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.

Clinical treatment of necrotizing ulcerative gingivitis: a case report with 10-year follow-up.

The aim of this case report is to describe the diagnosis and treatment of a patient with necrotizing ulcerative gingivitis. An 18-year-old man with no systemic problems reported with chief complaints of gingival bleeding during toothbrushing and spontaneous pain. Clinical examination revealed significant plaque accumulation on the surfaces of all teeth as well as papillary necrosis involving mainly the anterior teeth. Treatment included an initial phase of supragingival plaque and calculus removal along with at-home use of 0.12% chlorhexidine gluconate mouthrinse twice a day for 30 days. After the initial phase, subgingival scaling was performed, and regular oral hygiene methods were resumed by the patient. After active therapy was completed, a periodontal maintenance regimen was established, and the patient was recalled for periodontal maintenance therapy. Follow-up occurred weekly throughout treatment, monthly for the first 6 months posttreatment, and 2-3 times a year during the periodontal maintenance therapy. Clinical results after 10 years showed that this approach controlled the acute phase and maintained the patient's periodontal health over time.

Implicaciones periodontales del abuso del cannabis. Revisión y casos clínicos / Periodontal implications of cannabis abuse. Review and cases report

Desde hace bastantes años, se ha asociado regularmente el abuso del cannabis, y sobre todo en su forma más habitual, la marihuana, con una boca más descuidada. Los adictos al cannabis suelen tener mayores índices de placa, xerostomía y caries. Sin embargo, son pocas las publicaciones que relacionan la marihuana con enfermedad periodontal, salvo casos clínicos aislados. En este artículo, se revisa la literatura que existe al respecto y se presentan tres casos clínicos de pacientes fumadores habituales de marihuana con periodontitis

The abuse of cannabis, overall in its most habitual format, marihuana, has commonly been related to oral neglect. Cannabis abusers have higher plaque scores, xerostomia and increase in the risk of dental caries. Nevertheless, there are few the papers that show a relationship between marihuana and periodontal disease, except in isolated clinical cases. In this article, literatura related to the topic is revised and three cases report of habitual smokers of marihuana with necrotizing periodontitis are shown

Estomatitis Urémica como Complicación Oral de Insuficiencia Renal Crónica: Reporte de Caso y Revisión de la Literatura / Uremic Stomatitis as an Oral Complication of Chronic Renal Failure: Case Report and Literature Review

RESUMEN: La Estomatitis Urémica es una lesión oral poco frecuente que se presenta generalmente en pacientes con insuficiencia renal crónica avanzada o no tratada. A continuación, se reporta un caso clínico de un paciente masculino de 22 años de edad que acude a un servicio de urgencia con la presencia de placas blanquecinas indoloras en piso de boca, cara interna de mejilla, y lengua. Las probables causas, presentaciones clínicas, y manejo odontológico son discutidos.

ABSTRACT: Uremic stomatitis is a rare oral lesion that usually occurs in patients with advanced or untreated chronic renal failure. Here we report a case of a 22-year-old male patient who comes to an emergency department with the presence of painless whitish plaques on the floor of the mouth, internal cheek face, and tongue. Probable causes, clinical presentations, and dental management are discussed.

Necrotising Ulcerative Gingivitis: A Literature Review.

PURPOSE: The literature surrounding necrotising ulcerative gingivitis (NUG) is extensive, yet the rare nature of this disease means that there is a lack of good quality research available. This paper aims to scrutinise the literature and provide an up-to-date summary of the available information. MATERIALS AND METHODS: A literature search was performed electronically using the Cochrane Library, Ovid Medline, Embase, PubMed Clinical Queries and Google Scholar. Keyword searches were carried out, utilising MeSH terms and free text. English language articles primarily were included, with key foreign language (French and German) articles included where possible from the 1900s to the present day. RESULTS: Necrotising ulcerative gingivitis is a rare disease (prevalence <1%), with an acute, painful and destructive presentation. It is an opportunistic bacterial infection which is predominantly associated with spirochetes. Treatment of NUG must be provided on a case-by-case basis, tailored to what the individual can tolerate and the extent of the infection. CONCLUSION: Although there is low prevalence of NUG, its importance should not be underestimated as one of the most severe responses to the oral biofilm. Risk factors must be investigated and addressed. Treatment should consist of gentle superficial debridement, oral hygiene instruction and prescription of mouthwash and antibiotics in severe cases.

[NUG--necrotizing ulcerative gingivitis: a review].

Necrotizing Ulcerative Gingivitis (NUG) is an acute and rare (0.5-11% of the population) infectious disease of the gum tissue, which is characterized by ulceration and inflammation of the inter-dental gum tissue. NUG was documented by historians since the fourth century BC, most of the reports from the ancient world were in the context of illness among fighting troops, present studies of NUG in the modern world are still common among soldiers. NUG is associated with poor oral hygiene and weakening of the host, especially in immunocompromised patients, malnutrition and poor living conditions, as well as in the context of mental stress. NUG is more common in young adults, but reports of morbidity in young children with malnutrition in the background are not uncommon. NUG diagnosis is based on three essential symptoms: sore gums, bleeding gums and the most diagnostic characteristic, ulceration and necrosis of the interdental papillae. The disease is considered to have a clear initial infectious etiology, when the main bacteria, associated with the disease, include: Bacteroides intermedius and Fusobacterium sp. The infection involves anaerobic \ aerobic bacteria with a majority of Gram-negative bacteria. The treatment of NUG is based on combining mechanical removal of tartar with local and systemic delivery of antimicrobial agents. Adequate treatment usually prevent the progression of the disease and ulcer healing is expected in a few days. Nevertheless, lack of treatment can lead to deterioration in the form NUP to Noma.

Gender differences in oral manifestations among HIV-infected Brazilian adults.

AIM: The purpose of this study was to compare gender differences in the prevalence of oral lesions in HIV-infected Brazilian adults. METHODOLOGY: A retrospective study was conducted of medical records from HIV/AIDS patients from 1993 to 2004. Oral lesions were only included in this study if definitively diagnosed through microscopic analysis, therapeutic test or according to EC-Clearing house criteria. RESULTS: A total of 750 men and 237 women were included in the study. Statistically significant differences were observed only for oral hairy leukoplakia, Kaposi sarcoma and lymphadenopathy (P < 0.01). However, a model of logistic regression showed that only oral hairy leukoplakia presented a significant association with gender and males had a significantly likelihood (four times higher than females) of presenting with this oral manifestation [OR 4.3 (95% CI: 1.39-13.36)]. CONCLUSION: These data shows that oral manifestations are less prevalent in females than in males, particularly oral hairy leukoplakia.

The prevalence of HIV associated oral lesions among adults in the era of HAART.

INTRODUCTION: The overall prevalence of HIV associated oral lesions among adults has decreased since the advent of highly active anti-retroviral therapy (HAART). AIMS AND OBJECTIVES: This study describes the prevalence and types of oral mucosal lesions in adults, who accepted a dedicated oral and dental programme for HIV-infected patients. The incidence of oral lesions and the CD4 cell counts on those patients, were related to cases receiving HAART and to those who were not. DESIGN: This was a retrospective, descriptive cross-sectional study. METHODS: Patients were interviewed, using a structured questionnaire to obtain information regarding medical history, current medications and demographic details. Data relating to CD4 cell counts were extracted from clinical medical records of the patent. In each case, the oral cavity of the sitting patient was examined under artificial light, by a clinician using a mouth mirror. Oral lesions were categorised in accordance with EC-Clearinghouse diagnostic criteria. RESULTS: The prevalence of HIV-associated oral lesions was significantly reduced (p < 0.001) in patients receiving HAART. There was, however, no significant difference (p = 0.29) in mean CD4 counts between patients receiving HAART and those not receiving HAART. The presence of oral lesions was statistically significantly, associated with both CD4 counts of < 200 cells/mm3 (p < 0.001) and the absence of HAART (p = 0.033). CONCLUSIONS: The study confirmed that the incidence of oral lesions and of pseudo-membranous candidiasis in particular, were statistically significantly reduced in patients receiving HAART.

Post-chemotherapeutic resolution of acute myeloid leukaemia-induced gingival enlargement: a case report.

INTRODUCTION: Leukaemia is a neoplastic dsorder characterized by an excessive proliferation of immature white blood cells and their precursors. Patients with this potentially fatal condition may often first present with gingival enlargement. Early diagnosis of the underlying condition and prompt referral for appropriate therapy, may be life-saving. CASE REPORT: A 27-year-old female was referred to the Department of Oral Medicine and Periodontology complaining of a generalised gingival enlargement that was aesthetically displeasing to her. She insisted on immediate surgical removal of the enlarged gingival tissue but, on counseling, agreed to have prior diagnostic tests performed. A full blood count suggested the presence of an underlying acute myeloid leukaemia. The patient was consequently referred to the Oncology Department for further investigation and management. The diagnosis was confirmed and the subsequent chemotherapeutic intervention was strikingly successful, leading to the complete resolution of the gingival enlargement. CONCLUSION: This paper emphasises the importance of a full diagnostic evaluation of all cases of gingival enlargement and immediate referral should a life-threatening condition be identified, such as, in the present case, acute myeloid leukaemia.

Oral ulcers and necrotizing gingivitis in relation to HIV-associated neutropenia: a review and an illustrative case.

An unusual case of necrotizing gingivitis and neutropenic oral ulcers in an HIV-seropositive patient is presented. In spite of a very low CD4(+) T cell count and severe neutropenia, the necrotizing gingivitis responded favorably to standard periodontal treatment, and the oral ulcers healed after administration of granulocyte colony-stimulating factor (G-CSF). Nonspecific oral ulcers in HIV-seropositive subjects with neutropenia should be regarded as neutropenic ulcers. The term nonspecific ulcers should be restricted to those ulcers with nonspecific histopathological features in patients without neutropenia or a nutritional deficiency such as iron, folic acid, and vitamin B.

Necrotic ulcerative changes in Fanconi's anaemia: a case report.

SUMMARY: This case report is of a rare occurrence of necrotic ulcerative changes in a female patient with Fanconi's anaemia and its successful periodontal management. BACKGROUND: The response of the periodontium to certain genetic and haematological disorders may vary from bleeding, ulcerations and necrosis to a more severe form of periodontitis. Periodontal management in such conditions still remains an enigma with respect to the timing of the periodontal intervention with regard to the systemic wellbeing of the patient. METHODS: Necrotising ulcerative lesions in a patient with Fanconi's anaemia (FA) progressed rapidly in a week's time necessitating early preliminary periodontal care, which included scaling and root planning using ultrasonic equipment supplemented with hydrogen peroxide irrigation, in conjunction with systemic antibiotics and blood transfusion. RESULTS: Following 1 unit (500ml) of fresh whole blood transfusion 24 hours preoperatively, basic periodontal therapy, comprising of removal of necrotic slough and thorough scaling was done. There was marked resolution of the necrotic ulceration and related symptoms when the patient was followed up for a period of 1 month. CONCLUSION: This report reconfirms most oral manifestations of Fanconi's anaemia and is the first of its kind to associate necrotic ulcerative changes of the gingiva with FA. It also goes a step further to emphasise the clinical significance of multidisciplinary approach towards successful patient management, which was the primary objective.

Severe presentation of necrotizing ulcerative periodontitis in a Nigerian HIV-positive patient: a case report.

OBJECTIVE: To report a case of severe necrotizing ulcerative periodontitis (NUP) with a rarely associated sequestrum formation in a Nigerian HIV-positive patient. CLINICAL PRESENTATION AND INTERVENTION: A 47-year-old HIV-positive male patient with no history of previous dental visits presented with a severe toothache in his lower jaw of 4 weeks' duration, which had affected his ability to chew properly. Clinical examination revealed marked gingival inflammation, moderate gingival recession and mobility of some of his lower anterior teeth: 31, 32, and 33. There was also a sequestrum present associated with the affected teeth. His CD4 cell count was 226 cells/mm(3). His viral load was very high (360,082 copies/ml). The intervention included thorough debridement of the necrotic lesion and sequestrectomy. The patient responded well to treatment after 1 week of follow-up. Unfortunately, the CD4 count was not assessed further because the patient was lost to follow-up. CONCLUSION: This case showed that a high CD4 cell count does not necessarily prevent the occurrence of NUP in HIV-positive patients. Intervention might have enhanced a rapid positive response to the treatment within a short time.

Chronic ulcerative stomatitis: evidence of autoimmune pathogenesis.

OBJECTIVES: Chronic ulcerative stomatitis is a condition characterized by chronic, painful oral ulcers, whose pathogenesis is unknown. Patients demonstrate specific IgG autoantibodies against ΔNp63α, an epithelial nuclear transcription factor. The aim of this study was to investigate the role of patient autoantibodies in the disease pathogenesis. METHODS: Three-dimensional in vitro tissues consisting of a fully differentiated, multilayer epithelium that mimics its in vivo counterpart were incubated with serum from patients with chronic ulcerative stomatitis. RESULTS: Our results show a subepithelial detachment of the epithelium at the basement membrane interface, mimicking the oral ulcerations that are seen clinically. Expression of basement membrane proteins Type IV collagen and laminin-5 was unaltered, whereas the expression of α6ß4 integrins, hemidesmosome components that attach basal keratinocytes to the basement membrane, was reduced, as determined by immunohistochemistry. CONCLUSION: These results give evidence that patient autoantibodies are pathogenic; and support an autoimmune pathogenesis in chronic ulcerative stomatitis.

Comparison of oral manifestations with CD4 count in HIV-infected patients.

AIM AND OBJECTIVE: This study was carried out with the primary aim of correlating oral changes and general changes of HIV-infected patients with their CD4 count. MATERIALS AND METHODS: 124 patients were selected, and after taking their informed consent, they were subjected to detailed history taking and thorough clinical examination. Specific oral lesions and general physical changes were recorded. Every patient was subjected to laboratory investigation for CD4 count. All these findings were tabulated. The clinical observation and laboratory findings were subjected to critical analysis and correlated. Statistical test, i.e. Student's " t" test, was applied and objective conclusions were drawn. RESULT: Out of 124 patients, 40 had oral candidiasis, 6 had oral hairy leukoplakia, 12 had periodontal disease, 20 had xerostomia, 30 had melanin pigmentation, while 4 had HSV2, and atypical ulceration. Out of 40 patients with oral candidiasis, 28 patients had CD4 count <200 (group A), 10 patients were in group, B (CD4 count 200-500 cell/mm 3 ) and 2 patients in group C(CD4 >500 cell/mm 3 ). Oral hairy leukoplakia occurred in equal proportions in group A and B. These periodontal diseases were more commonly in group B; xerostomia and melanin pigmentation was equally seen in group A and B. CONCLUSION: Oral candidiasis, oral hairy leukoplakia, linear gingival erythema, necrotizing ulcerative gingivitis, and necrotizing ulcerative periodontitis are specific oral indicators which will definitely suggest to the dental surgeon that the disease is running a rapid downhill course and due to this the oral physician is in a position to raise a suspicion and alert the general physician regarding the declining immune status of patient.

Ulcerativas Necrotizantes / Necrotizing Ulceratives

Las lesiones ulcerativas necrotizantes han sido documentadas a través de la historia. Su denominación, diagnóstico y tratamiento ha evolucionado con el paso de los años, hasta el presente, partiendo en Gingivitis Ulcerativa Necrotizante (GUN) caracterizada como una lesión de rápida evolución, de dolor paroxístico, confinada al margen gingival y papilar. La Periodontitis Ulcerativa Necrotizante (PUN), es ampliamente considerada como una evolución de GUN, involucrando al tejido óseo y a las estructuras de inserción, la falta de medidas terapéuticas ante estas entidades, generará la evolución a Estomatitis Ulcerativa Necrotizante (EUN), la cual involucra estructuras diferentes a los tejidos dentales y de soporte, como las mucosas circundantes. Dichas entidades exhiben signos patognomónicos comunes como sangrado, ulceración, necrosis papilar, supuración, dolor y mal olor, con predominio de microflora específica: fusobacterias y espiroquetas asociadasa factores predisponentes como stress, cigarrillo, desnutrición y alcohol. En la actualidad, la más fuerte asociación epidemiológica es con el Virus de inmunodeficiencia humana (VIH), en pacientes que presentan estados de inmunosupresión menores a 200.000 linfocitos T CD4, por tal motivolos portadores de cualquiera de estos tipos de lesión deben orientar al clínico la necesidad de confirmar el diagnóstico presuntivo de seropositividad. Los parámetros de tratamiento están encausados a la erradicación del agente etiológico, empleando medios mecánicos, como detartraje y alisado radicular apoyado en empleo de antimicrobianos locales y sistémicos, y el control de los factores de riesgo.

Necrotizing ulcerative lesions have been documented throughout history. Your name, diagnosis and treatment has evolved over the years, to date, starting in Necrotizing Ulcerative Gingivitis (NUG) characterized as a rapidly developing lesion, paroxysmal pain, confined to the gingival margin and papillary. Necrotizing Ulcerative Periodontitis (NUP) is widely regarded as an evolution of NUG, involving the bone and the insertion structures, lack of therapeutic measures against these entities generate evolution, Necrotizing Ulcerative Stomatitis (EUN), which involves different structures to the dental tissues and support, as the surrounding mucosa. Such entities exhibit common pathognomonic signs such as bleeding, ulceration, papillary necrosis, suppuration, pain and bad smell, with a predominance of specific microflora: Fusobacteria and spirochetes associated with predisposing factors such as stress, smoking, malnutrition and alcohol. Currently, the strongest epidemiological association is with the human immunodeficiency virus (HIV) in patients with immunosuppressive states below 200.000 CD4 T cells, as such carriers of either type of injury should guide the clinician to confirm the presumptive diagnosis of HIV infection. The treatment parameters are prosecuted to the eradication of the causative agent using mechanical means such as scaling and root planning supported employment for local and systemic antimicrobials, and control of risk factors.

Comportamiento de la gingivitis ulceronecrotizante aguda: departamento de estomatología de Conuco Viejo / Behavior of acute ultranecrotizing gingivitis at the stomatologic Department of Conuco Viejo

Se realizó un estudio observacional descriptivo prospectivo de corte transversal, con el objetivo de determinar el comportamiento de la gingivitis ulceronecrotizante aguda, en 37 pacientes entre 15 y 50 años de edad, quienes acudieron al servicio de estomatología de Conuco Viejo, municipio García, en el período comprendido de enero a diciembre de 2009. Se caracterizaron a los pacientes estudiados según variables sociodemográficas, y se identificó los factores de riesgo presentes, así como el nivel de conocimientos sobre salud bucodental. Se les realizó un examen clínico minucioso y se le aplicó una encuesta de conocimiento de salud bucal. Se encontró que los adolescentes de 15-20 años y adultos jóvenes de 21-26 años fueron los más afectados, con un 32,44 por ciento y 29,73 por ciento, respectivamente. El sexo femenino, con un 62,16 por ciento, el nivel educacional secundaria básica con 40,55 por ciento fueron los de mayor porcentaje. Dentro de lo factores de riesgo, los mayores por cientos correspondieron a la gingivitis crónica en los locales, con un 75,67 por ciento, mientras que el estrés en los generales, con 59,45 por ciento. Al aplicarse la encuesta de conocimientos un 54,05 por ciento de los pacientes estudiados fue evaluado de mal...(AU)

We carried out a transversal prospective descriptive observational study with the objective of determining the behavior of acute ultranecrotizing gingivitis, in 37 15 to 50 years-old patients, who visited the Stomatologic Service of Conuco Viejo, municipality of García, in the period from January to December 2009. The studied patients were characterized according to sociodemographic variables and the present risk facts were identified, and also the level of knowledge on buccal dental health. A thorough clinic examination was made and the patients applied an inquiry of knowledge on buccal health. We found that 15-20 years-old adolescents and 21-25 years-old young adults were the most affected patients, with 32,44per cent and 29,73 per cent respectively. The female genre, with 62,16 per cent, and the high school scholarship with 40,55 per cent showed the highest percentages. Among the local risk facts, the highest percents corresponded to chronic gingivitis, with 75,67 per cent, while stress represented the highest percent among general risk facts, with 59,45 per cent. As the result of the enquiry, the knowledge of 54,05 per cent of the studied patients were evaluated as unsatisfactory...(AU)

Comportamiento de la gingivitis ulceronecrotizante aguda: departamento de estomatología de Conuco Viejo / Behavior of acute ultranecrotizing gingivitis at the stomatologic Department of Conuco Viejo

Se realizó un estudio observacional descriptivo prospectivo de corte transversal, con el objetivo de determinar el comportamiento de la gingivitis ulceronecrotizante aguda, en 37 pacientes entre 15 y 50 años de edad, quienes acudieron al servicio de estomatología de Conuco Viejo, municipio García, en el período comprendido de enero a diciembre de 2009. Se caracterizaron a los pacientes estudiados según variables sociodemográficas, y se identificó los factores de riesgo presentes, así como el nivel de conocimientos sobre salud bucodental. Se les realizó un examen clínico minucioso y se le aplicó una encuesta de conocimiento de salud bucal. Se encontró que los adolescentes de 15-20 años y adultos jóvenes de 21-26 años fueron los más afectados, con un 32,44 por ciento y 29,73 por ciento, respectivamente. El sexo femenino, con un 62,16 por ciento, el nivel educacional secundaria básica con 40,55 por ciento fueron los de mayor porcentaje. Dentro de lo factores de riesgo, los mayores por cientos correspondieron a la gingivitis crónica en los locales, con un 75,67 por ciento, mientras que el estrés en los generales, con 59,45 por ciento. Al aplicarse la encuesta de conocimientos un 54,05 por ciento de los pacientes estudiados fue evaluado de mal.

We carried out a transversal prospective descriptive observational study with the objective of determining the behavior of acute ultranecrotizing gingivitis, in 37 15 to 50 years-old patients, who visited the Stomatologic Service of Conuco Viejo, municipality of García, in the period from January to December 2009. The studied patients were characterized according to sociodemographic variables and the present risk facts were identified, and also the level of knowledge on buccal dental health. A thorough clinic examination was made and the patients applied an inquiry of knowledge on buccal health. We found that 15-20 years-old adolescents and 21-25 years-old young adults were the most affected patients, with 32,44per cent and 29,73 per cent respectively. The female genre, with 62,16 per cent, and the high school scholarship with 40,55 per cent showed the highest percentages. Among the local risk facts, the highest percents corresponded to chronic gingivitis, with 75,67 per cent, while stress represented the highest percent among general risk facts, with 59,45 per cent. As the result of the enquiry, the knowledge of 54,05 per cent of the studied patients were evaluated as unsatisfactory.

Attenuation of radiation- and chemoradiation-induced mucositis using gamma-D-glutamyl-L-tryptophan (SCV-07).

OBJECTIVE: To evaluate the efficacy of a novel immunomodulating peptide (SCV-07) in attenuating the course of radiation-induced mucositis in an established animal model of oral mucositis (OM). MATERIAL AND METHODS: In three separate experiments, golden Syrian hamsters received either an acute radiation challenge to the buccal mucosa of eight fractionated doses of 7.5 Gy of radiation over a 2-week-period, or a combination of acute radiation and cisplatin. In each experiment, animals were treated with varying doses or schedules of SCV-07 or placebo. OM was scored in a blinded fashion using digital images obtained during the experimental period. RESULTS: We found that SCV-07 reduced the severity and duration of both acute and fractionated radiation-induced OM. Similarly, when radiation and chemotherapy were used to induce OM, treatment with SCV-07 significantly reduced the duration of ulcerative OM. The therapeutic benefit was dependent on both dose and schedule of administration. CONCLUSION: Taken together, we found SCV-07 was able to modify the duration and severity of oral mucositis and was dependent on schedule and dose.