Periodontology 2000, Vol. 65, 2014, 149-177 © 2014 John Wiley & Sons A / S.
© 2014 John Wiley & Sons A / S. Published by John Wiley & Sons Ltd.
Printed in Singapore. All rights reserved
Acute periodontal lesiones
D AVID H Errera, B Ettin A Lons, L ORENZO DE A Llegan,
Y Sabel S ANTA C RUZ, C RISTINA S Errani & M Arian S ANZ
Acute lesiones in the periodontium, such as abscesses and necrotizing
periodontal diseases, are among the few clinical situations in
periodóntico where patients may seek urgente care, Mostly because of
the associated pain. In addition, and in contraste tono mosto other
periodontal conditions, rápido destruction of periodontal tissues may
occurre during the course of these lesiones, thus stressing the
importance of prompt diagnosis and treatment. In spite of this, the
available Scientia fin c knowledge donde these conditions is limited and is
based on somewhat Outdated literature. This lack of contemporary
fecha makes it rather Challenging to devise evidence-based therapeutic
guidelines. Hence, an update is imperative, although it must be cono fin ned
to an evaluation of narrative reviews and experto opiniones.
Other gingival and periodontal lesionsmay also show an acute
presentation, including different Infectious processes not related to oral
bacterial bio fin lms, mucocutaneous disorders, oro traumático and
Allergic lesiones.
This artículo provides an overview and updates of existing
information on acute conditions affecting the periodontal tissues,
including abscesses in the periodontium, necrotizing periodontal
diseases and other acute conditions.
Abscesses in the periodontium
de fin nition of periodontal absceso
Abscesses in the periodontium are odontogénicos infecciones that may
be caused by pulp necrosis, periodontal infecciones, Pericoronaritis,
trauma oro surgery (109). Odontogénicos oro dental abscesses are cla fin
ed, according to the source of infección, into periapical (dentoalveolar)
absceso, periodontal absceso and pericoronal absceso (327).
A periodontal absceso has been de fin ned as a localized purulento
infección in the periodontal tissues
PERIODONTOLOGY 2000
(210). A more comprehensive de fin nition has also been proposed: ' a
lesión with an Expressed periodontal breakdown occurring during a
limited period of time, and with easily detectable clinical symptoms,
including a localized accumulation of pus located within the gingival wall
of the periodontal pocket '( 130) (Fig. 1).
clasi fin cation of periodontal abscesses
Different criteria have been used to Classify periodontal abscesses.
Location
Abscesses can be clasif fin ed as gingival oro periodontal abscesses
(110). A gingival absceso is a localized Painful swelling that affects only
the marginal and interdental gingivoestomatitis and is normally
associated with subgingivally impacted foreign objects. These conditions
may occurre in a Previously healthy gingivoestomatitis (7). A periodontal
absceso is a localized Painful swelling that affects deeper periodontal
structures, including deep pockets, furcations and vertical osseous
defects, and is usually situado beyond the mucogingival line.
Histologically, both lesiones are Identical, but a gingival absceso affects
only the marginal soft tissues of Previously healthy sites, whilst a
periodontal absceso occurre in a periodontal pocket associated with a
periodontitis lesión (76).
Course of the lesión
The course of the lesión can be acute and chronic. An acute periodontal
absceso usually manifiestos symptoms such as pain, tenderness,
sensitivity to palpation and suppuration upon gentle pressure. A chronic
absceso is normally associated with a seno tract and it is usually
asymptomatic, although the patient can experience mild symptoms
(250). A localized acute absceso may become a chronic absceso when
drainage is established through a seno oro through the
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Herrera et al.

Fig. 1. A periodontal absceso, manifesting as a localized purulento lesión within

Fig. 2. Pericoronal absceso associated with the right mandibular third molar.
the gingival wall of the periodontal pocket.

disease-free area '. A periodontal absceso (which can be acute oro

sulcus. Similarly, a chronic absceso may have an acute exacerbación.
chronic) is de fin ned as ' a localized accumulation of pus within the
gingival wall of a periodontal pocket resulting in the destruction of the
Number of abscesses colágeno fin bre attachment and the loss of nearby alveolar bone '. A
pericoronal absceso is ' a localized accumulation of pus within the
The number of periodontal abscesses (single and multiple) has also
overlying gingival fl ap arredores the crown of an incompletely erupted
been used for cla fin cation Purposes (321). A single periodontal absceso
tooth '( Fig. 2).
is usually associated with local factores, which Contribute to the closure
of the drainage of a periodontal pocket. Multiple periodontal abscesses
have been reported in uncontrolled diabetes mellitus, in medically
compromised patients and in patients with untreated periodontitis after
Systemic antibiótico therapy for nonoral reasons (125, 126, 321). Clinical firme fin cancelación of periodontal absceso
Multiple abscesses have also been described in a patient with multiple
external root resorptions (339).
A common periodontal emergency

Periodontal abscesses represented ca. 14% of all dental emergencias in

Tipo de etiological factores
A periodontal absceso is usually associated with a Previously existing
periodontal pocket, although it can also develop in the absence of a
pocket (130). Thus, different types of abscesses may be Considered, as
related to their etiological factores; this cla fin cation will be described in
the section donde etiology.
International Workshop for a Clasi fin cation of Periodontal
Diseases and Conditions
According to the International Workshop for a clasificar
fin cation of Periodontal Diseases and Conditions ( year
1999), abscesses in the periodontium include gingival, periodontal,
pericoronal and periapical abscesses (210). A gingival absceso is de fin ned
as ' a localized, Painful, rapidly expanding lesión involving the marginal
gingivoestomatitis oro interdental papilla sometimes in a Previously
a study in the USA (7). In general practices in the UK, 6 - 7 & of the
patients treated in 1 month suffered from a periodontal absceso, which
was the third mosto prevalente infección that demanded emergency
treatment, after dentoalveolar abscesses (14 - 25 &) and Pericoronaritis
(10 - 11 &) (177). In an army dental clinic, 3.7% of the patients had
periodontitis and, among these, 27.5% had a periodontal absceso, with
clear differences between patients undergoing active periodontal
treatment (13.5%) and untreated patients (59.7%) (117). Among patients
in supportive periodontal therapy, a periodontal absceso was detected in
37% of the patients and in 3.7% of the teeth followed for 5 - 29 years
(mean 12.5 years) (209); in the Nebraska prospective longitudinal study,
53% of the patients followed for 7 years had a periodontal absceso, and
85% of these abscesses were associated with teeth treated only with
coronal scaling. Sixteen out of 27 absceso sites had initial Probing
pocket Depths deeper than 6 mm, and in eight sites Probing

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 acute lesiones

pocket Depths were 5 - 6 mm (156). Abscesses occurre more often in (245), oro en Sickle-cell crisis in a patient with Sickle-cell anemia (255).
molar sites, representing more than 50% of all sites Affected by absceso
formation (128,
209, 300), probably because of the presence of furcation, and complejo
Etiology, pathogenesis and histopathology of
anatomy and root morphology. However, one case series suggested
periodontal absceso
that the mandibular anterior incisor were the most frequently Affected
teeth (149). Periodontal abscesses may develop in periodontitisaffected sites (with a
pre-existing periodontal pocket) oro in healthy sites (without a
pre-existing pocket).
Tooth loss

Periodontal abscesses may lead to tooth loss, especially if they affect
teeth with pre-existing moderate to severe attachment loss, as occurre
during supportive periodontal therapy in patients with severe chronic
periodontitis. In fact, periodontal absceso has been Considered as the
main cause for tooth extracción during supportive periodontal therapy
(55, 209, 294, 300). Similarly, teeth with repeated absceso formation
were Considered to have a Hopeless prognosis (36), and 45% of teeth
with a periodontal absceso during supportive periodontal therapy were
extracted (209). The main reason for tooth extracción in teeth with a
cuestionable prognosis, followed for 8.8 years, was a periodontal
absceso (55). Taking these reports into account,
In periodontitis, a periodontal absceso may represento a period of
disease exacerbación that is favored by the existence of tortuous
pockets, the presence of furcation involvement (Fig. 3) oro en vertical
defect, in which marginal closure of the pocket may lead to spread of the
infección into the arredores periodontal tissues (76, 158, 224). Also,
changes in the composition of the subgingival microbiota, with an
increase in bacterial virulence, oro a decrease in the host defence, could
result in a diminished capacity to drain the increased suppuration.
Among periodontal abscesses in periodontitis patients, different
subgroups can be distinguished:

after nonsurgical periodontal therapy. After scaling oro profesional

prophylaxis, dislodged calculus fragmentos can be pushed into the
tissues (74), oro inadequate scaling may allow calculus to remain in
deep pockets, whilst the coronal parte will occlude the normal
drainage (156). after surgical periodontal therapy - associated with
the presence of foreign bodies, such as membranas for
regeneration oro suturas (106). acute exacerbación of an untreated
Association with Systemic Dissemination of a localized
periodontitis (74) (Fig. 4).
infección

Numerous case reports have described the occurrence of Systemic

infecciones from a suspected source in a periodontal absceso, either
through Dissemination during therapy oro related to an untreated acute exacerbación in refractory periodontitis (97). acute
absceso. During the treatment of an absceso, the concomitante exacerbación in supportive periodontal therapy, as described
bacteremia may lead to Colonization of pathogenic microorganismos in Previously (55, 209, 294).
other body sites and to the development of different infecciones, such as
Pulmonary actinomycosis (315), a brain absceso containing Prevotella
melaninogenica and other

Prevotella spp. (103), oro en total knee arthroplasty infección (330). It

has been suggested that the risk of bacteremia during absceso drainage
may be reduced if a needle aspirate of the absceso contentos is
obtained before the procedure (99, 265).

There are also case reports of bacteremia originating from untreated

abscesses, such as celulitis in breast-cancer patients (198), a cervical
necrotizing fascitis (57), a necrotizing cavernositis containing
Fig. 3. Periodontal absceso with the presence of furcation involvement.
Peptostreptococcus spp. and Fusobacterium spp.

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Herrera et al.
? Systemic antimicrobial intake without subgingival debridement. In
patients with severe periodontitis this may also cause abscesos
formation (125, 126,
321), probably related to an overgrowth of opportunistic bacteria
(125).
Periodontal abscesses también puede occurre in Previously healthy
sites (ie nonperiodontitis periodontal abscesses) Owings to impaction of
foreign bodies oro to alteration of the root surfaces:
different foreign bodies have been described to be associated with
the development of a periodontal absceso, for example: an
Orthodontic elástico (250); a piece of dental fl oss (5); a dislodged
cemental tear (124); a piece of a toothpick (100); oro pieces of nails
in subjects with nail-Biting habits (304). The term ' oral hygiene
abscesses ' has been proposed for abscesses caused by the
impaction of foreign bodies that are oral hygiene aids (110). the root
surface may be Altered by different factores: perforation by an
endodóntico instrumento (4); cervical cemental tears (124, 146);
external root resorption (339); an invaginated tooth (60); oro a
cracked tooth (116).
In the development of a periodontal absceso, the fin rst step may be the
invasion of bacteria into the soft tissues arredores the periodontal
pocket, which will develop an in fl ammatory process through the
chemotactic factores released by bacteria that Attractant in fl ammatory
cells and lead to the destruction of the Connective tissues, the
encapsulation of the bacterial infección and the production of pus. Once
the absceso is formed, the rate of destruction within the absceso will
depende on the growth of bacteria inside the foco, their virulence and
the local pH (año acídico environment will favor the activity of lysosomal
enzymes) (76).
The histopathology of periodontal absceso lesiones was described
following evaluation of biopsias
Fig. 4. Periodontal absceso in untreated periodontitis.
152
Retrieved from 12 abscesses (76), Observing the following areas from
the outside to the inside of the lesión:
a normal oral epithelium and lamina propria. an acute in fl ammatory
in fin ltrate. an intense focos of in fl ammation, with neutrophils and
lymphocytes presente in an area of ​destroyed and necrótico
Connective tissue. a destroyed and ulcerated pocket epithelium. In
seven biopsias analyzed using electron microscopy, gram-negative
bacteria were found to invade the pocket epithelium, and the Affected
Connective tissue formed a mass of granular, acidophilic and
amorphous debris.
Microbiological fin Ndinga
Purulento oral infecciones are usually polymicrobial and are caused by
commensal bacteria (317). In microbiological reports on periodontal
abscesses, gramnegative bacteria predominated over gram-positive
bacteria, and rods predominated over cocci (224), with large proportion
of strict anaerobia (128, 224,
321).
The most prevaleciendo bacterial species identi fin ed in periodontal
abscesses, using culture-based oro molecular-based diagnóstico
techniques, is Porphyromonas gingivalis, with a range in prevalence of
50 - 100% (82, 123, 128, 149, 224, 321, 327) (Fig. 5). Other strict
anaerobias frequently detected include Prevotella intermedia, Prevotella
melaninogenica, Fusobacterium nucleatum, Tannerella Forsyth,
Treponema spp.
Parvimonas micra, Actinomyces spp. and bi fin dobacterium spp. Among
the facultative anaeróbico gram-negative bacteria, Campylobacter spp., Capnocytophaga
spp. and Aggregatibacter actinomycetemcomitans
have been reported (123), as well as gram-negative entérico rods (149).
Fig. 5. Microbiological sampling in a periodontal absceso.

In summary, previous studies have shown that the microbiota of
periodontal abscesses is not different from the microbiota of chronic
periodontitis lesiones. Está polymicrobial and Dominated by nonmotile,
gram-negative, Strictly anaeróbico, rod-shaped species. Among these
bacteria, P. gingivalis is probably the most virulento and relevant
microorganismos. Although it is not Clearly mentioned, these studies
described the microbiology of abscesses in patients with periodontitis.
Conversely,
there is limited
information on the microbiota of other types of abscesses, except for
those associated with Systemic antibiótico intake for nonoral reasons in
patients with periodontitis (125, 126, 321): por estos abscesses, similarly
to other abscesses in periodontitis, periodontal Pathogens were
presente, although opportunistic bacteria were also detected,
especially
Staphylococcus aureus, leading the authors to suggest that this type of
absceso could be Considered as a superinfection.
Diagnosis of a periodontal absceso
The diagnosis of a periodontal absceso should be based on the overall
evaluation and interpretation of the patient ' s symptomatology, together
with the clinical and Radiological signs found during the oral examination
(67).
A series of symptoms (ranging from light disconfort to severe pain,
tenderness of the gingivoestomatitis, swelling, tooth mobility, tooth
elevation and sensitivity of the tooth to palpation) has been described to
be associated with an absceso (7, 128, 145).
The most prominente sign during the oral examination is the
presence of an ovoides elevation in the gingivoestomatitis along the
lateral part of the root, although abscesses situado deep in the
periodontium may be more dif fin cult to identify and may be found as a
Diffuse swelling oro simply as a red area. Another common fin Ndinga is
suppuration, either through a
fin Stüler oro, mosto commonly, through the pocket opening (Fig. 6),
which may be spontaneous oro occurre after applying pressure on the
lesión. The absceso is usually found at a site with a deep periodontal
pocket, and signs of periodontitis, including bleeding donde Probing oro
increased tooth mobility (123, 128, 300).
The radiographic examination may reveal a normal appearance, oro
some degree of bone loss (as mosto abscesses will occurre in a
pre-existing periodontal pocket).
Periodontal abscesses may be associated with elevated body
temperature, malaise and regional lymph-
acute lesiones
Fig. 6. Periodontal absceso demonstrating suppuration through the periodontal
pocket.
adenopathy (128, 145, 300), and 30% of the patients may have elevated
numbers of blood leukocytes (128).
The anamnesis may also provide relevante information, especially in
abscesses associated with previous treatment - either dental oro
periodontal treatments oro nonoral therapies, such as Systemic
antimicrobiales. Moreover, in abscesses related to impaction of foreign
bodies, the interview with the patient may be of great help.
Differential diagnosis is critical because periodontal abscesses may
be similar to other oral conditions:
other abscesses in the mouth: periapical oro dentoalveolar oro
endodóntico abscesses; lateral periapical cyst; vertical root
fracturas; endoperiodontales absceso; and postoperative infección
(7). A combination of different factores, such as pulp vitality, the
presence of dental caries, the presence of periodontal pockets, the
location of the absceso and a careful radiographic examination,
should be assessed in detail to reach an accurate diagnosis. other
serious oral diseases may also have a similar appearance:
osteomyelitis in patients with periodontitis (241); squamous cell
carcinomas (162, 163,
322); a metastásico carcinoma of Pancreatic origin (289); a
metastásico head and neck cancer (85); an eosinophilic granuloma
(111); oro en pyogenic granuloma (237). Therefore, in patients not
responding to conventional therapy, a biopsy and histopathological
diagnosis should be recommended. self-in fl icted gingival injurias:
including trauma of the gingivoestomatitis with a pencil (267) oro
with a safety pin (37), oro en nail-Biting habit (304). The anamnesis
is the key factor in the diagnosis of these lesiones.
Treatment of a periodontal absceso
Treatment of a periodontal absceso should include two distinct phases:
control of the acute condition
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Herrera et al.

to arresto tissue destruction and control the symptoms; and both protocolos were similarly effective. Eguchi et al. (82) compared
management of a pre-existing and / or residual lesión, especially in IRRIGATION with sterile Physiological saline and 2% minocycline
patients with periodontitis. hydrochloride ointment vs. IRRIGATION with sterile Physiological saline
without the local antibiótico, in 91 patients for 7 days.

Control of the acute condition

Four therapeutic alternativas have been proposed: tooth extracción;
drainage and debridement; Systemic oro local antimicrobiales; and
surgery.
If the tooth is severely Damaged, and its prognosis is Hopeless after
the destruction caused by the absceso, the preferred treatment should
be tooth extracción (300).
Surgical procedures have also been proposed, mainly for abscesses
associated with deep vertical defects (158) oro in casas occurring after
periodontal debridement in which residual calculus is presente
subgingivally after treatment (74). A case series Evaluating a
combination of an access fl ap with deep scaling and IRRIGATION with
doxycycline is also available and reports ' good results ', but Scientia fin c
fecha were not provided (316).

The most logical treatment of a periodontal absceso, as in other

abscesses in the body, should include drainage (through the pocket oro
through an external incision), compresión and debridement of the
soft-tissue wall, and the application of topical antisépticos after drainage.
If the absceso is associated with a foreign-body impaction, the object
must be eliminated through careful debridement (5), although it may no
longer be presente.
Systemic antimicrobiales may be used as the sole treatment, as initial
treatment or as an adjunctive treatment to drainage. Systemic
antimicrobiales as the sole oro as initial treatment may only be
recommended if there is a need for premedication, if the infección is not
well localized oro if adequate drainage can not be ascertained (176). As
an adjunctive treatment, Systemic antimicrobiales should be Considered
if a clear Systemic involvement is presente (7, 176). The duration of
therapy and the type of antibiótico is also a matter for discusión,
including the Recommendation of shorter courses of therapy (176, 202).
However, the available Scientia fin c evidence on the ef fin cacy of these
After drainage and debridement the patient should be recalled 24 - 48
h after treatment to evaluate the resolution of the absceso (Fig. 7A, B)
and the duration of the intake of antimicrobiales. Once the acute phase
has resolved, the patient should be scheduled for a follow-up therapeutic
phase.
In summary, numerous treatment protocolos have been proposed,
but suf fin ciente Scientia fin c evidence is not available to recommend a
de fin nitive approach. It is, however, clear that drainage and debridement
should be established when the Systemic condition and the access to
the absceso is adequate. When immediate drainage is not posible oro a
Systemic affect is evidente, therapy with Systemic antimicrobiales
A

therapies is very limited, with only two prospective case series and two
randomized clinical trials. Smith & Davies (300) evaluated incision and
drainage of the absceso, together with adjunctive Systemic metronidazol
(200 mg, three times daily for 5 days), followed by a delayed periodontal
therapy, in 22 abscesses para hasta 3 years. Hafstr €

om et al. (123) proposed drainage through the periodontal

pocket, IRRIGATION with sterile saline, supragingival scaling and
tetracycline for 2 weeks (1 g / day), and tested this therapy in 20
abscesses, with 13 followed for 180 days, highlighting the importance of
drainage and the potential of regeneration. Herrera et al. (129)
compared azithromycin (500 mg, once per day for 3 days) vs. amoxicillin
plus clavulanate (500 + 125 mg, three times daily for 8 days), with
delayed scaling (after 12 days), in 29 patients with abscesses followed
for 1 month, and concluded that
Fig. 7. ( A) Periodontal absceso before treatment. (B) Periodontal absceso, 12
days later, after treatment with azithromycin.

154

should be Considered. The drug with the most appropriate pro fin le is
metronidazol (normally prescribed for acute conditions at 250 mg, three
times daily). Azithromycin (500 mg, once per day) and amoxicillin plus
clavulanate (500 + 125 mg, three times daily) have also shown good
clinical results. The duration of the therapy should be restricted to the
duration of the acute lesión, which is normally 2 - 3 days.
Management of a pre-existing and / or a residual lesión
As mosto periodontal abscesses occurre in a pre-existing periodontal
pocket, periodontal therapy should be evaluated after resolution of the
acute phase. In casas where the patient has not been treated
Previously, the appropriate periodontal treatment should be provided. If
the patient is already within the active phase of therapy, the periodontal
therapy should be completed once the acute lesión has been treated. In
patients receiving supportive periodontal therapy, careful evaluation of
the recurrence of the absceso should be made, as well as assessment
of the tissue damage and how this affects tooth prognosis.
Summary
Abscesses in the periodontium are importante because they are a
relatively frecuente dental emergency, they can compromise the
periodontal prognosis of the Affected tooth and because the bacteria
within the absceso can spread and cause infecciones in other body
sites.
Although histologically all absceso lesiones are similar, different types
of absceso have been identi fin ed, mainly cla fin ed by their etiological
factores because there are clear differences between those affecting a
pre-existing periodontal pocket and those affecting healthy sites.
For the management of this condition, rapid and accurate diagnosis
(mainly based on clinical features) and provision of early therapy are
mandatory. Therapy for the acute condition should be based on
drainage and debridement, with evaluation of the need of Systemic
antimicrobial therapy based on local and Systemic factores. When the
supporting tissues have been destroyed to the extent of compromising
the tooth prognosis, tooth extracción may be the only valid alternative.
The de fin nitive treatment of the preexisting condition should be
accomplished after the acute phase has been controlled, as mosto
abscesses are found in patients with untreated periodontitis, thus
Needing periodontal therapy.
acute lesiones
Necrotizing periodontal diseases
de fin nition
Necrotizing periodontal diseases are a group of Infectious Diseases that
include necrotizing ulcerative gingivitis, necrotizing ulcerative
periodontitis and necrotizing stomatitis. However, it has also been
suggested that these conditions may represento different stages of the
same disease because they have similar etiologías, clinical
characteristics and treatment, although they vary in disease severity
(138, 140). These diseases share common clinical features consisting of
an acute in fl ammatory process and the presence of periodontal
destruction (Fig. 8).
Necrotizing ulcerative gingivitis has been diagnosed for centuries but
referred to by various names, such as Vincent ' s disease, trench-mouth
disease, necrotizing gingivoestomatitis-stomatitis, fuso-Spirochaetales
stomatitis, ulcerative membranous gingivitis, acute ulcerative gingivitis,
necrotizing ulcerative gingivitis and acute necrotizing ulcerative gingivitis
(21, 138, 152, 269). Necrotizing ulcerative periodontitis was de fin ned
both in the 1989 WorldWorkshop (54) and in the 1993 European
Workshop (26). At the International Workshop for a Clasi fin cation of
Periodontal Diseases and Conditions in 1999 (22), the new category of ' necrotizing
periodontal diseases ' was Introduced, which includes necrotizing
ulcerative gingivitis and necrotizing ulcerative periodontitis. More
recently, the terms necrotizing gingivitis and necrotizing periodontitis
have been used instead of the terms necrotizing ulcerative gingivitis and
necrotizing ulcerative periodontitis (138). The Simpler terms necrotizing
gingivitis and necrotizing periodontitis adequately Describe these
diseases and these terms will be used in the rest of the texto.
Fig. 8. Multiple gingival crater formation. The clinical scenario includes rápido
progresión and severe periodontal destruction.
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Herrera et al.
clasi fin cation of necrotizing periodontal diseases
According to the location of the tissue Affected by the acute disease
process, necrotizing periodontal diseases can be cla fin ed as (138, 140):
necrotizing gingivitis: when only the gingival tissues are Affected.
necrotizing periodontitis: when the necrosis progresas into the
periodontal ligamento and the alveolar bone, leading to attachment
loss. necrotizing stomatitis: when the necrosis progresas to deeper
tissues beyond the mucogingival line, including the lip oro Cheek
mucosa, the tongue, etc.
Clinical firme fin cancelación of necrotizing
periodontal diseases
Necrotizing periodontal diseases are Considered to be among the most
severe in fl ammatory conditions associated with oral bio fin lm bacteria
(138). Therefore, it is importante to control predisposing factores, and
once the disease has developed, to act quickly in order to límite its
progresión and exacerbación.
The prevalence of necrotizing periodontal diseases in systemically
healthy populations has not been adequately established because
mosto studies have focused on a SPECI fin c group of patients with clear
predisposing factores, such as military personnel (141, 248), students
(108, 188, 307), patients positive for HIV (136, 137) oro subjects with
severe malnutrition (88, 234). In addition, fecha from these conditions
originate from hospitales oro dental clinic settings, which may
overestimate the true Epidemiologic information. A high prevalence of
necrotizing gingivitis (14%) was observed in different populations
(including military groups) during the Second World War (12, 138) and a
moderately high rate (2.2%) was observed in populations in North
America in the 1950s ( 122). After the Second World War, the
prevalence Clearly decreased in developed countries and currently the
prevalence is low.
Necrotizing periodontal diseases have been described in young
people from both developed and developing countries (12). In North
America and Europe, these diseases have been studied Mostly in
groups of subjects in their late teens to mid-20s. In 326 North-American
students in the 1960s (108), the prevalence of necrotizing periodontal
diseases ranged from 2.5% to 6.7%. The current estimates in developed
countries are 0.5% oro less (33, 141), with 0.001% reported in young
Danish army Recruiter (138).
156
In developing countries, the reported prevalence of necrotizing
periodontal diseases is higher than in developed countries, especially in
children (12). In Chile, among 9,203 students, 6.7% Presented at least a
papilla with necrosis. In India, 54 - 68% of the casas were observed in
children younger than 10 years of age (249). In South Africa, 3.3% of
subjects 3 - 48 years of age, Presented with necrotizing gingivitis; 73% of
these subjects were 5 - 12 years of age and mosto were of a low
socio-económico class (20). In Nigeria, the prevalence of necrotizing
gingivitis ranged between
1.7% and 15% in children of 2 - 6 years of age, and was
27.2% in children with severe malnutrition (12, 88,
292). In Kenia, 0,15% of patients who attended the Nairobi Hospital
during one year were diagnosed with necrotizing gingivitis and 58.5%
were younger than 11 years of age (155). In spite of these fin guras,
subjects of año age may be Affected.
Necrotizing periodontitis is less frecuente than necrotizing gingivitis
and it has been mosto frequently reported in HIV-positive patients, with
a prevalence of 0 - 11% (40, 136, 261, 338). The prevalence is lower in
studies Performed outside hospitales oro dental clínicos. In HIV-positive
patients under anti-retroviral therapy (204, 272, 318), the prevalence of
necrotizing periodontitis may not Diff from that in the general population.
Necrotizing periodontal diseases can progress rapidly and cause
severe tissue destruction. It is therefore importante for these conditions
to be managed promptly because there is evidence Proving that
necrotizing periodontal diseases can be controlled by adequate
periodontal treatment combined with effective oral-hygiene measures
and control of predisposing factores (152). However, patients with
necrotizing gingivitis are frequently susceptible to future disease
recurrence, Mostly as a result of the dif fin Cultivo in controlling
predisposing factores as well as the dif fi-
culty in Achieving próximo supragingival bio fin lm control, in parte
because of the sequelae of these diseases, including the presence of
gingival cráteres (196).
Necrotizing gingivitis can heal without clinical sequelae (38), but often
the necrotizing lesión extends laterally from the papilla to the gingival
margin, affecting both the buccal and lingual sites, and progresas to
other sites in the mouth, Evolving from a localized disease into a
generalized disease (Fig. 9). Necrotizing gingivitis may also progress
apically, Evolving into necrotizing periodontitis (Fig. 10). In fact,
necrotizing periodontitis can be the result of one or various episodes of
necrotizing gingivitis, oro it can be the result of a necrotizing periodontal
disease affecting a site with pre-existing periodontitis (227).

Fig. 9. Necrótico area in a localized papilla: necrotizing gingivitis starts at the
interdental papilla and different degrees of destruction can be observed in
different areas of the same mouth.
Fig. 10. Necrotizing periodontitis: it can occurre after
numerous episodes of necrotizing gingivitis, oro as a necrotizing disease over a
pre-existing periodontitis.
Necrotizing periodontal diseases también puede become chronic, with a
slow reduction in their symptomatology and progresión, and ensuing
destruction, although at a slower rate (138, 248). Some authors believe
that these conditions remain acute and may be ' recurrente '( 152).
In casas of severe Systemic involvement, such as in patients with
AIDS or with severe malnutrition, necrotizing gingivitis and necrotizing
periodontitis can progress further with rapid involvement of the oral
mucosae. The severity of these lesiones are normally related to the
severity of the Systemic condition and to the compromised host inmune
response, leading to extensive bone destruction and the presence of
large osteitis lesiones and oral - antral fin stulae (335). Necrotizing
stomatitis has common features with cancrum oris oro Noma. Some
Investigators suggest that Noma is a progresión of necrotizing stomatitis
affecting the skin, whereas others believe that necrotizing stomatitis and
Noma are two distinct clinical entities. Noma is a destructive gangrenous
disease affecting the facial tissues. It is associated with high
acute lesiones
ratas of Mortality and Morbidity (32, 89, 91), and it is almost exclusively
observed in developing countries, especially in children suffering from
Systemic diseases, including severe malnutrition. Noma is normally
preceded by measles, malaria, severe diarrhea and necrotizing
gingivitis, which highlights the importance of prevention, early detection
and treatment during the fin rst stages of the disease (269).
Etiology, pathogenesis and histopathology of necrotizing
periodontal diseases
Necrotizing periodontal diseases are caused by Infectious agentes,
although predisposing factores, such as a compromised host inmune
response, are the main factores facilitating bacterial pathogenicity. This
bacterial etiology was already demonstrated by Plaut in 1894 and by
Vicente in 1896 (269), as microscópico examination of placa samples
Retrieved from Affected subjects Clearly showed the presence of
spirochetes and fusiformes bacteria, even within the tissues. Moreover,
clinical resolution was observed after mechanical debridement and
antimicrobial treatments (302). However, knowledge of the pathogenesis
of these diseases is limited because it is not clear whether these
bacteria observed in the lesiones are the cause oro the Consequence,
The spirochetes and fusiformes bacteria described in the necrótico
lesiones have the capacity to invade the epithelium (131) and the
Connective tissue (181), as well as to release endotoxina that may
cause periodontal tissue destruction through the activación oro modi fin cation
of the host response.
Necrotizing gingivitis lesiones show a distinct pathology under light
microscopy (181), with the presence of an ULCER within the Strata fin ed
squamous epithelium and the super fin cial layer of the gingival
Connective tissue rodeado with a nonspeci fin c acute in fl ammatory
reaction. Four areas have been described within these lesiones:
the bacterial area with a super fin cial fin caldos mesh Composed of
Degenerated Epithelial cells, leukocytes, cellular ristras and a wide
variety of bacterial cells, including rods, fusiformes and spirochetes.
the neutrophil-rich zone, Composed of a high number of leukocytes,
especially neutrophils, and numerous spirochetes of different sizes
and other bacterial morphotypes located between the host cells.
157
Herrera et al.
? the necrótico zone, containing disintegrated cells, together with
medium- and large-size spirochetes and fusiformes bacteria. the
spirochetal in fin ltration zone, where the tissue componentes are
adequately preserved but are in fin ltrated with large- and
medium-size spirochetes. Other bacterial morphotypes are not
found.
Microbiology of necrotizing periodontal diseases
A similar composition of the microbiota associated to necrotizing
periodontal diseases has been observed in different studies, including Treponema
leukocytes (eg leukemia) are among the most importante predisposing
spp., Selenomonas spp., Fusobacterium spp. and P. intermedia.
Other microorganismos have also been described, although these were
de fin ned as ' variable ' fl Actualmente and were not presente in all casas
(187). As this typical microbiological description también puede be
detected in healthy, gingivitis oro periodontitis sites, the use of
microbiological testing does not provide relevante diagnóstico
information (67, 152).
In HIV-positive patients with necrotizing periodontal diseases the
microbiological fin Ndinga are also nonspeci fin c (204, 266, 338), except
in regard to the counts of Yeast (namely, Candida albicans), the
presence of herpes viruses (62, 272, 338, 340) oro the detection of
superinfecting bacterial species, such as entéricos bacteria including EnterococcusHIV-negative and HIV-positive patients. It has been suggested that
avium, Enterococcus faecalis, Clostridium clostridioforme, Clostridium dif fin
cile, Mycoplasma spp. and Klebsiella pneumoniae ( 258,
340). Most recently, with the use of molecular technologies (PCR), some
bacterial species (including Eubacterium saphenus, Eubacterium
sabbureum, Filifactor Alocén, Dialister spp. and Porphyromonas
endodontalis) were found to be frequently associated with necrotizing
periodontal disease lesiones, whilst the typical periodontitis-associated
Pathogens P. gingivalis and
T. Forsythia were less frequently found (243).
Some researchers have pointed out the posible etiological role of
viruses (including human Cytomegalovirus) in necrotizing periodontal
diseases (78, 273). In children with necrotizing gingivitis in Nigeria, in
addition to the presence of Cytomegalovirus in the lesiones, other
viruses were detected, including Epstein - Barr virus type 1 and herpes
simplex virus (64).
Predisposing factores for necrotizing periodontal
diseases
The most common predisposing factores for necrotizing periodontal
disease are those that alter the host
158
inmune response, although usually more than one factor is necessary
for initiating the disease (138). In a study in the USA, the most
importante factor was HIV infección. In non-HIV patients, the most
importante factores were a previous history of necrotizing periodontal
disease, poor oral hygiene, inadequate sleep, unusual psychological
stress, poor diet, reciente Systemic diseases, alcohol abuse, tobacco
smoking, Caucasian ethnicity and age below 21 years (140).
Systemic conditions
Conditions that IMPA the host inmune response favor necrotizing
periodontal diseases. Infection with HIV oro with diseases affecting
factores. Other Systemic conditions that have shown a positive
association with necrotizing periodontal diseases include malnutrition,
measles, chickenpox, tuberculosis, herpética
gingivoestomatitis-stomatitis, malaria, oro even diabetes, which was
identi fin ed in a study of Chilean adolescentes (188).
Among predisposing Systemic conditions, HIV infección and
malnutrition have been studied in more depth:
in HIV-positive patients, necrotizing periodontal diseases are more
frecuente and show faster progresión, although no differences have
been detected between the characteristics of the disease in
HIV-positive patients have a higher Tendency for recurrence and a
diminished response to both mechanical and / or pharmacological
periodontal treatment (227). In HIV-positive patients, the reduction
in the counts of peripheral CD4 lymphocytes has been correlated
with necrotizing gingivitis and necrotizing periodontitis (113, 303)
and therefore the diagnosis of necrotizing periodontal disease
should prompt the likelihood that the patient may have an HIV
infección, and therefore the Affected subjects should be screened
for HIV (138, 139).
234). The basis for this interacción has been intermedios ' protein-energy
malnutrition ', implying a marked reduction in key antioxidante
nutrientes and an Altered acute-phase response against infección.
Other consequences are an inversed proportion in the ratio of
helper T-lymphocytes / suppressor T-lymphocytes, histaminemia,
increased free cortisol in blood and saliva and defects in mucosal
Integrity (90).
 acute lesiones

Psychological stress and insufi fin ciente sleep

Acute psychological stress and situations of acute stress have been

associated with necrotizing gingivitis (140, 152, 291). Certain situations
may predispose individuales to necrotizing periodontal disease, such as
military personnel in Wartime, new Recruiter for military services,
drug-abusers during Abstinence síndrome, students during examination
periods and patients with depresión oro other psychological conditions
(108, 122, 248). During these stress periods, not only is the inmune
response Altered, but also the subject ' s behavior, leading to inadequate
oral hygiene, poor diet oro increased tobacco consumption. The
proposed mechanisms to explain this association are based on
Reduction of the gingival microcirculation and salivary fl ow and Increaser
in the serum and Urine levels of 17-hydroxycorticosteroid, which are Fig. 11. Placa and calculus accumulation in a patient with chronic gingivitis:
associated with an alteration in the function of polymorphonuclear necrotizing periodontal diseases affect tissues with pre-exisitng chronic
leukocytes and lymphocytes, oro even with an increase in the levels of periodontal conditions.

periodontal Pathogens, such as P. intermedia ( 187). Higher Urinary

levels of 17-hydroxycorticosteroid have been reported in patients with
necrotizing gingivitis than in healthy oro treated patients; in addition, the
former group demonstrated statistically firme fin canto higher levels of
anxiety, depresión oro emotional alteration (138). Patients with
necrotizing gingivitis also had polymorphonuclear leukocytes with
Altered functions because their bactericidal, phagocytic and chemotactic
Capacities were depressed (63).
Explaining this association are probably related to the effect of smoking
on in fl ammation and the tissue response, because smoking interfería
with both polymorphonuclear Leukocyte and lymphocyte function and
nicotina Induc vasoconstriction in gingival blood vessels.
Alcohol consumption has also been associated with the Physiological
and psychological factores favoring necrotizing periodontal disease
(139).

Young age and ethnicity

In developed countries, young people, Mostly between 21 and 24 years

of age, are more prone to suffer necrotizing periodontal disease, usually
combined with other predisposing factores, such as smoking and stress
(139, 140, 307). In developing countries, necrotizing periodontal disease
Inadequate oral hygiene, pre-existing gingivitis and previous history of
affects even younger people, with malnutrition and the occurrence of
necrotizing periodontal disease
infecciones being the most frecuente predisposing factores (89, 90,
Placa accumulation has been Considered a predisposing factor for 269). Studies in North America have reported that up to 95% of casas of
necrotizing periodontal disease (140, necrotizing periodontal disease occurre in Caucasian patients (33, 140,
152), although it may also be a Consequence of the presence of úlceras 307), although more studies are needed to cono fin rm this fin Ndinga.
and crater lesiones that may límite toothbrushing as a result of pain.
Necrotizing periodontal disease usually occurre over a pre-existing
periodontal disease, usually chronic gingivitis (248) (Fig. 11). In one
study, 28% de of the patients with necrotizing periodontal disease
reported a history of Painful gingival
Diagnosis of necrotizing periodontal diseases

in fl ammation and 21% de showed

lesiones compatible with previous necrotizing periodontal disease (140).
Alcohol and tobacco consumption
Smoking is a risk factor for necrotizing periodontal disease (152, 153,
264) and, in fact, mosto HIV-negative patients diagnosed with
necrotizing periodontal disease were smokers (108, 248, 307). The
mechanisms
The diagnosis of necrotizing periodontal diseases is based mainly on the
clinical fin Ndinga (67, 269). Although the reported histology and the
typical microbiota associated with these lesiones have a Distinctive
character, neither biopsy nor microbiological sampling are usually
essential diagnóstico tools in these diseases (67). The different stages
of necrotizing periodontal disease share clinical features, but also

159
Herrera et al.
distinct fin Ndinga, depending on the extent and severity of the lesiones
(1, 67, 138, 152, 269).
Necrotizing gingivitis
The diagnosis is based on the presence of necrosis and úlceras in the
free gingivoestomatitis. These lesiones usually start at the interdental
papilla and have a typical
' punched-out ' appearance. In addition, a marginal erythema, named ' lineal
erythema ', may be presente, separating the healthy and the diseased
gingivoestomatitis. These necrótico lesiones can progress to the
marginal gingivoestomatitis. The most typical location is the anterior
teeth, especially in the Mandible (Fig. 12). In necrotizing gingivitis,
gingival bleeding is a frecuente fin Ndinga, and it is usually spontaneous
oro occurre after minimal contact (Fig. 13). Pain normally has rapid
onset and occurre with different degrees of severity, depending on the
severity and extent of the lesiones. The Bouts of pain increase with
eating and with oral
Fig. 12. Necrotizing gingivitis affects more frequently the mandibular anterior
sextante.
Fig. 13. Bleeding observed in necrotizing gingivitis: it can occurre spontaneously
oro after minimal stimulus.
160
hygiene practices and is normally the reason for the patient ' s
consultation.
Other less common fin Ndinga include the presence of:
pseudomembrane over the necrótico area. The pseudomembrane
consiste of a whitish / yellowcolored meshwork, Composed of
necrótica tissue,
fin brin, erythrocytes, leukocytes and bacterial cells. When this ' membrane
' is removed, the Underlying Connective tissue becomes Exposed
and Bleed. halitosis, although this is not an exclusive sign of
necrotizing gingivitis.
adenopathies, which are usually found in the most severe casas of
disease. If presente, submandibular Lympha nodos are more
Affected than those in the cervical area (150, 151). fever and
general feeling of disconfort.
Necrotizing periodontitis
The same clinical picture described in necrotizing gingivitis occurre in
necrotizing periodontitis, but in addition, in necrotizing periodontitis the
following characteristics may be presente:
necrosis affects the periodontal ligamento and the alveolar bone,
leading to loss of attachment. As there is concomitante necrosis of
the soft tissue, the presence of pockets is not an usual fin Ndinga
(Fig. 14).
as the disease progresas (Fig. 15), the interdental papilla is Divided
into a buccal parte and lingual / palatal parte, with a necrótica area
in the middle, known as the interproximal cráter. If the cráteres are
deep, the interdental crestal bone becomes Exposed and
denudated. In addition, crater formation favores disease progresión
by allowing the accumulation of more bacteria. Interproximal
necrótico areas spread laterally and merge with the
Fig. 14. Papilla destruction in necrotizing gingivitis: no pocket formation is
observed following the loss of soft tissues.

Fig. 15. Crater formation and bleeding in a posterior area.
neighboring areas, creating an extensive zone of destruction.
in severe casas, especially in inmune-compromised patients, bone
sequestrum (necrótico bone fragmentos within the tissues but
separated from the healthy bone) may occurre, mainly interdentally,
but also in the buccal oro lingual / palatal partes of the alveolar
bone.
Necrotizing stomatitis
When bone denudation extends through the alveolar mucosa, larger
bone secuestra may occurre, with large areas of osteitis and oral - antral fin
stulae. These lesiones are of greater severity in patients with severe
Systemic compromise,
including patients with AIDS and
patients with severe malnutrition (335).
Management of necrotizing periodontal diseases
Owings to the (Previously listed) SPECI fin c features of necrotizing
periodontal disease (tissue destruction, acute course and pain),
diagnosis and treatment have to be Performed as soon as posible, and
conventional periodontal therapies may need adjunctive therapeutic
measures (2, 152).
The treatment should be organized in successive stages: treatment of
the acute phase; treatment of the pre-existing condition and correctiva
treatment of the disease sequelae; supportive oro maintenance phase.
Treatment of the acute phase
There are two main objetivas of therapy: to arresto the disease process
and tissue destruction; and to control the patient ' s general feeling of
disconfort and pain that is interfering with nutrition and oral hygiene
practices (138). The fin rst task should be a careful super fin cial
debridement to remove the soft and mineralized depósitos.
Power-driven debridement devices (eg ultrasónicos) are usually
recommended, exerting
acute lesiones
minimal pressure over the ulcerated soft tissues. The debridement
should be Performed daily, Becoming deeper as the tolerance of the
patient Improves, and lasting for as long as the acute phase Last
(normally 2
- 4 days). Mechanical oral hygiene measures should be limited because
brushing directly in the Wounds may IMPA healing and INDUCE pain.
During this period the patient is advised to use chemical placa-control
Formulations, such as chlorhexidine-based
mouthrinses (12:12 - 0.2%, twice daily). Other products have also been
suggested, such as 3% hydrogen peroxide diluted 1: 1 in warm water,
and other oxygenreleasing agentes, which not only Contribute to the
mechanical cleaning of the lesiones but also provide the antibacterial
effect of oxygen against anaerobia (333) . Other oxygen therapies have
also been evaluated, such as local oxygen therapy, which may help to
reduce, oro even eradicate, microorganismos, resulting in faster clinical
healing with less periodontal destruction (101).
In casas that show unsatisfactory response to debridement oro show
Systemic effects (fever and / or malaise), the use of Systemic
antimicrobiales may be Considered. Metronidazol (250 mg, every 8 h)
may be an appropriate fin rst choice of drug because it is active against
strict anaerobia (187). Other Systemic drugs have also been proposed,
with aceptable results, including penicillin, tetracyclines, clindamycin,
amoxicillin oro amoxicillin plus clavulanate. Conversely,
locally Delivered antimicrobiales are not recommended
because of the large numbers of bacteria presente within the tissues,
where the local drug will not be able to ACHIEVE adequate
Concentrations.
These patients have to be followed up very closely (daily, if posible)
and as the symptoms and signs improve, strict mechanical hygiene
measures should be enforced, as well as complete debridement of the
lesiones.
Treatment of the pre-existing condition
Necrotizing periodontal diseases normally occurre over a pre-existing
chronic gingivitis oro periodontitis infección. Once the acute phase has
been controlled, treatment of the pre-existing chronic condition should
be started, including profesional prophylaxis and / or scaling and root
planning. Oral hygiene instructions and motivación should be enforced.
Existing predisposing local factores, such as overhanging Restoration,
interdental open spaces and tooth malposition, should be carefully
evaluated and treated (140). At this stage, and also during the acute
phase, attention should be paid to the control of the Systemic
predisposing factores, including smoking, adequate sleep,
161
Herrera et al.
reduction of stress oro treatment of involved Systemic conditions.
Correctiva treatment of disease sequelae
The corrección of the Altered gingival Topography caused by the
disease should be Considered (Fig. 16) because gingival cráteres may
favor placa accumulation and disease recurrence. Gingivectomy and / or
gingivoplasty procedures may be helpful for treatment of super fin cial
cráteres; periodontal fl ap surgery, oro even regenerative surgery, are
more suitable options for deep cráteres (138).
Supportive oro maintenance phase
During supportive oro maintenance phases, the main goal is compliance
with the oral hygiene practices (Fig. 17) and control of the predisposing
factores.
Fig. 16. Gingival cráteres are importante sequelae because they can límite
mechanical placa control.
Fig. 17. Esthetic consequences of necrotizing periodontal diseases.
162
Spec fin c considerations for HIV-positive patients
HIV-positive patients may not be aware of their serológico status. The
occurrence of necrotizing periodontal disease in systemically healthy
individuales is suggestive of HIV infección and, therefore, the Affected
individuales should be screened for HIV (138, 140). The SPECI fin c
management of necrotizing periodontal disease in HIV-positive patients
includes debridement of bacterial deposits combined with IRRIGATION
of the site with iodine-povidone, based on its hypothetic anesthetic and
bleeding control effects (338), although no Scientia fin c studies are
available to support this protocolo (271, 336, 338). Careful consideration
should be made regarding the use of Systemic antimicrobiales because
of the risk of overgrowth of Candida
spp. Metronidazol has been recommended for its narrow spectrum and
limited effects on gram-positive bacteria, which prevent Candida spp.
overgrowth (272, 336, 338), although HIV-positive patients may not
need antibiótico prophylaxis for the treatment of necrotizing periodontal
disease (194). In nonresponding casas, the use of antifungals may be
bene fin cial, including clotrimazol lozenges, nystatin vaginal tablets,
Systemic fl uoconazole oro itraconazol, mainly in casas of severe inmune
suppression (272, 338). In HIV-positive patients, the Systemic status
should be closely monitored, including the viral load and the
hematológicos and inmune conditions, leading to development of a
customized periodontal treatment plan (266, 272, 338).
Summary
Necrotizing periodontal disease includes necrotizing gingivitis,
necrotizing periodontitis and necrotizing stomatitis, and these may be
Considered as different stages of the same pathologic process. This
group of diseases always presentes three typical clinical features
- papilla necrosis, bleeding and pain - which makes them different from
other periodontal diseases. Although their prevalence is not high, their
importance is clear because they represent the most severe bio fin lm-related
periodontal conditions, leading to rapid tissue destruction. In their
etiology, together with bacteria, numerous factores that alter the host
response may predispose to these diseases, including HIV infección,
malnutrition,
stress oro tobacco
smoking.
Owings to their acute presentation, together with the associated pain
and tissue destruction, treatment should be provided immediately upon
diagnosis; this should include super fin cial debridement, careful

mechanical oral hygiene, rinsing with chlorhexidine and daily revisiones.
Systemic antimicrobiales may be used adjunctively in severe casas oro
in nonresponding conditions, and the best option is metronidazol. Once
the acute disease is under control, de fin nitive treatment should be
provided, including adequate therapy for the pre-existing gingivitis oro
periodontitis as well as adequate oral hygiene practices and supportive
therapy. Surgical treatment of the sequelae should be Considered based
on the needs of the individual case.
Other acute conditions in the
periodontium
This group of acute gingival lesiones includes lesiones manifesting
initially as acute conditions oro as acute episodes of a chronic condition.
They can appear as isolated lesiones oro as part of complejo clinical
pictures and they are frequently responsible for emergency consultation.
The clinical lesión is usually año ULCER oro erosion, which may be
the primary lesión oro secondary to a vesicle-Bullou lesión. The most
frecuente Symptom is localized pain, which initiates with the lesión oro
may PRECEDE it, although it may also occurre in conjunction with pain
in the pharynx oro dysphagia. To Establish the próximo diagnosis, a
clinical history, anamnesis and careful examination are mandatory
because frequently there is a direct and reciente relationship with the
cause (68). In the following discusión, the lesiones are cla fin ed
according to their etiology because their clinical appearance is similar
and a careful differential diagnosis is key to their therapy (22, 134, 326).
Gingival diseases of Infectious origin
Gingival lesiones of SPECI fin c bacterial origin
Spec fin c bacterial infecciones localized in the oral mucosa are
Uncommon. They may be caused by bacteria normally presente in the
oral cavity that eventually become pathogenic, and also by bacteria
exogenous to the oral cavity, such as gonococia, tularemia oro anthrax.
In addition, the lesiones presente in the oral cavity may be a secondary
location of generalized Infectious disease, as in scarlatina, diphtheria,
Syphilis oro tuberculosis.
Both staphylococci and streptococci may cause oral infecciones with
gingival involvement, leading to a lesión with a nonspeci fin c appearance
(usually erythematous oro erosive) (102, 201). Group B streptococcal
infecciones frequently result in pharynx-amigdalitis
acute lesiones
that affects ajo oral mucosae and may be associated with fever and
malaise. Treatment includes rehydration, rest and the prescription of
Systemic antimicrobiales (154, 157, 160, 183). Stomatitis associated
with
S. aureus is characterized by Bullou generalized dermatitis, with
vesicles and desquamation, which affects the lips, oral mucosa and
other mucosae. Its appearance is similar to multiformato erythema oro
impétigo and it is usually treated with Systemic antimicrobiales (102,
299).
Despite the presence of the oral epithelium as a protective barrier
against infección with Neisseria gonorrhoeae, gonococcal lesiones may
develop as a result of direct contact. In the newborn, N. gonorrhoeae infección
may occurre through contact when passing through the birth canal. In
adultos, transmisión may be bucco-genital and super fin cial lesiones are
found as white / yellowish placas oro pseudomembrana that, when
removed, result in a bleeding úlceras. Salivary fl ow may be reduced and
saliva can be denso. The clinical history is crucial and treatment should
consistencia of the administration of Systemic antimicrobiales (61, 92,
293, 332).
Among generalized Infectious Diseases, Syphilis may often affect the
gingival tissues. Syphilis is caused by Treponema pallidum and may be
dif fin cult to diagnose because of similaridad with other Systemic
conditions (96, 172, 256). Syphilis can be congenital oro Acquired.
In Acquired Syphilis, the
incubation period may vary from 12 to 40 days, and the lesiones may
follow different stages. In primary Syphilis, the lesión se encuentra at the
point of transmisión, normally as a Chanco that may be located on the
lips, tongue oro tonsils (11). The gingivoestomatitis may be Affected by
secondary Syphilis after 6 - 8 weeks, oro even 6 months, with the
presence of a placa (elevated papule with central erosion) that may last
for weeks oro even a year (18, 168, 193, 197, 257, 268). Tertiary
Syphilis is Uncommon and, when presente in the oral cavity, it may
affect the Palate and the tongue (171). Differential diagnosis is critical
and sometimes dif fin cult. Treatment consiste of the administration of
SPECI fin c Systemic antimicrobiales (96, 197).
viral infecciones
Different viruses may cause lesiones in the oral cavity, with or without
concomitante skin involvement (215). The most frequently associated
viruses Causing gingival and periodontal lesiones are from the
Herpesviridae family (herpes simplex virus type 1, the causal agente of
oral and labial herpes lesiones; herpes simplex virus type 2, associated
with genital herpes; and varicela-zoster virus, responsible for varicela
and herpes
163
Herrera et al.

zoster) (64 - 66, 119, 137, 211, 240, 298). Herpesviruses adapt easily to
the host, and after the primary infección they remain inside the Infected
cells in a latente oro silente state; they show tropismos for Epithelial and
neural cells, and the preferred site for latency of herpes simplex viruses
and varicela-zoster virus is gangliones in the nervous system (66, 83,
84, 324, 337).

Varicela is the outcome of an infección with varicela-zoster virus and

occurre after the initial contact with the virus. It results in a generalized
condition, especially in children, with vesicle erupción in skin after an
incubation period of 1 - 3 weeks. Before oro after appearance of the skin
lesiones, vesicles can be evidente in the oral cavity, including the Fig. 18. Herpética gingivoestomatitis-stomatitis: Painful gingivitis with generalized
gingivoestomatitis, and they break easily, forming úlceras rodeado año vesicles in primary herpética infección.
erythematous halo. The result of the re-activación of the varicela-zoster
virus from the regional sensitive ganglios is herpes zoster, which occurre
especially in the elderly oro associated with inmune-depresión. It may
affect the trigeminal ganglion, with clinical Manifestation preceded by
pain or an itching feeling. Clinical lesiones are vesicles rodeado año
erythematous halo, with a unilateral distribution; the vesicles break
easily, forming erosive areas (214, 262,

312). Primary herpética infección with herpes simplex virus type-1 is

normally asymptomatic, but it is sometimes very evidente in the form of
generalized gingivostomatitis, with dysphagia,
fever, malaise and
submandibular adenopathy. It is more frequently observed in children 2 - 5
years of age, with oral lesiones in the form of úlcera oro erosiones, after
the vesicles have broken (Fig. 18). Treatment may include antiviral
agentes and adequate nutritional support, Mostly when pain
compromisos eating (66, 84, 216,
Fig. 19. Recurrente herpética infección: vesicles break, leading to erosive
lesiones. Gingival location is not infrecuente.
tiones: Infectious mononucleosis (Epstein - Barr virus) oro hand, foot and
mouth disease (Coxsackie virus). Sometimes they may also cause
unspeci fin c conditions, including acute stomatitis with oral úlceras and
malaise and adenopathy. These conditions can be importante in
inmune-compromised patients (25,

287, 324). 127, 189, 218, 231).

Recurrente herpética infección with herpes simplex virus type-1 may
be either intraoral oro labial. Initial symptoms include local disconfort in
the form of itching oro stinging. The lesiones develop as an erythema,
and then variable number of grouped vesicles break, forming an erosion
in the oral mucosae, gingivoestomatitis oro the lip (Fig. 19). Lesiones
normally last for 7
In addition to the acute conditions already discutida, viruses are
associated with chronic conditions that may require emergency attention
for Complications during their development, trauma oro unexpected fin Ndinga,
including viral Wart oro condyloma acuminata.

- 10 days and heal without scarring. Differential diagnosis with other
conditions showing úlcera, such as recurrente aphthous stomatitis, is
importante, although the Latter lesiones will not affect keratinized tissues
(178, 252, 254, 284, 341). As the condition is self-limiting, no treatment
is usually required, although if presente
in inmune-compromised patients, antiviral agentes should be
prescribed (216, 287, 311, 337).
Other viruses, such as Epstein - Barr virus, Cytomegalovirus and
Coxsackie virus, are frequently transmitted vía saliva and may result in
SPECI fin c oral manifestaciones
Fungal infecciones
Many Fungal species are part of the residente fl Actualmente of the
mouth, but they may cause pathology when local oro Systemic factores
trigger their overgrowth (114, 207,
222). Among these opportunistic Fungal infecciones, candidiasis is the
most frecuente, normally affecting inmune-compromised subjects,
especially HIV-positive patients, oro during infancy and in the elderly
(49,
118, 133, 229, 278, 328). Although their localized forms are usually not
severe, it may spread and lead to more severe infecciones, such as
esophagic oro Systemic

164
 acute lesiones

Fig. 21. Mucocutaneous disorders: mosto of themmay have oral and gingival

Fig. 20. Oral candidiasis: one of the predisposing factores is a Removable lesiones, normally with a chronic evolution but also with acute periods.

prosthesis, and erythematous lesiones are among the most frecuente lesiones.

mation and erythematous, vesicle-Bullou oro erosive lesiones in the

candidiasis. Among Candida spp., C. albicans is the most relevant for
gingivoestomatitis. Although it is normally part of a chronic process,
oral infecciones (263).
Painful acute phases también puede occurre, with intense and Diffuse
Multiple factores are associated with the pathogenesis of oral
redness in the attached and free gingivoestomatitis. The epithelium is
candidiasis (Fig. 20), and these may be Divided into host-related
fragile and easily detached, leaving a Reddish surface, which Bleed
factores and local and environmental factores (49, 134, 275, 278, 314).
after minimal stimulus (313). When the lesiones are limited to the
Among the host-related factores are the presence of concomitante
gingival tissues, they are more frequently situado en dentate areas at
Systemic diseases (such as diabetes) oro debilitating conditions leading
buccal sites (Fig. 21). Women in the fourth to fin FTH décadas of life are
to a reduced host response. The most common local and environmental
more prone to presente these lesiones (172, 184,

factores
include Removable prostheses, Systemic antimicrobiales,
185, 199, 310, 325). Therapy is usually based on treatment with topical
corticosteroides and tobacco smoking (9, 49, 104,
oro Systemic corticoides (51, 52, 95,
114, 118, 134, 207, 275, 278, 314).
115, 191, 226). Lichen planus is a chronic in fl ammatory disease
Acute candidiasis can presente as pseudomembranous oro
affecting the skin and the mucosae, and is the most common
erythematous candidiasis, with itching oro stinging being. The diagnosis
noninfectious disease of the oral cavity. The oral Manifestation is very
is mainly clinical (28,
common, Mostly in adulto women (30 - 50 years) of Caucasian ethnicity
135). Treatment includes antifungal agentes, such as nystatin,
(186,
amphotericin B oro miconazol in solutions oro geles. In severe casas,
oro in inmune-compromised patients, the treatment of choice is
213, 280). The oral lesiones usually PRECEDE the skin lesiones oro are
Systemic fl uconazole. It is also mandatory to evaluate and control the
the only lesión (Fig. 22). Clinical Manifestation range from the typical
associated predisposing / adjunctive local and / or Systemic factores (9,
reticular form, affecting the buccal and Cheek mucosae, tono erosive
43, 104, 319).
forms, usually encuentra en el tongue and gingivoestomatitis, that cause
pain and tenderness, as well as bleeding. When

Gingival Manifestation of Systemic conditions

Mucocutaneous disorders

Mucocutaneous disorders represento a group of chronic autoinmune

diseases that are characterized by the presence of vesicle-Bullou
lesiones, with liquid contento (either serum oro hemorrhagic). Although
the evolution of these diseases is chronic, acute Bouts may occurre and
affect año intraoral location, and also the skin oro other mucosae (50,
310, 331).

Vesicle-Bullou diseases usually presente in the gingival tissues as

desquamative gingivitis. This Manifestation re fl ects the presence of Fig. 22. Lichen planus: gingival involvement includes erosive lesiones and
Epithelial desqua- reticular whitish lesiones.

165
Herrera et al.
Fig. 23. Liquenoides lesiones: Identical to lichen planus
lesiones, but Clearly associated with a causative factor (such as Amalgam fin lling);
these lesiones disappear after elimination of the causative factor.
presente in the gingivoestomatitis, the lesiones are usually observed as
a desquamative gingivitis affecting the attached gingivoestomatitis. The
diagnosis is both clinical (bilateral and symmetric lesiones, whitish
reticular lesiones oro red lesiones, not disappearing after scraping) and
histological (53, 186, 213, 281). If some of the diagnostic criteria are not
met, the lesiones will be de fin ned as lichenoides reactions (Fig. 23),
normally associated with restorative materiales, pharmaceutical drugs,
Graft vs. host disease oro some Systemic conditions (10,
75, 80, 147, 169, 233, 246).
Pemphigus is a severe, autoinmune mucocutaneous disease, with a
chronic and aggressive progresión, characterized by the destruction of
the
intercelular adhesion systems between keratinocytes, leading to
intra-Epithelial bulla formation (39, 170,
221, 288). Among the different clinical forms, only the vulgaris and the
vegetan can affect the oral mucosae, although the Latter is very
infrecuente. Pemphigus vulgaris is more frecuente in women, 40 - 60
years of age, with a Mediterranean oro Jewish background. Skin
lesiones are more common, but in 50% of the casas oral lesiones may
PRECEDE the skin lesiones (295). Intraoral lesiones, if affecting the
gingivoestomatitis, appear as desquamative gingivitis (86). Diagnosis
may be dif fin cult and will be based on histology and immune- fl uorescence which may affect the majority of human systems and even compromise
(48, 87, 212, 230, 282, 286, 288, 296).
Pemphigoid includes a group of autoinmune mucocutaneous
diseases that affect either the skin (Bullou pemphigoid and gestational
herpes) oro the mucosae (mucous membrane pemphigoid oro cicatricial
pemphigoid). In the Latter, the autoinmune reaction affects the basal
membrane (subepithelial bulla) and frequently occurre in women older
than 50 years of age, presenting oral lesiones in more than 90% of the
casas. These lesiones are usually encuentra en el gin-
166
Giva, later spreading tono neighboring tissues oro to other sites.
Gingival tissues are Affected in 40 - 100% of the casas as desquamative
gingivitis, including periods of exacerbación and remisiones (19, 31,
170, 239, 274,
285).
Other mucocutaneous conditions, characterized as vesicle-Bullou
conditions, include lineal IgA disease, Bullou epidermolisis, erythema
multiforme and lupus erythematosus. When affecting the
gingivoestomatitis, they manifiesto as desquamative gingivitis and the
differential diagnosis should be based on histológico oro laboratory
evidence, as well as the involvement of other body sites oro órganos
(13, 50, 94, 200, 225, 310,
323, 331).
Allergic reactions
Allergy is an Abnormal reaction of the human body: an exaggerated
response to a contact with a foreign substance oro product (alergia) that
does not necessarily INDUCE a similar reaction in other individuales (3,
27, 44, 72, 195, 228). Food products, including frutos, seafood, nuts oro
some vegetables, INDUCE mosto Allergic reactions; however, some
medicinas, including antibióticos (eg penicillin) oro nonsteroidal anti-in fl ammatory
drugs (eg acetylsalicylic acid) también puede be responsible for Allergic
reactions (15, 17,
23, 42, 46, 70, 72, 112, 179, 228, 235). Other potentially allergenic
products are haptenos, which need to be linked to proteins in order to
become alérgenos, and are very relevante in Dentistry because they are
presente in some metales and dental materiales (3, 41,
72, 73, 164, 169, 173, 203, 217), in topical anesthesia, in oral hygiene
products (161), as well as in rubber DAMS, latex examination gloves
and cosmetics (16,
45, 79, 169, 180, 208, 277, 297). Alergias in the mouth may have
different clinical Manifestation, ranging from the typical urticarial reaction
to angioedema, although they do not normally affect the gingival tissues
(27, 159, 205).
Erythema multiforme is a disseminated hypersensitivity reaction,
the patient ' s life (3, 24, 29, 34, 47, 58, 81, 93, 98, 107, 167, 260, 270,
279, 306). An inductor oro precipitating factor is normally presente;
these include herpes simplex virus infecciones; drugs such as
sulfamide, penicillin oro salicylate; oro gastrointestinal conditions,
including Crohn ' s disease and ulcerative colitis (29, 190, 270). Clinically,
exudative erythema multiforme may affect the skin and mucosae,
presentes as minor and mayor (también conocido como Stevens - Johnson
syndrome) forms and is characterized by bullae formation (24, 34, 47,
93, 132, 143, 190, 223, 260). The diagnosis is mainly

Fig. 24. Iatrogénica lesiones: gingival erosiones.
clinical and, when affecting gingival tissues, differential diagnosis with
other conditions that manifiesto as desquamative gingivitis should be
Considered (24, 47,
144). In mild casas, topical corticoides, analgésicos and a soft diet may
be suf fin ciente. In severe casas, Systemic corticoides are the fin rst
option, and in refractory casas the treatment is with azathioprine oro
dapsone (144,
192, 223, 232).
Contact allergy of an intraoral location is an ill-de-
fin ned entity (3, 27, 72, 73) y está normally associated with drugs
(antimalarial, nonsteroidal anti-in fl ammatory, antihypertensive oro
antidiabéticos Medication) oro metales (especially Amalgam (41, 169,
208), gold (334) oro nickel (73)), oro with other dental materiales,
including acrylic Resins oro dental composites (6, 164, 173,
203, 217, 277) (Fig. 24). Contact alergias associated with toothpastes,
mouthrinses oro chewing gums are rare (16, 79, 161, 180, 297). The
lesiones are usually not clinically distinguishable from a tooth-related
irritation oro trauma (73, 305, 329). Symptoms include burning, itching
oro stinging, and the lesión is often de fin ned as a liquenoides reaction
(165, 206). The clinical aspect of intraoral contact alergias includes
erythematous and edematous gingival tissues, sometimes with úlceras
and whitish areas. The same lesiones can be observed on the lip,
buccal oro lingual mucosae. Therefore, diagnosis is often dif fin cult, with
a need to
fin nd a direct association between the clinical lesiones and the exposure
to alérgenos. The most importante therapeutic measure is to remove the
alergias, although this is not always easy and sometimes it will not solve
the case, including casas of incorrect diagnosis (16, 79, 161, 180, 297).
Traumatic lesiones
The clinical presentation of lesiones associated with physical and
chemical agentes will depende donde Weth
acute lesiones
the action of the agente is direct or indirect. The effect of a direct action
depends on the type of agente, the length of exposure to the agente and
the amount of surface of mucosa Affected. Indirect effects appear as
color alteration, erythema, erosion, úlceras, gingival enlargement,
Hemorrhage oro dysgeusia (59, 236, 259).
Among traumático lesiones, iatrogénico lesiones are relevant in
Dentistry because they are Produced during therapeutic intervention or
as a result of the therapy (Fig. 24). They are normally Considered as
treatment Complications because dental instrumentos and chemical
products can cause injurias oro burns, including lesiones in the gingival
tissues (8, 59, 71, 105, 112, 220,
236, 247, 251, 259, 276, 277, 290, 305).
Physical (mechanical and thermal) injury
Physical mechanical injurias may appear as erosiones oro úlceras,
associated with gingival recesión. However, they can also presente as
hyperkeratosis, vesicles oro bullae, sometimes in combination with other
oral lesiones on the lips, tongue oro teeth; they may be asymptomatic,
but they can also INDUCE intense, localized pain at the area of ​the
lesión. The correct diagnosis is based not only on the clinical aspect, but
also in the identi fin cation of the noxious agente, and for that, patient
collaboration is crucial (148, 182, 236,
259, 305).
Physical mechanical injurias are most frequently caused by
traumático accidentes, but they can also be related to incorrect oral
hygiene habits and parafunctions (182, 238, 242, 301). If the physical
trauma is limited, but continuous over time, the gingival lesión will be
Frictional hyperkeratosis that may lead to a leukoplakic lesión. If the
physical trauma is more aggressive, super fin cial laceration oro more
severe tissue loss can occurre, eventually resulting in gingival recesión
(Fig. 25). For example, the use of an abra-
Fig. 25. Traumatic lesiones: often self-in fl icted, oro associated with traumático
toothbrushing oro incorrect oral hygiene habits.
167
Herrera et al.

sive dentifrice and Vigorous horizontal brushing will result in an ULCER

oro an erosion in the gingivoestomatitis, frequently leading to tooth
abrasion (182, 301). The use of dental fl huesos también puede result in
gingival ulceration oro in fl ammation, especially at the most coronal part
of the interdental papilla (142).

Some physical traumático lesiones are self-induced and they are

intermedio self-induced gingitivis, patomimias, factitious lesiones oro
artifacts (14, 30, 37, 77, 120,
121, 244, 308, 309). Lesiones presente as úlceras in the gingival margin
and are associated with gingival recesión; patients are frequently
Fig. 26. Burning lesión: associated with the intake of very hot food, leading to
children oro teenagers, sometimes with psychological conditions. There lesiones with vesicles that result in erosive areas.
is a clear Tendency for recurrence, and the traumático agente can be
the fin ngers, uñas oro different instrumentos (pencil, pen, etc.) (69, 166,
253, 259).

Summary
Another group of physical traumático lesiones are related to dental
fracturas oro broken teeth, Orthodontic oro Prosthetics appliances and This is a group of periodontal lesiones, with acute onset, which are not

oral piercings (56, etiologically associated with oral bio fin lm microorganismos. However,

148, 174, 175). Normally, they are observed as úlceras oro erosiones, they result in pain and in dif fin Culties with oral hygiene practices.

but dental oro periodontal abscesses can be triggered, as well as Infectious diseases, mucocutaneous diseases and traumático oro

chronic infecciones such as subprosthesis palatitis oro lesiones such as Allergic lesiones can be included among these conditions.

as fin ssured Epulón. Frictional hyperqueratosis también puede occurre.

In addition, the risk of precancerous oro carcinoma lesiones is presente,
especially if other factores (infección, irritation, chemicals, etc.) also act In mosto casas, the gingival involvement is not severe, but it is

over the traumatized area. importante to be familiar with these lesiones because they are common
and may be a reason for emergency dental consultation. In addition,
some may represento the fin rst lesión of a severe Systemic disease, as

Ionizing radiation may cause physical injurias to the gingival tissues in mucocutaneous diseases, and they usually manifiesto with the

(320). This type of lesión is observed after irradiation therapy as part of Characteristic gingival lesión of desquamative gingivitis.

the headand-neck cancer treatment. The gingival tissues show

mucositis, with erythema, followed by Epithelial necrosis with whitish
placas, which results in bleeding surfaces after dislodging (283). Many of these conditions have the appearance of an erythematous
lesión, sometimes erosive, with pain induced by toothbrushing oro
chewing. The differential diagnosis is crucial with special focus on the

Relevant lesiones related to hot, cold oro electrical trauma are anamnesis and clinical history and progresión of the lesiones. Erosive

Uncommon, although burns caused by very hot food oro líquidos may lesiones may be the result of direct Aggression, such as trauma, oro

need emergency consultation (35, 219, 220, 236). The patient will feel indirect reactive lesiones related to dental oro iatrogénica Interventions.

pain in the Affected area, which appears with erythema oro is The próximo differential diagnosis will lead to the appropriate therapeutic

desquamated, sometimes with vesicles, erosiones oro úlcera. Normally, intervention.

diagnosis is straightforward (Fig. 26).

Chemical and pharmacological injury

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