Necrotising Periodontal Diseases

Necrotizing Periodontal Diseases

• Necrotizing periodontal diseases (NIDs) are severe conditions linked to dental biofilm.
• Prevalence of NIDs is low.
• They cause rapid tissue destruction.

GDC Learning Outcomes

• Describe oral diseases and their role in prevention, diagnosis and treatment.
• Explain the cause and progression of oral diseases (aetiology and pathogenesis).
• Recognize psychological and social factors influencing oral health, disease progression, and treatment success.
• Recognize changes in patient oral health and take action.
• Recognise and manage patients with acute oral conditions.
• Ensure appropriate dental team member involvement.

Intended Learning Outcomes

• Identify key features of necrotizing periodontal diseases.
• Determine predisposing factors for necrotizing periodontal diseases.
• List the signs and symptoms of necrotizing ulcerative gingivitis (NUG).
• Outline the treatment for NUG.

Necrotizing Ulcerative Gingivitis (NUG)

• Acute infection affecting the marginal gingiva.
• Characterized by a white/grey slough of necrotic tissue.
• Surrounding tissue is red and inflamed.
• Necrotic areas start at papillae tips, often presenting as punched-out ulcers.
• Microorganisms involved include: spirochaetes, Borrelia vincentii, and Fusobacterium.
• Bacterial composition varies between patients and sites. (Loesche et al 1982)

Predisposing Factors

• Pre-existing gingivitis
• Poor oral hygiene (poor OH)
• Smoking
• Stress
• Poor immune system (common in poorly controlled conditions)

Signs and Symptoms

• Ulceration of gingival papillae or margin.
• Formation of a pseudo-membrane.
• Pain.
• Distinct halitosis (bad breath).

Treatment of NUG

• Debridement (removal of necrotic tissue), which can be painful.
• Mouthwashes with chlorhexidine or hydrogen peroxide.
• After the acute phase, address predisposing risk factors to prevent recurrence.
• Possible antibiotic therapy with metronidazole.

Necrotising Ulcerative Periodontitis (NUP)

• NUP is an extension/progression of NUG.
• Characterised by necrosis affecting the periodontal ligament and alveolar bone.
• NUP lesions can be extensive, extending more than 10mm beyond the gingival margin or mucogingival junction.
• Patients using recreational drugs might exhibit NUP type lesions.
• Noma (cancrum oris), a severe and often fatal condition, may develop as a complication in some individuals.
• NUP requires specialist treatment.

Case Study - Gladys

• Born December 1988.
• African origin.
• Moved to the UK aged 2.
• Lived with her mother.
• HIV positive.
• History of several medical conditions involving the immune system (e.g., Pulmonary TB, various infections) including oral candidosis.
• 1991 (age 2.8 years): Developmental delay, CD4 count 612, Bilateral parotid enlargement, Bilateral tympanic membrane perforations.
• Developed conditions throughout the 90s and into the 2000s such as various infections.
• Severe immunocompromise with a multi-drug resistant virus.
• Referred to EDH (Eastman Dental Hospital) in January 2006 with worsening gum infection (Acute Necrotizing Periodontitis).
• Specific medication information was provided (prednisolone, ranitidine, Lamivudine, Didanosine, fluconazole, septrin, azithromycin, ethambutol, ciprofloxacin, valaciclovir, etc).
• Had significant bilateral cervical lymphadenopathy, marked gingival ulceration of the palatal mucosa (from UL5 to UR5), and marginal inflammation of the lower labial gingivae.

Management

• Clinical photographs.
• Continued medication (including metronidazole).
• 2% Lignocaine ointment.
• Mouth rinses (Corsodyl and Difflam).
• Intensive debridement of affected areas at the School of Hygiene and Therapy from the outset (immediately).
• Duration of treatment was a week.

Conclusion

• NUG is easily recognizable once observed and smelled.
• NUG usually occurs on top of other health problems.
• Patients with poor oral hygiene are more susceptible to NUG.
• NUP is rare; specialized treatment is necessary.