Acute Gingival

Infections
NECROTIZING
ULCERATIVE
GINGIVITIS
Dr. Ahmed Tawfig
Reference: Carranzas 10th
Edn 391-397 & 706-710

 Necrotizing

ulcerative gingivitis (NUG) is

a 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
Classification
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. When bone loss occurs, the
condition is called necrotizing ulcerative
periodontitis (NUP)

 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 patients 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
First

Visit
Second Visit
Third Visit
Additional Treatment Considerations
Contouring of Gingiva as Adjunctive
Procedure.
Supportive Systemic Treatment.
Nutritional Supplements.

PRIMARY

HERPETIC
GINGIVOSTOMATI
TIS
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
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.

The

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