Necrotizing Ulcerative Necrotizing Ulcerative GingivitisGingivitis

Necrotizing ulcerative gingivitis can be defined Necrotizing ulcerative gingivitis can be defined as an acute , and sometimes recurring gingival as an acute , and sometimes recurring gingival

infection of complex etiology .infection of complex etiology .

Characterized by rapid onset of gingival pain, Characterized by rapid onset of gingival pain, interdental gingival necrosis , and bleeding . interdental gingival necrosis , and bleeding .

Necrotizing ulcerative gingivitis Necrotizing ulcerative gingivitis has been called many names:has been called many names:

-Vincent’s disease-Vincent’s disease- Trench mouth- Trench mouth

-Acute necrotizing ulcerative -Acute necrotizing ulcerative gingivitisgingivitis

- Fusospirochetal gingivitis- Fusospirochetal gingivitis

The patients affected are The patients affected are typically adolescents or young typically adolescents or young

adults, may be cigarettes adults, may be cigarettes smokers, and are often smokers, and are often psychologically stressedpsychologically stressed..

During world II up to 14% of the During world II up to 14% of the Danish military personnel Danish military personnel

encountered NPD.encountered NPD. Also civilians suffered from the Also civilians suffered from the

disease disease

After world war II the prevalence After world war II the prevalence of NPD declined substantially of NPD declined substantially and in industrialized countries and in industrialized countries

NPD it is now rareNPD it is now rare

Clinical signs “NUGClinical signs “NUG””•PainPain

•UlcerationUlceration

•Necrosis of the interdental papillaeNecrosis of the interdental papillae

•Bleeding either spontaneous or to gentle Bleeding either spontaneous or to gentle manipulation.manipulation.

Necrotizing gingivitis is an Necrotizing gingivitis is an inflammatory destructive inflammatory destructive

gingival condition , gingival condition , characterized by ulcerated and characterized by ulcerated and necrotic papillae and gingival necrotic papillae and gingival

margins resulting in a margins resulting in a characteristic punched out characteristic punched out

appearanceappearance

The ulcers are covered by a The ulcers are covered by a yellowish – white or grayish yellowish – white or grayish

slough which is termed slough which is termed “Pseudo membrane“Pseudo membrane“ “

The sloughed material has no The sloughed material has no coherence , and bears little coherence , and bears little

resemblance to a membrane.resemblance to a membrane.It consists primarily of fibrin and It consists primarily of fibrin and necrotic tissue with Leucocytes, necrotic tissue with Leucocytes,

erythrocytes and masses of erythrocytes and masses of bacteriabacteria

Removing of the sloughed Removing of the sloughed material results bleeding and material results bleeding and ulcerated underlying tissue ulcerated underlying tissue

becomes exposedbecomes exposed

The necrotizing lesions develop The necrotizing lesions develop rapidly and are painful , but in the rapidly and are painful , but in the initial stages , when the necrotic initial stages , when the necrotic

areas are relatively few and small , areas are relatively few and small , pain is usually moderate.pain is usually moderate.

Severe pain is often the chief Severe pain is often the chief reason for the patient to seek reason for the patient to seek

treatmenttreatment

Bleeding is readily provoked .Bleeding is readily provoked .And may start spontaneously as And may start spontaneously as

well as in response to even well as in response to even gentle touch.gentle touch.

In early phases of the disease lesions are In early phases of the disease lesions are typically confined to the top of a few typically confined to the top of a few

interdental papillaeinterdental papillae

The first lesions are often seen The first lesions are often seen interproximally in the interproximally in the

mandibular anterior region .mandibular anterior region .But they may occur in any But they may occur in any

interproximal spaceinterproximal space

In regions where lesions first appear , there In regions where lesions first appear , there are usually also signs of preexisting chronic are usually also signs of preexisting chronic

gingivitis , but the papillae are not always gingivitis , but the papillae are not always edematous at this stageedematous at this stage. .

The zone between the marginal The zone between the marginal necrosis and the relatively necrosis and the relatively

unaffected gingiva usually exhibits unaffected gingiva usually exhibits a well demarcated narrow a well demarcated narrow

erythematous zoneerythematous zone

This is an expression of hyperemia This is an expression of hyperemia due to dilation of the vessels in the due to dilation of the vessels in the

gingival connective tissue in the gingival connective tissue in the periphery of the necrotic lesionsperiphery of the necrotic lesions

Acute necrotizing ulcerative gingivitis; Acute necrotizing ulcerative gingivitis; typical lesions with progressive tissue typical lesions with progressive tissue

destructiondestruction

Acute necrotizing ulcerative Acute necrotizing ulcerative gingivitis: typical lesions with gingivitis: typical lesions with

spontaneous hemorrhagespontaneous hemorrhage

Acute necrotizing ulcerative Acute necrotizing ulcerative gingivitis: typical lesions gingivitis: typical lesions have produced irregular have produced irregular

gingival contourgingival contour..

Involvement of Alveolar Involvement of Alveolar MucosaMucosa

When the necrotic progresses beyond the When the necrotic progresses beyond the mucogingival junction the condition is donated mucogingival junction the condition is donated

Necrotizing Stomatitis (NS)Necrotizing Stomatitis (NS)

The disease is related to compromised The disease is related to compromised immune functions , and malnutritionimmune functions , and malnutrition

Differential diagnosis of NUG is Differential diagnosis of NUG is that from primary herpetic that from primary herpetic

gingivostomatitisgingivostomatitis

Differential DiagnosisDifferential Diagnosis

NUGEtiology: BacteriaAge: 15-30 yearsSite: Interdental papillaeSymptoms: Ulceration and

necrotic tissue and a yellowish-white

Duration:1-2 days if treatedContagious: NoImmunity: NoHealing: Destruction of

periodontal tissue remain.

PHGSEtiology: Herpes simplex virusAge : Frequently childrenSite: Gingiva and entire mucosaSymptoms: Multiple vesicles

which burst leaving small round fibrin-covered ulcers which tend to coalesce.

Duration: 1-2 weeksContagious: YesImmunity: PartialHealing: No permanent

destruction

AHGSAHGS

Swelling of Lymph NodesSwelling of Lymph Nodes

Swelling of regional lymph nodes may occur in NPD is particularly evident in advanced cases.

Such symptoms are usually confined to the submandibular lymph nodes , but the cervical

lymph nodes may also be involved.

In children with NPD , swelling of lymph nodes and increased bleeding tendency are often the most

pronounced clinical findings

Fever and MalaiseFever and Malaise

Fever and malaise is not a consistent characteristic Fever and malaise is not a consistent characteristic of NPD. Some investigations indicate that elevated of NPD. Some investigations indicate that elevated body temperature is not common in NG and when body temperature is not common in NG and when

present the elevation of body temperature is usually present the elevation of body temperature is usually moderatemoderate..

The disagreement on this point may , in fact be due The disagreement on this point may , in fact be due to misdiagnosis of primary herpetic gingivostomatitisto misdiagnosis of primary herpetic gingivostomatitis

HistopathologyHistopathology

Necrotizing gingivitis are characterized by ulceration with necrosis of epithelium and superficial layers of the connective tissue

An important aspect is the role of the microorganisms in the lesion , because they have been demonstrated not only in the necrotic tissue components but also in vital epithelium and connective tissue

The surface cover of yellowish – The surface cover of yellowish – white or grayish sloughwhite or grayish slough

the tissue is infiltrated by large the tissue is infiltrated by large and medium sized spirochetes , and medium sized spirochetes ,

but no other microorganisms but no other microorganisms have been seenhave been seen

In the vital connective tissue the In the vital connective tissue the vessels are dilated. They also vessels are dilated. They also

proliferate to form granulation tissue , proliferate to form granulation tissue , and the tissue is heavily infiltrated by and the tissue is heavily infiltrated by

leucocytes.leucocytes.In acute processes the inflammatory In acute processes the inflammatory

infiltrate is dominated by Neutrophils , infiltrate is dominated by Neutrophils , in the deeper tissue the inflammatory in the deeper tissue the inflammatory process comprises large numbers of process comprises large numbers of

monocytes and plasma cellsmonocytes and plasma cells

Oral HygieneOral Hygiene

The oral hygiene in patients with NPD is usually poor . Moreover , brushing of teeth and contact with the acutely

inflamed gingiva is painful . Therefore , large amounts of plaque on the teeth are

common , especially along the gingival margin .A thin , whitish film sometimes covers parts of the attached

gingiva.This film is a characteristic finding in patients who have

neither eaten nor performed oral hygiene for days, it is composed of desquamated epithelial cells and bacteria ,

it is easily removable

TreatmentTreatment

The treatment of the necrotizing periodontal diseases is divided into two phases:

• Acute

• Maintenance

Acute Phase TreatmentAcute Phase Treatment

The aim of the acute phase treatment is to eliminate disease activity as manifest by

ongoing tissue necrosis developing laterally and apically.

A further aim is to avoid pain and general discomfort which may severely

compromise food intake

The first consultation scaling should The first consultation scaling should be attempted as thorough as the be attempted as thorough as the

condition allows.condition allows.Ultrasonic scaling may be Ultrasonic scaling may be

preferable, with minimal pressure preferable, with minimal pressure against the soft tissues , ultrasonic against the soft tissues , ultrasonic

cleaning may accomplish the cleaning may accomplish the removal of soft and mineralized removal of soft and mineralized

depositsdeposits

Patients should be instructed in Patients should be instructed in substituting tooth brushing with substituting tooth brushing with chemical plaque control in such chemical plaque control in such

areas until healing is areas until healing is accomplishedaccomplished

Hydrogen peroxide and other Hydrogen peroxide and other oxygen – releasing agents also oxygen – releasing agents also

have a long standing tradition in the have a long standing tradition in the initial treatment o NPD.initial treatment o NPD.

The favorable effect of hydrogen The favorable effect of hydrogen peroxide is mechanical cleaning peroxide is mechanical cleaning and the influence on anaerobic and the influence on anaerobic bacterial flora of the liberated bacterial flora of the liberated

oxygenoxygen

Twice daily rinses with 0.2% Twice daily rinses with 0.2% chlorhexidine solution to reduce chlorhexidine solution to reduce

plaque formation, particularly plaque formation, particularly when tooth brushing is not when tooth brushing is not

performedperformed

In some cases of NPD the In some cases of NPD the patient response to debridement patient response to debridement is minimal or the general health is minimal or the general health

is affected to such an extent is affected to such an extent that the supplementary use of that the supplementary use of

systemic antibioticssystemic antibiotics

Supplementary TreatmentSupplementary Treatment

• Metronidazole 250mg three times daily is the first choice in the treatment of NPD

• Penicillin 500mg three times daily

• Tetracycline also effective

• Topical application of antibiotics is not indicated in the treatment of NPD is not indicated

Non – Plaque Induced Non – Plaque Induced Inflammatory Gingival LesionsInflammatory Gingival Lesions

Gingival inflammation , clinically presenting as gingivitis , is not always due to

accumulation of plaque on the tooth surface , and non plaque induced

inflammatory gingival reactions often present characteristic clinical features

They may occur due several They may occur due several causes , such as specific causes , such as specific bacterial , viral , or fungal bacterial , viral , or fungal

infection without an associated infection without an associated plaque related gingival plaque related gingival inflammatory reactioninflammatory reaction

Gingival lesions of genetic origin Gingival lesions of genetic origin are seen in hereditary gingival are seen in hereditary gingival

fibromatosis , and several fibromatosis , and several mucocutaneous disorders manifest mucocutaneous disorders manifest as gingival inflammation ( Lichen as gingival inflammation ( Lichen planus , pemphigoid , pemphigus planus , pemphigoid , pemphigus

vulgaris and erythema multiforme )vulgaris and erythema multiforme )

Gingival Diseases Of Specific Gingival Diseases Of Specific Bacterial OriginBacterial Origin

Infective gingivitis and Stomatitis may occur on Infective gingivitis and Stomatitis may occur on rare occasions in both immunocompromised rare occasions in both immunocompromised and non – immunocompromised individualsand non – immunocompromised individuals

Necrotizing Necrotizing Stomatitis in Stomatitis in mandibular mandibular

left molar arealeft molar area

This lesions are due to This lesions are due to infections with:infections with:

-Neisseria gonorrhea-Neisseria gonorrhea-Treponema pallidum-Treponema pallidum

-Streptococci-Streptococci-Mycobacterium chelonae-Mycobacterium chelonae

The gingival lesions manifestThe gingival lesions manifest•Fiery red edematous painful ulcerationsFiery red edematous painful ulcerations

•Asymptomatic chancres or mucous patchesAsymptomatic chancres or mucous patches

•Highly inflamed gingivitisHighly inflamed gingivitis

Biopsy supplemented by microbiologic Biopsy supplemented by microbiologic examination reveals the background of the examination reveals the background of the

lesionslesions

Acute herpetic gingivostomatitis vesicles on the

gingiva

Acute herpetic gingivostomatitis

typical diffuse erythema

Gingival Diseases Of Viral OriginGingival Diseases Of Viral Origin

A number of viral infections are known to cause gingivitis . The most important are

herpes viruses. 1) Herpes simplex viruses type 1.

2) Herpes simplex viruses type 2

3) Varicella zoster virus

These viruses usually enter the These viruses usually enter the human body in childhood and human body in childhood and may give rise to oral mucosal may give rise to oral mucosal disease followed by periods of disease followed by periods of

latency and sometimes latency and sometimes reactivationreactivation

Herpes simplex virus type 1 Herpes simplex virus type 1 usually causes oral usually causes oral

manifestationsmanifestations

Herpes simplex virus type 2 is Herpes simplex virus type 2 is mainly involved in anogenital mainly involved in anogenital

infections and only occasionally infections and only occasionally is involved in oral infectionis involved in oral infection

Treatment Of Herpetic Treatment Of Herpetic GingivostomatitisGingivostomatitis

Treatment includes careful plaque removal to limit bacterial super infection of the ulcerations , which delay their healing.

In severe cases , including patients with immunodeficiency , the systemic use of

antiviral drugs such as Acyclovir or Valacyclovir is recommended

Gingival Diseases Of Fungal OriginGingival Diseases Of Fungal Origin

Fungal infection of the oral mucosa includes a range of diseases such as aspergillosis ,

blastomycosis , candidosis , coccidioidomycosis , cryptococcosis , histoplasmosis , mucormycosis and

paracoccidioidoycosis infections.

Not all of them manifest as gingivitis

CandidosisCandidosis

Various Candida species are recovered from the mouth of humans including Candida

Albicans ; Candida glabrata ;Candida krusei Candida tropicalis ; Candida parapsilosis ; Candida guillermondii .

Candida Albicans is the most common

Candida AlbicansCandida Albicans

The prevalence of oral carriage of Candida Albicans in healthy adults ranges from 3%

to 48%. The proportion of Candida Albicans in total yeast population can

reach about 50%-80%

Invasion and increased Invasion and increased desquamation is due to desquamation is due to

hyluronidase production.hyluronidase production.Infection by Candida Albicans Infection by Candida Albicans

usually occurs as a consequence of usually occurs as a consequence of reduced host defense posture reduced host defense posture including immunodeficiency , including immunodeficiency ,

reduced saliva secretion , smoking reduced saliva secretion , smoking and treatment with corticosteroidsand treatment with corticosteroids . .

Disturbances in the oral Disturbances in the oral microbial flora , such after microbial flora , such after

therapy with broad spectrum therapy with broad spectrum antibiotics may also lead to oral antibiotics may also lead to oral

candidosiscandidosis

Healthy individuals oral Healthy individuals oral candidosis rarely manifests in candidosis rarely manifests in

the gingiva.the gingiva.Candida Albicans is frequently Candida Albicans is frequently isolated from Subgingival flora isolated from Subgingival flora

of patients with severe of patients with severe periodontitisperiodontitis

Various types of oral mucosal Various types of oral mucosal manifestations are pseudo- manifestations are pseudo- membranous candidosis membranous candidosis erythematous candidosis , erythematous candidosis ,

plaque type candidosis , and plaque type candidosis , and nodular candidosisnodular candidosis

Pseudomembranous candidosis Pseudomembranous candidosis shows whitish patches , which can shows whitish patches , which can be wiped off the mucosa with an be wiped off the mucosa with an

instrument or gauze leaving a instrument or gauze leaving a slightly bleeding surface. This type slightly bleeding surface. This type

has no major symptoms. has no major symptoms. Erythematous lesions can be found Erythematous lesions can be found

anywhere in the oral mucosaanywhere in the oral mucosa

The intensely red lesions are The intensely red lesions are usually associated with pain , usually associated with pain , sometimes with severe painsometimes with severe pain

The plaque type of oral The plaque type of oral candidosis is a whitish plaque , candidosis is a whitish plaque ,

which cannot be removed.which cannot be removed.There are usually no symptoms There are usually no symptoms

and the lesion is clinically and the lesion is clinically indistinguishable from oral indistinguishable from oral

leukoplakialeukoplakia

Nodular candidal lesions are Nodular candidal lesions are infrequent in the gingiva.infrequent in the gingiva.

Slightly elevated nodules of Slightly elevated nodules of white reddish color characterize white reddish color characterize

themthem

Diagnosis of Candidal InfectionDiagnosis of Candidal Infection

Can be accomplished on the basis of culture smear , and biopsy

TreatmentTreatment

Topical treatment involves application of antifungal such as nystatin , amphotericin B , or

miconazole.Nystatin may be used as an oral suspension

Miconazole exits as an oral gel , it should not be given during pregnancy and it can interact with

anticoagulants and phenytoin.The treatment in the severe or generalized forms

also involves systemic antifungal such as fluconazole

Aphtous recurrent gingivostomatitisAphtous recurrent gingivostomatitis“ Canker Sores“ Canker Sores“ “

White swellings that change into ulcers surrounded by an area of redness.

Appearing suddenly , their most painful last three to six days.

Canker sores are more common in women and usually begin to appear by age of twenty. The attacks decrease with age

The cause of canker sores has The cause of canker sores has never been proven , predisposing never been proven , predisposing

factors in some people may include factors in some people may include deficiencies in iron , folic acid , deficiencies in iron , folic acid ,

vitamin B12 ,vitamin B12 ,genetic tendency , trauma , genetic tendency , trauma ,

cigarette smoking , allergies to cigarette smoking , allergies to certain foods , stress , and certain foods , stress , and

immunologic factorsimmunologic factors

Conventional TreatmentConventional Treatment

• Mouth rinse such as dexamethazone

• Topical preparations

• Mild pain relievers

• Corticosteroids

Antibiotics and vaccines have not been proved beneficial

Blood analysis will indicate if deficiencies of vit . B12, iron ,folic acid are present

PercoronitisPercoronitis

Percoronitis is a special type of acute Percoronitis is a special type of acute periodontal abscess that occurs when periodontal abscess that occurs when gingival tissue (operculum) overlies an gingival tissue (operculum) overlies an erupting tooth (usually a third molar, erupting tooth (usually a third molar,

also known as a wisdom tooth). also known as a wisdom tooth). Recurring acute symptoms are usually Recurring acute symptoms are usually initiated by trauma from the opposing initiated by trauma from the opposing tooth or by impaction of food or debris tooth or by impaction of food or debris under the flap of tissue that partially under the flap of tissue that partially

covers the erupting toothcovers the erupting tooth

Procedure for relieving the pain Procedure for relieving the pain is surgical removal of the is surgical removal of the

operculum. inject local operculum. inject local anesthetic directly into the anesthetic directly into the

overlying tissue and then cut it overlying tissue and then cut it away using the outline of the away using the outline of the

tooth as a guide for the incision. tooth as a guide for the incision. Sutures are not requiredSutures are not required

Irrigate with a weak (2%) hydrogen peroxide Irrigate with a weak (2%) hydrogen peroxide solution. Purulent material can be released solution. Purulent material can be released by placing the catheter tip of the irrigating by placing the catheter tip of the irrigating syringe under the tissue flap overlying the syringe under the tissue flap overlying the

impacted molar. impacted molar.

Prescribe oral analgesics for comfort as Prescribe oral analgesics for comfort as well as penicillin over the next 10 days well as penicillin over the next 10 days

(penicillin VK 500mg ). (penicillin VK 500mg ). Instruct the patient on the importance Instruct the patient on the importance of cleansing away any food particles of cleansing away any food particles that collect beneath the gingival flap. that collect beneath the gingival flap. This can be accomplished by simply This can be accomplished by simply using a soft toothbrush or by using using a soft toothbrush or by using

water jet irrigationwater jet irrigation

Follow-up should be provided to Follow-up should be provided to observe the resolution of the observe the resolution of the

acute infection and to evaluate acute infection and to evaluate the need for removal of the the need for removal of the

gingival flap or molargingival flap or molar . .

Do not undertake any major Do not undertake any major blunt dissection while draining blunt dissection while draining

pus. This could spread a pus. This could spread a superficial infection into the superficial infection into the

deep spaces of the head and deep spaces of the head and neck or follow a deep abscess neck or follow a deep abscess

posteriorly into the carotid posteriorly into the carotid sheathsheath