Nup

Necrotizing Ulcerative PeriodontitisAssociate professor Dr Alaa Moustafa Attia

Necrotizing Ulcerative PeriodontitisNUP may be an extension of necrotizing ulcerative gingivitis (NUG) into the periodontal structures, leading to periodontal attachment and bone loss.

NUP and NUG may be different diseases

Many authors suggested that the NUG is precursor to NUP.

NomenclatureTerm NUP was first adopted at the 1989 World Workshop in Clinical Periodontics.

Old name was NU gingivoperiodontitis

incidenceMore cases of NUP were being described in immunocompromised patients, especially those who were human immunodeficiency virus (HIV) positive or had acquired immunodeficiency syndrome (AIDS).

Differences of NUG/NUP

The distinction between the two conditions (NUG and NUP) as separate diseases has not been clarified, but they are distinguished by the presence or absence of attachment and bone loss.

Clinical features of NUP 1Similarity to NUG:

Similar to NUG, clinical cases of NUP are defined by necrosis and ulceration of the coronal portion of the interdental papillae and gingival margin, with a painful, bright red marginal gingiva that bleeds easily. Show gingival crater on interdental papillae.

NUP characterized by destructive progression

Clinical features of NUP 2NUP distinguished by:By the destructive progression of the disease that includes periodontal attachment and bone loss. Deep interdental osseous craters demonstrate periodontal lesions of NUP.

Gingival lesion destroys the marginal epithelium and connective tissue, resulting in gingival recession.

Periodontal pockets are formed because the junctional epithelial cells remain viable and can therefore migrate apically to cover areas of connective tissue loss.

Tooth mobility

Ultimately tooth loss.

Clinical features of NUP 3

NUP patients may present with:

Oral malodor (foul odor)

Fever

Malaise

lymphadenopathy.

Clinical features of NUP 4

Necrotizing ulcerative periodontitis in 45-year-old, HIV-negative, white male patient. A, Buccal view of maxillary cuspid-bicuspid area.

Necrotizing ulcerative periodontitis in 45-year-old, HIV-negative, white male patient. B, Palatal view of same area.

Necrotizing ulcerative periodontitis in 45-year-old, HIV-negative, white male patient. C, Buccal view of mandibular anteriors. Note the deep craters associated with bone loss.

Complications of NUP & severe form of NUG: =========================== Gangrenous (necrotic) stomatitis: extensive necrotic process to adjacent gingival mucosa (check, palate, tongue, floor of m., lips) Noma (cancrum oris): serious (fatal ) form of necrotic stomatitis that lead to exposure of bone and perforation of check & nasal cavity.Clinical features of NUP 4

Necrotic stomatitis

Noma (cancrum oris)

Commonly similar to NUG1- surface biofilm composed of a mixed microbial flora with different morphotypes and a subsurface flora with dense aggregations of spirochetes (bacterial zone). 2- Dense aggregations of PMNs (neutrophil-rich zone) .3- Necrotic cells (necrotic zone).4- Spirochetal infiltration zone.5- High levels of yeasts and herpes-like viruses were observed.Microscopic finding

HIV/AIDS Patients Gingival and periodontal lesions with distinctive features are frequently found in patients with HIV infection and AIDS.

- Linear gingival erythema (LGE), and NUG, and NUP are the most common HIV-associated periodontal conditions reported in the literature.

NUP lesions found in HIV-positive/AIDS patients can present with similar features to those seen in HIV-negative patients.

NUP lesions in HIV-positive/AIDS patients can be much more destructive and frequently result in complications that are extremely rare in non-HIV/AIDS patients.

HIV-positive NUP may be extremely rapid.

- Other complications: - Large areas of soft tissue necrosis.- Exposure of bone and sequestration of bone fragments. - Necrotizing ulcerative stomatitisHIV/AIDS Patients

Some researchers: reported that the NUP to be a marker for immune deterioration and a predictor for the diagnosis of AIDS.

Other author: suggested that NUP may be used as an indicator of HIV infection in undiagnosed patients.

HIV/AIDS Patients

Shangase etal (2007) reported that a diagnosis of NUG or NUP in systemically healthy, asymptomatic South Africans was strongly correlated with HIV infection. Of patients presenting with NUG or NUP, 39 of 56 (69.6%) were subsequently found to be HIV positive

HIV/AIDS Patients

Etiology of NUPGenerally as NUG:

1- Bacteria role: NUP in HIV-positive patients demonstrated significantly greater numbers of the opportunistic fungus Candida albicans and a higher prevalence of A. actinomycetemcomitans, P. intermedia, P. gingivalis, Fusobacterium nucleatum, and Campylobacter species compared with HIV-negative controls.

Low or variable level of spirochetes, which is inconsistent with the flora associated with NUG.

Immunocompromised Status :

Clearly, both NUG and NUP lesions are more prevalent in patients with compromised or suppressed immune systems. Commonly in HIV-positive and AIDS patients.

Etiology of NUP

Psychologic Stress Stress increases systemic cortisol levels, and sustained increases in cortisone have a suppressive effect on the immune response by microcirculation in gingiva and altered phagocytic functions.

Some researchers: Found that urinary levels of 17-hydroxycorticosteroid were higher in subjects with NUG than in all other subjects diagnosed with periodontal health, gingivitis, or periodontitis.Etiology of NUP

Malnutrition Direct evidence of the relationship between malnutrition and necrotizing periodontal disease is limited to descriptions of necrotizing infections in severely malnourished children.

Many of the host defenses, including phagocytosis; cell-mediated immunity; and complement, antibody, and altered cytokine production, are impaired in malnourished individuals.Etiology of NUP

Reduction of nutrients to cells and tissues results in immunosuppression and disease susceptibility.

Malnutrition can predispose an individual to opportunistic infections or intensify the severity of current oral infections.

Etiology of NUP

Other factors

- Smoking

- Plaque and other local factors e.g. calculus

Etiology of NUP

Treatment The treatment is mostly similar to NUG

1- Lavage of necrotic tissue and pseudomembrane under local anesthesia. 2- Correction of the systemic condition as possible and consultation with patients physician .

3- Periodontal debridement (scaling and root planing).

4- Local and systemic antibiotics 5- Antiseptic mouth wash (chlorhexidine)6- Antifungal and antiviral drugs7- Good nutrition and enhancement the psychic status.8- Oral hygiene instruction and patient motivation to control dental plaque.9- Maintenance recall visits to evaluate periodontal health and observe the recurrence of lesions.

Exercise

Comparison between NUG and NUP

Documents

Nup