Periodontology Diagnosis - Necrotizing Periodontal Disease

Necrotizing periodontal diseases is one of the seven different categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. It is also one of the three different classifications of periodontal diseases and conditions included in the 2017 classification.

The 1999 classification system includes the following categories:

• Gingivitis
• Chronic Periodontitis
• Aggressive Periodontitis
• Periodontitis as a manifestation of systemic disease
• Necrotizing Ulcerative Gingivitis/Periodontitis
• Abscesses of the Periodontium
• Combined Periodontic-Endodontic Lesions

Necrotizing periodontal diseases are a form of inflammatory periodontal or gum disease. They are caused by bacteria, particularly fusobacteria and spirochaete species. These types of diseases have a sudden onset, hence why the term “acute” is commonly used for the diagnosis. The mildest form on the spectrum is necrotizing ulcerative gingivitis (NUG). This is then followed by more severe conditions which include necrotizing ulcerative periodontitis (NUP), necrotizing stomatitis and finally, cancrum oris (noma), which can be fatal.

Necrotizing ulcerative gingivitis (NUG), which is also called necrotizing gingivitis (NG), is a common infection in the gums. Acute necrotizing ulcerative gingivitis (ANUG) is the acute form of NUG, and a natural progression of the disease. When it is not properly treated, NUG can become chronic and reoccur. In developed countries, ANUG primarily occurs in young adults who have another contributing factor such as sleep deprivation, poor oral hygiene, smoking, and has poor nutrition. In developing countries, ANUG is most prevalent in malnourished children. Because of the common predisposing factors in a population, ANUG often occurs in an epidemic-type pattern. This leads some people to believing that ANUG is contagious, however, it is not. The primary symptoms of NUG include painful, bleeding gums, ulcers, and necrosis of the interdental papilla. Patients may also experience halitosis, swollen lymph nodes, and discomfort. The acute disease is treated with the removal of the infected tissue and antibiotics. The patient may also need to correct poor oral hygiene or stop smoking in order to prevent the disease from returning. Another term used for ANUG is “trench mouth”, because it occurred in the mouths of front line soldiers in World War I.

Necrotizing ulcerative periodontitis

Necrotizing ulcerative periodontitis (NUP), or necrotizing periodontitis (NP), or acute necrotizing ulcerative periodontitis (ANUP) occurs when the infection results in attachment loss. The disease occurs in the gingiva, periodontal ligament and alveolar ligament. In most cases, the disease results in the loss of attachment. As a result, many ANUG diagnoses may actually be called NUP. Though ANUG is most commonly used. NUP can also be an extension of NUG which reaches into the periodontal ligaments. NUG and NUP are usually classified together under the term necrotizing periodontal diseases.

Necrotizing stomatitis

The progression of NUP into the tissue beyond the mucogingival junction is a feature of necrotizing stomatitis. Necrotizing stomatitis shares has many features in common with cancrum oris.

Cancrum oris, which is also called noma, is the necrotizing and destructive infection of the mouth and face. Because it impacts areas outside the mouth, it is not specifically a periodontal disease. This condition is commonly found in malnourished children from developing countries. The disease can cause disfiguration and is often fatal. While some suggest that cancrum oris develops from pre-existing cases of NUG, this has not been confirmed. In addition, most cases of NUG and NUP do not progress into the more severe forms, even when the patient does not seek treatment.