Necrotizing Periodontal Diseases Flashcards
what are necrotizing periodontal diseases
a rare and destructive form of periodontal disease caused by microorganisms in the context of an impaired host response
what is necrotizing periodontal disease characterized by
- gingival tissue necrosis and ulceration
- has a sudden onset and can become a chronic condition
what is the nomenclature for necrotizing periodontal disease
- ulceromembranous gingivitis
- trench mouth
- vincents gingivostomatitis
- phagedenic gingivitis
- fusospirallary periodontitis
- plaut- vincent stomatitis
what are the stages of necrotizing disease
- stage 1: necrosis of the tip of the inerdental 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 exposing alveolar bone
- stage 7: necrosis perforates facial skin
necrotizing periodontal disease is mainly seen in:
HIV infected individuals and malnourished children
what is the prevalence/incidence of necrotizing periodontal disease in gen pop, military, students, HIV/AIDS
- gen pop: 0.51-3.3%
- military: 0.19-6.19%
- students: 0.9-6.7%
- HIV/AIDS patients: 0-30%
what are the main etiology and risk factors
- microbiology
- host immune response
- predisposing factors
what are the main species in necrotizing periodontal disease
- main: spirochetes and fusiform bacteria
- P. intermedia
- treponema
- selenomonas
- fusobacterium species
what are the specific features in HIV
- candida albicans
- herpes viruses
- superinfecting bacterial species
what is the host response that are risk factors for necrotizing periodontal disease
- PMN function: chemotaxis and phagocytosis are impaired
- immune system: may be related to various levels of nutritional deficiency, fatigue caused by chronic sleep deprivation, alcohol or drug abuse, pyschosocial factors, or systemic diseasew
what are the predisposing factors that are risk factors for necrotizing periodontal disease
- pre-existing systemic disease: leukemia, leukopenia, HIV/AIDS
- previous hx of NPD
- inadequate OH
- malnutrition
- stress/insufficient sleep
- smoking/alcohol consumption
- young age and ethnicity
Why is HIV/AIDS a risk factor for necrotizing periodontal disease
-AIDS: marked shift of CD4/CD8 ratio (normal 2:1)
- definition is one of the following
- CD4 count less than 200 cells in a HIV positive patient
- HIV+ patients with more than one opportunistic infection: pulmonary TB, recurrent pneumonia, invasive cervical carcinoma
what are the categories of disease in HIV/AIDS
- normal count: 900-1800
- preventative therapy: less than or equal to 500
- infection occurs frequently HIV+ becomes AIDS: 200-500
- significant changes occur less than or equal to 200
how do you interpret the viral count
monitor status of disease, guide therapy, prognosis
how do you interpret the absolute neutrophil count
require antibiotic prophylaxis when ANC <500
how should you interpret the platelet count
no procedures if below 50,000
what are the oral lesions with HIV/AIDS
- candidiasis
- viral lesions
- major aphthous ulcers
- necrotizing gingivitis
- linear gingival erythema
- necrotizing periodontitis
- neoplasms: non hodkins lymphoma, oral hairy leukoplakia, Kaposi’s sarcoma
what is the histopathology of necrotizing gingivitis lesions
the presence of necrotic tissue forming the gray marginal pseudomembrane and an ulcer and accumulation of leukocytes and fibrin replacing the normal epithelium
what is the tissue involved and observation with psuedomembrane
- surface epithelium
- it is destroyed and replaced by a meshwork of fibrin, necrotic epithelium, PMNs and various types of microorganismswh
what is the tissue involved and the observation with linear erythema
- underlying connective tissue
- it is hyperemic with numerous engorged capillaries and a dense infiltration of PMNs
what are the 4 zones in histology and describe each
- bacterial zone: contains a mass of bacteria, mainly spirochetes
- neutrophil rich zone: many leukocytes predominately neutrophils, spirochetes
- necrotic zone: contains disintegrating tissue cells- spirochetes and fusiforms
- spirochetal infiltration zone: tissue components infiltrated with spirochetes. no other microorgansims found in this zone
what is the pathophysiology of necrotizing periodontal disease
- conventional periodontal pockets with deep probing depths are not found in NG and NP
- the necrosis of the JE in NG and NP creates an ulcer that prevents the junctional epithelium migration apically
- a periodontal pocket cannot form due to this
what is the assessment for necrotizing periodontal diseases
- clinical findings account for dx of NPD
- microbiological or biopsy assessment can be performed in cases of atypical presentations or non responding cases
what are the primary signs and symptoms of NPD
- gingival necrosis and ulcer in the interdental papila
- gingival bleeding spontaneously or brushing
- mild to moderate pain
- psuedomembrane formation
- halitosis
- may have aggressive tissue destruction/bone loss
- severe gingival recession
- hypersensitivity
- suppuration
- dysgeusia
- low grade fever
- lymphadenopathy
what are the other common signs and symptoms of NPD
- psuedomembranes
- halitosis
- adenopathies
- fever
what are the main signs and symptoms for NPD
- gingival necrosis
- gingival bleeding
- pain
what are the clinical characteristics of necrotizing gingivitis
- not contagious
- age onset is generally 15-30 years old
- strong relationship between onset of disease and level of stress/anxiety
- responds to antibiotic and non surgical periodontal therapy
- 75% of patients exhibit a localized defect in neutrophil chemotaxis and/or phagocytosis
why does stress cause necrotizing gingivitis
- increased serum cortisol
- immune system depression
what are the clinical signs and symptoms of NG and percentage of prevalence
- necrosis and ulceration in interdental papillae (94-100%)
- gingival bleeding (95-100%)
- pain (86-100%)
- psuedomembrane formation (73-88%)
- halitosis (84-97%)
- adenopathy (44-61%)
- fever (20-39%)
what is the microbio of NG
- fusobacterium nucleatum
- prevotella intermedia
- treponema spp.
-spirochetes
what is the diff dx for NG
- gingivitis
- herpetic gingivostomatitis
- mucous membrane pemphigoid
- allergic reaction (nickel)
- mild or grade A/B periodontitis
- factitial injury
what are the keys to differentiate between herpetic gingivostomatitis and NPD
- age
- body temperature
- lesion site
- clinical symptoms
what is the etiologyf of NPD and PHG
- NPD: bacteria
- PHG: herpes simplex virus
what is the age of NPD and PHG
- NPD: 15-30 years
- PHG: frequently children
what is the site of NPD and PHG
- NPD: interdental papillae. rarely outside gingiva
- PHG: gingival and entire oral mucosa
what are the symptoms of PHG and NPD
- NPD: ulcerations, necrotic tissue and a yellowish- white plaque. low grade fever
- PHG: multiple vesicles which disrupt leaving small round fibrin covered ulcerations. fever greater than 38 degrees C
what is the duration of NPD and PHG
- NPD: 1-2 days if treated
- PHG: 1-2 weeks
is NPD or PHG contagious
- NPD: no
- PHG: yes
do you get immunity from NPD or PHG
- NPD: no
- PHG: yes
what is the healing of NPD and PHG
-NPD: destruction of periodontal tissue remains
- PHG: no permanent destruction
describe linear gingival erythema
- prior to other opportunistic infections
- incidence of about 30-40% of AIDS cases
- seen when CD4 count is 200-500 cells/mm^3 or less than 200 cells/mm^3
what is the microbiology in linear gingival erythema
- fusobacterium nucleatum
- porphyromonas gingivalis
- A. actinomycecomitans
- Treponma spp
- candida
what is the tx for necrotizing gingivitis
- non surgical therapy: improve OH, debridement, 0.12% chlorhexidine pre/post treatment rinse
- antibiotics: metronidazole 250 mg 3X daily for 7 days ( first choice) OR amoxicillin 500mg 3x daily for 7 days
what are the clinical characteristics of necrotizing periodontitis
- seen in conjunction with other opportunistic infections
- disease incidence of about 20% of AIDS cases- percentage may be decreasing with ART medications
- seen when CD4 count is below 200cells/mm^3
what is the NP association with AIDS
- NP is used as a marker for immune deterioration and a predictor for the diagnosis of AIDS since it appears with CD4 counts below 200 cells/mm^3
- NP diagnosis to time of death:
- 60% within 18 months
- 73% within 24 months
what are the clinical signs and symptoms of NP
- 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
what are the dominant cultivable microbes in NP and their percentages
- candida albicans (70%)
- prevotella intermedia (67%)
- campylobacter rectus (47%)
- actinobacillus actinomyces (28%)
- porphyromonas gingivalis (23%)
- miscellaneous enteric bacteria
what enteric bacteria are associated with NP
- enterococcus avium
- enterococcus faecalis
- clostridium difficile
- clostridium clostridiforme
- klebsiella pneumonia
what is the differential dx for necrotizing periodontitis
- severe or grade C periodontitis
- uncontrolled/undiagnosed diabetes
- osteomyelitis, ostenecrosis of the jaw, osteoradionecrosis
- severe immune suppression, chemotherapy or leukemia
what is the treatment for NP
- consult patients physician to prevent drug interactions
- non surgical: improve OH, debridement with hand instruments, 0.12% chlorhexidine pre/post treatment rinse
- antibiotics: metronidazole 250mg 4x daily for 7-10 days. antifungal therapy if needed
- surgical correction may be involved
what are the clinical characteristics of necrotizing stomatitis
- 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
- seen in less than 5% of AIDS cases
- seen when CD4 count is below 50 cells/mm^3
- seen as NP with areas of exposed necrotic alveolar bone
what are the clinical signs and symptoms of necrotizing stomatitis
- necrosis and ulceration of the gingiva extending into the alveolar mucosa radpidly
- exposure of necrotic bone with extension into osteomyelitis
- tooth mobility
- lymphadenopathy
- fever
- bacteremia, speticemia
what is the microbio for necrotizing stomatitis
- candida albicans
- mixed gram negative anaerobic infection
- miscellaneous enteric bacteria
what is the differential dx for necrotizing stomatitis
- severe or grade C periodontitis
- uncontrolled/undiagnosed diabetes
- osteomyelitis, osteonecrosis of the jaw, osteoradionecrosis
- severe immune suppression, chemotherapy or leukemia
what is the tx for necrotizing stomatitis
- consult patients physician to prevent drug interactions
- non surgical: improve OH, debridement with hand instruments, 0.12% chlorhexidine pre/post treatment rinse
- antibiotics: metronidazole 250mg 4x daily for 7-10 days. antifungal therapy if needed
- surgical correction may be involved
what are the clinical characteristics of cancrum oris (Noma)
- a rapidly preogressive, often gangrenous infection from the mouth to the face
- preceded by NP, NP, and NS
- seen in impoverished and malnourished children 2-6 years old mostly in the poorest countries of africa, asia and south america
- HIV infected individuals in some regions are affected but not in other regions
what is the treatment for cancrum oris
- consult patients physician to prevent drug interaction
- admit patient to hospital for IV antibiotics, fluids, nutritional supplementation, and supportive medical care (physician)
- non surgical periodontal therapy is done after patients general condition is stable: debridement with hand instruments. 0.12% chlorhexidine pre/post treatment rinse
