Necrotising periodontal disease

What is necrotising periodontal disease?

Necrotising periodontal disease is the term used to describe a group of relatively rare infections affecting the mouth in which ulceration with necrosis is the common feature. Necrosis is the term used to describe death of tissue.

There are three major forms:

1. Necrotising (ulcerative) gingivitis – affects only the gums
2. Necrotising (ulcerative) periodontitis – involves loss of the specialised tissue that surrounds and attaches the teeth
3. Necrotising stomatitis – in which more extensive mucosal and bone loss occurs beyond the gums and tissue surrounding and supporting the teeth. Stomatitis means a sore mouth.

There are many other names given to these conditions including necrotising gingivostomatitis, cancrum oris, noma, trench mouth, Vincent gingivostomatitis, acute membranous gingivitis, Bergeron disease, fusospirally infection/gingivitis, phagedenic gingivitis, acute septic gingivitis.

Who gets necrotising periodontal disease and why?

Necrotising periodontal disease is triggered by the accumulation of dental plaque associated with poor oral hygiene.

However host factors are also important in allowing these necrotising conditions to develop from the dental plaque. Well recognised host factors known to predispose to necrotising periodontal disease include:

• Immunodeficiency – HIV infection, leukaemia, neutropenia/agranulocytosis, diabetes mellitus, immunosuppressant medications
• Malnutrition
• Psychological and physical stress
• Smoking – is frequently present, in combination with one of the other factors
• A genetic predisposition may also be required.

Necrotising periodontal disease is common in the HIV-positive population (in whom it may be the presentation indicating infection) and in early childhood in developing countries (due to malnutrition), but is believed to be rare outside of these groups.

Necrotising gingivitis is usually the first stage. It may progress to necrotising periodontitis or necrotising stomatitis particularly in the immunosuppressed patient.

Necrotising periodontal disease involves a mixture of many different microorganisms, most of which are found in the normal oral cavity:

• bacteria – especially spirochaetes and fusiform bacilli
• viruses – including cytomegalovirus and herpes viruses
• fungi/yeasts – such as candida species

These invade the oral mucosa, initially into the gums and then into the tissues supporting the teeth and/or elsewhere in the oral mucosa.

Clinical features of necrotising periodontal disease

1. Necrotising gingivitis

Necrotising gingivitis is defined as an infection of the gums in which the tips of the gums seen between the teeth (gingival papillae) are lost with associated bleeding and pain.

The major consistent symptoms noted by the sufferer are:

• Pain – is constant, ranging from mild to moderate in severity, worse with pressure such as when chewing
• Bleeding – can occur spontaneously or with cleaning of the teeth or chewing

Less commonly, the following may be noted:

• Low grade fever
• Halitosis (bad breath)

Patients who have had a previous episode, may report prodromal symptoms such as burning gums before a sudden onset of the typical gingivitis.

Features seen on examination:

• Ulceration and necrosis of the gum margin between the teeth, initially with loss of the tip of gum usually seen between two teeth. It is mainly the gum margin that is affected resulting in loss of gum architecture.
• White pseudomembrane may be seen over the necrotic area(s). Attempted removal leads to bleeding.
• Enlarged tender or painful lymph glands, usually under the chin and lower jaw, particularly with severe necrotising gingivitis in children.
• HIV-positive patients commonly also have other conditions of the mouth associated with HIV such as oral hairy leukoplakia, oral candidiasis or oral Kaposi sarcoma.

An episode of necrotising gingivitis may result in:

• Spontaneous healing with no residual sign of infection
• Persistent ulcers or craters that may quickly flare into another episode of necrotising gingivitis
• Progress to necrotising periodontitis with possible involvement of bone and loosening then loss of teeth
• Progress to necrotising stomatitis, involving widespread areas of the oral mucosa and bone

2. Necrotising periodontitis

Infection involves the specialised attachment tissues surrounding one or more teeth and the resulting inflammation is more destructive and deeper than in necrotising gingivitis. The affected tooth becomes loose. Bone is exposed and sometimes destroyed with possible loss of the involved tooth. Loss of tooth attachment and bone can be rapid, taking only months rather than the more usual years.

Symptoms and signs include:

• Severe deep pain – main symptom
• Spontaneous bleeding – usual
• Halitosis (bad breath) – usual
• Multiple sites of gum necrosis - usual
• Loss of alveolar bone – usual
• Pseudomembrane formation – very common
• Lymph gland enlargement – common
• Low grade fever – common

3. Necrotising stomatitis

The infection and inflammation spreads along the surface to involve the oral mucosa beyond the gums. It can also invade deeply, affecting many teeth. Because the surface mucosa is lost, the underlying bone can be exposed with subsequent bone loss. This can result in mouth deformity and be life-threatening if untreated.

How is necrotising periodontal disease diagnosed?

Necrotising periodontal disease is a clinical diagnosis. A microbiological swab will show mixed microorganisms. Biopsy is generally unhelpful as it shows nonspecific inflammation. Special stains will demonstrate the mixed infection. X-rays may be required looking for bone involvement in necrotising periodontitis and necrotising stomatitis.

It is very important to take blood tests for predisposing illnesses such as leukaemia, neutropenia/agranulocytosis or HIV infection. In most HIV-positive patients with necrotising periodontal disease, the CD4+ T cell count is less than 200 cells/mm3, thus this oral disease can be a marker of HIV status and disease deterioration. However, most HIV-positive patients with CD4 counts of this level do not develop necrotising periodontal disease.

Treatment of necrotising periodontal disease

Treatment of necrotising gingivitis can be successful if treated early and if there is no predisposing systemic illness.

1. Acute phase emergency treatment may include:

• pain relief – paracetamol or nonsteroidal anti-inflammatory drugs
• debridement of necrotic gum tissue
• antiseptic mouth rinses – chlorhexidine or hypertonic saline
• thorough regular dental cleaning and flossing
• oral antibiotics if severe or signs of systemic infection
  • amoxycillin/clavulenic acid, metronidazole or clindamycin
• anti-fungal agents – for immunosuppressed patients treated with antibiotics

2. Treat any predisposing illness or trigger. Very important to stop smoking.

3. Surgical correction of any remaining defects such as craters:

• gingivectomy
• gingivoplasty

4. maintain good dental hygiene and good health to reduce the risk of recurrence

However, where there is a predisposing condition such as AIDS, recurrence or relapse is common.