S4 Recognising periodontitis and necrotising diseases Flashcards
Define periodontitis.
A chronic multifactorial inflammatory disease associated with dysbiotic biofilm.
Progressive destruction of the tooth supporting stuctures.
Name the clinical signs of periodontitis.
- Gingival inflammation
- Bleeding on probing
- Pocket formation
- Gingival recession
- Alveolar bone resorption
- Mobility and drifting
- Tooth loss
- Interdental recession (black triangles)
Describe the “advanced lesion”.
- Destructive
- Loss of CT attachment (collagen and PDL)
- Ulceration of the junctional epithelium and apical migration (pocket)
- Extension of subgingival anaerobic plaque
- Chronic inflammatory infiltrate: lymphocytes and plasma cells
- Osteoclast action causing alveolar bone resorption
- Balance between damage and repair is lost
What type of microorganisms are present in periodontitis?
Red complex microorganisms:
- Porphyromonas gingivalis
- Tannerella forsythia (Previously known as B. forsythus)
- Treponema denticola
Aa is also associated with aggresive forms of periodontitis, but is not a red complex microorganism.
How are periodontal diseases classified into 3 major groups?
- Necrotising periodontal diseases
- Periodontitis
- Periodontitis as a manifestation of sytemic disease
Describe how periodontitis is diagnosed.
1) Identify the nature of the disease: biofilm induced gingivitis, periodontitis or other disease
2) Extent of periodontitis: localised or generalised (>30%), if they don’t have a lot of teeth remaining, were these teeth lost due to periodontitis?
3) Pattern: gives an indication of the progression of the disease/how aggressive, can be a molar/incisor distribution, horizontal or vertical bone loss?
4) Staging: early/mild, moderate, severe, very severe (I,II,III,IV)
5) Grading: disease progression rate, A, B, C
6) Status: stable/in remission/unstable
7) Associated risk factors: smoking, diabetes, OH
Describe how periodontitis is staged.
Staged according to bone loss.
Periapical radiographs are typically needed rather than BWs to determine bone loss extent more accurately.
Describe how periodontitis is graded.
Graded by dividing bone loss percentage at worst site by patient age.
Determines the rate of progression.
- <0.5 = grade A (slow)
- 0.5-1.0 = grade B (moderate)
- >1.0 = grade C (rapid)
What is molar incisor pattern periodontitis/localised aggressive periodontitis?
- Rare type of aggressive periodontitis affecting the incisors and first molars
- Affects adolescents and young adults, minimal plaque, good oral hygiene and non-associated medical history
- Rapid attachment loss (grade B or C)
- Rapid rate of progression
- Possible hereditary links, seems to affect members of the same family
Cause is not completely understood.
What are the clinical features of necrotising diseases?
- Intensely red gingivae
- Spontaneous bleeding
- Extensive necrosis of soft tissues with yellow/white slough
- Punched out papillae
- Pain
- Odour
What is the aetiology of necrotising diseases?
- Systemic immune deficiency, previously common in patients with AIDS
- Malnutrition
- Stress
- Smoking
Describe the microbiology of necrotising diseases.
Spirochaetes and Fusiforms.
Name the necrotising diseases in periodontics.
- Necrotising ulcerative gingivitis
- Necrotising ulcerative periodontitis
- Necrotising stomatitis
What is NUG?
Necrotising ulcerative gingivitis
- An infection characterised by gingival necrosis presenting as “punched out” papillae, with bleeding and pain
Describe the epidemiolgoy of NUG.
- Prevalence has decreased over the past 20 years
- Seen mostly in young adults, mean age 23 years
- More common in Caucasians
- Affects men and women equally
- More common during autumn and winter months
- Associated with stress, more common in students e.g. during exams
What are the predisposing factors for NUG?
- Poor oral hygiene and pre-existing gingivitis
- Emotional stress
- Smoking
- Poor nutrition/malnutrition
- Immunosuppression
Describe the aetiology of NUG.
- An opportunistic infection caused by anaerobic commensal bacteria
- Spirochaetes and fusiform Bacilli = ‘Fusospirochaetal complex’
- Bacteria invade the gingival tissues
- The exact trigger is not fully known, if a patient repeatedly presents with NUG you would want to liaise with the GP as it could be due to immunosuppression
What are the symptoms of NUG?
- Sudden onset of painful gingivae
- Gingival bleeding
- Metallic taste
- Halitosis
- Malaise possible (generally feeling unwell)
What are the signs of NUG?
- Erythematous marginal gingivae
- May be localised or generalised
- Lower anterior region is a commonly affected site
- Necrotic ulceration produces yellow/grey slough, commonly affecting the interdental papillae giving punched out appearance
- Raw, bleeding mucosa beneath slough
- Painful to probe
- Bleeding on probing
- Lymphadenopathy may be present
How is NUG managed at the first appointment?
- Immediate management: aiming to relieve pain
- Definitive management: address cause and prevent recurrence
- Debridement of the effected gingival margin is essential at the initial emergency appointment
- LA is advisable
- Ultrasonic to remove necrotic slough
- Soft toothbrush to use at home
- Hydrogen peroxide mouthwash (Peroxyl)
- Abx as an adjunct where there is evidence of systemic involvement: Metronidazole 400mg TDS for up to 5 days
How is NUG managed approx. 1 week after the first appointment?
After 1 week, symptoms should have resolved.
- Improve existing OHI, use interdental aids
- Meticulous sub and supra gingival scaling
- Remove plaque retentive factors
- Smoking cessation advice
- Perio surgery to improve gingival contour if there are poor aesthetics
- Be suspicious of an underlying systemic disorder of the immune system, particularly if a patient repeatedly presents with NUG
- Patients with unexplained recurrences or persistent NUG should be assessed with blood tests, inform GP
What is NUP?
Necrotising ulcerative periodontitis.
- An infection characterized by the necrosis of gingival tissues, periodontal ligament and alveolar bone.
- If NUG is inadequately treated, NUG may develop into NUP.
- May be a feature of an HIV infected patient (somewhat historic).
What are the predisposing factors, aetiology and symptoms of NUP?
Same as NUG:
- Poor OHI, stress, smoking, poor nutrition, immunosuppression
- Opprotunistic infection, Fusospirochaetal complex, bacteria invade gingival tissues
- Sudden onset of paingul gingivae, bleeding, metallic taste, malaise, halitosis
What are the signs of NUP?
Same as NUG, plus:
- Severe deep aching pain
- Very rapid rate of bone destruction
- Deep pocket formation not evident immediately
What is the management for NUP?
- Local debridement
- Anaesthetic as required
- OHI
- Oral rinses: chlorhexidine gluconate, hydrogen peroxide or water
- Pain control, analgesic advice
- Antibiotics for systemic involvement, metronidazole (400mg TDS up to 5 days)
- Modify predisposing factors e.g. smoking cessation, OHI, stress
- Frequent follow-ups until resolution of symptoms
Comprehensive periodontal chart following acute phase.
What condition may follow on from NUP?
Noma (cancrum oris)
- A disfiguring condition that may follow on from NUP, mostly in developing parts of the world
- Extensive necrosis and destruction of facial tissue
- Associated with severe malnourishment
