Necrotising Ulcerative Periodontitis

Necrotising ulcerative periodontitis is a rapidly destructive periodontal infection with necrosis of gingival tissue, periodontal ligament and alveolar bone. It sits in the spectrum of necrotising periodontal diseases, between necrotising gingivitis and necrotising stomatitis.

It is strongly linked to severe immunosuppression, especially HIV infection with CD4 count under 200 cells/mm3, and also to severe malnutrition, haematological malignancy and chemotherapy. Prevalence in untreated HIV is a few percent.

Pathophysiology. Impaired host defence allows overgrowth of spirochaetes (Treponema), fusiform bacteria and Prevotella intermedia in plaque, with invasion of the gingival tissue and necrosis of the interdental papillae.

Smoking, stress, poor oral hygiene and malnutrition add to risk. In severely malnourished children the disease can progress to noma.

Severe, deep seated pain, spontaneous gingival bleeding, foul breath and punched out, cratered interdental papillae covered by a grey slough. Attachment loss and bone exposure progress over days to weeks, and teeth become mobile.

Fever, malaise and regional lymphadenopathy can be present. Progression to necrotising stomatitis, with bone sequestrum and oroantral communication, occurs in severe disease.

Spreading facial cellulitis, trismus, dysphagia, noma like facial tissue loss, or systemic sepsis needs emergency admission.

• Clinical diagnosis from interdental necrosis, bleeding and pain, with rapid loss of attachment shown on probing and radiographs.
• HIV test with CD4 count and viral load when the status is unknown. Offer HIV testing to everyone with the disease.
• Full blood count, glucose, urea and electrolytes, and nutritional markers (albumin, ferritin, vitamin B12, folate).
• Radiographs (bitewing or panoramic) to show bone loss and sequestra.
• Swab or biopsy only when the lesion is atypical, ulcerates through bone or is not responding, to exclude leukaemia, lymphoma, tuberculosis and fungal infection.

Differential diagnosis.

• Necrotising gingivitis without attachment loss
• Chronic periodontitis
• Herpetic gingivostomatitis
• Acute leukaemia with gingival infiltration
• Desquamative gingivitis
• Noma (cancrum oris) in the malnourished child
• Osteomyelitis of the jaw

• Local debridement with ultrasonic scaling under local anaesthesia, gentle irrigation, and repeated at 24 to 48 hours. This is the main treatment.
• Chlorhexidine 0.2% mouthwash 10 mL for 1 minute twice daily for up to 2 weeks. Hydrogen peroxide 3% diluted 1 to 1 with water may be used for rinsing for a few days, but not for prolonged use.
• Antibiotics when there is fever, lymphadenopathy, facial swelling or immunosuppression: metronidazole 400 mg orally three times daily for 3 days (500 mg twice daily is an alternative), advised to avoid alcohol during and for 48 hours after treatment. If an additional agent is needed, amoxicillin 500 mg orally three times daily for 3 days, or clarithromycin 500 mg twice daily in penicillin allergy, with attention to drug interactions in people on antiretroviral therapy.
• Analgesia: paracetamol 1 g every 6 hours (maximum 4 g daily, reduced to 3 g in low weight, chronic alcohol use or liver disease) with ibuprofen 400 mg every 8 hours with food, avoided in renal impairment and in thrombocytopenia.
• Treat the cause: start or optimise antiretroviral therapy, correct malnutrition, and manage diabetes or neutropenia with the specialist team.
• Smoking cessation and oral hygiene instruction. Definitive periodontal treatment, including removal of hopeless teeth, follows after the acute phase.
• Surgical debridement and sequestrectomy for necrotic bone, and sepsis needs intravenous antibiotics and hospital care.

Special groups. Children with severe malnutrition and necrotising disease need urgent nutritional rehabilitation and parenteral antibiotics to prevent noma. Metronidazole is avoided in the first trimester when alternatives exist.

Monitoring. Review at 24 to 48 hours and at 1 week, then at 4 to 6 weeks for periodontal reassessment. Follow CD4 count and viral load with the HIV team.

Referral and escalation. Refer to a periodontist or oral medicine specialist, and to infectious diseases when HIV is new or the response is poor. Emergency admission for airway threat, spreading infection or noma.