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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

INTRA ORAL SIGNS & SYMPTOMS


Punched out, crater like depression at the crest of interdental papillae-may extend to marginal & attached gingivae. Gray pseudomembranous slough, on denudation exposes red, shiny & hemorrhagic gingiva.
Linear erythematous zone

Pronounced bleeding on slightest stimulation or spontaneous

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

EXTRAORAL SIGNS & SYMPTOMS


Fever Increased pulse rate Loss of appetite;lassitude Leukocytosis Lymphadenopathy GIT disturbances Rarely- Noma

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.

Second visit-continuation of first medicaments, supragingival scaling

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.