Introduction

Periodontal diseases are the diseases that affect the tissues surrounding the tooth (gum, bone, cementum, and periodontal ligament). In 1999, the term necrotising ulcerative periodontitis was introduced at the workshop on periodontal disease classification. 

Necrotising ulcerative periodontitis includes–Necrotising ulcerative gingivitis and necrotising ulcerative periodontitis.¹

The first documented case of NUG is among the military personnel during the Second World War as a result of stress, anxiety, nutritional deficiencies, tobacco smoking, and poor oral hygiene.²

Currently, the term necrotising gingivitis is used as an alternative to the old term necrotising ulcerative gingivitis.¹

Based on the location of the lesion, necrotising periodontal diseases (NPD) are divided into 3 subtypes:¹

• Necrotising gingivitis (NG)
• Necrotising periodontitis (NP)
• Necrotising stomatitis (NS)

Each is more severe and affects more structures than the previous. (NG) affects only the gingiva, while in (NP)—which is always preceded by (NG)—the infection spreads from the gingiva to the alveolar bone and periodontal ligament, and the affected site undergoes bone loss. The progression of (NP) is (NS), which is a life-threatening condition characterised by gangrenous lesions affecting both mouth and face. It’s also called Noma.³

What is necrotising gingivitis?

Necrotising gingivitis is a rapidly destructive, non-contagious rare condition characterised by a bacterial infection of the gum that results in necrosis (death) of the gingival tissues.^1,3

It has an acute onset and course of progression.² It’s typically seen in the younger population (aged between 15-30 years).³ NUG is a rare condition, despite this fact, it affects up to 25% of the population in developing countries. It predominantly affects gums in the front region of the upper and lower jaws.¹

Causes of necrotising gingivitis

It occurs due to infection of specific types of bacteria such as spirochetes species, fusobacteria, prevotella, and peptostreptococcus.^1,4 Mainly NPD occurs as a result of mutualism between fusobacteria and spirochetes, and the impact of the risk and predisposing factors which negatively affect the host defence response and diminish the resistance.³

Risk factors of necrotising gingivitis

They are divided into systemic (affecting the entire body) and local (limited to a tissue or organ) risk factors:

Systemic factors

• Malnourishment (particularly in the developing countries)
• Immunodeficiency (ex: human immunodeficiency virus infection)
• Systemic disease (leukaemia, tuberculosis, measles, syphilis, anaemia)
• Emotional stress and anxiety
• Poor sleeping time (insomnia) and fatigue
• Chemotherapy

Local factors

• Poor oral hygiene and pre-existing gingivitis 
• Presence of dental plaque retentive factors (Orthodontic brackets, restoration, dental calculus)
• Smoking tobacco and alcohol abuse
• Local trauma or injury

Role of poor oral hygiene

Practising poor oral hygiene results in the accumulation of dental plaque which mainly consists of bacteria. These bacteria consume oxygen creating a suitable condition for the development of anaerobic bacteria (fusobacteria and spirochetes) which grow in the absence of oxygen. Thus, poor oral hygiene is integral to developing necrotising periodontal diseases.

Role of smoking

Smoking is one of the important risk factors for NPDs. A study done by The American Academy of Periodontology found that 98% of necrotising periodontal diseases are smokers. Smoking has an impairing effect on immunity, it decreases the count of helper T-cells and disturbs the function of polymorphonuclear neutrophils (immune cells). Additionally, smoking increases the secretion of Adrenaline which acts as a vasoconstrictor (constriction of the blood vessels) and hinders the access of the immune cells to the affected site.³

Role of emotional and physiological stress

Stress and emotional disorders (for example: students during exams, military personnel, depressed patients and other emotional conditions) play an important role in the development of NPD. They reduce the tissue resistance for bacteria and increase the level of cortisol and catecholamines (dopamine, adrenaline and nor-adrenaline). This decreases the patient’s immunity by affecting both neutrophils and lymphocytes and thus facilitating periodontal tissue destruction.³

Role of malnutrition

With the same mechanism, malnutrition plays a role in decreasing the resistance to infections. Vitamin B12, Vitamin C and protein deficiency are the key factors for developing necrotising gingivitis, especially in severely malnourished individuals in low socioeconomic countries. It also affects the immune cells, and the body’s hormones and makes them in a state of imbalance.³

Role of systemic diseases affect the immunity

Human immunodeficiency virus infection (HIV), individuals with (AIDS) or people with severe viral infections (measles, malaria, chicken pox, herpes zoster, herpetic gingivostomatitis), in addition to systemic diseases that affect the immune cells (leukaemia, neutropenia and uncontrolled diabetes) have a direct role due to immune dysfunction.³

Signs and symptoms of necrotising gingivitis

Signs and symptoms start to manifest after the occurrence of the infection and reduction of the host resistance as a result of the effect of predisposing factors.³

Signs and symptoms are:

• Pain, discomfort and soreness of the gum
• Bad smell from mouth
• Formation of a white membrane (layer) that covers the gum
• Necrosis (death) of the interdental gingiva (part of the gum that lies between teeth)
• Fever
• Lymphadenopathy
• Malaise (weakness and fatigue)
• Bleeding
• Tenderness and difficulty of eating

Diagnosis of necrotising gingivitis

Diagnosis of necrotising gingivitis is mainly clinical by identifying the previously mentioned signs and symptoms.¹ It starts by taking the history from the patient and asking them about the symptoms they have. Then the physician runs a physical examination to detect any signs of the condition, for example, enlarged or tender lymph nodes in the submental area.

Management and treatment of necrotising gingivitis

The process of managing and controlling the infection of necrotising gingivitis takes different modalities according to the age and physical state of the patient.¹

Management in pediatric (children) population

• Mechanical debridement of the lesion to remove the food debris and the infected membrane
• Antibiotic prescription: 3 mg/kg of Metronidazole for 7 days
• Washing the mouth twice daily using 0.12% chlorhexidine mouthwash
• Professional cleaning with sonic instrument under conscious sedation 
• Evaluation of the treatment and recall visits every 3 months for a year

Management in adult population

• Gentle cleaning and debridement of the affected tissues
• Antibiotic therapy: clindamycin, amoxicillin - clavulanate or metronidazole plus macrolide
• Mouthwashing using warm normal saline or 3% peroxide solan
• Scaling and root planning

Management in HIV population

• Mechanical debridement and use of povidone-iodine solution as an irrigation solution for the tissues
• Antibiotic therapy: 500 mg of metronidazole 3 times per day for 7 days or amoxicillin-clavulanate 500 mg 3 times per day for 5 days
• Administration of antifungal
• Using 0.12% chlorhexidine mouthwash twice daily
• Thorough scaling and root planing
• Recall visits every 3 months

Oral hygiene instructions should be provided to all patients. Local causes must be removed. Systemic factors should be managed through medical and psychological consultation.²

Outcome and follow-up

Regular recall visits and follow-ups are necessary to guarantee good results of the treatment. Sticking to the oral health instructions will bring about satisfactory outcomes and the clinical evaluation will reveal no signs and symptoms.

Prevention of necrotising gingivitis

Here are some tips to stay shielded from the infection:

• Maintain good and proper oral hygiene by brushing your teeth twice daily
• Floss daily to remove the dental plaque
• Visit your dentist regularly for dental checkups 
• Limit the sugar consumption and maintain a healthy diet containing vegetables and fruits
• Avoid tobacco and alcohol consumption
• Manage your stress by doing exercises, meditation, deep breathing and psychological consultation
• Stay hydrated and enforce your immune system
• If you experience symptoms like pain or bleeding, immediately seek medical care

Summary

Necrotising gingivitis (NG) is a rare condition characterised by rapid onset, progression, and destruction of the gum tissues. It is associated with malnutrition, especially in lower socioeconomic communities in the developing countries. The patient with NG experiences pain, bleeding, bad odour, a white membrane covering the gum and systemic symptoms like fever and lymphadenopathy. Poor oral hygiene, stress, immunosuppression, tobacco and alcohol consumption, and systemic conditions are all considered to be risk factors.

The management of NG has different modalities according to age and immunity status, but they share the same concepts of mechanical debridement, antibiotic therapy, and regular follow-up.

Necrotising gingivitis could be prevented by maintaining proper oral hygiene, staying hydrated, and consuming a balanced diet with balanced sugar consumption. Visit a dentist for regular check-ups and seek medical help immediately in case of developing symptoms.