Acute Gingival InfectionsNECROTIZING ULCERATIVE GINGIVITIS

Dr. Ahmed TawfigReference: Carranzas 10th Edn 391-397 & 706-710

Necrotizing ulcerative gingivitis (NUG) is a microbial disease of the gingiva in the background of an impaired host response. It is characterized by the death and sloughing of gingival tissue and presents with characteristic signs and symptoms.

Clinical FeaturesClassificationNUG is usually identified as an acute disease. NUG often undergoes a reduction in severity without treatment, leading to a subacute stage with milder clinical symptoms. NUG can cause tissue destruction involving the periodontal attachment apparatus, especially in patients with long standing disease or severe immunosuppression. When bone loss occurs, the condition is called necrotizing ulcerative periodontitis (NUP)

NUG is characterized by sudden onset of symptoms, sometimes following an episode of debilitating disease or acute respiratory tract infection. A change in living habits, protracted work without adequate rest, poor nutrition, tobacco use, and psychologic stress are frequent features of the patients history.

Oral SignsCharacteristic lesions are punched-out, craterlike depressions at the crest of the interdental papillae, subsequently extending to the marginal gingiva and rarely to the attached gingiva and oral mucosa. The surface of the gingival craters is covered by a gray, pseudomembranous slough, demarcated from the remainder of the gingival mucosa by a pronounced linear erythema

NUG can be superimposed on chronic gingivitis or periodontal pockets. However, NUG or NUP does not usually lead to periodontal pocket formation because the necrotic changes involve the marginal gingiva, causing recession rather than pocket formation.Oral SymptomsExtraoral and Systemic Signs and Symptoms ?

Clinical CoursePindborg et al. have described these stages in the progress of NUG: erosion of only the tip of the interdental papilla;the lesion extending to marginal gingiva and causing a further erosion of the papilla and potentially a complete loss of the papilla; the attached gingiva also being affected; and exposure of bone.

Horning and Cohen extended the staging of these oral necrotizing diseases as follows (% incidence among cases of NUG in the authors series):Stage 1: Necrosis of the tip of the interdental papilla (93%)Stage 2: Necrosis of the entire papilla (19%)Stage 3: Necrosis extending to the gingival margin (21%)

Stage 4: Necrosis extending also to the attached gingiva (1%)Stage 5: Necrosis extending into buccal or labial mucosa (6%)Stage 6: Necrosis exposing alveolar bone (1%)Stage 7: Necrosis perforating skin of cheek (0%)

Relation of Bacteria to Characteristic LesionLight microscopy shows that the exudate on the surface of the necrotic lesion contains microorganisms that morphologically resemble cocci, fusiform bacilli, and spirochetes.

DiagnosisDiagnosis is based on clinical findings of gingival pain, ulceration, and bleeding. A bacterial smear is not necessary or definitive because the bacterial picture is not appreciably different from that in marginal gingivitis, periodontal pockets, pericoronitis, or primary herpetic gingivostomatitis.

EtiologyRole of BacteriaRole of the Host ResponseLocal Predisposing FactorsSystemic Predisposing FactorsPsychosomatic Factors

Sequence of TreatmentFirst VisitSecond VisitThird VisitAdditional Treatment ConsiderationsContouring of Gingiva as Adjunctive Procedure.Supportive Systemic Treatment.Nutritional Supplements.

PRIMARY HERPETIC GINGIVOSTOMATITISPage no: 711-712

Primary herpetic gingivostomatitis is an infection of the oral cavity caused by the herpes simplex virus type 1 (HSV-1). It occurs most often in infants and children younger than 6 years of age, but it is also seen in adolescents and adults. It occurs with equal frequency in male and female patients. In most persons, however, the primary infection is asymptomatic.

Clinical FeaturesOral SignsPrimary herpetic gingivostomatitis appears as a diffuse, erythematous, shiny involvement of the gingiva and the adjacent oral mucosa, with varying degrees of edema and gingival bleeding. In its initial stage, it is characterized by the presence of discrete, spherical gray vesicles, which may occur on the gingiva, labial and buccal mucosae, soft palate, pharynx, sub-lingual mucosa, and tongue.

After approximately 24 hours, the vesicles rupture and form painful, small ulcers with a red, elevated, halo-like margin and a depressed, yellowish or grayish white central portion. These occur either in widely separated areas or in clusters, where confluence occurs

Oral SymptomsExtraoral and Systemic Signs and Symptoms

TREATMENTSupportive treatmentMucosal ointmentsAntiviral chemotherapy acyclovir ointment (apply five times daily for 5 days)

PERICORONITISThe term pericoronitis refers to inflammation of the gingiva in relation to the crown of an incompletely erupted tooth. It occurs most often in the mandibular third molar area. Pericoronitis may be acute, subacute, or chronic.

TreatmentA. Non surgical therapyB: Surgical therapy:Operculectomy

Treatment of Periodontal AbscessPage no: 714-721

CLASSIFICATIONA. Depending on the location of the lesion: Periapical abscess Periodontal abscess Pericoronal abscessB. Depending on the course of lesion: Acute abscess Chronic abscessC. Depending on the tissue involved: Gingival abscess Periodontal abscess Pericoronal abscess

CLINICAL FEATURES OF PERIODONTALABSCESS1. Pain of acute periodontal abscess is throbbing andradiating whereas in chronic periodontal abscess painis dull and gnawing.2. The gingiva is edematous and red, with a smooth,shiny, ovoid elevation 3. Suppuration may be spontaneous or occur afterputting pressure on the outer surface of the gingiva.4. Swelling5. Sensitivity to percussion of the affected tooth6. Tooth elevation7. During the periodontal examination, the abscess isusually found at a site with a deep periodontal pocket.8. Bleeding on probing9. Pinpoint orifice of sinus may be present. Sinus maybe covered by small, pink, bed - like mass ofgranulation tissue

Acute periodontal abscess is associated with:PainTendernessSensitivity to palpationSuppuration upon gentle pressureChronic abscess is associated with :Sinus tractUsually asymptomatic

Periodontal versus Pulpal AbscessEndo-perio lession

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