necrotising perio

Question 1

What is necrotising periodontal disease and what is it caused by

Answer 1

The most severe inflammatory periodontal disorder caused by plaque bacteria

Question 2

What are the main features of NPD

Answer 2

painful, bleeding gums and ulceration and necrosis of the interdental papilla - punched-out appearance

Question 3

What are the classifications of necrotizing perio diseases

Answer 3

Necrotizing gingivitis

Necrotizing periodontitis

Necrotizing stomatitis

Question 4

What is Necrotizing gingivitis

Answer 4

when only the gingival tissues are affected

Question 5

What is necrotizing periodontitis

Answer 5

when the necrosis progresses into the periodontal ligament and the alveolar bone, leading to attachment loss

Question 6

What is necrotizing stomatitis and what may it lead to

Answer 6

when the necrosis progresses to deeper tissues beyond the mucogingival line, including the lip or cheek mucosa, the ton- gue, etc

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

Question 7

What is cancrum oris

Answer 7

(also termed noma) is a necrotizing and destructive infection of the mouth and face, and therefore not strictly speaking a periodontal disease

Question 8

What is a diagnosis of NPD based on

Answer 8

Symptoms

Question 9

What are the symptoms of NPD

Answer 9

Ulcerated and necrotic papillae and gingival margin resulting in a characteristic punched-out appearance

The ulcers are covered by a yellowish, white or greyish slaim, no coherence only slime made of fibrin, necrotic tissue, leucocytes, erythrocytes and mass of bacteria. When this ‘membrane’ is removed, the underlying connective tissue becomes exposed and bleeds.

Lesions develop quickly

Lesions are very painful – severe pain

Bleeding readily provoked

The first lesions are most often seen interproximally in the mandibular anterior region

Foetor ex ore

Question 10

What is meant by Foetor ex ore

Answer 10

bad breathe

Question 11

What is the ulcerations often associated with in NPD

Answer 11

deep pockets formation as gingival necrosis coincides with loss of crestal alveolar bone

Ulcers with central necrosis develop into craters

Question 12

What is found in most severe cases

Answer 12

adenopathies

If present, submandibular lymph nodes are more affected than those in the cervical area

Question 13

Why is diagnosis of NPD not based on any test

Answer 13

Biopsy – histopathology is not pathognomic (characteristic) for NPD

Microbiology – not characteristic as well

Question 14

What is it important to differentiate NPD from

Answer 14

Oral mucositis

HIV-associate periodontitis

Herpes simplex virus (HSV)

Scurvy

Gingivostomatitis

Desquamative gingivitis

Invasive fungal disease

Illicit-drug related gingival disease

Agranulocytosis

Leukemia

Chronic periodontitis

Question 15

In developed countries NPD occurs mostly in what group and what are the predisposing factors

Answer 15

Young adults

stress, sleep deprivation, poor oral hygiene, smoking, immunosuppression (HIV infection and leukaemia) and/or malnutrition

Question 16

In developing countries NPD mostly occurs in what group

Answer 16

malnourished children

Question 17

What are the objectives of the acute phase treatment of NPD

Answer 17

1) to arrest the disease process and tissue destruction;

2) to control the patient′s general feeling of discomfort and pain that is interfering with nutrition and oral hygiene practices

Question 18

What is carried out in the acute phase of treatment

Answer 18

The first task should be a careful superficial debridement to remove the soft and mineralized deposits. Exerting minimal pressure over the ulcerated soft tissues

The debridement should be performed daily and lasting for as long as the acute phase lasts (normally 2 –4 days)

Question 19

What should be limited during treatment and what should replace it

Answer 19

Mechanical oral hygiene measures should be limited because brushing directly in the wounds may impair healing and induce pain.

During this period the patient is advised to use chemical plaque control formulations, such as chlorhexidine-based mouthrinses (0.12–0.2%, twice daily)
Other products have also been suggested, such as 3% hydrogen peroxide diluted 1:1 in warm water

Question 20

When would antibiotics be used

Answer 20

In cases that show unsatisfactory response to debridement or show systemic effects (fever and/or malaise)

Question 21

What antibiotics would you use and how much and long for

Answer 21

Metronidazole 400mg 1 tablet three times daily for 3 days

Question 22

How often should you see patients with NPD

Answer 22

Patients have to be followed up very closely (daily, if possible) and as the symptoms and signs improve, strict mechanical hygiene measures should be enforced, as well as complete debridement of the lesions

Question 23

Once the acute phase has been treated what do you do

Answer 23

Treatment of the pre-existing condition

NPD normally occurs over a pre-exsisting condition (chronic gingivitis , periodontitis) so once the acute phase is finished carry out professional prophylaxis and/or PMPR

OHI and motivation should be reinforced and predisposing local factors (overhanging restorations, interdental open spaces and tooth malposition) evaluated and treated

Question 24

After acute phase and pre-existing condition have been reated what would be considered next and why and how

Answer 24

Corrective phase treatment

As the disease may leave behind altered gingival topography (e.g. gingival craters) These should be treated as they may favour plaque accumulation and disease recurrence

This would be done by Gingivectomy and/or gingivoplasty procedures (periodontal flap surgery, or even regenerative surgery, are more suitable options for deep craters)

Question 25

After the corrective phase treatment what is next

Answer 25

Supportive or maintenance phase

Main goal is compliance with the oral hygiene practises and control of predisposing factors