necrotizing perio dx Flashcards
necrotizing perio dx characterized by:
necrosis and
ulceration
necrotizing perio dx onset and duration
Sudden onset
and it can become a
“chronic condition”
necrotizing perio dx defined
A rare and destructive form of periodontal disease caused by microorganism in the context of an impaired host response
nomenclature of necrotizing perio dx over time
1989 classification of necrotizning perio dx: stages 1-7
staged
1999 classification of necro perio dx
4 forms
2017 classification
Prevalence/Incidence of necrotizing perio dx in general pop
0.5 - 3.3% in general populations
Prevalence/Incidence of necrotizing perio dx in military
0.2 - 6.2% in military personnel
* 4%-20.6% when it was close to the end of WW2
Prevalence/Incidence of necrotizing perio dx in students
0.9 - 6.7% in students
Prevalence/Incidence of necrotizing perio dx in HIV/AIDS
0 - 30 % in HIV/AIDS patients
* Children (2.2‐5.0%)
* HIV adults (0.0–27.7% for NG and 0.3–9.0% for NP)
* HIV/AIDS patients (10.1–11.1% for NG and 0.3–9.0% for NP)
highest prevalence populations for necrotizing perio dx
HIV-infected individuals
Malnourished children
etiology/risk factors of necrotizing perio dx: microbial factors
Spirochetes and fusiform bacteria
P. intermedia
Treponema
Selenomonas
Fusobacterium species
specific microbio risk factors of HIV pts
Candida albicans
Herpes viruses
Superinfecting bacterial species
host determinant risk factors of necrotizing perio dx
Systemic modifying factors
PMN function
Pre-exsisting systemic disease
- Leukemia
- Leukopenia
- HIV/AIDS
Previous history of NPD
Pre‐existing gingivitis
Young age and ethnicity
environmental risk factors of necro perio dx
Mulnutrition
Stress
Insufficient sleep
Smoking/alcohol consumption
Inadequate oral hygiene
stress effects for necro perio
HIV/AIDS
- HIV: Human Immunodeficiency Virus
- AIDS: Late stage of the HIV infection
- Marked shift of CD4/CD8 ratio
- normal ratio is 2:1
AIDS
defined? susceptiable to?
Late stage of the HIV infection
* Definition (one of the following)
* CD4 count <200 cells/mm3 in an HIV+ patient
* HIV+ patients with ≥ one opportunistic infection
* - Pulmonary TB
* - Recurrent pneumonia
* - Invasive cervical carcinoma
HIV/AIDS severity based on?
Disease severity based on CD4 counts (T-helper cell)
oppurtunistic infections and t cell count of AIDS/HIV
400-500
301-400
201-300
101-200
0-100
r
important lab data of necro perio
interpreatation of these?
HIV/AIDS
Oral lesions
- Candidiasis
- Viral lesions
- Major aphthous ulcers
- Necrotizing gingivitis
- Linear gingival erythema
- Necrotizing periodontitis
- Neoplasms: Oral hairy leukoplakia, Kaposi’s sarcoma, Non-Hodgkins lymphoma
When to premeditate
HIV/AIDS patients for
invasive procedures?
When Absolute Neutrophil Count is less than 500
Necrotizing Gingivitis histopathology
It shows nonspecific acute inflammatory reaction surrounding an ulcer within the stratified squamous epithelium and the gingival connective tissue
Necrotizing Periodontitis light microscopy
Identical to a necrotizing gingivitis lesion
Except the destruction of the underlying periodontium
light microscopy clinical features observed
Pseudomembrane and linear erythema
pseudomembrane location and microscopic appearence
Surface epithelium:
It is destroyed and replaced by a meshwork of fibrin, necrotic epithelium, PMNs and various types of microorganism.
linear erythema location and microscopic observations
Underlying connective tissue:
It is hyperemic with numerous engorged capillaries and dense infiltration of PMNs
Electron Microscopy: microscopic zones
what is seen in this electromicroscopy
Bacterial smear
* Spirochetes
* Rods
phago in electronmicroscopy
- Neutrophil approach the bacterial zone
steps to managing necro perio
Assessment
Diagnosis
Treatment
assessing necro perio
* Find out?
* Clinical findings account for?
*atypical presentation or non-responding cases?
- Find out predisposing factors
- Clinical findings account for diagnosis of NPD
- Microbiological or biopsy assessment in atypical presentation or non-responding cases
assessing: possible signs and symptoms of necro perio
primary vs other
Signs and Symptoms necro perio dx’s
* Necrosis where?
* Bleeding?
* pain?
* Pseudomembrane?
* breath?
* tissue destruction/bone loss?
* gingival recession?
* sensitivity?
* Suppuration?
* Dysgeusia?
* fever?
* Lymph nodes?
- Necrosis and ulcer in the interdental papilla
- Bleeding spontaneously or while brushing
- Mild to moderate pain
- Pseudomembrane formation
- Halitosis
- May have aggressive tissue destruction/bone loss
- Severe gingival recession
- Hypersensitivity
- Suppuration
- Dysgeusia
- Low-grade fever
- Lymphadenopathy
Possible Necrotizing Periodontal Diseases
Possible Necrotizing Periodontal Diseases
Necrotizing Gingivitis Clinical Characteristics
* Contagious?
* Age onset?
* Strong relationship between?
- Not Contagious
- Age onset is generally 15-30 years old
- Strong relationship between onset of disease and level of stress/anxiety
Necrotizing Gingivitis Clinical Characteristics
* Respond to what tx?
* 75% patients exhibit localized defects with what immune processes?
- Respond to antibiotic and non-surgical periodontal therapy
- 75% patients exhibit a localized defect in neutrophil chemotaxis and/or phagocytosis
Necrotizing Gingivitis Clinical Symptoms & Signs
- Necrosis and ulcer in the interdental papilla (94–100%)
- Gingival bleeding (95–100%)
- Pain (86–100%)
- Pseudomembrane formation (73–88%)
- Halitosis (84–97%)
- Adenopathy (44–61%)
- Fever (20‐39%)
Necrotizing Gingivitis: Differential Diagnosis possible
- Gingivitis
- Herpetic gingivostomatitis
- Mild or grade A/B periodontitis
- Facticial injury
- Allergic reaction(Nickel)
- MMP
- Linear gingival erythema
Differential Diagnosis:
Herpetic Gingivostomatitis
keys to differentiate
- Primary herpetic gingivostomatitis (PHG) is frequently
mistaken for NPD. (Klotz 1973) - Keys to differentiate: Age, body temperature, lesion
site, clinical symptoms
NPD vs PHG
Differential Diagnosis: necrotizing gingivits vs
HIV association
HIV with: Linear gingival erythema, Intense erythematous marginal gingivitis May have profuse BOP
Linear gingival erythema with HIV
* Prior to?
* Incidence rate?
* Seen when CD4 count is?
- Prior to other opportunistic infections
- Incidence of about 30-40% of AIDS cases
- Seen when CD4 count > 200 cell/mm3
Necrotizing Gingivitis non-surgical Treatment
- Improve oral hygiene and debridement
- 0.12% Chlorhexidine pre/post-treatment rinse
Necrotizing Gingivitis Abx Treatment
- Metronidazole 250 mg 3x daily for 7 days (first choice)
- Or Amoxicillin, 500 mg 3x daily for 7 days
Necrotizing Periodontitis Clinical Characteristics
* Seen in conjunction with?
* Disease incidence in AIDS?
* % may be decreasing with?
* Seen when CD4 count is?
- Seen in conjunction with other opportunistic infections
- Disease incidence of about 20% AIDS cases
- % may be decreasing with ART medications
- Seen when CD4 count < 200 cells/mm3
Necrotizing Periodontitis used as HIV prognostic marker?
- NP used as a marker for immune deterioration and a predictor for the diagnosis of AIDS since it appears with CD4 counts below 200 cells/mm3
- NP diagnosis to time of death (Glick et al, 1994)
- 60% within 18 months
- 73% within 24 months
Necrotizing Periodontitis: Clinical Symptoms & Signs
* Appearance of?
* Necrosis of?
* pain?
* mobility?
* systemic?
- Appearance of NG superimposed over rapid /progressive attachment and bone loss
- Necrosis of marginal and papillary gingiva
- Persistent throbbing pain
- Tooth mobility
- Lymphadenopathy and low-grade fever
Necrotizing Periodontitis: Microbiology
spp
- Candida albicans 70%
- Prevotella intermedia 67%
- Campylobacter rectus 47%
- Actinobacillus actinomyces 28%
- Porphyromonas gingivalis 23%
- Miscellaneous enteric bacteria
Necrotizing Periodontitis: potential Differential Diagnosis
- Severe or grade C periodontitis
- Uncontrolled/Undiagnosed diabetes
- Severe immune suppression: chemotherapy or leukemia
- ONJ
Necrotizing Periodontitis: Treatment, consult?
Consult patients’ physician prevent drug interaction
Necrotizing Periodontitis non-surgical Treatment
- 0.12% Chlorhexidine pre/post-treatment rinse
- Debridement with hand instruments
Necrotizing Periodontitis: Abx Treatment
- Metronidazole 250 mg 4x daily for 7-10 days
- Antifungal therapy if indicated
Necrotizing Periodontitis Treatment surgery?
Surgical correction may be indicated
Necrotizing Stomatitis: Clinical Characteristics
* An extension of?
* May be considered?
* Occurs with other?
- An extension of the infection of NP to involve interradicular, interseptal and crestal bone
- May be considered as a localized severe osteomyelitis
- Occurs with other opportunistic infections
Necrotizing Stomatitis: Clinical Characteristics with AIDS
* Seen in how many AIDS cases?
* Seen when CD4 count is?
* Seen as?
- Seen in less than 5% of AIDS cases
- Seen when CD4 count < 50 cells/mm3
- Seen as NP with areas of exposed necrotic alveolar bone
Necrotizing Stomatitis: Clinical Symptoms & Signs
* Necrosis and ulceration?
* Exposure of?
* mobility?
* lymph nodes?
* systemic?
- Necrosis and ulceration of the gingiva extending into the alveolar mucosa rapidly
- Exposure of necrotic bone with extension into osteomyelitis
- Tooth mobility
- Lymphadenopathy and fever
- Bacteremia, septicemia
Necrotizing Stomatitis Microbiology
- Candida albicans
- Mixed gram negative anaerobic infection
- Miscellaneous enteric bacteria
Necrotizing Stomatitis: potential Differential Diagnosis
Necrotizing Stomatitis Treatment with physician
Consult patients’ physicianprevent drug interaction
Necrotizing Stomatitis non-surgical Treatment
- 0.12% Chlorhexidine pre/post-treatment rinse
- Debridement to remove oral necrotized tissue
- Scaling with hand instruments
Necrotizing Stomatitis Abx Treatment
- Metronidazole 250 mg 4x daily for 7-10 days
- Antifungal therapy if indicated
Necrotizing Stomatitis surgical Treatment
Surgical correction
Cancrum Oris (Noma)
* app/defined?
* demo?
* where?
- A rapidly progressive often gangrenous infection extends from mouth to face
- Affects impoverished and malnourished children (2-6 years old)
- In countries in poverty (Africa, Asia, South America)
