Diagnosis and tx of necrotising gingivitis/periodontitis

Question 1

What are the different diagnosis of necrotising gingivitis periodontitis

Answer 1

necrotising periodontal disease NPD
necrotising gingivitis NG
necrotising periodontitis
necrotising stomatitis NS
acute necrotising ulcerative gingivitis ANUG
acute necrotising ulcerative periodontitis ANUP
fusospirochetosis
trench mouth
vincent’s gingivitis, gingivostomatitis, infection

Question 2

What are the main features of NPD

Answer 2

painful, bleeding gums and ulceration and necrosis of the interdental papilla
rapidly destructive and debilitating

Question 3

Why is ANUG/P known to occur in epidemic type patterns

Answer 3

due to shared predisposing factors in a population

it is not contagious

Question 4

What type of infection is necrotising gingivitis/periodontitis

Answer 4

opportunistic infection - caused by bacteria inhabiting healthy oral cavity

Question 5

What is acute necrotizing ulcerative gingivitis

Answer 5

ANUG
or simply necrotizing gingivitis
common non contagious infection of gums
if improperly treated can become chronic and or recurrent

Question 6

What is NUP/NP/ANUP

Answer 6

this is when the infection leads to attachment loss

it may be the extension of NUG into the periodontal ligaments although this is not completely proven

it may be that both diseases develop without connection

Question 7

What is necrotizing stomatitis

Answer 7

progression of NUP into tissue beyond the mucogingival junction and

may result in denudation of the bone leading to osteitis and oro-antral fistulas

Question 8

Who is necrotizing stomatitis mostly seen in

Answer 8

those with malnutrition dn HIV infection

Question 9

What is cancrum oris (aka norma)

Answer 9

necrotizing and destructive infection of the mouth and face and therefore not strictly speaking a periodontal disease

in modern times it usually occurs in malnutrition children in developing countries

Question 10

What is the diagnosis based on

Answer 10

symptoms

Question 11

What is the diagnostic symptoms

Answer 11

ulcerated and necrotic papillae and gingival margin resulting in characteristic punched out appearance

the ulcers are covered by a yellowish, white or grayish slough

lesions develop quickly

lesions are very painful - severe pain

Question 12

What are the symptoms

Answer 12

bleeding readily provoked

first lesions most often seen inter proximally in mandibular anterior region

in NUP the ulcerations are often associated with deep pockets formation as gingival necrosis coincides with loss of crystal alveolar bone

swelling of the lymph nodes particularly in the advanced cases

usually no elevation of body temperature - herpetic gingivostomatitis

Question 13

Why is the diagnosis not based on any test

Answer 13

as if u took a biopsy the histopathology is not characteristic for NPD

microbiology - not characteristic

it is an opportunistic infection

Question 14

What are risk factors for NPD

Answer 14

mostly young adults with predisposing factors such as stress, sleep deprivation, poor OH, smoking and immune supression and/r malnutrition

Question 15

In developing country who does ANUG mostly occur in

Answer 15

malnourished children

Question 16

What makes clinical characteristic of HIV px different to the normal ones

Answer 16

not associated with big amounts of plaque and calculi

Question 17

What is the tx

Answer 17

tx of the acute disease is debridement and AB - usually metronidazole

need to get good OH

1. ultrasonic debridement
2. if painful on brushing use 0.2% chlorhexidine moutwash
3. for those with systemic symptoms, lack of response and with impaired immunity then 200mg metronidazole TID
4. smoking cessation, vitamin supplementation, dietary advice
5. in case of necrotising periodontitis, after emery of acute symptoms need to carry out HPT to treat periodontal disease

Question 18

What are the tx strategies for periodontal disease

Answer 18

mechanical disruption
systemic abitbioticss or local antimicrobias
host modulation therapy

Question 19

What is mechanical disruption

Answer 19

reducing the bacterial challenge
scaling and root surface debridement
targeting biofilm

Question 20

What are systemic antibiotics or local antimicrobials targeting

Answer 20

biofilm

Question 21

What is host modulation therapy

Answer 21

targeting function of the immune system

Question 22

Why are systemic AB not the first line of tx

Answer 22

we are fighting a biofilm

Question 23

If prescribing AB what must they be used w

Answer 23

mechanical disruption

Question 24

When can we consider treating with systemic AB with mechanical disruption

Answer 24

in cases of young people with grade B/C (fast progressing periodontitis)

Question 25

What is the tx protocol for those px that need the Ab

Answer 25

1. OH
2. supra gingival scaling and RSD of all sites indicated in pocket chart
3. start the antibiotic regiment on the morning of the first RSD visit
4. 500mg amoxicillin with 200mg metronidazole TID 7 days
   OR
   400mg metronidazole TID 7 days for those allergic to amoxicillin

Question 26

What are advantages of local antimicrobials

Answer 26

reduced systemic dose
high local concentration
superinfection such as c difficile unlikely
drug interactions unlikely
site specific
px compliance not an issue as applied by healthcare provider
can utilize agents that can’t be utilized systemically e.g chlorhexidine

Question 27

What are the indications for using local antiseptics

Answer 27

only persisting pockets
always with RSD
only in isolated pockets
in case of periodontal abscess after evacuation of pus and RSD

Question 28

What are the possible host modulation therapies

Answer 28

corticosteroids
NSAID 
anticytokine and biologi therapies
lipid mediators of resolution of inflammation
small molecule compounds
bisphosphonates