Necrotizing Ulcerative Periodontitis in a HIV Seronegative Patient

Case Reports in Odontology

Journal homepage: http://www.casereportsinodontology.org

Necrotizing Ulcerative Periodontitis in a HIV Seronegative Patient– A Case Report [PP: 05-09] Syed Wali Peeran Karthikeyan Ramalingam Department of Periodontology and Oral Implantology Department of Oral Pathology & Microbiology Faculty of dentistry, Sebha University Faculty of dentistry, Sebha University Sebha, Libya Sebha, Libya [email protected]

Syed Ali Peeran Yasmen Elhadi Elamin Elsadek Department of Oral and maxillofacial Prosthodontics Faculty of Dentistry, Sebha University Faculty of Dentistry, Jazan University Sebha, Libya Jazan, KSA

ARTICLE INFO ABSTRACT Article History Paper received on: Necrotizing ulcerative periodontitis (NUP) is characterized by soft tissue 03/03/2014 necrosis, rapid periodontal destruction, and interproximal bone loss. Accepted after review on: Unlike other periodontal diseases, it presents with substantial necrosis of 02/04/2014 gingival tissues, and loss of periodontal ligament and alveolar bone. Published on: 01/06/2014 Herewith, we present a case report of NUP in a patient of Libyan origin. Keywords To the best of our knowledge, it is the first case report from Libya in Necrotizing ulcerative English literature. periodontitis, HIV seronegative, Libyan origin

Cite this article as: Syed, W. P., Ramalingam, K., Syed, A. P., & Elsadek, Y. E. (2014) Necrotizing Ulcerative Periodontitis in a HIV Seronegative Patient – A Case Report. Case Reports in Odontology. 1(1), 05-09 Retrieved from http://www.casereportsinodontology.org

Case Reports in Odontology Volume: 1 Issue: 1 January-June, 2014

he was a heavy smoker, smoking 50 Introduction cigarettes per day and had been smoking for Necrotizing ulcerative periodontitis 15 years. Past medical history revealed (NUP) is the most severe inflammatory episodes of heavy stress. Past dental history periodontal disorder caused by plaque revealed that he had experienced mobility of bacteria. Unlike conventional periodontitis, multiple teeth with spontaneous exfoliation NUP is characterized by clinical features and extraction of affected teeth. HIV such as soft tissue ulceration and necrosis serostatus was negative. usually arising from the interdental papillae, The intraoral examination revealed severe profuse bleeding on provocation, and pain.1 ulcerations and necrosis of the marginal Compared to chronic or aggressive gingiva and the interdental papillae of the periodontitis, one of the most important mandibular central incisors, where the features of NUP is the rapid and severe loss alveolar bone was exposed (Figure 1). There of clinical attachment and alveolar bone was severe necrosis involving the gingiva of within a few days or weeks 2. The prevalence right maxillary molars (Figure 2), left for NUP is about 0.5% and decreases with maxillary premolars and molars (Figure 3) age.3, 4 along with left mandibular third molar In addition to the presence of human regions. The affected teeth exhibited severe immunodeficiency virus (HIV), other mobility. He was also partially edentulous predisposing factors for NUP are history of with multiple missing posterior teeth and had NUP, poor oral hygiene, inadequate sleep, extensive alveolar bone loss as shown in unusual psychologic stress, poor diet, recent OPG (Figure 4). illness, alcohol abuse, and smoking. Usually, The patient was advised acute phase one of these factors alone is not sufficient to management with removal of soft & establish disease, except for HIV4. Although mineralized deposits through complete oral a characteristic bacterial flora of spirochetes prophylaxis. He was also advised oral rinse and fusobacteria can be isolated from these with 0.12% chlorhexidine. The patient has lesions, it still remains unclear whether these not yet returned for initiating the treatment bacteria are primarily involved in causing the regimen. disease.5 Herewith, we report the first case Discussion report of NUP from Libya in English Bacterial plaque is the main etiological literature. factor of periodontal disease6. The characteristics of NUP include acute and Case Report intense pain, abundant gingival hemorrhage, A 32-year-old male patient of Libyan halitosis, loss of periodontal insertion, and origin, reported to the outpatient department occasional bone exposure. Crater-like lesions of Faculty of Dentistry, Sebha University, are formed in the gingival tissue, while Sebha, Libya. He complained of severe oral necrosis and ulcerations are seen in interproximal papillas, which are directly pain, intermittent swelling of the cervical 7, 8 lymph nodes and fever. He also complained associated with the regions of bone loss. of severe mobility of his teeth and difficulty NUP is more frequently seen as a localized in mastication. Personal history revealed that lesion, with areas of gingival tissue necrosis, Cite this article as: Syed, W. P., Ramalingam, K., Syed, A. P., & Elsadek, Y. E. (2014) Necrotizing Ulcerative Periodontitis in a HIV Seronegative Patient – A Case Report. Case Reports in Odontology. 1(1), 05-09 Retrieved from http://www.casereportsinodontology.or Page | 6

Case Reports in Odontology Volume: 1 Issue: 1 January-June, 2014 surrounded by areas of unaffected tissue. The irrigation with 10% povidone-iodine, or 2% formation of periodontal pockets is rare, and sodium iodide mixed in equal proportions the crestal bone loss coincides with gingival with 10 volumes of oxygenated water. These necrosis, leading to the exposure of alveolar substances have antimicrobial activity and bone and areas of intra-septal bone immediately reduce discomfort. Oral hygiene sequestration. Pain is often described as a instructions along with analgesics like “profound tooth ache” or as “pain in the paracetamol 500mg every 4 hours and anti- bones of the mouth” that does not yield to inflammatory drugs like ibuprofen 400- analgesics.9, 10 Spontaneous nocturnal 600mg every 8 hours, can be given for relief hemorrhage may also be seen6. The of fever, necrosis, bone exposure, or severe pathogenesis of the NUP appears to involve pain10. diverse etiologic factors like malnutrition, The antibiotic of choice is tobacco smoking, intravenous drug use, metronidazole 500 mg every 12 hours or 250 psychological stress, and mg every 6 hours, for 7 days 11. Mouth immunosuppression, the latter two being washes with 0.12% chlorhexidine gluconate interrelated through the hypothalamic– every 8 h must also be recommended to pituitary–adrenal axis 11. Our patient prevent and control plaque formation10. presented with history of excessive smoking The second stage includes mechanical along with stress episodes. debridement to remove calculus and necrotic The clinical appearance of NUP can be tissues6. The third stage consists of very variable. Initial lesions may not show maintenance and follow-up. The follow-up is radiographic evidence of bone loss and tooth performed initially every month, which can mobility. Moderate NUP generally involves be postponed to every three months after the the entire attached gingiva with partial bone stabilization of the periodontal condition10. exposure and sequestration to the Microscopic studies and cultivation of mucogingival junction. Severe NUP the predominant microbes associated with manifests as extensive necrosis of gingival NUG have consistently found significant tissue and alveolar bone that extends beyond levels of Prevotella intermedia, the mucogingival junction. Widespread bone Fusobacterium sp., and Treponema sp. loss and significant tooth mobility leads to Several investigators have also reported high loss of the involved teeth10. Our patient had a recovery rates of microbes not generally history of teeth mobility and exfoliation of associated with the indigenous oral microbial those mobile teeth. He also presented with flora, e.g. Enterococcus sp., Clostridium sp., extensive necrosis of multiple quadrants with Klebsiella sp., Pseudomonas sp., bone destruction and mobility of teeth. Enterobacter sp and Candida sp 12. Differential diagnosis of NUP could Nowadays, lasers are used in dentistry include Acute herpetic gingivostomatitis, as an adjunct to new therapies in order to Desquamative gingivitis, Agranulocytosis, obtain better results, improved treatments Leukemia, Noma & Necrotizing stomatitis. and consequently faster healing of injured NUP does not respond to conventional tissues.11 Low level laser therapy has been treatment6. The treatment of NUP is shown to be efficient in cicatrization, performed in stages. In the first session, reducing inflammatory conditions and symptomatic pain relief is achieved with accelerating tissue repair. Lasers can benefit

Case Reports in Odontology Volume: 1 Issue: 1 January-June, 2014 in alleviation of severe, uncontrollable pain 6. Shulten EA, Kate RW, Van Der Wall I. Oral with its analgesic and anti-inflammatory Manifestations of Hiv Infection In 75 Dutch effects. 10 Healing effects of laser may be Patients. J Oral Pathol Med 1989; 18:42-46. based on the improvement of local 7. Kenrad B, Rindum JL, Pindbord JJ. Oral microcirculation and stimulation of fibroblast Findings in 23 Patients with Antibodies against Hiv (Human Immunodeficiency proliferation, yielding a more organized Virus). Tandlaegerbladet 1987; 91:100-102. production of collagen fibers, increasing 8. Souza LB, Pinto LP, Medeiros AMC, Araújo granulation tissue, and promoting a 12 Jr RF, Mesquita OJX. Manifestações Orais concomitant and rapid epithelial healing . em Pacientes com AIDS em uma População Brasileira. Pesq Odont Brás, 2000; 14:1: 79- Conclusion 85. We have reported a rare presentation 9. Winkler JR, Murray RA, Greenspan D, Greenspan JS. Aids Virus Associated With of NUP in a HIV seronegative patient. The Periodontal Disease. J Dent Res 1986; 65: etiology of our patient could be attributed to Abstract 139. smoking and episodes of stress accompanied 10. Elcio MG, Rosemary BM, Jose JM, Nicolau with poor oral hygiene. The true cause of T. Use of GaAlAs Laser in the Treatment of such diseases could be elucidated only with Necrotizing Ulcerative Periodontitis in further microbiological and immunological Patients Seropositive for HIV/AIDS. J Oral evaluation. Laser Application 2007; 7: 55-64. 11. Cobb CM, Ferguson BL, Keselyak NT, Holt References LA, Macneill SR, Rapley JW. A TEM/SEM 1. Murayama Y, Kurihara H, Nagai A, Study of the Microbial Plaque Overlying the Dompkowski D, Van Dyke TE. Acute Necrotic Gingival Papillae of HIV- necrotizing ulcerative gingivitis: Risk factors Seropositive, Necrotizing Ulcerative involving host defense mechanisms. Periodontitis. J Periodont Res 2003; 38:147- Periodontol 2000 1994; 6:116–124. 155. 2. Ouhayoun JP, Goffaux JC, Sawaf MH, 12. Giovani EM, et al. Effects of low-level laser Shabana AH, Collin C, Forest N. Changes in therapy in HIV/AIDS positive patients after cytokeratin expression in gingiva during exodontic procedures. J Oral Laser Applic inflammation. J Periodontal Res 1990; 2003; 3:109-115. 25:283–292. 3. Liu RK, Cao CF, Meng HX, Gao Y. Polymorphonuclear neutrophils and their mediators in gingival tissues from generalized aggressive periodontitis. J Periodontol 2001; 72:1545–1553. 4. Tiitta O, Luomanen M, Hietanen J, Virtanen I. Tenascin expression in mucocutaneous diseases and related lesions of human oral mucosa. Arch Oral Biol 1995; 40:1039– 1045. 5. Johnson BD, Engel D. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. J Periodontol 1987; 57:141–150.

Case Reports in Odontology Volume: 1 Issue: 1 January-June, 2014

Legends:

Figure: 3 Clinical picture showing gingival necrosis

Figure:1 Clinical picture showing extensive gingival and bone loss in left maxillary posterior region. necrosis in mandibular incisor region. Pseudomembrane is absent due to recent usage of Pseudomembrane is absent due to recent usage of oxygenating mouthrinse. oxygenating mouthrinse.

Figure: 4 Orthopantomograph showing wide-spread Figure:2 Clinical picture showing severe bone loss bone loss in mandibular anterior region, maxillary with gingival necrosis in right maxillary molar and mandibular posterior region. region. Pseudomembrane is absent due to recent usage of oxygenating mouthrinse.