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Review Article Review Article Management strategies of necrotizing ulcerative periodontitis Sarah Abul Hasan, Dhanraj Ganapathy, Ashish R. Jain* ABSTRACT Aim: The aim of this study was to review the various literature on the signs and symptoms, diagnosis, investigation, and treatment of necrotizing ulcerative periodontitis (NUP). Background: NUP is the most severe inflammatory periodontal disorders caused by bacterial plaque and usually run an acute course. Clinical features in NUP are characterized by the presence of punched out, ulcerated and necrotic lesions that may be covered by a pseudomembrane of necrotic tissue. The ulcerations are extremely painful and show spontaneous bleeding. An important feature of NUP is the rapid and severe loss of clinical attachment and alveolar bone in few days or weeks. Other clinical features include the presence of oral halitosis, adenopathies, fever, and general discomfort. Methodology: A Medline literature search was conducted on the management of NUP. The articles ranging from 1988 to 2016 were searched. 14 articles were relevant to this review article of 43 articles that were searched. Conclusion: Early diagnosis and treatment planning is crucial in treating necrotizing periodontal diseases. In human immunodeficiency virus/acquired immunodeficiency syndrome patients, the lack of oral hygiene, plaque accumulation, and reduced CD4 counts increase the risk factor for periodontal diseases and other opportunistic infections. KEY WORDS: Acquired immunodeficiency syndrome, Gingival bleeding, Human immunodeficiency virus, Necrotizing ulcerative gingivitis, Necrotizing ulcerative periodontitis INTRODUCTION in children and young adults, military personnel, and immunocompromised individuals, especially Necrotizing ulcerative periodontitis (NUP) is a those with human immunodeficiency virus (HIV) severe inflammatory periodontal disorder caused or acquired immunodeficiency syndrome (AIDS).[3] by bacterial plaque and usually follows an acute Approximately 43 articles ranging from 1988 to 2016 [1] course. The pathognomonic clinical feature of were searched, of which 14 articles were relevant to NUP is the destructive progression of the disease this review. that includes periodontal attachment and bone loss. The distinguishing features of NUP are the punched DISCUSSION out appearance and interproximal craters that may be covered by pseudomembranous necrotic tissue. The NUG, NUP, and necrotizing ulcerative stomatitis are ulcerations are extremely painful and there may be severe periodontal diseases that have an acute course. spontaneous bleeding.[2] NUP may be an extension The features of NUG consist of areas of ulceration of necrotizing ulcerative gingivitis (NUG) into the and necrosis of the interdental papilla covered by periodontal structures resulting in loss of periodontal a whitish-yellow pseudomembrane and surrounded attachment and bone loss. Numerous predisposing by erythematous halo. The lesions are painful, factors have been listed including poor oral hygiene, bleed easily and the patients also present with oral preexisting periodontal disease, malnutrition, smoking, malodor, localized lymphadenopathy, fever, and viral infections, immunocompromised status, and malaise. The bacterial flora commonly associated psychological stress. The disease commonly occurs with NUG lesions are Prevotella intermedia, Treponema, Selenomonas, and Fusobacterium Access this article online species.[4] However, host response and resistance are an important factor in the pathogenesis of NUG. NUP Website: jprsolutions.info ISSN: 0975-7619 is defined by necrosis and ulceration of the coronal Department of Prosthodontics, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India *Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha University, Poonamallee High Road, Chennai - 600 127, Tamil Nadu, India. Phone: +91-9884233423. E-mail: dr.ashishjain_r@ yahoo.com Received on: 18-07-2018; Revised on: 22-08-2018; Accepted on: 27-09-2018 Drug Invention Today | Vol 10 • Special Issue 3 • 2018 3289 Sarah Abul Hasan, et al. portion of the interdental papilla and gingival margin HIV-positive and AIDS patients have a diminished host with a painful, erythematous marginal gingival that immune response. An impaired T-cell function and bleeds easily. Deep osseous craters is a characteristic altered T-cell ratios present in immunocompromised of necrotizing ulcerative periodontitis. The ulcerative patients predispose them to NUG and NUP. and necrotizing nature of NUP results in destruction There is a depression in the phagocytic activity of of the marginal epithelium and connective tissue polymorphonuclear neutrophils (PMNs) in patients resulting in gingival recession. In advanced cases with NUP. Patients with NUP were diagnosed with of NUP, there are severe bone loss, tooth mobility, dysfunctioning of the PMNs, defective mitogenic and ultimately tooth loss. The progression of NUP lymphocyte reaction, and a reduced expression of beyond the mucogingival junction is characteristic of immunoglobulins.[10] There is a shift in oral disease necrotizing ulcerative stomatitis.[3] in patients undergoing highly active antiretroviral therapy.[7,11] A study conducted by Gnanasundaram to identify the oral manifestations of HIV/AIDS in patients Severe malnutrition contributes to decreased host from India. He reported that there were 15 response to infections and necrotizing diseases. different lesions that were exhibited in HIV/AIDS Impairment of the host defenses such as phagocytosis, patients.[5] The oral manifestations are increased in cell-mediated immunity and complement cascade, and case of full-blown AIDS due to its severity. Of the antibody and cytokine production and function are 86% of patients affected with oral manifestations, seen in malnourished individuals. The mechanisms 34.77% had pseudomembranous candidiasis, 12.8% that predispose an individual with stress to necrotizing had atrophic candidiasis, 10% had NUG, 8.8% had periodontal diseases are due to the increased systemic hairy leukoplakia, 6.9% had angular cheilitis, 5.4% cortisone levels which have a suppressive action on had oral ulcers, 4.7% had hypertrophic candidiasis, immune response. However, evidence supporting the etiological role of stress on the pathogenesis of NUP 4.57% had NUP, 3% had herpes simplex, 1.86% had is not clear.[10] herpes zoster, 1.5% exhibited gangrenous stomatitis, 1.5% pigmented lesions, 1.35% had oral warts, and Diagnosis 0.16% exhibited Kaposi sarcoma.[5] The diagnosis of NUP is based on the clinical Etiological Factors presentation of the disease. The characteristic features of NUP are punched out lesions and interdental A mixed fusiform-spirochete bacterial flora plays a craters, attachment loss, bone loss, mobility of the key role in the pathogenesis of NUP.[6] The microbial affected teeth, oral malodor, pain (mostly felt deep composition of NUP lesions in HIV patients is similar within the bone), and, in severe cases, localized to the microbial composition of NUG lesions. NUP is lymphadenopathy. commonly associated with the diagnosis of AIDS or HIV- positive status.[7] Murray et al. reported significantly Studies have shown that 40% of HIV-positive higher numbers of opportunistic fungus Candida patients exhibited one or more HIV-associated albicans and a higher prevalence of Actinobacillus, oral manifestations and these rates increased to Aggregatibacter actinomycetemcomitans, P. intermedia, over 90% when the patient reaches late stages of Porphyromonas gingivalis, Fusobacterium nucleatum, immunosuppression caused due to the infection. and Campylobacter species. This study was conducted Candidiasis and oral hairy leukoplakia are the in cases of NUP in HIV- positive and AIDS patients.[8] most common oral lesions seen in HIV-positive patients. According to EC-Clearinghouse on Oral Feller and Lemmer suggested that spirochetes, Problems Related to HIV Infection and WHO herpes viruses, candida, and HIV have a pathogenic Collaborating Centre on Oral Manifestations of the role in NUP lesions in a HIV-seropositive Immunodeficiency Virus (1993), periodontal diseases patient.[6] Spirochetes have the ability to modulate the are classified under oral manifestations of HIV. The host innate and adaptive immunity and stimulate the classification consists of linear gingival erythema, host inflammatory response. This results in decreased NUG, and NUP.[4,12] local immune response and facilitates necrotizing disease.[9,10] Activated herpes viruses have the potential Treatment to deregulate the host immune system which results The objective of the treatment in the acute phase in the colonization and activity of other pathogenic should be pain relief and rapid elimination of the microorganisms.[9] C. albicans produces eicosanoids disease. Hydrogen peroxide and other oxygen- which result in the release of pro-inflammatory releasing agents are used in the treatment of mediators which facilitate spirochete colonization necrotizing periodontal diseases due to the effect and invasion, thus promoting the development of of the released oxygen on the anaerobic bacteria. necrotizing diseases. 3% hydrogen peroxide is used to clean the necrotic 3290 Drug Invention Today | Vol 10 • Special Issue 3 • 2018 Sarah Abul Hasan, et al. tissue in the form of oral rinses (equal proportions REFERENCES of 3% hydrogen peroxide and hot water). A recent study has reported shallower residual
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