What is Necrotizing Periodontal Diseases?
Necrotizing periodontal diseases (NPDs) are a group of oral health problems that include necrotizing gingivitis (NG), necrotizing periodontitis (NP), necrotizing stomatitis (NS), and in severe cases, noma (also known as cancrum oris). These conditions progress in stages, originating from the same causes and typically displaying similar symptoms. Common signs of these diseases include pain, gum tissue death, mouth sores, and in severe cases, death of bone tissue.
Necrotizing gingivitis is the most common form of these diseases. It may worsen to necrotizing periodontitis, particularly in individuals with weakened immune systems. In this stage, tissue damage is confined to small triangular pieces of gum between the teeth (interdental papillae), resulting in a distinct ‘punched-out’ appearance. At this point, the damage hasn’t led to loss of connection between tooth and gum and can be reversed with treatment. If left untreated, necrotizing gingivitis can lead to rapid gum damage, the formation of a false membrane, and body-wide symptoms like fever, increased body temperature (pyrexia), and swollen lymph nodes (lymphadenopathy). This condition is known as necrotizing periodontitis.
Although rare, the disease can further worsen to affect the bone that houses the teeth, leading to death and shedding of bone tissue (osteonecrosis and sequestration). This advanced stage is known as necrotizing stomatitis. The most severe form of these diseases is noma, a rapidly spreading oral and facial tissue death that isn’t contagious. This condition primarily affects malnourished children in underdeveloped, tropical regions like sub-Saharan Africa. Noma quickly attacks both soft and hard facial tissues and can be life-threatening.
What Causes Necrotizing Periodontal Diseases?
Although infections are sometimes the cause of necrotizing periodontal diseases, which are severe gum infections, the most common risk factor is having a weakened immune system. This means that these types of gum disease are often found in people who have conditions that weaken their immune systems, especially HIV. People with HIV who have a CD4 count—a measurement of the immune system’s health— under 200 have a greater risk of getting necrotizing periodontal diseases than any other group. However, other conditions such as leukemia, diabetes, neutropenia, and long-term use of medicines that suppress the immune system can also increase this risk.
Additional factors that may contribute to getting these diseases include smoking tobacco, experiencing unusual levels of stress, severe malnutrition, poor sleeping habits, and not taking care of your oral hygiene. Most cases of necrotizing periodontal diseases are seen in people who smoke. Not eating well has also been identified as an important risk factor. In wealthy countries, these diseases are seen in people who eat poorly, such as college students. In developing countries, they are often seen in young children who do not consume enough protein. It’s also worth noting that those who have had necrotizing gingivitis, a type of gum inflammation, are at heightened risk of developing necrotizing periodontitis.
Particular types of harmful bacteria have been found in the dead tissue connected with these diseases. Additionally, antibiotics have been shown to lessen symptoms during the disease’s acute, or intense, phase, which suggests bacteria play a role in these diseases. However, it’s not clear whether these organisms cause the disease or if they thrive because of the weakened immune system. It’s also important to note that these diseases are not known to be contagious, implying that the causes are not external but rather connected to the person’s individual health factors.
The exact cause of necrotizing periodontal diseases is not fully understood, but evidence suggests that the diseases could occur when an existing gum disease gets the chance to worsen and cause more damage.
Risk Factors and Frequency for Necrotizing Periodontal Diseases
Necrotizing periodontal diseases, or NPDs, are relatively rare, affecting less than 1% of the global population. These diseases commonly affect young adults aged 18 to 30, malnourished children, and individuals with weakened immune systems. NPDs are often more prevalent in countries with lower socioeconomic statuses and are rare in developed countries.
The key risk factor for NPDs is malnutrition, particularly low protein intake. This is why the diseases are often seen among very young children in developing countries. Other factors that can increase the risk of NPDs include tobacco smoking and poor oral hygiene. These factors are particularly common in emerging countries.
- Necrotizing periodontal diseases affect less than 1% of the global population.
- They are common in young adults aged 18 to 30, malnourished children, and immunocompromised individuals.
- These diseases are more prevalent in lower socioeconomic countries and rare in developed countries.
- Malnutrition, especially low protein intake, is a key risk factor.
- These diseases are common in very young children in developing countries because of malnutrition.
- Tobacco smoking and poor oral hygiene, common in emerging countries, also increase the risk of NPDs.
Signs and Symptoms of Necrotizing Periodontal Diseases
Necrotizing periodontal diseases often occur in people who have a compromised immune system or are experiencing a high level of stress. Smoking is also a risk factor that could increase a person’s susceptibility to these diseases. Symptoms of this condition generally include severe pain in the mouth, an unpleasant smell and a fast onset of symptoms. Necrotizing periodontitis, a type of these diseases, can lead to the quick loss of the gums’ attachment to the teeth over a few days.
Sometimes, this condition can cause swelling in the lymph nodes near the affected region, fever, and a general feeling of tiredness or discomfort. Unlike regular gum diseases, necrotizing periodontal diseases are very painful, which can lead to neglect of oral hygiene due to pain and can contribute to bad breath. As a result of the pain, patients might also eat and drink less, which could lead to malnourishment and can worsen symptoms such as fever or general fatigue.
The most noticeable sign of these diseases is often tissue death, which appears as ulcerated and necrotic gums with a unique “punched-out” or “cratered” look. This dead tissue is covered by a pseudomembrane made up of plasma proteins and white blood cells. If the condition progresses from gingivitis to periodontitis, it results in the loss of the periodontal ligament and alveolar bone. There can also be a red line marking the area between the ulcerated zone and the healthy gum tissue. Bleeding may be easily triggered or could occur spontaneously.
One of the key features of necrotizing periodontitis is the loss of attachment between the gums and the teeth. However, deep periodontal pockets are rare, because these diseases progress so rapidly that there’s little time for such pockets to form. In advanced cases called necrotizing stomatitis, destruction extends beyond the gum line to damage oral mucosa and bone, possibly causing necrosis and sequestration, or shedding, of the alveolar bone.
Testing for Necrotizing Periodontal Diseases
Necrotizing periodontal diseases (NPDs) are identified by a clinical inspection, which should include a complete mouth and face examination. It’s important for your doctor to also check for any facial swelling or enlarged lymph nodes. It’s important to know that a biopsy, which is a sample of tissue taken from the body to examine more closely, helps little in this case, as it only shows universal inflammation and doesn’t provide specific information about NPDs.
X-rays can be quite useful for NPDs. They can show how much bone loss has occurred around your teeth, helping the doctor understand the severity of your condition. However, the x-ray findings could differ vastly: in some cases, significant changes can be seen in the bone while in others, very few changes might be apparent.
Sometimes, the decayed bone could appear as a “moth-eaten” patchy area on the x-ray, but this can be confused with other conditions like medication-related bone death of the jaw, radiation-related bone death, and bone infections. Dense areas may be seen on the x-ray, which corresponds to sections of dead bone. Computed tomography (CT) scans can be more valuable in distinguishing the exact bone disorder.
However, a definite diagnosis will come from your medical history and clinical check-up. Blood tests can be requested to check for conditions that might predispose you to NPDs, like leukemia, neutropenia (which is a low count of a type of white blood cell), and agranulocytosis (which is a severe reduction in one type of white blood cells).
Treatment Options for Necrotizing Periodontal Diseases
Necrotizing gingivitis and necrotizing periodontitis are types of gum disease that are primarily treated using local methods. How these conditions are treated depends on how far the disease has progressed and how severe it is. Generally, the following steps are taken to manage these diseases:
First, a dentist will gently clean the affected area under local anesthesia. This process is called mechanical debridement. The dentist may also use a cotton pellet soaked in a 0.12% solution of chlorhexidine, a type of antiseptic, to remove a layer of tissue that forms due to the disease. Following these procedures, the dentist will provide instructions on maintaining good oral hygiene at home. This might include regular use of a 0.12% chlorhexidine mouthwash or a hydrogen peroxide mouth rinse to keep the mouth clean and prevent infection.
In some cases, non-steroidal anti-inflammatory drugs (NSAIDs), a type of pain killer, could be recommended to help manage pain. If the patient shows signs of systemic involvement, meaning the disease is affecting the body beyond the mouth (indicated by fever, general feeling of discomfort or illness, or swollen lymph nodes), they may be prescribed antibiotics. Metronidazole is usually the first choice due to the specific bacteria involved in these conditions. Amoxicillin is an alternative, especially if the patient cannot take metronidazole.
It’s also important to identify and address what might have caused these conditions. Common risk factors such as tobacco use, psychological stress, and poor nutrition should be managed to reduce the chances of the disease reoccurring. People with these gum diseases should also be checked for underlying conditions that may weaken the immune system, like HIV, as these could worsen the dental issues. If such conditions are found, they need to be treated alongside the dental therapy.
Additionally, patients may be advised to take vitamin supplements, avoid spicy food, stay hydrated, and get sufficient sleep. It’s very important to return to the dentist for review and maintenance to improve the prognosis for these conditions.
Necrotizing periodontitis not only causes damage to the gums (soft tissue) but also to the alveolar bone (hard tissue) that holds the teeth in place. As a result, it might create defects or abnormalities that make it difficult to maintain oral hygiene. After the initial treatment phase, patients may need additional treatments to fix these defects. These could include surgery to reshape the gums (gingivoplasty) for smaller tissue defects or surgery to reshape the bone (osteoplasty) for larger defects.
What else can Necrotizing Periodontal Diseases be?
When trying to diagnose necrotizing periodontal diseases, doctors must first rule out a variety of other conditions that may present with similar symptoms. These include:
- Oral Mucositis (a painful condition that causes sores in the mouth)
- HIV-associated Periodontitis (gum disease related to HIV)
- Herpes simplex virus infections (HSV)
- Scurvy (a deficiency of vitamin C)
- Gingivostomatitis (an inflammation of gums and mouth)
- Desquamative Gingivitis (a condition that results in gum redness and soreness)
- Invasive fungal diseases
- Gum diseases related to illicit drug use
- Agranulocytosis (a serious condition where white blood cell count is greatly reduced)
- Leukemia (a type of cancer that affects blood and bone marrow)
- Chronic Periodontitis (long-term gum infection)
Physicians need to carry out suitable tests and have a detailed discussion about the patient’s medical history to make an accurate diagnosis.
What to expect with Necrotizing Periodontal Diseases
It’s not unusual for necrotizing periodontal diseases, diseases that cause severe gum damage, to happen again, so regular check-ups are recommended to keep an eye out for any signs of the disease returning. Furthermore, how these diseases are managed greatly affects the likely outcome.
The outlook tends to be better if patients can improve their risk factors such as better oral hygiene (taking good care of teeth and gums), a balanced diet, less psychological stress, and stopping smoking. Also, treating related health conditions like HIV may help boost the patient’s immune system, which can lead to an improved outlook.
Possible Complications When Diagnosed with Necrotizing Periodontal Diseases
Necrotizing periodontal diseases can lead to several complications, mostly due to the fact that these diseases can cause destruction in the mouth. The following are some of the complications that can occur:
- Loss of teeth
- Increase in the loss of attachment of teeth
- Significant damage to the soft tissues in the mouth
- Exposure of the alveolar bone, which is the bone in the jaw that holds the teeth
- Removal of fragments of bone
- Bacteria entering the bloodstream
- Loss of weight and dehydration
Preventing Necrotizing Periodontal Diseases
It’s crucial for people who are at risk of necrotizing periodontal diseases (serious gum infections) to understand the importance of maintaining good oral hygiene and a healthy diet. These steps can help prevent the onset and recurrence of these diseases. A team of health professionals from various fields should collaborate to identify, monitor, treat, and manage these diseases in patients. They’ll also focus on treating any underlying conditions that may be present.
Patients must know the significance of promptly recognizing any signs and symptoms of necrotizing periodontal diseases. Quick identification allows for immediate and effective treatment, which can minimize the damage caused by these diseases.
