Good Morning Good Morning

NECROTIZING ULCERATIVE PERIODONTITIS

Introduction Necrotizing Ulcerative Periodontitis (NUP) is an extension of ANUG into periodontal structures. Leads to attachment & bone loss. It is suggested that ANUG is a precursor to NUP

Incidence of NUP Most cases are described in immunocompromised patients, especially those who are HIV +ve or have AIDS

Difference between ANUG and NUP Distinguished by the presence or absence of attachment and bone loss

Clinical Features Systemic features – Fever Malaise Lymphadenopathy

Clinical Features Intra Oral Features – Halitosis Necrosis & ulceration of coronal portion of interdental papillae &/or gingival margin Painful bright red marginal gingiva Bleeding Periodontal attachment loss Gingival recession Mobility of teeth

Radiographic Features Bone loss Deep interdental osseous craters

Complications of NUP Gangrenous (Necrotic) Stomatitis – Extensive necrosis extending to adjacent mucosa (cheek, tongue, floor of mouth, lip, palate)

Noma (Cancrum Oris) – Serious form of necrotic stomatitis that lead to exposure of bone and perforation of cheek and nasal cavity

Types of NUP Two types of NUP have been described according to their relationship with AIDS – - Non AIDS Type Necrotizing Ulcerative Periodontitis - AIDS Associated Necrotizing Ulcerative Periodontitis

Non - AIDS Type Necrotizing Ulcerative Periodontitis Clinical Features: Occurs after repeated long term episodes of NUG. Inflammatory infiltrate in lesions of NUG can extend into underlying bone resulting in deep crater like lesions especially in interdental areas. NUP is characterized by deep interdental craters. Deep conventional pockets are not found because the ulcerative & necrotizing character of ANUG destroys epithelium resulting in recession.

AIDS Associated Necrotizing Ulcerative Periodontitis HIV associated periodontal diseases include – - Linear gingival erythema - NUG - NUP Necrotizing forms appear in severe or advanced immunosuppressed patients

AIDS Associated Necrotizing Ulcerative Periodontitis Gingival & Periodontal lesions in HIV+ve patients appear to be similar to those seen in NUP in HIV-ve patients but are present with severe complications like Large areas of soft tissue necrosis Exposure of bone & sequestration of bone fragments which ,may extend to vestibular area &/or palate Necrotizing stomatitis Progression of bone loss in HIV+ve NUP may be extremely rapid, a case of 10mm bone loss in 3 months has been reported.

Etiology of NUP Bacterial Role Immunocompromised Status Psychological Stress Malnutrition Other Factors

Bacterial Role: Cases of NUP in AIDS patients show increased numbers of Candida albicans, A.a, Prevotella intermedia, Porphyromonas gingivalis, Fusobacterium nucleatum, Campylobacter. Low or variable level of spirochetes.

Immunocompromised Status: Both ANUG and NUP are more prevalent in patients with compromised or suppressed immune system Most common is HIV+ve and AIDS patients

Suppressed immune system Psychological Stress: Stress Systemic cortisol Suppressed immune system NUP

Malnutrition: Many of the host defences like – - Phagocytosis - Cell – mediated immunity - Complement system - Antibody production Are impaired in Malnourished individuals

Reduction of nutrients to cells and tissues Immunosuppression disease susceptibility

Smoking and local factors (plaque and calculus) Other Factors: Smoking and local factors (plaque and calculus)

Treatment of NUP Should be treated in consultation with physician Often have underlying predisposing systemic factor like AIDS These patients must be treated aggressively including a medical evaluation, local, topical & systemic antimicrobials

Oral hygiene in these patients is complicated by painful tissues. Irrigation with hydrogen peroxide & chlorhexidine is useful. Therapy for NUP pts. includes - - Scaling & root planing - Irrigation with chlorhexidine - oral hygiene - Antimirobials

Antibiotic therapy in HIV infected pts Antibiotic therapy in HIV infected pts. must be used with caution to avoid opportunistic & serious localized candidiasis or even candidal septicemia. Drug of choice is Metronidazole. Prophylactic topical or systemic antifungal agent is indicated if antibiotic is used.

Thank You