1. Good Morning
Good Morning

2. NECROTIZING ULCERATIVE PERIODONTITIS

3. 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

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

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

6. Clinical Features
Systemic features –
Fever
Malaise
Lymphadenopathy

7. 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

8. Radiographic Features
Bone loss
Deep interdental osseous craters

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

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

11. 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

12. 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.

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

14. 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.

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

16. 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.

17. 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

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

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

20. Reduction of nutrients to cells and tissues Immunosuppression disease susceptibility

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

22. 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

23. 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

24. 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.

25. Thank You