Necrotizing Periodontal Diseases Flashcards
What is Necrotizing Periodontal Disease?
◦ A rare and destructive form of periodontal disease caused by microorganisms in the context of an impaired host response.
◦ It is characterized by gingival tissue necrosis and ulceration.
◦ Has a sudden onset and can become a “chronic” condition.
What are the stages of oral necrotizing disease?
◦ Stage 1: Necrosis of the tip of the 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 exposing alveolar bone
◦ Stage 7: Necrosis perforates facial skin
What are the forms of necrotizing periodontal disease?
- necrotizing gingivitis
- necrotizing periodontitis
- necrotizing stomatitis
Who gets Necrotizing Periodontal Disease (NPD)?
Mainly in HIV-infected Individuals and Malnourished children
Prevalence/Incidence
◦ In general populations: .51-3.3%
◦ In military personnel: .19-6.19%
◦ In students: .9-6.7%
◦ In HIV/AIDS patients: 0-30% (wide variation)
What are the etiology and risk factors for necrotizing periodontal disease (NPD)?
- Microbiology
- Host Immune Response
- Predisposing Factors
What are the microbiologics involved in the etiology of nectrotizing periodontal disease (NPD)?
Spirochetes and fusiform bacteria
◦ P. intermedia
◦ Treponema
◦ Selenomonas
◦ Fusobacterium species
Specific features in HIV
◦ Candida albicans
◦ Herpes viruses
◦ Superinfecting bacterial species
How is the host immune system involved in nectrotizing periodontal disease (NPD)?
◦ Pre-existing systemic disease
— Leukemia
— Leukopenia
— HIV/AIDS
◦ Previous history of NPD
◦ Pre-existing gingivitis
◦ Inadequate oral hygiene
◦ Malnutrition
◦ Stress/Insufficient sleep
◦ Smoking/alcohol consumption
◦ Young age and ethnicity
What is HIV and AIDS?
- HIV: Human Immunodeficiency Virus
- AIDS: Late stage of the HIV infection
— Marked shift of CD4/CD8 ratio (normal 2:1)
— HIV+ patients with ≥ one opportunistic infection
What is the normal count of CD4 in blood (cells/mm3)?
900-1800
Infection occurs frequently/HIV+ becomes AIDS in what level of CD4 count in blood (cells/mm3)?
200-500
What CD4 count in blood (cells/mm3) for…
Usually no signs of immunosuppression associated disease
> 400-500
What CD4 count in blood (cells/mm3) for…
Staphylococcal skin infections, candidiasis
301-400
What CD4 count in blood (cells/mm3) for…
Herpes zoster, oral hairy leukoplakia
201-300
What CD4 count in blood (cells/mm3) for…
TB, histoplasmosis, Kaposi’s sarcoma, herpes simplex, etc
101-200
What CD4 count in blood (cells/mm3) for…
Cytomegalovirus
0-100
What are the important lab data to monitor for HIV/AIDS?
Viral count
Absolute Neutrophil Count
Platelet count
What is the interpretation of the CD4 counts?
Monitor disease severity, and opportunistic infection
What is the interpretation of the viral count?
Monitor status of disease, guide therapy, prognosis
What is the interpretation of the absolute neutrophil count?
Require antibiotic prophylaxis when ANC<500
What is the interpretation of the platelet count?
No procedures if below 50,000 (Normal 150,000-450,000)
What are common oral lesions in HIV/AIDS patients?
- Candidiasis
- Viral lesions
- Major aphthous ulcers
- Necrotizing gingivitis
- Linear gingival erythema
- Necrotizing periodontitis
- Neoplasms
— Non-Hodgkins lymphoma
— Oral hairy leukoplakia
— Kaposi’s sarcoma
What is the histopathology of necrotizing periodontal disease?
Necrotizing ulcerative gingivitis lesions showed the presence of necrotic tissue forming the gray marginal pseudomembrane and an ulcer and acculumlation of leukocytes and fibrin replacing the normal epithelium.
What is the tissue involved and observation for pseudomembrane in necrotizing periodontal disease?
- Tissue involved: Surface epithelium
- Observation: It is destroyed and replaced by a meshwork of fibrin, necrotic epithelium, PMNs and various types of microorganisms.
What is the tissue involved and observation for linear erythema in necrotizing periodontal disease?
- Tissue involved: underlying connective tissue
- Observation: It is hyperemic with numerous engorged capillaries and a dense infiltration of PMNs.
What are the microscopic zones from tissue surface (superficial) to lamina propria (deep)?
What is the pathophysiology of necrotizing periodontal disease?
◦ Conventional periodontal pockets with deep probing depths are not found in NUP.
◦ In periodontitis, periodontal pockets are formed because the junctional epithelial cells remain viable and can migrate apically to cover areas of lost connective tissue attachment.
◦ The necrosis of the junctional epithelium in NUG and NUP creates an ulcer that prevents the junctional epithelium migration apically.
◦ A periodontal pocket cannot form due to this.
What are the primary signs and symptoms of NPD?
Primary
◦ Gingival necrosis
◦ Gingival bleeding
◦ Pain
Other common signs and symptoms
◦ Pseudomembranes
◦ Halitosis
◦ Lymphadenopathies
◦ Fever
◦ May have aggressive tissue destruction/bone loss
◦ Severe gingival recession
◦ Hypersensitivity
◦ Suppuration
◦ Dysgeusia
◦ Low-grade feve
What is NUG?
(Acute) Necrotizing Ulcerative
Gingivitis
What is NUP
Necrotizing Ulcerative Periodontitis
What is NS?
Necrotizing Stomatitis
What is Noma?
Cancrum Oris
What are the clinical characteristics of necrotizing gingivitis (NG)?
- 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
What are the clinical signs and symptoms of necrotizing gingivitis?
◦ Necrosis and ulceration in the interdental papillae (94-100%)
◦ Gingival Bleeding (95-100%)
◦ Pain (86-100%)
◦ Pseudomembrane formation (73-88%)
◦ Halitosis (84-97%)
◦ Adenopathy (44-61%)
◦ Fever (20-39%)
What causes necrotizing gingitivis?
Stress and Disease Onset
- Stress/Anxiety/Depression + Negative Life Event
- leads to
— Increased Serum Cortisol
— Immune System Depression
What is the microbiology of necrotizing gingivits?
◦ Fusobacterium nucleatum
◦ Prevotella intermedia
◦ Treponema spp.
◦ Spirochetes
What is the differential diagnosis for necrotizing gingivitis?
- Gingivitis
- Allergic reaction(Nickel)
- Herpetic gingivostomatitis
- Mild or grade A/B periodontitis
- Mucous membrane pemphigoid
- Factitial injury
Primary herpetic gingivostomatitis (PHG) is frequently mistaken for…
NPD (nectrotizing periodontal disease)
Keys to differentiate:
◦Age
◦Body temperature
◦Lesion site
◦Clinical symptoms
What is the difference between NPD (necrotizing periodontal disease) and PHG (primary herpetic gingivostomatitis)?
What is the treatment for necrotizing gingivitis?
Non-surgical therapy:
◦ Improve oral hygiene
◦ Debridement
◦ 0.12% Chlorhexidine pre/post-treatment rinse
Antibiotics:
◦ Metronidazole 250 mg 3X daily for 7 days (first choice)
◦ Amoxicillin 500 mg 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 (% may be decreasing with ART medications)
- Seen when CD4 count is below 200 cells/mm3
NP used as a marker for immune deterioration and a predictor for the diagnosis of AIDS since it appears with CD4 counts below _____ cells/mm3
200
NP diagnosis to time of death is…
not so much anymore with new medications and such
- 60% within 18 months
- 73% within 24 months
What are the clinical signs and symptoms of necrotizing periodontitis?
◦ 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 is the microbiology of necrotizing periodontitis?
probably won’t be tested on this
Dominant cultivable microbes
◦ Candida albicans 70%
◦ Prevotella intermedia 67%
◦ Campylobacter rectus 47%
◦ Aggregatibacter Actinomycetemcomitans 28%
◦ Porphyromonas gingivalis 23%
◦ Miscellaneous enteric bacteria
What are the differential diagnoses for necrotizing periodontitis?
- Severe or Grade C Periodontitis
- Uncontrolled/undiagnosed diabetes
- ONJ (Osteonecrosis of the Jaw)
- Severe immune suppression (Chemotherapy or leukemia)
What is the treatment for necrotizing periodontitis?
Consult patient’s physician to prevent drug interaction
Non-surgical therapy:
◦ Improve oral hygiene
◦ Debridement with hand instruments (to limit aerosols)
◦ 0.12% Chlorhexidine pre/post-treatment rinse
Antibiotics:
◦ Metronidazole 250 mg 4X daily for 7-10 days
◦ Antifungal therapy if indicated
Surgical correction may be indicated
What are the clinical characertistics 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/mm3
- Seen as NP with areas of exposed necrotic alveolar bone
Necrotizing periodontitis is seen when CD4 count is below _____ cells/mm3
200
What are the clinical signs and symptoms of necrotizing stomatitis?
◦ Necrosis and ulceration of the gingiva extending into the alveolar mucosa rapidly
◦ Exposure of necrotic bone with extension into osteomyelitis
◦ Tooth mobility
◦ Lymphadenopathy
◦ Fever
◦ Bacteremia, Septicemia
Necrotizing stomatitis is een when CD4 count is below ____ cells/mm3
50
What is the microbiology of necrotizing stomatitis?
◦ Candida albicans
◦ Mixed gram negative anaerobic infection
◦ Miscellaneous enteric bacteria
What are the differential diagnoses for necrotizing stomatitis?
- Severe or Grade C Periodontitis
- Uncontrolled/undiagnosed diabetes
- ONJ (Osteonecrosis of the Jaw)
- Severe immune suppression (Chemotherapy or leukemia)
What is the treatment for necrotizing stomatitis?
Consult patient’s physician to prevent drug interaction
Non-surgical therapy:
◦ Debridement with hand instruments
◦ 0.12% Chlorhexidine pre/post-treatment rinse
Antibiotics:
◦ Metronidazole 250 mg 4X daily for 7-10 days
◦ Antifungal therapy if indicated
Surgical correction may be indicated
What are the clinical characteristics of cancrum oris (noma)?
◦ A rapidly progressive, often gangrenous, infection from the mouth to the face
◦ Preceded by NG, NP, and NS
◦ Seen in impoverished and malnourished children (2-6 year olds) 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 (noma)?
◦ Consult patient’s physician to prevent drug interaction
◦ Admit patient to hospital for IV antibiotics, fluids, nutritional supplementation, and supportive medical care. (Physician)
◦ Non-surgical therapy is done after patient’s general condition is stable.
— Debridement with hand instruments
— 0.12% Chlorhexidine pre/post-treatment rinse
