Necrotising periodontal disease

Author: Dr Delwyn Dyall-Smith FACD, Dermatologist, Australia, 2010.

What is necrotising periodontal disease?

Necrotising periodontal disease is the term used to describe a group of relatively rare infections affecting the mouth in which ulceration with necrosis is the common feature. Necrosis is the term used to describe death of tissue.

There are three major forms:

  1. Necrotising (ulcerative) gingivitis – affects only the gums
  2. Necrotising (ulcerative) periodontitis – involves loss of the specialised tissue that surrounds and attaches the teeth
  3. Necrotising stomatitis – in which more extensive mucosal and bone loss occurs beyond the gums and tissue surrounding and supporting the teeth. Stomatitis means a sore mouth.

There are many other names given to these conditions including necrotising gingivostomatitis, cancrum oris, noma, trench mouth, Vincent gingivostomatitis, acute membranous gingivitis, Bergeron disease, fusospirally infection/gingivitis, phagedenic gingivitis, acute septic gingivitis.

Who gets necrotising periodontal disease and why?

Necrotising periodontal disease is triggered by the accumulation of dental plaque associated with poor oral hygiene.

However host factors are also important in allowing these necrotising conditions to develop from the dental plaque. Well recognised host factors known to predispose to necrotising periodontal disease include:

Necrotising periodontal disease is common in the HIV-positive population (in whom it may be the presentation indicating infection) and in early childhood in developing countries (due to malnutrition), but is believed to be rare outside of these groups.

Necrotising gingivitis is usually the first stage. It may progress to necrotising periodontitis or necrotising stomatitis particularly in the immunosuppressed patient.

Necrotising periodontal disease involves a mixture of many different microorganisms, most of which are found in the normal oral cavity:

These invade the oral mucosa, initially into the gums and then into the tissues supporting the teeth and/or elsewhere in the oral mucosa.

Clinical features of necrotising periodontal disease

1. Necrotising gingivitis

Necrotising gingivitis is defined as an infection of the gums in which the tips of the gums seen between the teeth (gingival papillae) are lost with associated bleeding and pain.

The major consistent symptoms noted by the sufferer are:

Less commonly, the following may be noted:

Patients who have had a previous episode, may report prodromal symptoms such as burning gums before a sudden onset of the typical gingivitis.

Features seen on examination:

An episode of necrotising gingivitis may result in:

2. Necrotising periodontitis

Infection involves the specialised attachment tissues surrounding one or more teeth and the resulting inflammation is more destructive and deeper than in necrotising gingivitis. The affected tooth becomes loose. Bone is exposed and sometimes destroyed with possible loss of the involved tooth. Loss of tooth attachment and bone can be rapid, taking only months rather than the more usual years.

Symptoms and signs include:

3. Necrotising stomatitis

The infection and inflammation spreads along the surface to involve the oral mucosa beyond the gums. It can also invade deeply, affecting many teeth. Because the surface mucosa is lost, the underlying bone can be exposed with subsequent bone loss. This can result in mouth deformity and be life-threatening if untreated.

How is necrotising periodontal disease diagnosed?

Necrotising periodontal disease is a clinical diagnosis. A microbiological swab will show mixed microorganisms. Biopsy is generally unhelpful as it shows nonspecific inflammation. Special stains will demonstrate the mixed infection. X-rays may be required looking for bone involvement in necrotising periodontitis and necrotising stomatitis.

It is very important to take blood tests for predisposing illnesses such as leukaemia, neutropenia/agranulocytosis or HIV infection. In most HIV-positive patients with necrotising periodontal disease, the CD4+ T cell count is less than 200 cells/mm3, thus this oral disease can be a marker of HIV status and disease deterioration. However, most HIV-positive patients with CD4 counts of this level do not develop necrotising periodontal disease.

Treatment of necrotising periodontal disease

Treatment of necrotising gingivitis can be successful if treated early and if there is no predisposing systemic illness.

1. Acute phase emergency treatment may include:

2. Treat any predisposing illness or trigger. Very important to stop smoking.

3. Surgical correction of any remaining defects such as craters:

4. maintain good dental hygiene and good health to reduce the risk of recurrence

However, where there is a predisposing condition such as AIDS, recurrence or relapse is common.

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