Treating Necrotizing Periodontal Disease

Treating Necrotizing Periodontal Disease

Periodontal Disease is typically characterized as slowly developing with few clinical symptoms that alert an individual to its presence, especially in the early stages of progression.  Necrotizing Periodontal Diseases – Necrotizing Ulcerative Gingivitis (NUG) or Necrotizing Ulcerative Periodontitis (NUP) – however, are accompanied by symptoms that cause acute pain which, many times, result in an individual seeking immediate periodontal care.

When diagnosing a patient who appears to be suffering from necrotizing periodontal disease, it is important to discuss not only their dental history, but also their social history as well.  In many cases, a stressful event will be associated with the aforementioned predisposing factors such as an increase in smoking, a decrease in nutritional status, and/or a decrease in oral hygiene.  Stressful events have also been associated with an increase in corticoid steroid levels, which cause a decrease in neutrophil function, and therefore, immunosuppression.  Other disease processes that cause immunosuppression have also been associated with NUG and NUP.  In a study conducted in South Africa, nearly 70% of systemically asymptomatic patients who presented with NUG or NUP tested positive for HIV or AIDS.  Interestingly, participants in this study did not realize they were positive for HIV/AIDS prior to their positive test result.  While this figure seems high when compared to similar studies, it highlights the importance of obtaining a complete medical history, including questions regarding the possibility of HIV infection, when a NUG / NUP patient is identified.   Furthermore, practitioners should encourage those individuals to be tested for possible immunosuppressive diseases if they deny or are unaware of their status.

The information gained from a comprehensive medical history of a NUG / NUP patient should include a list of current medications, learning about any recent illnesses, any history of HIV infection, a description of the patient’s level of stress, information about his or her diet, a smoking history, and a report of any previous NUG / NUP infection.  During the clinical exam, in addition to noting oral findings such as halitosis, necrotic tissue, inflammation, oral hygiene status, and the presence of punched out papilla, attention should also be given to palpation of the lymph nodes and observation of any extraoral skin lesions — which may suggest an HIV/AIDS infection.  Full mouth periodontal probing may be delayed because often times doing so is too painful for the patient.

During the first visit supragingival plaque and necrotic pseudomembranous tissue are removed by gentle swabbing with moist gauze and with the aid of sonic or ultrasonic scalers with irrigation, which helps to lavage the area and to remove supragingival calculus.  The American Dental Association Code on Dental Procedures and Nomenclature (CDT) utilized during this first visit would be D4355 – the code for gross debridement.  It is recommended not to perform subgingival debridement because this may promote bacteremia and extend the infection deeper into the highly inflamed tissues.  If multiple teeth are involved, or if lymphadenopathy is detected during the clinical examination, it is recommended to place the patient on systemic antibiotics, with the first choice being combinations of amoxicillin and metronidazole.  Additionally, chlorhexidine gluconate 0.12% mouth rinse is prescribed to be used at least twice daily.  Pain relief can usually be obtained with non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen 600 mg – 800 mg every four to six hours.  Prescription of narcotics to address more severe pain can also be considered.

Many times once the initial pain has subsided, patients suffering from NUG or NUP will discontinue the recommended therapy.  It is important, therefore, to stress that even though the pain is subsiding, treatment is not complete and the painful lesions can recur, and to have your office staff follow up with those patients emphasizing the need to return to complete care.
The second appointment should occur two days to one week following the initial visit, and one should expect notable reductions in pain and inflammation.  Further supragingival scaling is accomplished to remove calculus that has become exposed as the erythema and edema decrease with healing.  A comprehensive exam and treatment plan can also be created at this appointment as many times the initial pain from the infection has subsided and full mouth probing is possible.  The third appointment should occur any time after one week following the initial visit.  Scaling and root planing (SRP) and any extractions that are recommended can be performed at this visit.  Following SRP, oral hygiene measures to mechanically remove bacterial plaque biofilm are stressed and further counseling regarding stress management, diet, smoking, and immunosuppression are given.

Periodontal surgery should be postponed until the patient has been symptom free for at least four to eight weeks to allow for re-epithelialization and connective tissue attachment to occur.  The interdental papilla will often return to their original state as long as minimal interproximal bone loss has occurred or tooth malposition is not present.  This process may take several weeks to months and follow up with a regular recall schedule is recommended.  In patients where the condition does not resolve, additional therapy to remove deposits that were left behind and / or medical consultations may be indicated. These conditions may have a tendency to recur and frequent periodontal maintenance visits and meticulous oral hygiene may be necessary.