Chapter 5 - acute conditions of the periodontium

Question 1

what are the 3 types of necrotising periodontal conditions?

Answer 1

Necrotising ulcerative gingivitis
Necrotising ulcerative periodontitis
Necrotising stomatitis

Question 2

what tissues are affected by NUG, NUP and NS?

Answer 2

NUG - confined to gingivae only
NUP - periodontal tissues affected causing LOA
NS - surrounding tissues involved

Question 3

what are predisposing factors for necrotising periodontal conditions?

Answer 3

1- poor OH
2- smoking
3- stress
4- immunocomprimised (eg HIV, leukaemia, immunosuppresants etc)
5- malnutrition (associated with poor protein intake in developing countries)
6- fatigue
7- pre-existing gingivitis

Question 4

What are the clinical oral features of NUG?

Answer 4

• necrotic ulcers (starts on tips of ID papilla)
• initially red swollen ID papilla which then spreads laterally along the gingival margin
• change in gingival contour = loss of apex of papilla/punched out appearance)
• PAIN (sudden onset - can affect eating)
• bleeding (spontaneous)
• metallic taste
• pseudomembranous grey slough (frequently seen on surface where there is tissue necrosis) This slough can be easily removed leaving a red raw bleeding surface.
• necrosis gives an unpleasant halitosis (unforgettable) called foetor oris
• can be localised or generalised

Question 5

what are the clinical systemic features of NUG

Answer 5

There is usually no systemic features but in severe cases

• lymphadenopathy
• malaise
• fever (pyrexia) = very very uncommon

Question 6

in addition to the symptoms of NUG what can clinically accompany NUP?

Answer 6

necrosis of the PDL and the bone (this creates loss of attachment)

it can be a rapid process

if extends to the interproximal bone or the facial bone it can lead to a sequestrum

Question 7

what is a sequestrum?

Answer 7

a fragment of dead bone

Question 8

what is the treatment of necrotising ulcerative perio disease?

Answer 8

1 . debridement (removal of soft/hard plaque dep & slough)
the use of USS to do this is much more gentle for patient and takes less time - cavitational effect of the USS means that anaerobic bacteria is killed.

2. recommend a hydrogen peroxide based mouth rise to help ulcerated areas. Benefit = mechanical cleansing properties & releases oxygen into area which is predominantly infected with anaerobic bacteria.
3. chlorhexidine mouth rinse (0.2%) is effective way or reducing plaque growth - helpful if patient is unable to brush due acute pain from infection

Question 9

What is the prevalence of NUG and who is it more likely to affect?

Answer 9

rapid decline in prevalence over the last 30 but still common in the HIV population.

affects 5% of the population

affects men and women equally

affects mostly between ages of 16-30

formerly called trench mouth

Question 10

how to diagnose NUG?

Answer 10

clinical signs enough

Question 11

what will happen if NUG is left untreated in UK?

Answer 11

• acute symptoms will last 2-3 weeks
• healing will lead to chronic gingivitis
• tend to reoccur and give further loss of ID papilla
• creates stagnation areas

Question 12

what will happen if NUG is left untreated in developing countries?

Answer 12

can lead to cancrum oris which is where there is severe oro-facial necrosis which can be disfiguring and fatal.

particularly affects children who are malnourished/diseased

Question 13

what is microbiology behind NUG? give 4 specific principle bacteria

Answer 13

the anaerobic fuso-spirochetal complex

principle bacteria are:

• treponema vincentii and denticola
• fusobacterium nucleatum
• prevotella intermedia
• porphyromonas gingivalis

Question 14

is NUG transmittable?

Answer 14

no evidence to say yes

Question 15

what evidence suggests that bacteria play an important role?

Answer 15

the condition responds quickly and well to antibiotics

Question 16

what antibiotics would be given to treat necrotising condititons and when would they be given?

Answer 16

only given if patient showing systemic signs. If so, give systemic

• metronidazole 200mg 3xdaily for 3-5 days

alternatively can give penicillin and tetracycline

Question 17

will topical antibiotics work for treatment of NUG?

Answer 17

no because the infection has penetrated the tissues where there the topical antibiotic would not gain access to

Question 18

what advice may you consider once you have stabilised the acute symptoms?

Answer 18

• OHI
• smoking cessation advice
• supra/subgingival debridement
• review & maintenance
• perio surgery? to reverse lost architecture
• advice pt to see medical practitioner as we know their is a link to other systemic conditions

Question 19

what % of cases of NUG are in smokers and why is there thought to be a close link with smoking?

Answer 19

98% in smokers

• worse OH (more calculus formation)
• tobacco causes vasoconstriction which can result in a more anaerobic environment

smoking suppresses the IgG serum levels against subgingival bacteria

smoking depresses the T-helper lymphocytes

smoking reduces the motility and chemotaxis of PMNs

Question 20

what are PMNs?

Answer 20

polymorphonuclear leukocyte

a type of white blood cell called a granulocyte because it contains granules that contain enzymes which digest micro-organisms

Question 21

how is stress seen to be a predisposing factor to NUG?

Answer 21

leads to behaviour change

• poor OH
• increased smoking
• poor diet

reduces salivary flow

causes vasoconstriction to gingival end arteries

suppresses immune response

Question 22

what causes primary herpetic gingivostomatitis?

Answer 22

herpes simplex virus

Question 23

what are the symptoms of primary herpetic gingivostomatitis?

Answer 23

• lymphadenopathy
• fever (pyrexia)
• malaise
• flu-like symptoms
• oral pain
• gingivitis
• oral ulceration
• stomatitis

Question 24

what is the treatment of primary herpetic gingivostomatitis?

Answer 24

1. keep fluid intake up
2. analgesia/anti fever
3. anti-viral (ACICLOVIR) only if immunocomprimised patient

Question 25

is primary herpetic gingivostomatitis contageous?

Answer 25

yes, highly - through oral lesions

Question 26

what is the incubation period for primary herpetic gingivostomatitis?

Answer 26

around 7 days

Question 27

what are the 5 types of dental abscess?

Answer 27

1. gingival
2. periodontal
3. peri-coronal
4. endodontic
5. combined

Question 28

what is a gingival abscess usually caused by?

Answer 28

trauma to the gingival tissue

Question 29

when can you get a periodontal abscess?

Answer 29

when you have a periodontal pocket

Question 30

what is a peri-coronal abscess?

Answer 30

usually related to a operculum overlying a partially erupted third molars

Question 31

what is an operculum?

Answer 31

a flap of gum

Question 32

a combined abscess is where?

Answer 32

where periodontal abscess and endodontic lesion meet in the middle of the tooth

Question 33

all abscesses can be what or what?

Answer 33

acute (painful, active & destructive)

chronic (painless and slowly progressing)

Question 34

if a chronic abscess cannot drain then what wil happen? why?

Answer 34

you will get acute infection because there is a build up of pressure and infection

Question 35

what can a periodontal abscess follow..? 3 things

Answer 35

incomplete scaling - therefore important to fully debride any pocket completely

trauma from a foreign body

addition of a new more virulent bacteria

Question 36

what is the treatment for a periodontal abscess?

Answer 36

same as for NUG - prescribe antibiotics not only if there is systemic features but also if there is facial swelling or the patient is medically comprimised