Managing Patients With Necrotizing Ulcerative Periodontitis

May 31, 2013
 

Necrotizing ulcerative periodontitis (NUP)

Necrotizing ulcerative periodontitis (NUP) is characterized by soft tissue necrosis, rapid periodontal destruction, and interproximal bone loss. Unlike other periodontal diseases, it presents substantial necrosis of gingival tissues, and loss of periodontal ligament and alveolar bone.

Presentation

Population

  • Usually: young adults (age 18–30); sometimes: malnourished children or immunocompromised individuals

Risk Factors

  • Immunosuppressed patients including but not limited to HIV-positive patients; HIV-positive with CD4 count < 200 is more strongly associated with NUP than any other predisposing factors
  • Severe malnutrition
  • Smoking
  • Poor oral hygiene
  • Unusual emotional or psychological stress
  • Sequela of single or multiple episodes of necrotizing ulcerative gingivitis (NUG)

Signs

  • Localized or generalized periodontitis, with rapid/sudden onset with excruciating intense pain
  • Characterized by necrosis of gingival tissues, and loss of periodontal ligament and alveolar bone (See Fig. 1)
  • Linear erythematous zone separating the ulcerated area from the adjacent free gingiva, attached gingiva, and alveolar mucosa with provocation and/or spontaneous bleeding
  • Severe loss of periodontal attachment
  • Deep pocket formation is not evident (junctional epithelium is necrotized)
  • Intense radiating pain and fetid breath due to tissue necrosis
  • Sometimes bone is exposed, resulting in necrosis and subsequent sequestration
  • Lymphadenopathy, fever and malaise may occur
  • Characteristic microbiota: fusiform bacteria, Prevotella intermedia, Porphyromonas gingivalis, Treponema sp., and Candida albicans (increased prevalence in HIV-positive patients)

Figure 1: Generalized attachment loss with punch out papillae. Pseudomembrane covering erythematous gingival and spontaneous bleeding (photo courtesy of Dr. Eraldo Batista).

Symptoms

  • Intense, excruciating pain

Evolution

  • Untreated, the infection may lead to rapid destruction of the attachment apparatus.
  • With treatment, the progression of clinical attachment loss is controlled. However, the sequela of the affected periodontal tissues sites will be present with recession and loss of interdental papilla.
  • HIV-infected individuals present 72.9% cumulative probability of death within 24 months of an NUP diagnosis.

Investigation

  1. Obtain a detailed medical history, including nutrition and health habits.
  2. Medical consult to rule out any immunosuppressive disease may be necessary. NUP has been associated with HIV-positive and AIDS patients.
  3. Obtain a dental history: previous history of NUG and/or periodontal disease, foul metallic taste, pasty saliva, intense excruciating pain.
  4. Perform an extraoral examination: check for lymphadenopathy in the head and neck, facial asymmetry.
  5. Perform an intraoral examination: look for clinical features of NUP.

Diagnosis

Based on the clinical examination, a diagnosis of NUP is determined.

Differential Diagnosis

  • Acute herpetic gingivostomatitis
  • Desquamative gingivitis
  • Agranulocytosis
  • Leukemia
  • Noma
  • Necrotizing stomatitis
  • Chronic periodontitis

Treatment

Common Initial Treatments

  1. Perform debridement under local anesthesia, including gentle scaling.
  2. Remove pseudomembrane, using cotton pellet dipped in 0.12% chlorhexidine.
  3. Provide the patient with oral hygiene instructions and prescribe antibacterial mouthwash (0.12% chlorhexidine, b.i.d.) or peroxide hydroxyl mouth rinse (b.i.d.).
  4. Tell the patient to control pain with analgesics (ibuprofen 400–600 mg, t.i.d. or acetaminophen 750 mg, t.i.d.).
  5. Provide patient counseling: ensure proper nutrition, take vitamin supplements, avoid spicy foods, adopt appropriate fluid intake, increase sleep, decrease stress, and quit smoking, if possible.
  6. Prescribe antibiotics if signs of systemic involvement (e.g., fever, malaise, lymphadenopathy):
    • Amoxicillin: 500 mg, t.i.d for 7 days; or combination of amoxicillin 250 mg and metronidazole 250 mg one tab of each t.i.d. for 7 days

If the patient is immunocompromised (e.g. AIDS, HIV-positive, leukemia, cyclic neutropenia), it is important to follow-up with their physician when you prescribe antibiotics. The risk of super infection with oral Candida must be considered when using systemic antibiotics in immunocompromised patients. In those cases antifungal medication might be needed.

Follow Up

Immunocompromised patients should be treated in close communication with their physician. Depending on the degree of immunosupression, it may be advisable to perform only conservative, minimally invasive procedures and monitor them closely.

  1. Assess treatment outcomes in 24 hours, then every other day until all acute signs and symptoms are controlled. Frequent periodontal maintenance visits and meticulous oral hygiene are necessary as NUP may continue to progress rapidly.
  2.  After the first consult or control of the acute stage, referral to a periodontist or oral surgeon is advised.
  3. Follow up with a comprehensive periodontal evaluation.

THE AUTHORS

 
 

Dr. Todescan is an assistant professor in periodontology in the division of periodontics, department of dental diagnostic and surgical sciences, faculty of dentistry, University of Manitoba, Winnipeg, Manitoba.

 

Dr. Atout is is an assistant professor in periodontology in the division of periodontics, department of dental diagnostic and surgical sciences, faculty of dentistry, University of Manitoba, Winnipeg, Manitoba.

Correspondence to: Dr. Sylvia Todescan, Dental Diagnostic Surgical Sciences, D343 Dental Building, 790 Bannatyne Avenue, Winnipeg, MB, Canada, R3E 0W2. Email: todescan@cc.umanitoba.ca

The authors have no declared financial interests.

This article has been peer reviewed.

Suggested Resources

  1. Batista EL Jr, Novaes AB Jr, Calvano LM, do Prado EA, Goudouris ES, Batista FC: Necrotizing ulcerative periodontitis associated with severe congenital immunodeficiency in a prepubescent subject: clinical findings and response to intravenous immunoglobulin treatment. J Clin Periodontol. 1999; 26(8): 499–504.
  2. Corbet EF. Diagnosis of acute periodontal lesions. Periodontol 2000. 2004;34:204-16.
  3. Klokkevold PR. Necrotizing ulcerative periodontitis. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, editors. Carranza’s Clinical Periodontology. 11th ed. St. Louis: Saunders; 2012. p.165-8.
  4. Novak MJ. Necrotizing ulcerative periodontitis. Ann Periodontol. 1999;4(1):74-7.
  5. Rees TD. Pathology and management of periodontal problems in patients with HIV infection. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, editors. Carranza’s Clinical Periodontology. 11th ed. St. Louis: Saunders; 2012. p.181.

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