlorhexidine gluconate
mouthwash. After 4 weeks of non surgical therapy pain and clinical symptoms
were resolved and it was further decided to treat the patient surgically for
the reconstruction of the lost periodontal support which comprised of open flap
debridement using Kirkland flap. Patient was put on Supportive periodontal
therapy thereafter. Patient responded well to the treatment undertaken.
Although it is known that complete removal of subgingival plaque and calculus
is unrealistic, especially as pocket depth increases 8  we can expect that the majority of
patients with chronic periodontitis will be successfully maintained following
both surgical or nonsurgical periodontal therapy.9-12,13-15

Hence in this case the cause of pain was attributed
to the extreme sensitivity which the patient was having as a result of severe
clinical attachment level loss and deep periodontal pocket.

The challenge in treating periodontitis is
a timely and proper diagnosis. Proper diagnosis and treatment in its earliest
stages will prevent future breakdown. Because the disease is painless, patients
rarely seek care. Thus, it is not uncommon for the disease to go undiagnosed until
it has progressed to moderate to advanced degrees of severity, characterized by
obvious radiographic bone loss and/or tooth mobility.


I'm Simon!

Would you like to get a custom essay? How about receiving a customized one?

Check it out