Bactericidal and clinical efficacy of photochemotherapy in acute necrotizing ulcerative gingivitis.

AIM: This study was designed to investigate the clinical and microbiological parameters with photochemotherapy (PCT) against conventional debridement (CD) among patients with necrotizing ulcerative gingivitis (NUG). MATERIALS AND METHODS: Patients with a diagnosis of NUG were divided into two groups: 'Group-PCT' that underwent indocyanine green-mediated PCT with adjunctive mechanical debridement, and Group-CD that underwent mechanical debridement with adjunctive 3 % hydrogen peroxide/chlorhexidine rinse. Clinical inflammatory gingival parameters including full-mouth plaque scores (FMPS), bleeding scores (FMBS), and probing depth (PD) were measured. Counts of Treponema microdentium, Fusobacterium nucleatum and Prevotella intermedia were assessed using polymerase chain reaction technique. All assessments were done at baseline, 3 weeks and 6 weeks. RESULTS: Twenty-six participants were contacted and agreed to participate in the trial. The mean age of participants in group-PCT was 24.5 years while the mean age of patients in group-CD was 26.7 years. FMPS showed significant but equal reduction in both the groups at 3 weeks and 6 weeks (p < 0.01). The reduction in mean FMBS was higher in the group-PCT at 6 weeks follow-up (p < 0.05). All bacterial levels reduced from baseline to follow-up with both PCT and CD groups (p < 0.05). Group-PCT showed significantly reduced counts of T. microdentium and F. nucleatum at 3 weeks and 6 weeks compared with group-CD (p = 0.024). Equal reduction was shown for P. intermedia between both the groups at 3 and 6 weeks, respectively. CONCLUSION: Application of adjunctive photochemotherapy was both clinically and microbiologically effective in the treatment of NUG.

Acute periodontal lesions.

This review provides updates on acute conditions affecting the periodontal tissues, including abscesses in the periodontium, necrotizing periodontal diseases and other acute conditions that cause gingival lesions with acute presentation, such as infectious processes not associated with oral bacterial biofilms, mucocutaneous disorders and traumatic and allergic lesions. A periodontal abscess is clinically important because it is a relatively frequent dental emergency, it can compromise the periodontal prognosis of the affected tooth and bacteria within the abscess can spread and cause infections in other body sites. Different types of abscesses have been identified, mainly classified by their etiology, and there are clear differences between those affecting a pre-existing periodontal pocket and those affecting healthy sites. Therapy for this acute condition consists of drainage and tissue debridement, while an evaluation of the need for systemic antimicrobial therapy will be made for each case, based on local and systemic factors. The definitive treatment of the pre-existing condition should be accomplished after the acute phase is controlled. Necrotizing periodontal diseases present three typical clinical features: papilla necrosis, gingival bleeding and pain. Although the prevalence of these diseases is not high, their importance is clear because they represent the most severe conditions associated with the dental biofilm, with very rapid tissue destruction. In addition to bacteria, the etiology of necrotizing periodontal disease includes numerous factors that alter the host response and predispose to these diseases, namely HIV infection, malnutrition, stress or tobacco smoking. The treatment consists of superficial debridement, careful mechanical oral hygiene, rinsing with chlorhexidine and daily re-evaluation. Systemic antimicrobials may be used adjunctively in severe cases or in nonresponding conditions, being the first option metronidazole. Once the acute disease is under control, definitive treatment should be provided, including appropriate therapy for the pre-existing gingivitis or periodontitis. Among other acute conditions affecting the periodontal tissues, but not caused by the microorganisms present in oral biofilms, infectious diseases, mucocutaneous diseases and traumatic or allergic lesions can be listed. In most cases, the gingival involvement is not severe; however, these conditions are common and may prompt an emergency dental visit. These conditions may have the appearance of an erythematous lesion, which is sometimes erosive. Erosive lesions may be the direct result of trauma or a consequence of the breaking of vesicles and bullae. A proper differential diagnosis is important for adequate management of the case.

Invasive oral aspergillosis in a patient with acute myeloid leukaemia.

Aspergillosis (a fungal infection by an organism of the Aspergillus species) of the oral cavity is an uncommon condition which most frequently occurs in immunocompromised patients, such as those with haematological malignancies. In such patients, prolonged neutropenia secondary to chemotherapeutic agents enables the spread of invasive aspergillosis, which is unaffected by anatomical barriers. Early detection and treatment of the condition is essential to avoid more serious complications, such as disseminated infection, which results in increased morbidity and mortality. This case report describes a patient with acute myeloid leukaemia who developed localized invasive Aspergillus flavus of the palate. High-dose antifungal therapy was instituted along with surgical removal of the involved tissues. Aspergillosis of the palate was successfully eradicated with no long-term ill effects from the treatment. Management of invasive aspergillosis includes early aggressive antifungal medication combined with surgical removal of the involved tissues.

Borrelia tonsillitis: common symptoms but uncommon organism.

We present a severe case of acute tonsillitis caused by Borrelia vincenti. B. vincenti does not only cause Plaut-Vincent's angina, but also a more localised infection of the tonsil.

Necrotizing periodontal diseases in HIV-seropositive subjects: pathogenic mechanisms.

Necrotizing gingivitis (NG) is a well-known periodontal condition characterized by marginal gingival necrosis, bleeding and pain. Necrotizing periodontitis is an extension of NG into the periodontal attachment apparatus, and the two stages are referred to collectively as necrotizing periodontal diseases (NPD). Necrotizing periodontal diseases in HIV-seropositive subjects are similar with regard to the spectrum of periodontopathic bacteria, the clinical manifestations, the natural course and the response to treatment when compared to NPD in HIV-seronegative subjects. However, in the former group, there is an increase in the prevalence of candidal species and herpesviruses in the subgingival plaque and gingival biopsy specimens. In the periodontal tissues, spirochaetes, activated herpesviruses, Candida species and HIV have the capability of deregulating host innate and adaptive immune responses and of stimulating host inflammatory reactions, and may therefore explain the greater prevalence of NPD in HIV-seropositive subjects compared to immunocompetent subjects.

Gingivitis úlcero-necrosante y su relación con el VIH/SIDA / Necrotizing ulcerative gingivitis and its relationship with HIV/AIDS

En el presente trabajo se realizó una revisión de la literatura, con el fin de compartir con la comunidad odontológica la información recolectada sobre la Gingivitis Ulcero Necrosante (GUN) y su relación con el Virus de Inmunodeficiencia Humana y el Síndrome de Inmunodeficiencia Adquirida (VIH/SIDA).

This paper reports a literature review which shares the gathered information with the Dental community about Necrotizing Ulcerative Gingivitis associated to opportunistic infections related to the Human Immunodeficiency Virus and the Acquired Immunodeficiency Syndrome (HIV /AIDS).

Necrotizing ulcerative periodontal diseases in children and young adults in Medellín, Colombia, 1965--2000.

Previous findings that necrotizing ulcerative gingivitis (NUG) is a precursor to noma or cancrum oris were confirmed by the follow-up of these clinical conditions in a study of 45 Colombian patients: necrotizing ulcerative gingivitis (NUG, n = 29), necrotizing ulcerative periodontitis (NUP, n = 7) and noma (n = 9). Patients were diagnosed at the outpatient clinic of the School of Dentistry at the University of Antioquia, at the University Hospital Saint Vincent of Paul, at the Luz Castro de Gutierrez University Hospital, at the Red Cross Hospital and at the private office of one of the authors (Jiménez L., M) in Medellín, Colombia, from 1965 until 2000. Almost all the patients came from low socioeconomic groups and presented with predisposing and/or contributing factors, such as acute herpetic gingivostomatitis, measles, and leukemia (including acute lymphoblastic and chronic lymphoid leukemia). Malnutrition and poor oral hygiene were associated with the necrotizing process and favored progression from the gingiva to deeper periodontal tissues and other structures within the oral cavity or the facial tissues. No patients had human immunodeficiency virus (HIV) or AIDS, which makes these findings different from other reports. Noma can be prevented by vaccinating children against infectious diseases, by controlling malnutrition and by improving their oral hygiene. It is arrested by mechanical lesion debridement, improving oral hygiene and antibiotic therapy. Necrotizing ulcerative gingivitis may progress in some cases to ulcerative necrotizing stomatitis, necrotizing ulcerative periodontitis, and, finally, to noma. Microbial studies among new Colombian NUG, NUP and noma patients are necessary, using bacterial culturing and identification methods and molecular techniques such as PCR for viruses and bacteria, in order to establish the exact nature of these lesions.

Acute necrotizing ulcerative gingivitis and bacteremia caused by Stenotrophomonas maltophilia in an immunocompromised host.

An 8-year-old girl with leukemia developed acute necrotizing ulcerative gingivitis with Stenotrophomonas maltophilia and herpes simplex virus. Progression to bacteremia with pathologic evidence of osteomyelitis occurred despite appropriate antimicrobial therapy. This case highlights the importance of prompt recognition, debridement and appropriate therapy in immunocompromised patients with acute necrotizing ulcerative gingivitis.

Fusospirochetosis causing necrotic oral ulcers in patients with HIV infection.

Under certain permissive circumstances, normally occurring fusiform bacteria and Borrelia spirochetes can result in a symbiotic overgrowth that leads to necrotic oral ulcers (stomatitis), gingivitis, and periodontitis. These lesions are collectively known as oral fusospirochetosis and may be under-appreciated in patients with HIV infection and AIDS. Fusospirochetal oral ulcers in patients with HIV are often large, necrotic, and malodorous; they respond completely to penicillin. We report 3 patients with HIV infection and fusospirochetal ulcerative stomatitis and review the clinical presentation, microbiologic diagnosis, potential pathogenesis, and treatment of these lesions.

Topical polyene antifungals in hematopoietic cell transplant patients: tolerability and efficacy.

PURPOSE: The effectiveness of amphotericin B oral suspension versus nystatin oral suspension for the prevention of oral colonization by Candida in hematopoietic cell transplant (HCT) patients was examined. METHODS: Prior to hematopoietic cell infusion, 40 patients receiving systemic fluconazole for prophylaxis were randomized to receive either amphotericin B oral suspension or nystatin oral suspension, q.i.d. The study continued to day 21 or until the patient was discharge from the hospital or withdrawn from the study. Oral examinations were conducted twice weekly, and adverse events and compliance were recorded. Cultures were taken for quantitative counts and species identification. Candida isolates were assessed for resistance to the oral antifungal agents. Blood was collected for assessment of amphotericin B levels. RESULTS AND DISCUSSION: Ulcerative mucositis occurred in 84.6% of patients undergoing HCT, and no correlation was observed between the severity of mucositis and the presence of oral Candida and the severity of mucositis. Systemic and topical antifungal treatment resulted in a decrease in the number of colonized patients (54.8% before treatment; 23.1% during treatment); however, oral colonization was not eliminated. Tolerability of the oral rinse products was limited, with greater noncompliance in the amphotericin B than the nystatin group. Reports of altered taste appeared to be greater in the amphotericin B group. Minimal absorption of amphotericin B was seen following oral rinsing (serum levels 0.12-0.50 microg/ml), and no consistent changes in organism susceptibility to polyenes were seen. The results suggest that topical antifungal rinses may further control oropharyngeal colonization by Candida in patients on systemic antifungals receiving HCT, but the effect is limited by tolerability and reformulation and should be considered in order to increase compliance.

Necrotizing stomatitis: report of 3 Pseudomonas aeruginosa-positive patients.

Necrotizing oral lesions have been described in immunosuppressed patients, usually in association with gingival and periodontal pathoses. The etiology of these lesions has not been completely elucidated. We present 3 patients with a type of necrotizing stomatitis in which clinical patterns appear distinct from the periodontal forms of the disease. The lesions yielded bacterial cultures positive for Pseudomonas aeruginosa and reverted to no growth in 2 patients after proper antibiotic therapy. We propose that P aeruginosa may be responsible for selected necrotizing oral lesions with a clinical presentation lacking typical necrotizing periodontal disease and that this condition may represent the intraoral counterpart of ecthyma gangrenosum. In such cases, bacterial culture of the lesion becomes imperative because the disease does not respond to typical periodontal and antimicrobial therapy.

Oral candidiasis in hematopoietic cell transplantation patients: an outcome-based analysis.

OBJECTIVES: Despite aggressive antifungal prophylaxis, the increased risk for systemic fungal infection in recipients of hematopoietic cell transplants (HCT) continues to be a significant concern because Candida infection can cause morbidity and mortality in these patients. The objectives of this study were to examine the relationship of oral colonization by Candida species to systemic infection, mortality, and the impact of antifungal treatment on a population of recipients of HCT. STUDY DESIGN: One hundred and fifteen consecutive patients undergoing hematopoietic cell transplantation were evaluated. Oral examinations and cultures for Candida were completed before transplantation and on a weekly basis until discharge. The oral complications were assessed, and the level of mucositis was scored by using the National Cancer Institute grade. Systemic antifungal prophylaxis was provided to all patients. Chlorhexidine oral rinses were also routinely provided. RESULTS: Colonization by Candida species was identified in 31% of patients. Fifty-six percent of patients with colonization had clinical evidence of oral candidiasis. Significantly decreased Candida colonization was seen in patients using chlorhexidine alone compared with those using chlorhexidine and nystatin together (P <.046). Twenty-five patients died in the immediate posttransplantation period, 17 of whom were Candida-positive. The length of hospital stay ranged from 15 to 153 days; increased stay was also associated with Candida colonization (P =.04). Seventy-four percent of all patients developed ulcerative mucositis. More severe mucositis was seen in patients undergoing chemotherapy and radiation therapy. There was no significant difference between Candida colonization and the presence or severity of mucositis. CONCLUSIONS: Despite systemic and topical antifungal prophylaxis, oropharyngeal colonization by Candida species was common in patients who had received HCT. Candidiasis was commonly present in those who did not survive the early transplant period. Of the 25 patients who died early after the transplantation, 92% had ulcerative mucositis in comparison with 70% of those who survived, reflecting the association of oral mucositis with the toxicity of HCT. There was a significant relationship among allogeneic and autologous HCT, length of stay, and colonization of Candida. In patients undergoing systemic antifungal prophylaxis, chlorhexidine rinse was statistically more effective in reducing colonization by Candida than chlorhexidine and nystatin combined (P =.046).

Acute myelogenous leukemia complicated by acute necrotizing ulcerative gingivitis due to Aspergillus terreus.

Infections caused by Aspergillus terreus are rare but have been associated with a poor outcome in immunocompromised patients due to frequent resistance to conventional antifungal therapy. This report describes a case of a woman who developed acute necrotizing ulcerative gingivitis (ANUG) due to A. terreus during induction chemotherapy for acute myelogenous leukemia. She initially failed to respond to treatment with amphotericin B but the infection resolved following the introduction of oral itraconazole. Opportunistic infections caused by A. terreus are an emerging problem and can be associated with a high mortality rate. Early microbiological diagnosis is critical since resistance to amphotericin B is likely and itraconazole appears to be an effective treatment for this infection.

A TEM/SEM study of the microbial plaque overlying the necrotic gingival papillae of HIV-seropositive, necrotizing ulcerative periodontitis.

The purpose of this study was to examine by transmission (TEM) and scanning electron microscopy (SEM) the supragingival microbial plaque overlying the ulcerated gingival papillae of necrotizing ulcerative periodontitis (NUP) lesions in HIV-seropositive patients. The microbiota of NUP and HIV-seropositive patients with periodontitis has been reported to be similar to that of conventional periodontitis in non-infected subjects, although several investigators have also reported high recovery rates of microbes not generally associated with the indigenous oral microbial flora. Light and electron microscopic observations and microbial culture studies indicate a similar high prevalence of spirochetes in both necrotizing ulcerative gingivitis (NUG) and NUP. In addition, several studies have reported more frequent isolation of Candida albicans from diseased periodontal sites in HIV-seropositive patients than from non-diseased sites. Ten male and six female patients, each HIV-seropositive and exhibiting NUP, constituted the study population. Two biopsies of involved gingival papillae from between posterior teeth were obtained from each patient and processed for examination by both TEM and SEM. Microscopic examination revealed a surface biofilm comprised of a mixed microbial flora of various morphotypes in 81.3% of biopsy specimens. The subsurface flora featured dense aggregations of spirochetes in 87.5% of specimens. Zones of aggregated polymorphonuclear leukocytes and necrotic cells were also noted. Yeasts were observed in 65.6% of specimens and herpes-like viruses in 56.5% of the specimens. Collectively, except for the presence of yeast and viruses, the results suggest that the microbial flora and possibly the soft tissue lesions of NUP and necrotizing ulcerative gingivitis are very similar.

Fatal necrotizing stomatitis due to Trichoderma longibrachiatum in a neutropenic patient with malignant lymphoma: a case report.

Primary invasive mold infection of the oral cavity is a rare but serious complication in immunocompromised hosts. We report a case of fatal Trichoderma longibrachiatum stomatitis in a 66-year-old female patient with malignant lymphoma. The infection rapidly disseminated from the oral mucosa to the lungs during neutropenia. Despite intensive antifungal therapy with amphotericin B and itraconazole, there was a fatal progression of the condition. While Trichoderma species have been recognized to be pathogenic in profoundly immunosuppressed hosts, this is the first report of the primary oral focus causing a fatal infection.

The use of metronidazole in the treatment of periodontal diseases.

Diagnostic microbiology and the use of antibiotics should be considered as available tools in periodontal therapy. It appears that the dental health profession has yet to develop a consensus as to whether or not the use of antibiotics alone can wholly or partially replace traditional treatments such as debridement and surgery. The combined use of periodontal microbiology and antibiotic therapy, however, perhaps qualifies as an extension of traditional courses of treatment following a proper clinical diagnosis. Metronidazole offers the periodontist (therapist) the benefits of a high degree of efficacy and relatively few and/or mild adverse side effects. Also it is an antibiotic to which susceptible anaerobes have yet to develop clinical resistance. Therefore, it qualifies as the preferred drug against anaerobic infections under this combined treatment program.

Role of Treponema denticola in periodontal diseases.

Among periodontal anaerobic pathogens, the oral spirochetes, and especially Treponema denticola, have been associated with periodontal diseases such as early-onset periodontitis, necrotizing ulcerative gingivitis, and acute pericoronitis. Basic research as well as clinical evidence suggest that the prevalence of T denticola, together with other proteolytic gram-negative bacteria in high numbers in periodontal pockets, may play an important role in the progression of periodontal disease. The accumulation of these bacteria and their products in the pocket may render the surface lining periodontal cells highly susceptible to lysis and damage. T. denticola has been shown to adhere to fibroblasts and epithelial cells, as well as to extracellular matrix components present in periodontal tissues, and to produce several deleterious factors that may contribute to the virulence of the bacteria. These bacterial components include outer-sheath-associated peptidases, chymotrypsin-like and trypsin-like proteinases, hemolytic and hemagglutinating activities, adhesins that bind to matrix proteins and cells, and an outer-sheath protein with pore-forming properties. The effects of T. denticola whole cells and their products on a variety of host mucosal and immunological cells has been studied extensively (Fig. 1). The clinical data regarding the presence of T. denticola in periodontal health and disease, together with the basic research results involving the role of T. denticola factors and products in relation to periodontal diseases, are reviewed and discussed in this article.

Noma (cancrum oris): questions and answers.

Noma (cancrum oris) is an infectious disease which destroys the oro-facial tissues and other neighboring structures in its fulminating course. It affects predominantly children aged 2-16 years in sub-Saharan Africa where the estimated frequency in some communities may vary from one to seven cases per 1000 children. The key risk factors are poverty, malnutrition, poor oral hygiene, deplorable environmental sanitation, close residential proximity to livestock, and infectious diseases, particularly measles. Malnutrition acts synergistically with endemic infections in promoting an immunodeficient state, and noma results from the interaction of general and local factors with a weakened immune system as the common denominator. Acute necrotizing gingivitis (ANG) is considered the antecedent lesion. Current studies suggest that evolution of ANG to noma requires infection by a consortium of microorganisms with Fusobacterium necrophorum and Prevotella intermedia as the suspected key players. Without appropriate treatment, mortality rate is 70-90%. Survivors suffer the two-fold affliction of oro-facial disfigurement and functional impairment. Reconstructive surgery of the resulting deformity is time-consuming and financially prohibitive for the victims who are poor.