Necrotising Periodontal Diseases

• NUG //  NUP //  Necrotising stomatitis – lesion spread to the tissues beyond mucogingival junction // Cancrum oris/noma – extensive destruction of face and jaw. Seen in malnourish

NUG starts of first as a gingivitis first. Then spirochaetes and further ppt factors will lead to NUG. 

Primary causative factors : 

-Opportunistic bacteria (Fusospirochaetes,Fusiform, Spirochaetes : treponema pallidum,Prevotella intermedia) NUG is a gram -ve anaerobic infection 

These bacteria are present in normal gingivitis also

Precipitating factors:

-pre existing gingivitis, injury to gingiva 

-Smoker (decrease host response by decreasing T lymphocytes and impairs chemotaxis and phagocytosis of neutrophils) 

-Stress(high prevalence in developing countries)

-Immunosuppression (DM, leukemia, anaemia, AIDS, pregnancy) NUG seen in apparently young healthy adults → suspect HIV → examine mouth to look for HIV signs → counselling, HIV test

-Malnutrition

-Poor oral hygiene

-Low socioeconomic status (healthcare not easily accessible, low education, more stressful)

-Previous history of NUG 

-halitosis/foetor oris, metallic taste, white pasty saliva 

-bleeding gum when i get up 

-radiating gnawing pain and extreme sensitivity to touch/ sensation of teeth being wedged apart

-fever, malaise lymphadenopathy, don’t feel like eating, insomnia, constipation, GI disease 

Clinical signs of NUG : 

-punched out interdental papilla with crater like formation and grayish white pseudomembrane slough 

-marginal gingiva will get affected by the adjacent interdental papilla (moth eaten appearance) 

-bleeding of marginal gingiva on retraction of lips /slightest stimulation

-mostly affects the anterior region 

-absence of pockets in NUG (cause requires a viable junctional epithelium to have pocket formation) 

-interproximal crater develop with loss of interdental bone and s/t bone sequestra

 -Tip of interdental papilla → marginal gingiva affected and whole of IDP loss → attached gingiva → bone

-herpetic gingivostomatitis (occurs in children , presence of pinhead vesicles, more diffuse, no whitish pseudomembrane, no punched out IDP, pain only on touching, no fetid odour)

-Desquamative gingivitis/ pemphigus (borders are irregular, nikolsky sign, immunofluorescence, presence of systemic manifestation)

-Diphtheria (seen in tonsillar area and pharyngeal area) 

Zone seen in electron microscope findings. These zones blend with each other. 

Zone 1 : bacterial zone (most superficial zone composed of various bacteria, including small, medium and large types of spirochaetes) 

Zone 2 : neutrophil rich zone (below the bacterial later, got dense agg of PMN leucocytes, neutrophils with bacteria including spirochetes of various types) 

Zone 3 : necrotic zone (consisting of lytic and dead tissue cells, remnants of CT fragments, collagen fibres and numerous spirochaetes)

Zone 4 : spirochaete infiltration zone:  presence of well preserved tissue infiltrated with medium and large size spirochetes w/o other microorganism 

Pathogenesis of periodontal disease : capacity of microorganism to invade the tissues 

Decrease oral immunity and defective mucosal integrity. 

Spirochaetes can invade the CT in larger extent, release endotoxin 

Direct effect :can release enzyme that directly can cause direct lysis of CT. 

Indirect effect : activates cells (lymphocytes, macrophages), releasing products and cause self destruction of host. It also activates complement system, causing damage to host tissue.

• Complete evaluation (get PMHx with illness, living status, employment, stress, nutritional status, smoking, hours of rest, occupation)
• Look for E/O and I/O examination 
• Apply topical anaesthetic gel for 2 minutes, use a cotton pellet to remove the pseudomembrane. Then, flush area with warm water 
• Remove superficial plaque and calculus +- LA using ultrasonic scalers cause they got flushing action (do supragingival scaling) 
• Rinse every 2 hours (equal mixture of 3% hydrogen peroxide and warm water (provide O2 to fight anaerobes)
• Rinse 0.2% chlorhex x 10ml 2x daily for antiplaque 
• Antibiotics (Metronidazole 200mg TDS 3 days) – only with fever, lymphadenopathy. Pink book say penicillin are also effective
• Analgesics (ibuprofen) 
• Palliative (rest, hydration, soft diet,) 
• OHI (Brush tooth surface only with gentle pressure, not on the damaged gums. X floss) 

#Subgingival scaling and curettage C/I in 1st visit (can lead to bacteraemia and can extend the bacteria into deeper tissues) Extractions and perio surgery C/I for at least 1 month (cause can exacerbate the lesion) 

2nd visit (After 1 – 2 days)

• Assess if condition improved. (pain is less,  pseudomembrane will be gone but gingival margin still red)
• Can perform subgingival scaling 

3rd visit (After 5 days) 

• Assess condition again (symptom free, some erythema still present) 
• OHI 
• Remove ppt factor to prevent recurrence (smoking, nutrition → take balanced diet,stress mx) → behavioural counselling and dietary counselling 
• Can stop hydrogen peroxide but continue chlorhexidine for 2 weeks 
• Repeat SnP if needed

4-6 weeks, 

-check pt maintenance, oral hygiene 

-if the gums have receded and if tooth appears longer, can do surgery. 

-gingivectomy in persistent craters (rare) 

3 months 

• For periodic recall