Acute Gingival

Infections
NECROTIZING
ULCERATIVE
GINGIVITIS

Dr. Ahmed Tawfig

Reference: Carranza’s 10th
Edn 391-397 & 706-710
Necrotizing ulcerative
gingivitis (NUG)
 isa microbial disease of the gingiva in the
background of an impaired host
response. It is characterized by the death
and sloughing of gingival tissue and
presents with characteristic signs and
symptoms.
Clinical Features
 NUG is usually identified as an acute disease.
NUG often undergoes a reduction in severity
without treatment, leading to a subacute
stage with milder clinical symptoms.
 NUG can cause tissue destruction involving
the periodontal attachment apparatus,
especially in patients with long standing
disease or severe immunosuppression.
 NUG is characterized by sudden onset of
symptoms, sometimes following an
episode of debilitating disease or acute
respiratory tract infection. A change in
living habits, protracted work without
adequate rest, poor nutrition, tobacco
use, and psychologic stress are frequent
features of the patient’s history.
 Oral Signs
 Characteristic lesions are punched-out,
craterlike depressions at the crest of the
interdental papillae, subsequently extending
to the marginal gingiva and rarely to the
attached gingiva and oral mucosa. The
surface of the gingival craters is covered by a
gray, pseudomembranous slough,
demarcated from the remainder of the
gingival mucosa by a pronounced linear
erythema
 NUG can be superimposed on chronic
gingivitis or periodontal pockets. However,
NUG or NUP does not usually lead to
periodontal pocket formation because the
necrotic changes involve the marginal
gingiva, causing recession rather than pocket
formation.
Oral Symptoms
Extraoral and Systemic Signs and Symptoms ?
 Clinical Course
 Pindborg et al. have described these stages in
the progress of NUG:
(1) erosion of only the tip of the interdental
papilla;
(2) the lesion extending to marginal gingiva and
causing a further erosion of the papilla and
potentially a complete loss of the papilla;
(3) the attached gingiva also being affected;
and
(4) exposure of bone.
 Horning and Cohen extended the staging of
these oral necrotizing diseases as follows (%
incidence among cases of NUG in the
authors’ series):
 Stage 1: Necrosis of the tip of the interdental
papilla (93%)
 Stage 2: Necrosis of the entire papilla (19%)
 Stage 3: Necrosis extending to the gingival
margin (21%)
 Stage 4: Necrosis extending also to the
attached gingiva (1%)
 Stage 5: Necrosis extending into buccal or
labial mucosa (6%)
 Stage 6: Necrosis exposing alveolar bone
(1%)
 Stage 7: Necrosis perforating skin of cheek
(0%)
Relation of Bacteria to Characteristic Lesion
 Light microscopy shows that the exudate
on the surface of the necrotic lesion
contains microorganisms that
morphologically resemble cocci, fusiform
bacilli, and spirochetes.
Diagnosis
 Diagnosis is based on clinical findings of
gingival pain, ulceration, and bleeding. A
bacterial smear is not necessary or
definitive because the bacterial picture is
not appreciably different from that in
marginal gingivitis, periodontal pockets,
pericoronitis, or primary herpetic
gingivostomatitis.
Etiology
 Role of Bacteria
 Role of the Host Response
 Local Predisposing Factors
 Systemic Predisposing Factors
 Psychosomatic Factors
 Sequence of Treatment
 FirstVisit
 Second Visit
 Third Visit
 Additional Treatment Considerations
 Contouring of Gingiva as Adjunctive
Procedure.
 Supportive Systemic Treatment.
 Nutritional Supplements.
CITEPREH PRIMARY
GINGIVOSTOMATITIS
Page no: 711-712
 Primary herpetic gingivostomatitis is an
infection of the oral cavity caused by the
herpes simplex virus type 1 (HSV-1).
 It occurs most often in infants and children
younger than 6 years of age, but it is also seen
in adolescents and adults.
 It occurs with equal frequency in male and
female patients. In most persons, however,
the primary infection is asymptomatic.
 Clinical Features
 Oral Signs
 Primary herpetic gingivostomatitis appears as
a diffuse, erythematous, shiny involvement of
the gingiva and the adjacent oral mucosa,
with varying degrees of edema and gingival
bleeding. In its initial stage, it is characterized
by the presence of discrete, spherical gray
vesicles, which may occur on the gingiva,
labial and buccal mucosae, soft palate,
pharynx, sub-lingual mucosa, and tongue.
 After
approximately 24 hours, the vesicles
rupture and form painful, small ulcers with
a red, elevated, halo-like margin and a
depressed, yellowish or grayish white
central portion. These occur either in
widely separated areas or in clusters,
where confluence occurs
 Oral Symptoms
 Extraoral and Systemic Signs and
Symptoms
TREATMENT
 Supportive treatment
 Mucosal ointments
 Antiviral chemotherapy acyclovir ointment
(apply five times daily for 5 days)
PERICORONITIS
 The term pericoronitis refers to
inflammation of the gingiva in relation to
the crown of an incompletely erupted
tooth. It occurs most often in the
mandibular third molar area. Pericoronitis
may be acute, subacute, or chronic.
 Treatment
 A. Non surgical therapy
 B: Surgical therapy:
 Operculectomy
Treatment of
Periodontal
Abscess
Page no: 714-721
 CLASSIFICATION
 A. Depending on the location of the lesion:
 • Periapical abscess
 • Periodontal abscess
 • Pericoronal abscess
 B. Depending on the course of lesion:
 • Acute abscess
 • Chronic abscess
 C. Depending on the tissue involved:
 • Gingival abscess
 • Periodontal abscess
 • Pericoronal abscess
CLINICAL FEATURES OF PERIODONTAL
ABSCESS
1. Pain of acute periodontal abscess is throbbing and
radiating whereas in chronic periodontal abscess pain
is dull and gnawing.
2. The gingiva is edematous and red, with a smooth,
shiny, ovoid elevation
3. Suppuration may be spontaneous or occur after
putting pressure on the outer surface of the gingiva.
4. Swelling
5. Sensitivity to percussion of the affected tooth
6. Tooth elevation
7. During the periodontal examination, the abscess is
usually found at a site with a deep periodontal pocket.
8. Bleeding on probing
9. Pinpoint orifice of sinus may be present. Sinus may
be covered by small, pink, bed - like mass of
granulation tissue
Acute periodontal abscess is
associated with:
Pain
Tenderness
Sensitivity to palpation
Suppuration upon gentle pressure
Chronic abscess is associated with :
Sinus tract
Usually asymptomatic
 Periodontal versus Pulpal Abscess
 Endo-perio lession