3. INTRODUCTION
An acute lesion is of sudden onset and short duration
and is painful.
They are manifested with severe pain along with
systemic manifestations
Thus these lesions must be treated at the earliest
with a proper treatment protocol.
5. HSV- type 1
Infants/ children younger than 6 yrs
Males=females
Primary infection asymptomatic
The virus ascends through the sensory or autonomic
nerves and persists in the neuronal ganglia that innervate
the site as a latent HSV
Sunlight, fever, trauma, stress , after oral surgical
procedures
8. CLINICAL FEATURES
Intra-oral
Diffuse, erythematous, shiny
involvement of the gingiva and
adjacent oral mucosa
Varying degree of edema and
gingival bleeding
Discrete spherical grey vesicles
Primary herpetic
gingivostomatitis
9. Rupture of vesicles and formation of ulcers after 24 hrs
Ulcers– small , painful, red, elevated, halo-like margin
with depressed yellowish/greyish white central portion
Widely spread/clusters
7-10 days
No scarring
10. Soreness, difficulty in eating and drinking
Ruptured vesicles sensitive to touch, thermal changes,
foods such as condiments and fruit juices
Infants show irritability and refusal to take food
13. Fusing of infected cells
Formation of multinucleated cells and intercellular edema
Formation of intraepithelial vesicles
Rupture
Secondary inflammatory response with fibropurulent exudate
Ulcers with central portion of acute inflammation and exudation
surrounded by zone rich in engorged blood vessels
14. DIAGNOSIS
Early diagnosis important (reducing symptoms and
recurrences)
History/clinical findings
Virus culture
Immunologic tests using monoclonal antibodies or DNA
hybridization techniques
16. Erythema multiforme:
o More extensive vesicles with pseudomembrane
formation on rupture
o Tongue more involved
o Skin lesions present
o Prolonged involvement may occur for weeks
17. Stevens-Johnson syndrome: rare form of EM
characterized by hemorrhagic lesions in the oral cavity,
hemorrhagic occular lesions and bullous skin lesions
20. Recurrent aphthous stomatitis
Small well defined round shallow
ulcers, yellowish grey central
areas & red halo
H/o previous mucosal ulcers is
dignostic, unknown etiology
No diffuse erythematous
involvement of the gingiva, no
acute toxic symptoms
21. COMMUNICABILITY
Contagious
Most adults develop immunity due to infection during
childhood – subclinical infection
Hence seen in infants & children
Recent studies have demonstrated HSV in periodontal
pockets (Slots J 2000)
22. TREATMENT
Consists of early diagnosis & immediate initiation of antiviral
therapy.
Antivirals :
o Acyclovir suspension 15mg/kg is given 5 times daily for 7
days (Amir et al,1997)
o It reduces days of fever, pain, lesion and virus shedding
23. o Acyclovir does not affect normal cells but inhibits DNA
replication in HSV infected cells
o Newer antivirals like Valacyclovir and Famicyclovir can
also be used
o <3 days– antiviral
o >3 days- (immunocompetent pt) limited value
24. Palliative measures:
o Removal of food debris, plaque and supra gingival
calculus
o NSAID (FEVER AND PAIN)
o Extensive periodontal therapy to be postponed
o Local /systemic antibiotics to prevent opportunistic
infection especially in immuno-compromised patients
25. o The patient must be informed that the disease is contagious,
thus precautions must be taken (vesicles –highest viral titer)
Supportive measures:
o Copious fluid intake
o Nutritional supplements
o Topical anesthetics while eating
26. Infection of fingers of health professional treating
infected patients may occur and is known as Herpetic
Whitlows
28. Necrotizing Gingivitis, Necrotizing Periodontitis and
Necrotizing Stomatitis are the most severe inflammatory
disorders caused by plaque bacteria
They are rapidly destructive and debilitating
A distinction between these diseases has not always been
made in the literature
29. Microbial diseases affecting gingiva/ periodontium in the
context of an impaired host response
Characterized by death and sloughing of tissues
30. HISTORY
Fourth century BC, Xenophon mentioned that Greek soldiers
were affected with “sore mouth” and foul-smelling breath
In 1778, John Hunter described the clinical findings and
differentiated ANUG from scurvy and chronic destructive
periodontal disease
ANUG occurred in epidemic form in the French army in the
19th century
31. In 1886, Hersch, a German pathologist, discussed some of
the features associated with the disease such as enlarged
lymph nodes, fever, malaise and increased salivation
In 1890s, Plaut and Vincent described the disease and
attributed its origin to fusiform bacilli and spirochetes
35. ORAL SIGNS AND SYMPTOMS
Punched out, craterlike depressions at the crest of the
interdental papilla
Can extend into the marginal gingiva, attached gingiva and
oral mucosa
Grey pseudomembranous slough
Linear erythema
Removing slough exposes red, hemorrhagic, shiny surface
which bleeds easily
36. Fetid odor
Metallic taste
Increased salivation/pasty saliva
Can be superimposed on chronic gingivitis/periodontitis
Recession rather than pocket formation
37. Constant radiating, gnawing pain that is intensified on
eating spicy and hot foods and on chewing
Lesions extremely sensitive to touch
Low socioeconomic groups
Seasonal variations (Skach et al, 1970)
38. EXTRAORAL AND SYSTEMIC SIGNS AND
SYMPTOMS
Local lymphadenopathy
Fever
Increased pulse rate, leukocytosis, loss of apetite and
general lassitude additionally seen in severe cases
Insomnia, constipation, GI disorders, headache and
mental depression in children
39. OTHER SEVERE SEQUELAE
1) Fusospirochetal meningitis
2) Peritonitis
3) Pulmonary infection
4) Toxemia
5) Fatal brain abscess
6) Noma
40. CLINICAL COURSE
ACCORDING TO HORNING AND COHEN:
Stage 1 : Necrosis of tip of the interdental papilla (93%).
Stage 2 : Necrosis of entire papilla (19%)
Stage 3 : Necrosis extending to gingival margin (21%)
Stage 4 : Necrosis extending to attached gingiva (1%)
Stage 5 : Necrosis extending to buccal / labial mucosa (6%)
Stage 6 : Necrosis exposing alveolar bone (1%)
Stage 7 : Necrosis perforating skin and check (0%)
41. ACCORDING TO PINDBORG:
Stage 1: Erosion of only tip of interdental papilla
Stage 2: Lesion extending to marginal gingiva and causing
potentially a complete loss of papilla
Stage 3: Involving attached gingiva
Stage 4: Exposure of bone
42. HISTOPATHOLOGY
Microscopically the lesion is acute necrotizing inflammation of
the gingiva, involving both the stratified squamous epithelium
and the underlying connective tissue
Epithelium destroyed and replaced by meshwork of fibrin,
necrotic epithelial cells and PMN’s and various types of
microorganisms (surface pseudomembrane)
Border: Epithelium edematous and individual cells exhibit
varying degree of hydropic degeneration along with infilteration
of PMN’s in the intercellular spaces
43. Underlying connective tissue: hyperemic with numerous
engorged capillaries and dense infiltration by PMN’s (linear
erythema)
Plasma cells at the periphery(underlying chronic condition)
Epithelium and CT alterations decrease with increase in distance
from the necrotic area and gradually blends with the uninvolved
area
44. Listgarten – described four zones that blend with each other
ZONE I - BACTERIAL ZONE- The Most superficial
zone
Consists of varied bacteria, including a few spirochetes
of small, medium and large type.
ZONE II – NEUTROPHIL RICH ZONE - Contains
numerous leukocytes, predominantly neutrophils, with
bacteria, including many spirochetes of various types,
between the leukocytes
45. ZONE III – NECROTIC ZONE- Consists of disintegrated
tissue cells, fibrillar material, remnants of collagen fibers and
numerous spirochetes of the medium and large types, with
few other organisms
ZONE IV – SPIROCHETAL INFILTRATION ZONE-
Consists of well preserved tissue infiltrated with medium and
large spirochetes without other organisms.
Spirochetes have been found as deep as 300 microns from the
surface
46. ETIOLOGY
Role of bacteria
o Plaut and Vincent in 1894 and 1896, respectively
introduced the concept NUG is caused by specific
bacteria – namely a fusiform bacillus and a spirochetal
organism.
o Fusiform bacilli and a spirochetal organism are always
found in the disease.
47. Rosebury and coworkers described a fusospirochetal
complex consisting of T. marcodentium, intermediate
spirochetes, vibrios, fusiform bacilli and filamentous
organisms in addition to several Borrelia species
48. More recently Loesche and colleagues described a constant
flora and a variable flora
Constant flora :- Fusospirochetal organisms, P.
intermedia, A. odontolyticus and
various spirilla like Selenomonas
species.
Variable flora :- Heterogenous array of bacterial
types
49. Bacteriologic findings have been supported by
immunological data presented by Chung et al who
reported increased IgG and IgM antibodies to
intermediate spirochetes, P. intermedia in NUG patients
as compared to those with chronic gingivitis and healthy
controls
Metronidazole effective
50. Role of host response
Presence of organisms insufficient to cause disease
NUG is not produced experimentally in humans and
animals by inoculation of bacterial exudates from the
lesion
Characteristic lesions occurs in animals when they are
under immunosupression
Not found in well nourished individuals with fully
functional immune system
51. Immunosupression essential- NUG patients displayed
depression in leukocyte chemotaxis and phagocytosis
(Cogen et al, 1983)
Nutritional deficiency, fatigue caused by chronic sleep
deprivation, alcohol/drug abuse, psychological factors,
systemic disease
It is hence concluded that -
The specific cause of NUG has not been established & it is
produced by a complex of bacterial organisms but requires
underlying tissue changes to facilitate the pathogenic activity
of the bacteria.
HIV
52. LOCAL PREDISPOSING FACTORS
Pre-existing gingivitis
Injury to the gingiva (eg: malocclusion)
Smoking
98% pts with NUG were smokers & frequency of the disease
increases with increasing exposure to tobacco smoke
(Pindborg et al, 1951)
Preexisting chronic periodontitis, pericoronal flaps (favourable
environment for anaerobic fusiform bacilli and spirochetes)
53. SYSTEMIC PREDISPOSING FACTORS
Nutritional deficiency
Produced in animals by giving them nutritionally deficient
diet
Nutritional deficiencies diminishes immune responses and
alteres the periodontal structures, making them more
susceptible
55. Psychosomatic factors
Disease often occurs in association with stressful situations
(induction into the armed forces, school examinations)
Hypothalamic-pituitary-adrenal axis activation resulting in
cortisol secretion and decrease in immune response
56. Increase in the levels of cortisol and catecholamines
leads to reduced gingival microcirculation and salivary
flow which enhances nutrition to P.intermedia
Depression in neutrophil and lymphocyte function leads
to bacterial invasion and tissue damage.
(Johnson and Engel 1986)
57. DIAGNOSIS
Clinical findings (gingival pain,ulceration and bleeding)
Bacterial smear not definitive
Microscopic examination of biopsy specimen (TB,
neoplastic disease)
58. DIAGNOSTIC CRITERIA
By Genco, Goldman and Cohen:
Interproximal necrosis and ulceration (punched-out papillae)
Painful gingiva
Bleeding (spontaneous or on slight provocation)
Pseudomembrane (fibrin, debris)
Fever, malaise, lymphadenopathy
“Fetor Oris”
63. STREPTOCOCCAL GINGIVOSTOMATITIS
Characterized by diffuse erythema of the gingiva and other
areas of the oral mucosa
Necrosis of the gingival margin – not a feature of this
disease.
No fetid odor
Bacterial smears– streptococcal forms
Streptococcus viridans , groupA ß-hemolytic streptococcus
64. GONOCOCCAL STOMATITIS
Caused by Neisseria gonorrhoeae
Mucosa is covered with a grayish membrane that sloughs
off in areas to expose an underlying raw bleeding surface
Most common in new born due to transmission through
maternal passages
65. AGRANULOCYTOSIS
Characterized by marked decrease in number of circulating
PMN’s
Lesions similar to NUG
No marked inflammation due to diminished defense mechanism
Blood studies can be used to differentiate between NUG and
agranulocytosis
66. VINCENT’S ANGINA
Fusospirochetal infection of oropharynx and throat,
distinguished from NUG, which affects marginal gingiva.
May extend to the larynx and the middle ear
67. NUG in Leukemia
Not produced by leukemia per se , but due to reduced
host defense mechanism
NUG may superimpose on gingival tissue alteration
caused by leukemia
68. NUG IN HIV PATIENTS
Same clinical features
Extremely destructive course leading to NUP
Presenting symptom for HIV
69. COMMUNICABILITY
Not contageous
Study by King
Kitchen facilities (controlled conditions, anaerobic
environment, do not survive on utensils)
Occurrence in epidemic like outbreaks– due to common
predisposing factors
Immunosupression+bacteria
70. NUP
Extension of NUG or different disease entity
No evidence
Clinical similarities
Until distinction can be proved/disproved, classified together
Classification first adopted in world workshop in clinical
periodontics in 1989
71. Deep interdental osseous craters
Recession
HIV positive patients
Strongly associated
Marker of immune supression and diagnosis of AIDS
HIV-P
Aggressive form of chronic periodontitis
72. TREATMENT
Alleviation of the acute symptoms by reducing microbial load
and removal of necrotic tissue
Treatment of chronic disease either underlying the acute
involvement or elsewhere in the oral cavity
73. Alleviation of the generalized symptoms such as fever
and malaise
Correction of the systemic conditions that contribute to
the initiation or progression of gingival changes.
74. SEQUENCE OF TREATMENT
FIRST VISIT
Complete evaluation
Comprehensive medical history with special attention to recent
illness, living conditions, dietary backgrounds, type of
employment, hours of rest, cigarette smoking, stress levels, HIV
Examination should include general appearance, presence of
halitosis, skin lesions, vital signs, lymph nodes
75. o Characteristic lesions
o Oral hygiene (Pericoronal flap Pockets Local irritants)
o Only acutely involved areas
o Isolated with cotton rolls and dried
o Topical anesthetic
76. Area swabbed to remove pseudo membrane with moistened
cotton pellet after 2-3 min
Cleanse area with warm water
Superficial calculus removed (ultrasonic scalers)
Subgingival scaling and curettage – contraindicated
(bacteremia, extend infection to deeper tissues)
77. Surgical procedures other than emergencies postponed
until pt is symptom free for 4 weeks
Antibiotic regimen (amoxicillin 500 mg orally every 6 hrs
for 10 days) in moderate to severe cases
Metronidazole (500mg BID 7 days)
Emergency procedures along with systemic antibiotics
78. PATIENT INSTRUCTIONS
Patient told to rinse every two hours – glass full of equal
mixture of warm water and 3 % Hydrogen peroxide and /
or twice daily with 0.12%chlorhexidine
Adequate rest
Confine toothbrushing to removal of surface debris,
ultrasoft brush, bland dentrifice
79. Analgesics
Avoid tobacco, alcohol, condiments
Report back in 1-2 days
Motivation
80. SECOND VISIT
Patient condition – usually improved. Pain is diminished
or no longer present.
Areas still erythematous but without pseudomembrane
Shrinkage of gingiva – expose calculus which is then
gently removed.
Instruction same as previous visit
81. THIRD VISIT
5 days after 2nd visit
Patient should be symptom free
Repeat scaling and root planing
Discontinue hydrogen peroxide mouthwash but continue CHX
mouthwash
Patient instructed in plaque control procedures
Councelling on nutrition, habits
82. SUBSEQUENT VISITS
Tooth surfaces in the involved areas are scaled.
Plaque control is checked and corrected if required.
Patient should now be scheduled for treatment of chronic
disease.
83. GINGIVAL CHANGES WITH HEALING
Removal of pseudo membrane – exposes red crater like
hemorrhagic depression.(loss of normal barrier function
of epithelium)
Next day: Bulk and redness of crater margins reduced –
but surface shiny.(reduction in inflammation and
reepithelization)
84. Early signs of restoration of normal gingival contour and
color. (further reduction in inflammation, reestablishment of
normal barrier function including keratinization)
Final stage- Normal gingival contour, colour, consistency are
restored. Portions of roots exposed are covered by healthy
gingiva
85. ADDITIONAL TREATMENT CONSIDERATIONS
Countouring of gingiva as adjunctive procedure
Shelf like margin
Unesthetic, favours plaque retention
Systemic antibiotics/topical antimicrobials
Only in pts with systemic complications and local adenopathy
Drug therapy—adjunctive to local debridement
87. Nutritional supplements
RATIONALE
Lesions similar to NUG have been produced in animals –
with certain nutritional deficiencies
Difficulty in chewing raw fruits and vegetables may lead
to selection of diet deficient in Vit B and C.
Fewer recurrences – local treatment of NUG is
supplemented by Vit B or C.
Supplements may be discontinued after two months
88. PERSISTANT OR RECURRENT CASES
Reassessment of differential diagnosis to rule out
diseases that resemble NUG
Underlying systemic disease causing immunosupression
(HIV)
Inadequate local therapy (mandibular anterior area due to
pericoronal infection)
Inadequate compliance
99. CLINICAL FEATURES
Chronic – no clinical signs or symptoms (chronic
inflammation and ulceration on inner surface)
Acute (trauma, occlusion, foreign body impaction)
Inflammatory involvement +systemic complications
100. Red swollen suppurating lesion
Tender
Radiating pain to ear, throat, floor of mouth
Foul taste
Inability to close jaws
Swelling of cheek, lymphadenitis, trismus
Fever, leukocytosis, malaise
103. Chronic pericoronitis
Removal as a preventive measure
Acute pericoronitis
Flushing area with warm water to remove debris and
exudate
Swabbing with antiseptic after elevating the flap gently
Occlusal adjustment
104. Abscess drainage
Antibiotics
Decision to retain or extract the tooth after acute
symptoms subside
105. Decision governed by likelihood of further eruption into
good functional position, bone loss distal to second
molars
Extraction- Early extraction before root formation is
completed
106. Retaining tooth- removal of pericoronal flap using
periodontal knives or electrosurgery
109. DEFINITION
Periodontal abscess is defined as a lesion with expressed
periodontal breakdown occuring during a limited period
of time and with easily detectable clinical symptoms, and
localized accumulation of pus within the gingival wall of
the periodontal pocket (Hafstrom et al, 1994)
110. Independent disease entity (AAP world workshop, 1999)
Represents period of active tissue breakdown due to
extension of infection into intact periodontal tissues
111. CLASSIFICATION
According to location (Meng et al, 1999)
Gingival abscess
Periodontal abscess
Pericoronal abscess
According to clinical signs and symptoms
Acute abscess
Chronic abscess
112. According to number
Single
Multiple (diabetes, immunosupression)
Localized periodontal abscess in pt with
poorly controlled type 2 diabetes mellitus
113. According to aetiology
A) Periodontitis related abscess
1) Exacerbation of chronic lesion
2) Post therapy periodontal abscess
a) Post scaling periodontal abscess (Dello Russo, 1985)—
calculus impaction or obstruction
b) Post surgery periodontal abscess (Garrett et al, 1997)–
foreign body reaction, incomplete removal of calculus
c) Post antibiotic periodontal abscess (no mechanical therapy,
superinfection)
Post scaling abscess
114. B) Non periodontitis related abscess
1) Impaction of foreign body in gingival sulcus
2) Root morphology alterations– invaginated root, fissured
root, external root resorption, root tears, iatrogenic
endodontic perforations
115. GINGIVAL ABSCESS
Localized acute inflammatory lesion
that may arise from a variety of
sources such as microbial plaque
infection, trauma and foreign body
impaction
Red, smooth, fluctuant, painful
Marginal gingiva/interdental papilla
117. PERIODONTAL ABSCESS
A localized purulent infection within the tissues adjacent to
the periodontal pocket that may lead to the destruction of
periodontal ligament and alveolar bone
In patients with untreated periodontitis
Moderate to deep pockets
118. Acute exacerbation of chronic condition
Incomplete calculus removal, antibiotic therapy,
periodontal surgery
Occlusion due to deep tortuous pocket, tooth
morphology, debris, closely adapted pocket epithelium
119. ACUTE ABSCESS
Exacerbation of chronic condition due to increase in number or
virulence of bacteria combined with lowered tissue resistance
and lack of spontaneous drainage
Exudation
Sensitivity to percussion
Pain, Mobility
Tooth elevation in socket
Systemic involvement
120. CHRONIC ABSCESS
Forms when spreading infection has been controlled by
spontaneous drainage, host response or therapy
No/dull pain
Fewer/no symptoms
Fistulous tract
No systemic involvement
121. Periodontal Vs. Periapical Abscess
Periapical Abscess
•Non-vital tooth
• Caries, restoration
• No pocket
• Apical radiolucency
• No or minimal mobility
• Percussion sensitivity
• Sinus tract opens via
alveolar mucosa
•Severe, diffuse pain
Periodontal Abscess
•Vital tooth
• No caries
• Pocket, bone loss
• Lateral radiolucency
• Mobility
• Percussion sensitivity variable
• Sinus tract opens via
keratinized gingiva
•Dull localized pain
122. PREVALENCE
8-14% among all dental conditions
needing emergency treatment (Ahl et
al, 1986)
Positively correlated with pocket depth
High prevalence in molars- 50%
(Smith and Davies, 1986)
3rd most frequent dental emergency
123. PATHOGENESIS AND HISTOPATHOLOGY
Contains bacteria, bacterial products, inflammatory cells,
tissue breakdown products and serum
Occlusion of pocket lumen, extension of infection into
soft tissues
Entry of bacteria into soft tissue pocket wall
124. Accumulation of leukocytes,
connective tissue destruction,
bacterial encapsulation,
formation of pus
Central area
Rate of tissue destruction
depends on– growth and
virulence of bacteria, Ph
125. MICROBIOLOGY
Polymicrobial, mainly caused by endogenous bacteria
(Tabaqhali, 1988)
Similar to flora of chronic periodontitis
Domination by gram negative, non-motile, strict
anaerobic, rod-shaped species
Pg
136. COMPLICATIONS
A) Tooth loss
B) Dissemination of infection
1) Dissemination of bacteria inside the tissues during
therapy
2) Bacterial dissemination through blood stream due to
bacteriema from an untreated abscess
138. CONCLUSION
Acute gingival infections lead to severe discomfort and
may lead to life-threatening complications, and therefore
they need to be treated promptly
Adequate patient education and motivation is necessary
as patients do not complete the treatment once the acute
phase has subsided
139. REFERENCES
o Newman, Takei, Klokkevold, Carranza: Carrazanza’s Clinical
Periodontology, Saunders, 10th edition.
o Acute necrotizing ulcerative gingivitis: risk factors involving
host defense mechanisms.-- Yoji, Hidemi, Atsushi:
Periodontology 2000, Vol. 6, 1994, 116-124.
o Burkitt – Textbook of oral medicine
o Shafer –Textbook of oral pathology
140. o Lindhe, Lang, Karring: Clinical Periodontology and Implant
Dentistry. Blackwell Munksgaard, 5th edition.
o The Periodontal abscess– A Review: Herrera et al, JCP 2000;
27: 377-386