Necrotizing gingivitis

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Necrotizing gingivitis
Other namesNG, Trench mouth
Ulcerative necrotizing gingivitis.jpg
A fairly mild presentation of necrotizing gingivitis at the typical site on the gums of the anterior mandibular teeth.
Specialty Periodontology
Symptoms pain, bad breath, fever, bleeding gums
Complications Progression
Causes bacterial infection by Prevotella intermedia, Treponema, Selenomonas, Fusobacterium spp, Spirochetes and compromised host immune response
Risk factors HIV/AIDS, malnutrition, psychological stress, sleep deprivation, inadequate oral hygiene, pre-existing gingivitis, history of necrotizing periodontal disease, tobacco and alcohol use, youth, white ethnicity, orthodontics
Diagnostic method Based on clinical findings (necrosis, ulcer of interdental papilla; gingival bleeding, pain, pseudomembrane formation, halitosis)
Differential diagnosis herpetic gingivostomatitis, mucous membrane pemphigoid, pemphigus vulgaris, toothbrush abrasion
Prevention oral hygiene
Treatment debridement (dental), metronidazole

Necrotizing gingivitis (NG) is a common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of inter-dental papillae (the sections of gum between adjacent teeth). This disease, along with necrotizing periodontitis (NP) and necrotizing stomatitis, is classified as a necrotizing periodontal disease, one of the three general types of gum disease caused by inflammation of the gums (periodontitis). [1]

Contents

The often severe gum pain that characterizes NG distinguishes it from the more common gingivitis or chronic periodontitis which is rarely painful. If NG is improperly treated or neglected, it may become chronic and/or recurrent. The causative organisms are mostly anaerobic bacteria, particularly Fusobacteriota and spirochete species.

Predisposing factors include poor oral hygiene, smoking, poor nutrition, psychological stress, and a weakened immune system. When the attachments of the teeth to the bone are involved, the term NP is used. Treatment of NG is by removal of dead gum tissue and antibiotics (usually metronidazole) in the acute phase, and improving oral hygiene to prevent recurrence. Although the condition has a rapid onset and is debilitating, it usually resolves quickly and does no serious harm. The informal name trench mouth arose during World War I as many soldiers developed the disease, probably because of the poor conditions and extreme psychological stress.

Signs and symptoms

In the early stages some affected people may complain of a feeling of tightness around the teeth. [2] Three signs/symptoms must be present to diagnose this condition: [2]

Other signs and symptoms may be present, but not always. [2]

Malaise, fever and/or cervical lymph node enlargement are rare (unlike the typical features of herpetic stomatitis). [3] Pain is fairly well localized to the affected areas. [3] Systemic reactions may be more pronounced in children. [2] Cancrum oris (noma) is a very rare complication, usually in debilitated children. [3] Similar features but with more intense pain may be seen in necrotizing periodontitis in HIV/AIDS. [3]

Causes

Necrotizing periodontal diseases are caused by a mixed bacterial infection that includes anaerobes such as P. intermedia [1] and Fusobacterium as well as spirochetes, such as Treponema . [3]

Necrotizing gingivitis may also be associated with diseases in which the immune system is compromised, including HIV/AIDS. [1] Necrotizing gingivitis is an opportunistic infection that occurs on a background of impaired local or systemic host defenses. The predisposing factors for necrotizing gingivitis are smoking, psychological stress, malnutrition, and immunosuppression.

The following zones of infection have been described (superficial to deep): the bacterial zone, the neutrophil rich zone, the necrotic zone and the spirochetal zone.

Diagnosis

Diagnosis is usually clinical. [3] Smear for fusospirochaetal bacteria and leukocytes; blood picture occasionally. [3] The important differentiation is with acute leukemia or herpetic stomatitis. [3]

Classification

Necrotizing gingivitis is part of a spectrum of disease termed necrotizing periodontal diseases. It is the most minor form of this spectrum, with more advanced stages being termed necrotizing periodontitis, necrotizing stomatitis, and the most extreme, cancrum oris. [2]

Necrotizing periodontitis (NP) is where the infection leads to attachment loss, and involves only the gingiva, periodontal ligament and alveolar ligament. [2] [1] Progression of the disease into tissue beyond the mucogingival junction characterizes necrotizing stomatitis.

Treatment

Treatment includes irrigation and debridement of necrotic areas (areas of dead and/or dying gum tissue), oral hygiene instruction and the uses of mouth rinses and pain medication. If there is systemic involvement, then oral antibiotics may be given, such as metronidazole. [3] As these diseases are often associated with systemic medical issues, proper management of the systemic disorders is appropriate. [1]

Prognosis

Untreated, the infection may lead to rapid destruction of the periodontium and can spread, as necrotizing stomatitis or noma, into neighbouring tissues in the cheeks, lips or the bones of the jaw. As stated, the condition can occur and be especially dangerous in people with weakened immune systems. This progression to noma is possible in malnourished susceptible individuals, with severe disfigurement possible.

Epidemiology

In developed countries, this disease occurs mostly in young adults. In developing countries, NUG may occur in children of low socioeconomic status, usually occurring with malnutrition (especially inadequate protein intake) and shortly after the onset of viral infections (e.g. measles). [2]

Predisposing factors include smoking, viral respiratory infections and immune defects, such as in HIV/AIDS. Uncommon, except in lower socioeconomic classes, this typically affects adolescents and young adults, especially in institutions, armed forces, etc., or people with HIV/AIDS. [3] The disease has occurred in epidemic-like patterns, but it is not contagious. [2]

History

Necrotizing gingivitis has been observed for centuries. Xenophon observes sore mouth and foul smelling breath in Greek soldiers in the 4th century BC. Hunter describes the clinical features of necrotizing gingivitis in 1778, differentiating it from scurvy (avitaminosis C) and chronic periodontitis. Jean Hyacinthe Vincent, a French physician working at the Paris Pasteur Institute describes a fusospirochetal infection of the pharynx and palatine tonsils, causing "ulcero-membranous pharyngitis and tonsillitis", [4] which later became known as Vincent's angina. Later in 1904, Vincent describes the same pathogenic organisms in "ulceronecrotic gingivitis". Vincent's angina is sometimes confused with NUG, however the former is tonsillitis and pharyngitis, and the latter involves the gums, and usually the two conditions occur in isolation from each other.

The term trench mouth evolved because the disease was observed in front line soldiers during World War I, thought to be a result at least partly because of extreme psychologic stress they were exposed to. [2] The same condition was appearing in civilians during periods of bombing raids, who were away from the front line, and who had relatively good diets during wartime due to rationing, so it is assumed that psychologic stress was the significant causative factor. It has also been associated with high tobacco use in the army.

Many other historical names for this condition (and Vincent's angina) have occurred, including: "acute membranous gingivitis", "fusospirillary gingivitis", " fusospirillosis", "fusospirochetal gingivitis", "phagedenic gingivitis", "Vincent stomatitis", "Vincent gingivitis", and "Vincent infection". [5]

In the late 1980s-early 1990s, it was originally thought that some necrotizing periodontal diseases seen in severely affected AIDS patients were strictly a sequela of HIV, and it was even called HIV-associated periodontitis. [6] It is now understood that its association with HIV/AIDS was due to the immunocompromised status of such patients; it also occurs with higher prevalence in association with other diseases in which the immune system is compromised. [1]

The 1999 American Academy of Periodontology Classification termed the condition "necrotizing ulcerative periodontitis". The "ulcerative" descriptor was removed from the name, because ulceration is considered to be secondary to the necrosis. [1]

See also

Related Research Articles

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Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cause of tooth loss for adults worldwide. In its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. Halitosis may also occur.

<span class="mw-page-title-main">Toothache</span> Medical condition of the teeth

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<span class="mw-page-title-main">Aphthous stomatitis</span> Common condition of mouth ulcers

Aphthous stomatitis, or recurrent aphthous stomatitis (RAS), is a common condition characterized by the repeated formation of benign and non-contagious mouth ulcers (aphthae) in otherwise healthy individuals. The informal term canker sore is also used, mainly in North America, although it may also refer to other types of mouth ulcers. The cause is not completely understood but involves a T cell-mediated immune response triggered by a variety of factors which may include nutritional deficiencies, local trauma, stress, hormonal influences, allergies, genetic predisposition, certain foods, dehydration, some food additives, or some hygienic chemical additives like SDS.

<span class="mw-page-title-main">Stomatitis</span> Medical condition

Stomatitis is inflammation of the mouth and lips. It refers to any inflammatory process affecting the mucous membranes of the mouth and lips, with or without oral ulceration.

Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

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<span class="mw-page-title-main">Noma (disease)</span> Medical condition

Noma is a rapidly progressive and often fatal gangrenous infection of the mouth and face. Noma usually begins as an ulcer on gums and rapidly spreads into the jawbone, cheek, and soft tissues of the face. This is followed by death of the facial tissues and fatal sepsis. Survivors are left with severe facial disfigurement and impairments in breathing, swallowing, speaking and vision. In 2023 noma was added to the World Health Organization's list of neglected tropical diseases.

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Desquamative gingivitis is an erythematous (red), desquamatous (shedding) and ulcerated appearance of the gums. It is a descriptive term and can be caused by several different disorders.

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<span class="mw-page-title-main">Scaling and root planing</span> Dental procedure

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<span class="mw-page-title-main">Periodontal abscess</span> Medical condition

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<span class="mw-page-title-main">Necrotizing periodontal diseases</span> Bacterial infection of the oral mucosa and periodontium

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References

  1. 1 2 3 4 5 6 7 Herrera, D., Retamal-Valdes, B., Alonso, B., Feres, M. (June 2018). "Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo-periodontal lesions: Dd56II Joint EFP-AAP Workshop". Journal of Periodontology. 89: S85–S102. doi: 10.1002/JPER.16-0642 . ISSN   0022-3492 . Retrieved 10 July 2023.
  2. 1 2 3 4 5 6 7 8 9 10 11 Lindhe, Jan; Lang, Niklaus P.; Karring, Thorkild, eds. (2008). Clinical periodontology and implant dentistry (5th ed.). Oxford: Blackwell Munksgaard. pp.  413, 459. ISBN   9781405160995.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 Scully, Crispian (2008). Oral and maxillofacial medicine : the basis of diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone. pp. 101, 347. ISBN   9780443068188.
  4. Taylor, FE; McKinstry, WH (1917). "The Relation of Peri-dental Gingivitis to Vincent's Angina". Proceedings of the Royal Society of Medicine. 10 (Laryngol Sect): 43–8. PMC   2017821 . PMID   19979715.
  5. "Definition of Vincent angina". Medterms.com. 2001-09-13. Archived from the original on 2011-06-05. Retrieved 2010-02-13.
  6. NYS Department of Health AIDS Institute. "Clinical Manifestations and Management of HIV-Related Periodontal Disease". Oral Health Care for People with HIV Infection: HIV Clinical Guidelines. p. 31.