Necrotizing Periodontal Diseases Flashcards
Necrotizing Periodontal Diseases
Clinical Presentation
Sudden onset
and it can become a
“—”
Characterized by
(2)
chronic condition
gingival tissue
necrosis and
ulceration
Necrotizing Periodontal Diseases
A rare and destructive form of
periodontal disease caused by
microorganism in the context of
an impaired host response
skipped
The 1989 Classification
stages (7)
Stage 1: Necrosis of the tip of interdental papillae
Stage 2: Necrosis of entire papillae
Stage 3: Necrosis extends to marginal gingiva
Stage 4: Necrosis extends to attached gingiva
Stage 5: Necrosis extends to labial/buccal mucosa
Stage 6: Necrosis and exposing alveolar bone
Stage 7: Necrosis perforates facial skin
The 2017 Classification
Forms of Periodontitis (3)
necrotizing gingivitis
necrotizing periodontistis
necrotizing stomatitis
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Epidemiology
Prevalence/Incidence
* —% in general populations
* —% in military personnel
* —% when it was close to the end of WW2
* —% in students
* —% in HIV/AIDS patients
0.5 - 3.3
0.2 - 6.2
4%-20.6
0.9 - 6.7
0 - 30
skipped
0 - 30 % in HIV/AIDS patients
(3)
- 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)
skipped
Spirochetes and fusiform bacteria
(4)
P. intermedia
Treponema
Selenomonas
Fusobacterium species
skipped
Specific features in HIV
(3)
Candida albicans
Herpes viruses
Superinfecting bacterial species
skipped
Systemic modifying factors
PMN function
Pre-exsisting systemic disease
- Leukemia
- Leukopenia
- HIV/AIDS
Previous history of NPD
Pre‐existing gingivitis
Young age and ethnicity
skipped
Environmental
Determinants
Mulnutrition
Stress
Insufficient sleep
Smoking/alcohol
consumption
Inadequate oral
hygiene
Stress/Anxiety/Depression
+ Negative Life Event
(3)
Increased Serum Cortisol
Immune System Depression
Necrotizing Gingivitis
- HIV:
- AIDS:
- Marked shift of — ratio
- normal ratio is –
Human Immunodeficiency Virus
Late stage of the HIV infection
CD4/CD8
2:1
AIDS: Late stage of the HIV infection
* Marked shift of
CD4/CD8 ratio
* normal ratio is 2:1
- AIDS: Late stage of the HIV infection
- Definition (one of the following)
(2)
- CD4 count <200 cells/mm3 in an HIV+ patient
- HIV+ patients with ≥ one opportunistic infection
- HIV+ patients with ≥ one opportunistic infection
(3)
- Pulmonary TB
- Recurrent pneumonia
- Invasive cervical carcinoma
HIV/AIDS
Disease severity based on CD4 counts (T-helper cell)
Normal count:
Preventive therapy:
Infection occur frequently
HIV+ becomes AIDS:
Significant changes occur:
900-1800
≤500
200-500
≤200
HIV/AIDS
Opportunistic infection CD4 count in blood
(cells/mm3)
Usually no signs of
immunosuppression-associated disease:
Staphylococcal skin infections,
candidiasis:
Herpes zoster, oral hairy leukoplakia:
TB, histoplasmosis, Kaposi’s sarcoma,
herpes simplex, etc:
Cytomegalovirus:
> 400-500
301-400
201-300
101-200
0-100
Viral count
Monitor status of disease,
guide therapy, prognosis
Absolute Neutrophil Count
Require antibiotic prophylaxis
when ANC<500
Platelet count
No procedures if below 50,000
(Normal 150,000-450,000)
skipped
ANC calculation
WBC(in 1000s) X (% segmented [mature] + % bands [immature])
If the WBC is 4.3, with segmented % of 48%, and 2% bands, then the ANC is 4.3 x (.5)=2,150
HIV/AIDS
Oral lesions
(7)
- Candidiasis
- Viral lesions
- Major aphthous ulcers
- Necrotizing gingivitis
- Linear gingival erythema
- Necrotizing periodontitis
- Neoplasms
- Neoplasms
(3)
- Oral hairy leukoplakia
- Kaposi’s sarcoma
- Non-Hodgkins lymphoma
When to premeditate
HIV/AIDS patients for
invasive procedures?
A. When CD4 count is less than 200 cells/mm3
B. When platelet count is less than 50,000
C. When Absolute Neutrophil Count is less than 500
D. When the viral count is less than 500
C. When Absolute Neutrophil Count is less than 500
Light Microscopy
Necrotizing Gingivitis
It shows nonspecific acute inflammatory reaction
surrounding an ulcer within the stratified squamous
epithelium and the gingival connective tissue
Light Microscopy
Necrotizing Gingivitis
Identical to
Except the
a necrotizing gingivitis lesion
destruction of the underlying periodontium
Clinical Feature: Linear erythema
Tissue involved
Observation
Underlying
connective tissue
It is hyperemic with numerous
engorged capillaries and
dense infiltration of PMNs
Clinical Feature: Pseudomembrane
Tissue involved
Observation
Surface epithelium
It is destroyed and replaced
by a meshwork of fibrin,
necrotic epithelium, PMNs
and various types of
microorganism.
Microscopic zones
(4)
Bacterial zone
Neutrophil‐rich zone
Necrotic zone
Spirochetal infiltration zone
Bacterial smear
(2)
- Spirochetes
- Rods
Phagocytosis
- Neutrophil approach
the bacterial zone
Assessment
* Find out — factors
* — findings account for diagnosis of NPD
* — assessment in
atypical presentation or non-responding cases
predisposing
Clinical
Microbiological or biopsy
Signs and Symptoms
Primary
Symptoms & Signs
(3)
gingival necrosis
gingival bleeding
pain
Other Common
Symptoms & Signs
(4)
Pseudomembrane
Halitosis
Lymphadenopathy
Fever
Signs and Symptoms
* Necrosis and ulcer in the —
* — spontaneously or while brushing
* Mild to moderate —
* — formation
* Halitosis
* May have aggressive tissue destruction/bone loss
* Severe gingival recession
* Hypersensitivity
* Suppuration
* Dysgeusia
* Low-grade —
* —
interdental papilla
Bleeding
pain
Pseudomembrane
fever
Lymphadenopathy
Necrotizing Gingivitis
Clinical Characteristics
(3)
- Not Contagious
- Age onset is generally
15-30 years old - Strong relationship
between onset of
disease and level of
stress/anxiety
Necrotizing Gingivitis
* Respond to
* –% patients exhibit a
localized defect in
neutrophil chemotaxis
and/or phagocytosis
antibiotic
and non-surgical
periodontal therapy
75
Necrotizing Gingivitis
Clinical Symptoms & Signs
(7)
- 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
Microbiology
(4)
Fusobacterium nucleatum
Prevotella intermedia
Treponema spp.
Spirochetes (Selenomonas spp.)
Differential Diagnosis:
Herpetic Gingivostomatitis
* Primary herpetic gingivostomatitis (PHG) is frequently
mistaken for
* Keys to differentiate: (4)
NPD
Age, body temperature, lesion
site, clinical symptoms
NPD
Etiology
Age
Site
Symptoms (3)
Duration
Contagious
Immunity
Healing
Bacteria
15-30 years
Interdental papillae, Rarely outside gingival
*Ulcerations, necrotic tissue and
a yellowish-white plaque
*Foetor ex ore
*Low grade fever
1-2 days if treated
No
NA
Destruction of periodontal tissue
remains
PHG
Etiology
Age
Site
Symptoms (3)
Duration
Contagious
Immunity
Healing
Herpes simplex virus
Frequently children
Gingiva and entire oral mucosa
*Multiple vesicles which disrupt,
leaving small round fibrin-
covered ulcerations
*Foetor ex ore
*Fever ( >38 oC)
1-2 weeks
Yes
Partial
No permanent destruction
Necrotizing Gingivitis?
Primary Herpetic Gingivostomatitis?
A. NG, because the gingival ulceration is limited to the gingiva
B. NG, because there is pseudomembrane
C. PHG, because the small round fibrin-covered ulcerations
are mainly on the papilla
D. PHG, because the small round fibrin-covered ulcerations
are on the gingiva with most of papilla intact
Differential Diagnosis:
HIV association
(3)
Linear gingival erythema
Intense erythematous marginal gingivitis
May have profuse BOP
Linear gingival erythema
(3)
- Prior to other
opportunistic infections - Incidence of about
30-40% of AIDS cases - Seen when CD4 count
> 200 cell/mm3
Linear gingival erythema
* Microbiology
(5)
- Fusobacterium nucleatum
- Porphyromonas gingivalis
- A. actinomycetemcomitans
- Treponema spp.
- Candidas (evidence showed
it may be the primary
etiology)
Necrotizing Gingivitis
Treatment
Non-surgical therapy:
Improve oral hygiene and debridement
0.12% Chlorhexidine pre/post-treatment rinse
Necrotizing Gingivitis
Treatment
Antibiotics:
Metronidazole 250 mg 3x daily for 7 days (first choice)
Or Amoxicillin, 500 mg 3x daily for 7 days
Necrotizing Periodontitis
Clinical Characteristics
(4)
- 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
HIV association
* 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)
* —% within 18 months
* —% within 24 months
60
73
Necrotizing Periodontitis
Clinical Symptoms & Signs
(5)
- 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
Dominant cultivable microbes (% of examined diseased sites)
(6)
Candida albicans 70%
Prevotella intermedia 67%
Campylobacter rectus 47%
Actinobacillus actinomyces 28%
Porphyromonas gingivalis 23%
Miscellaneous enteric bacteria
Necrotizing Periodontitis
Microbiology
Enteric bacterial spices associated with NP
(5)
Enterococcus avium
Enterococcus faecalis
Clostridium difficile
Clostridium clostridiforme
Klebsiella pneumonia
Necrotizing Periodontitis
Treatment
(4)
Consult patients’ physician:
Non-surgical therapy:
Antibiotics:
Surgical correction may be indicated
Consult patients’ physician:
Non-surgical therapy:
Antibiotics:
prevent drug interaction
0.12% Chlorhexidine pre/post-treatment rinse
Debridement with hand instruments
Metronidazole 250 mg 4x daily for 7-10 days
Antifungal therapy if indicated
Necrotizing Stomatitis
Clinical Characteristics
(3)
- 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
* Seen in less than –%
of AIDS cases
* Seen when CD4 count
- Seen as NP with areas
of
5
< 50 cells/mm3
exposed necrotic
alveolar bone
Necrotizing Stomatitis
Clinical Characteristics
(5)
- 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
(3)
Candida albicans
Mixed gram negative anaerobic
infection
Miscellaneous enteric bacteria
Necrotizing Stomatitis
Treatment
(4)
Consult patients’ physician:
Non-surgical therapy:
Antibiotics:
Surgical correction may be indicated
Consult patients’ physician:
Non-surgical therapy:
Antibiotics:
Surgical correction may be indicated
prevent drug interaction
0.12% Chlorhexidine pre/post-treatment rinse
Debridement to remove oral necrotized tissue
Scaling with hand instruments
Metronidazole 250 mg 4x daily for 7-10 days
Antifungal therapy if indicated
The patient reports a history of HIV infection,
and presents the oral lesion diagnosed as
necrotizing periodontitis. Please choose the
most appropriate management.
A. Treatment includes the debridement and 0.12% Chlorhexidine
rinse then prescribe Metronidazole 250 mg 4x daily for 7 days.
B. Treatment includes consulting the physician for drug interaction,
debridement and 0.12% Chlorhexidine rinse, then re-evaluate
for the indication of surgery.
C. Treatment includes the 0.12% Chlorhexidine rinse and leave the
pseudomembrane as the protection layer during debridement,
then prescribe Metronidazole 250 mg 4x daily for 7 days.
D. Treatment includes consulting the physician for drug interaction,
debridement and 0.12% Chlorhexidine rinse, prescribe
Metronidazole 250 mg 4x daily for 7 days then re-evaluate for
the indication of surgery.
Cancrum Oris (Noma)
(3)
- 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)
