Necrotising periodontal diseases and alcohol misuse - a cause of osteonecrosis?

'Necrotising periodontal diseases' is an umbrella term for necrotising gingivitis, necrotising periodontitis, necrotising stomatitis and noma. These rapidly destructive conditions are characterised by pain, interdental ulceration and gingival necrosis which, if left untreated, can result in osteonecrosis. Research indicates that patients with a history of alcohol misuse are at an increased risk of malnutrition, which negatively affects the immune response and predisposition to necrotising periodontal diseases. This article will discuss that osteonecrosis of the alveolar bone does not exclusively occur in association with antiresorptive medications, but can occur as a severe form of necrotising gingivitis. In this article, we will describe two cases to highlight the occurrence, presentation and management of necrotising periodontal diseases secondary to alcohol misuse.

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.

Necrotizing ulcerative gingivitis and the orthodontic patient: a case series.

Necrotizing ulcerative gingivitis (NUG) can be a painful periodontal disease that can lead to loss of the interdental papillae. It is usually accompanied by systemic signs of fever, malaise and cervical and submandibular lymphadenopathy. It is caused by the profileration of anaerobic bacteria and has been linked to smoking and immunosuppression. This case series reports the occurrence of NUG in orthodontic patients and demonstrates that there is a varying scale of severity of the condition. Orthodontists should be aware of the clinical signs of NUG to ensure early detection and treatment of their patients in order to prevent irreversible loss of the interdental papillae and reduce the likelihood of recurrence. A treatment regime is suggested.

Gingivitis ulceronecrotizante. Recuperación de las papilas después del tratamiento: informe de casos / Necrotizing ulcerative gingivitis. Papillae recovering after treatment: case reports

Objetivo: describir la cicatrización gingival en tres pacientes con gingivitis ulceronecrotizante y revisar el tratmiento propuesto en la literatura, para evaluar los factores que influyen en la respuesta gingival. Caso clínico: en los casos presentados, se priorizaron el diagnóstico y el tratamiento precoz de la lesión, a fin de ayudar a mantener y recuperar los tejidos interdentales. Conclusión: es importante preservar los tejidos gingivales interdentales, no solamente desde el punto de vista estético, sino también desde lo funcional. El diagnóstico y tratamiento temprano de las lesiones, seguidos de una intervención efectiva, ayudarán a reducir la destrucción del tejido interdentario. El mantenimiento a largo plazo es fundamental para garantizar la salud y evitar la recidiva

Periodontite ulcerativa necrosante: relato de caso, diagnóstico, tratamento e um ano de acompanhamento / Necrotizing ulcerative periodontitis: case report-diagnoses, treatment and one year follow-up

As doenças periodontais necrosantes (DPNs) são as formas mais graves de doença periodontal causada pela placa bacteriana. Nas DPNs, as bactérias são mais agressivas do que as observadas em uma periodontite crônica e, quando associadas a uma saúde debilitada do indivíduo, causam um dano ainda maior ao periodonto. Por outro lado, as DPNs têm uma prevalência extremamente baixa na população, o que faz com que casos diagnosticados dessa doença devam ser documentados e divulgados, para contribuir para o conhecimento da mesma pelos profissionais de saúde. Dessa forma, o objetivo do presente trabalho é ilustrar, através de um caso clínico, as características clínicas de uma das DPNs e as etapas clínicas do tratamento correspondente. Um indivíduo com 22 anos de idade compareceu à clínica odontológica para atendimento de urgência, apresentando como sinais e sintomas: febre, sangramento espontâneo, supuração, dor e halitose extrema. Clinicamente, apresentava na gengiva interproximal de diversos dentes ulcerações e necrose com ampla extensão, necrose e exposição de osso alveolar interproximal, e pobre higiene bucal. Radiograficamente, constataram-se perdas ósseas horizontais. O tratamento foi baseado no diagnóstico de periodontite ulcerativa necrosante. Noventa dias após o início do tratamento, foi realizada reavaliação periodontal, observando-se ausência de bolsas periodontais e permanência dos defeitos anatômicos produzidos pela inflamação. Após um ano do início do tratamento, observaram-se focos de placa bacteriana e cálculo supragengival, porém não foram observadas bolsas periodontais e sangramento à sondagem.

Necrotizing Periodontal Diseases (NPDs) are the most severe inflammatory periodontal disorders caused by plaque bacteria. In the NPDs the bacteria are more aggressive than those observed in chronic periodontitis and when combined with a poor health of the patient causing a further damage to the periodontium. On the other hand, the prevalence of NPD is extremely low in the population, however, diagnosed cases of this disease should be documented and disseminated to contribute to the knowledge by health professionals. The objective of this paper is to illustrate through a clinical case the clinical characteristics of one of the NPDs and the stages of its treatment. A 22-year-old patient attended in the dental clinic for urgent care presenting the following signs and symptoms: fever, spontaneous bleeding, suppuration, pain and extreme halitosis. Clinically, there were ulcerations and extensive necrosis in the interproximal gingiva of several teeth, exposure of interproximal alveolar bone and poor oral hygiene. In the radiograph it was found horizontal bone loss. The treatment realized was based on the diagnostic of Necrotizing Ulcerative Periodontitis. Ninety days after the treatment beginning it was performed a periodontal reevaluation, and there was absence of periodontal pockets, and anatomic defects produced by the inflammation were observed. After one year of the treatment beginning it was observed plaque and supragengival calculus, but pockets and bleeding on probing were not observed.

[Differential diagnosis of unilateral necrotic tonsillitis]. / Differenzialdiagnostik der nekrotisierenden Tonsillitis.

BACKGROUND: The best known clinical picture of a one-sided necrotisising, infectious tonsillitis is the by Plaut and Vincent (1894) described angina Plaut-Vincent. In addition to this fusospirochetosis it is in case of necrotisising inflammations in the oropharynx differential-diagnostically important to consider also the anaerobic type Prevotella, especially Prevotella disiens as a potential trigger . MATERIAL AND METHODS: Because the clinical course forms of a necrotisising oropharyngeal inflammations can be very different and complicate so a suitable diagnosis, it is very important to get a complete and perfect cause proof. For getting this proof a correct test production, transport and cultivation are of extreme importance . RESULTS: The type Prevotella consists of different species gram-negative, obligate anaerobic strains. They are regarded as a cause of suppurating inflammations and abscesses of the genital tract and are components of the aerobic anaerobic mixed flora in case of gingival infections. The sole proof in the microbiological culture as a smear test result of a one-sided necrotisising tonsillitis has to be seen as a first description by reason of missing literature . IMPLICATION: As triggers for one-sided necrotisising tonsillitis are considered different causes. Next a carcinoma of the tonsil, Lues, Angina Plaut-Vincent have to be excluded. An infection with Prevotella disiens is an extremely rare variation in contrast. However, the transmission is possible by insufficient hygiene, lack phenomena and sexual intercourse and to consider therefore as an exclusion diagnosis.

Chronic ulcerative stomatitis.

Chronic ulcerative stomatitis (CUS) is a recently described condition with specific immunopathologic findings. Demographics indicate that white women in their late middle age are more susceptible to this condition. The clinical history of CUS patients is of painful, exacerbating and remitting oral erosions, and ulcerations. The histologic features are non-specific, with a chronic inflammatory infiltrate, often appearing similar to oral lichen planus (OLP). Diagnosis of CUS requires surgical biopsy with immunofluorescence microscopic examination. Accurate diagnosis is important because the usual treatment option for immunologically mediated diseases, glucocorticoids, is often not effective in treating CUS. However, hydroxychloroquine pharmacotherapy is beneficial in many cases. The lack of awareness of the condition among clinicians and the technical challenges in specimen processing make diagnosis of CUS a challenge, and hence the true prevalence is unknown. Immunofluorescence studies show circulating and tissue-bound autoantibodies to a protein, DeltaNp63alpha, which is a normal component of stratified epithelia. It is unknown if the antibodies are pathogenic, thus the etiology of CUS is also unknown. Studies are needed to elucidate the pathogenesis of CUS, optimize clinical management, and clarify its relationship to OLP and neoplasia.

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 stomatitis in the developed world.

We present a case of a malnourished 68-year old man with occult hypothyroidism who presented with malaise, pyrexia, tongue swelling, oral ulceration and dysphagia after a 6-month period of increasing lethargy and failing self-care. Severe necrotic oral ulcerative lesions were accompanied by cutaneous purpura, blood-filled blisters and bedsores. It was concluded that the patient's clinical condition reflected necrotizing stomatitis on a background of malnutrition with scorbutic skin lesions and hypothyroidism. The patient made a good recovery with scrupulous oral hygiene, debridement, intravenous metronidazole and nutritional support. Healing occurred with marked fibrosis and trismus, which has slowly improved with mouth-opening exercises. Necrotizing stomatitis is more commonly encountered in malnourished children in developing countries, and may subsequently result in devastating facial defects and death. Patients in the developed world with poor oral hygiene, malnourishment and immunosuppression are also at risk, but early diagnosis and treatment is life-saving and reduces subsequent disability.

[Ulcerative gingivostomatitis and peridontitis]. / Ulzerierende Gingivostomatitis und Parodontitis.

Many systemic diseases have oral and/or pharyngeal manifestations. Mucosal lesions in the upper aerodigestive tract may be caused by granulomatous inflammations, and infectious, autoimmune and neoplastic diseases before they appear systemically or otherwise. ENT specialists can play a decisive role in identifying patients with pathological mucosal changes and transfer them to dermatology, hematology, gastroenterology or maxillofacial surgery in order to assure the best possible treatment. This article presents the case of an elderly female patient with a history of necrotising severe stomatitis that turned out to be a rare B-cell lymphoma. In the second part of the article, we present a number of common and rare diseases that may be encountered in ENT practice with an overview of clinical manifestations and current diagnostic modalities.

[Necrotizing periodontal disease: a manifestation of systemic disorders]. / Enfermedad periodontal necrosante: una manifestación de trastornos sistémicos.

Necrotizing periodontal disease (NPD) is an infection characterized by gingival necrosis presenting as "punched-out" papillae, with gingival bleeding, and pain. Prevotella intermedia and spirochetes have been associated with the gingival lesions. Predisposing factors may include emotional stress, immunosuppression, especially secondary to human immunodeficiency virus (HIV) infection, cigarette smoking, poor diet and pre-existing gingivitis. During the last few years, diagnosis of NPD has became more important not only because of its contribution to the appearance of clinical attachment loss and gingival sequelae, but also because it has been revealed as a marker for immune deterioration in HIV-seropositive patients.

[Necrotizing ulcerative periodontitis. Diagnosis, treatment and follow-up--a case report]. / Nekrotisierende ulzerierende Parodontitis. Diagnose, Behandlung und Betreuung--ein Fallbericht.

Necrotizing ulcerative gingivitis (NUG) and necrotizing ulcerative Periodontitis (NUP) share many clinical and etiologic characteristics. Both forms are characterized by necrotic gingival tissues, bleeding and pain. Malodor and malaise may be also present. NUG is an infection limited to the gingiva whereas NUP also involves the attachment apparatus. Predisposing factors may include immune dysfunction, poor oral hygiene, cigarette smoking and emotional stress. NUG and NUP might possibly be different stages of the same infection. This case report shows the successful treatment of a patient suffering from NUP.

Necotizing gingivostomatitis: NUG to noma.

Necrotizing gingivostomatitis (NG) is an increasingly rare but potentially serious infection that can present as a spectrum of clinical disease ranging from necrotizing ulcerative gingivitis to noma. The diagnostic triad for NG is pain, interdental ulceration, and gingival bleeding, but many cases also display fetid breath and pseudomembrane formation. Etiology is believed to be an opportunistic bacterial infection occurring in individuals debilitated by malnutrition, human immunodeficiency virus infection, or other systemic factors, including inadequate sleep, unusual stress, recent illness, alcohol use, and smoking. Treatment for NG includes bacterial control by strict oral hygiene, antiseptic rinses, antibiotic use in selected cases, and correction of predisposing factors. In compliant patients, gingivectomy or gingival grafting may be indicated after initial healing to resolve any residual defects.

Gengivite ulcerativa necrosante aguda / Acute necrotizing ulcerative gingivitis

A gengivite ulcerativa necrosante aguda é uma doença caracterizada por necrose com inversäo de papilas, dor e sangramento, causada pela associaçäo de vários fatores. O tratamento geralmente se constitui de debridamento, bochechos com soluçöes oxidantes, rigorosa higiene bucal e antibióticos específicos. Em alguns casos, cirurgias säo necessárias para devolver a forma anatômica da gengiva para evitar recorrências

Guna em paciente portador de HIV: relato de caso clínico / Necrosant ulcerative gengivitis in AIDS patient: clinic case report

Os autores relataram caso clínico onde o paciente, portador do virus da AIDS, apresentou gengivite ulcerativa necrosante aguda (GUNA) e discutiram o diagnóstico e tratamento desta patologia periodontal