Necrotizing Ulcerative Gingivitis
Necrotizing Ulcerative Gingivitis
Dr. Souvik Chatterjee MDS IInd year Department of Periodontology and Oral Implantology.
INTRODUCTION
Common periodontal diseases- in chronic form Acute- sudden, severe, of short duration Course- either self remission, or sub acute or chronic form
CLASSIFICATION-MANSON(1995)
TRAUMATIC -Physical injury -Chemical burn -Thermal burn BACTERIAL -Acute necrotizing ulcerative gingivitis -Specific bacterial lesions- e.g.- Tuberculous, syphylitic, stereptococcal. FUNGAL -Candidiasis
VIRAL -Acute herpetic gingivostomatitis-Herpes simplex virus -Associated with Herpes varicella/zoster -Others like, Herpangina, Hand Foot Mouth disease, Measles etc.
ABSCESS- e.g. gingival abscess IDIOPATHIC, AUTOIMMUNE - e.g. apthous ulcers, desquamative lesions ASSOCIATED WITH DRUG ALLERGY
DEFINITION
Necrotizing ulcerative gingivitis can be defined as an acute , and sometimes recurring gingival infection of complex etiology . Characterized by rapid onset of gingival pain, interdental gingival necrosis and bleeding. Other terms used for this disease are Vincents Gingivostomatitis, Trench mouth and ulceromembranous gingivitis
NUP may be extension of NUG into periodontal structure leading to attachment loss and bone loss It can be classified together under broader category of necrotizing periodontal disease although with differing level of severity.
CLINICAL FEATURES
Usually ambulatory, sometimes non-ambulatory
Sudden onset, sometimes milder & more persistent subacute, chronic or recurrent forms H/O - Debilitating disease - Respiratory tract infection - Stress - Heavy work without adequate rest
Extremely painful
Metallic taste Fetid odor Increased salivation Pasty saliva
Loss of junctional epithelium-so no pocket formation Can occur on healthy gingiva or chronic gingivitis & periodontitis Rare in edentulous mouth
Extremely painful
Metallic taste
SEQUELAE
Sometimes may resolve as such If untreated-may progress to marginal gingivae & attached gingivae Alveolar bone may be exposed-NUP May extend to alveolar mucosa Sometimes, though rare, may extend to cheek causing perforation
HISTOPATHOLOGY
Not specific for diagnosis
Involves both epithelium & connective tissue Epithelium-destroyed pseudomembrane & replaced by a
Pseudomembrane mesh work of fibrin, dead epithelial cells, leukocytes & microorganism
Surrounding epithelial cells- under hydropic degeneration, intra & inter cellular edema Connective tissue-increased & engorged capillaries, dense infiltration of PMNS, clinically as linear erythema, plasma cells it super imposed over chronic gingivitis
BACTERIAL POPULATION
Listgarten-electron microscopy
Four zones Zone 1- bacterial zone- varied bacteria & few spirochetes Zone 2- neutrophil- rich zone- PMNS+BACTERIA+ more SPIROCHETES Zone 3- necrotic zone- necrotic epithelial cells+fibrin, degraded collagen fibres, bacteria+numerous spirochetes Zone 4- zone of spirochetal infiltration- inside the healthy tissue- infiltration of spirochetes- more of intermediate & large types
ETIOLOGY
Exact mechanism is still unknown Produced due to host bacterial interaction Does not fulfill KOCHS POSTULATE
Complex of Bacillus fusiformis and Spirochetes is more closely associated, but requires underlying tissue changes locally or systemically for the pathogenesis
PREDISPOSING FACTORS
Pre existing periodontal disease, deep bite Smoking Nutritional deficiency Stress Debilitating diseases like GIT disturbances, anemia, blood dyscrasias such as leukemia & AIDS
Differential Diagnosis
Differential diagnosis of NUG is that from primary herpetic gingivostomatitis
TREATMENT
Management of 1.Local lesions 2.Systemic illness & 3.Predisposing factors. Non-ambulatory Ambulatory First visit- Topical LA, Swab with 3% H2O2, Rinse- 1:1 H2O2 - 3% every 2 hours, Chlorhexidine- twice, Analgesic, Antipyretic, Antibiotic- Penicillin derivative - Amoxicillin, Metronidazole. B-complex, Nutritional supplements.
visit
Third visit-usually symptom free, H2O2mouth wash is stopped, Plaque control measures instituted, thorough scaling & root planing are done. Fourth visit-Usually condition improves. Antibiotics stopped.Oral hygiene measures evaluated. Date is fixed for surgical correction.