INDIAN DENTAL ACADEMY    Leader in Continuing Dental Educationwww.indiandentalacademy.com
An Acute Lesion Is Of Sudden Onset AndShort Duration And Can Be Painful. A LessSevere Phase Of Acute Condition Is TermedAs...
Necrotizing Ulcerative         Gingivitis (Nug)• Is An Inflammatory Destructive Disease Of  The Gingiva, Which Presents Ch...
ANUG• Clinical Features• History : Sudden Onset• May Follow Debilitating Disease Or  Acute Respiratory Tract Infection.• P...
Oral Signs• Characteristic Lesions Are Punched Out,  Crater-like Depression At The Crest Of  Interdental Papillae.• May Ex...
www.indiandentalacademy.com
Gingival Crater Is Covered By Gray,Pseudomembranous, Slough, Demarcated FromThe Remainder Of The Gingival Mucosa By APron...
Oral Symptoms :•   Extremely Sensitive To Touch.•   Constant Radiating, Gnawing Pain,    Which Aggravates On Eating Spicy ...
Extra-oral Or Systemic Signs           ‘N’ Symptoms•   Local Lymphadenopathy•   Slight Elevation Of Temperature•   In Seve...
• General lassitude• Insomnia, constipation, GI disorder  headache and mental depression.  Sometimes accompany the conditi...
Horning and Conene staging• Stage 1 : Necrosis   of tip of the interdental papilla  (93%).• Stage 2 : Necrosis   of entire...
HISTOPATHOLOGY :• Microscopic appearance is non-specific,  involving stratified squamous epithelium  and underlying connec...
Relation of Bacteria• Light microscopy and electron microscopy shows  presence of cocci-, fusifom bacilli and spirochetes ...
Zone 2 : Neutrophil - Rich ZoneContains Numerous Leukocytes,Predominantly Neutrophils, With Bacteria,Including Many Spiroc...
Zone 3 : Necrotic ZoneConsists Of Disintegrated Tissue Cells,Fibrillar Material, Remnants OfCollagen Fibers And NumerousSp...
• Zone 4 : Zone Of Spirochetal  Infiltration• Consists Of Well Preserved Tissue  Infiltrated With Medium And Large  Spiroc...
DIAGNOSIS :• Clinical features• Microscopic examination of a biopsy  specimen is not sufficiently specific to be  diagnost...
DIFFERENTIAL DIAGNOSIS•   Herpetic Gingivostomatitis•   Chronic Periodontitis•   Desquamative Gingivitis•   Streptococcal ...
• Etiology• Bacterias Involved• Treponema• Fusioform Bacillus•   Local Predisposing Factors•   Injury To Gingiva•   Smokin...
• Psychosomatic Factors• Psycho logic Factors Appears To Be An  Important Etiologic Factor In NUG• Chone-cole And Colleagu...
• Communicability• The Occurrence Of The Disease In  Epidemic - Like Outbreak Does Not  Necessity Mean That It Is Contagio...
• RX OF ACUTE NECROTIZING  ULCERATIVE GINGIVITIS.• First visit• A detailed history of the patient must be  recorded along ...
Ultrasonic scaling is done to remove the calculussubgingival scaling curettage are contraindicatedbecause of possibility o...
• Second visit• Patient condition reevaluated : There is  usually marked improvement.• Scaling and root planning are repea...
• Subsequent visit :• The tooth surface is scaled & smoothned  and plaque control by patient is checked  and corrected if ...
• PRIMARY HERPETIC  GINGIVOSTOMATITIS• Caused by herpes simplex virus type I• Occurs commonly in children and  infants you...
• It Is Usually Asymptomatic. After Primary  Infection, The Virus Ascends Through  Sensory And Autonomic Nerves And  Persi...
• CLINICAL FEATURES :• Oral signs :• Diffuse, erythematous shiny involvement of gingiva  and adjacent oral mucosa.• Varyin...
www.indiandentalacademy.com
•   Oral symptoms•   Generalized soreness•   Inability to eat and drink•   Painful and sensitive to touch, thermal changes...
• History• Recurrent acute infection• Episode may occur after febrile disease as  pneumonia, meningitis, influenza typhoid...
• HISTOPATHOLOGY :• The virus target the epithelial cells which  show ‘ballooning degeneration’ consisting of  acantholysi...
•   DIAGNOSIS :•   Patient’s history•   Clinical findings•   Virus culture•   Immunologic list using monoclonal    antibod...
•   DIFFERENTIAL DIAGNOSIS :•   Primary herpetic ginginostomatitis•   Erythema multifome•   Stevens - Johnson Syndrome•   ...
• COMMUNICABILITY :• It is contagious• Most adults develop immunity due to  infection during childhood       www.indianden...
• Rx OF ACUTE HERPETIC GINGIVOSTOMATITIS• Various medications have been used to treat  herpetic gingivostomatitis with lit...
• PERICORONITIS• Periocoronitis refers to inflammation of gingiva in  relation to the crown of an incompletely erupted  to...
www.indiandentalacademy.com
• CLINICAL FEATURES :• Space between crown and overlying gingival  flap shows accumulation of food debris and  bacteria; c...
Patients is extremely uncomfortable because of a foultaste and an inability to close the jaws, in addition topain.Swelling...
• COMPLICATIONS :• Pericoronal abscess formation• May spread pericoronal into the oropharangeal  area and medialy to base ...
• Rx of acute pericoronitis• Rx depends on severity of inflammation, the  systemic complications and the advisability of  ...
•   Swabbing with antiseptic after elevating the    flap gently from the tooth with a scaler•   Then the dentist has to de...
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An acute gingival lesion /certified fixed orthodontic courses by Indian dental academy

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An acute gingival lesion /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in Continuing Dental Educationwww.indiandentalacademy.com
  2. 2. An Acute Lesion Is Of Sudden Onset AndShort Duration And Can Be Painful. A LessSevere Phase Of Acute Condition Is TermedAs Subacute. There Are Various AcuteGingival Lesions, The Most CommonlyOccurring Ones Are :*Necrotizing Ulcerative Gingivitis*Primary Herpetic Gingivostomatitis*Pericoronitis/Pericoronal Abcess*Acute gingival Abcess*Acute periodontal Abcess www.indiandentalacademy.com
  3. 3. Necrotizing Ulcerative Gingivitis (Nug)• Is An Inflammatory Destructive Disease Of The Gingiva, Which Presents Characteristic Signs And Symptoms.• Classification*Acute → Most Common Form Of Occurrence*Subacute → With Milder Clinical Features www.indiandentalacademy.com
  4. 4. ANUG• Clinical Features• History : Sudden Onset• May Follow Debilitating Disease Or Acute Respiratory Tract Infection.• Psychological And Physical Stress.• May Have A History Of Repeated Remissions And Exacerbations www.indiandentalacademy.com
  5. 5. Oral Signs• Characteristic Lesions Are Punched Out, Crater-like Depression At The Crest Of Interdental Papillae.• May Extend Upto Marginal Gingiva Or Rarely To Attached Gingiva And Mucous Membrane. www.indiandentalacademy.com
  6. 6. www.indiandentalacademy.com
  7. 7. Gingival Crater Is Covered By Gray,Pseudomembranous, Slough, Demarcated FromThe Remainder Of The Gingival Mucosa By APronounced Linear Erythema.At Times The Pseudomembrane May BeDenuded Exposing The Gingival Margin, WhichRed, Shiny And Hemorrhagic.Spontaneous Gingival Hemorrhage OrPronounced Bleeding On Slightest Stimulation IsCharacteristic Feature.Fetid Odor www.indiandentalacademy.comIncreased Salivation
  8. 8. Oral Symptoms :• Extremely Sensitive To Touch.• Constant Radiating, Gnawing Pain, Which Aggravates On Eating Spicy Or Hot Foods.• Metallic Foul Taste• Excessive Amount Of ‘Pasty’ Saliva www.indiandentalacademy.com
  9. 9. Extra-oral Or Systemic Signs ‘N’ Symptoms• Local Lymphadenopathy• Slight Elevation Of Temperature• In Severe Cases.• High Fever• Increased Pulse Rate• Leukocytosis• Loss Of Appetitie www.indiandentalacademy.com
  10. 10. • General lassitude• Insomnia, constipation, GI disorder headache and mental depression. Sometimes accompany the condition.• In severe cases Noma or gangrenous stomatitis may be seen www.indiandentalacademy.com
  11. 11. Horning and Conene staging• 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 (%)• Stage 5 : Necrosis extending to buccal / labial mucosa (6)• Stage 6 : Necrosis exposing alveolar bone (1%)• Stage 7 : Necrosis perforating skin and check (0%) www.indiandentalacademy.com
  12. 12. HISTOPATHOLOGY :• Microscopic appearance is non-specific, involving stratified squamous epithelium and underlying connective tissue. www.indiandentalacademy.com
  13. 13. Relation of Bacteria• Light microscopy and electron microscopy shows presence of cocci-, fusifom bacilli and spirochetes .• Listgarten described the following four zones which blend with each other and may not be present in every case.• Zone 1 : Bacterial Zone The Most superficial Consists of varied bacteria, including a few spirochetes of small, medium and large types. www.indiandentalacademy.com
  14. 14. Zone 2 : Neutrophil - Rich ZoneContains Numerous Leukocytes,Predominantly Neutrophils, With Bacteria,Including Many Spirochetes Of VariousTypes, Between The Leukocytes. www.indiandentalacademy.com
  15. 15. Zone 3 : Necrotic ZoneConsists Of Disintegrated Tissue Cells,Fibrillar Material, Remnants OfCollagen Fibers And NumerousSpirochetes Of The Medium And LargeTypes, With Few Other Organisms www.indiandentalacademy.com
  16. 16. • Zone 4 : Zone Of Spirochetal Infiltration• Consists Of Well Preserved Tissue Infiltrated With Medium And Large Spirochetes Without Other Organisms.• Spirochetis Have Been Found As Deep As 300 Microns From The Surface www.indiandentalacademy.com
  17. 17. DIAGNOSIS :• Clinical features• Microscopic examination of a biopsy specimen is not sufficiently specific to be diagnostic. www.indiandentalacademy.com
  18. 18. DIFFERENTIAL DIAGNOSIS• Herpetic Gingivostomatitis• Chronic Periodontitis• Desquamative Gingivitis• Streptococcal Gingititis• Apthous Stomatitis• Diptheritic And Syphilitic Lesions• Tuberculous Gingival Lesion• Candidiasis• Agranulocytosis• Dermatoses (Pemphigus, Erythema Multiforme In Lichen Planus www.indiandentalacademy.com
  19. 19. • Etiology• Bacterias Involved• Treponema• Fusioform Bacillus• Local Predisposing Factors• Injury To Gingiva• Smoking• Deep Periodontal Pockets And Periocoronal Flaps.• Systemic Predisposing Factors :• Nutritional Deficiency Eg. : Vit. C, Vit. B2• Debilitating Disease• Chronic Diseases Like Syphititis Etc.• Cancers• Gastrointestinal Disorders Like Ulcerative Collitis www.indiandentalacademy.com• Blood Dysplasia Such As Leukemia And Anaemia
  20. 20. • Psychosomatic Factors• Psycho logic Factors Appears To Be An Important Etiologic Factor In NUG• Chone-cole And Colleagues Suggested That A Psychiatric Disturbance (Eg. : Trait Anxiety, Depression And Pshchopathic Deviance) And The Impact Of Negative Life Events (Stress) May Lead To Activation Of The Hypothalmic Pituitary Adrenal Axis. This Results In Elevation Of Serum And Urine Cortisol Levels ,Lymphocytes And PNM Function That May Predispose To NUG. www.indiandentalacademy.com
  21. 21. • Communicability• The Occurrence Of The Disease In Epidemic - Like Outbreak Does Not Necessity Mean That It Is Contagious. The Affected Group May Be Affiliated By The Disease Because Of Common Predisposing Factors www.indiandentalacademy.com
  22. 22. • RX OF ACUTE NECROTIZING ULCERATIVE GINGIVITIS.• First visit• A detailed history of the patient must be recorded along with a through clinical examination of the patient.• The involved area are isolated and then clamed. The pseudomembrane and debris are removed where a local anesthetic may be used. www.indiandentalacademy.com
  23. 23. Ultrasonic scaling is done to remove the calculussubgingival scaling curettage are contraindicatedbecause of possibility of extending the infection todeeper tissues.Patient is adviced to rinse mouth twice with equalmixture of warm water to 3% hydrogen peroxide andtwice daily rinse with 12% chlorhexidine.Antibodies : penicillin 500 mg every 6 hrs.or (erythromycin 500 mg every 6 hrs.)along with metronidazole 500 mg twice daily for 7days.Patient is also advised to avoid tobacoo, alcohol andcondiments.Patient recalled after 1-2 days www.indiandentalacademy.com
  24. 24. • Second visit• Patient condition reevaluated : There is usually marked improvement.• Scaling and root planning are repeated.• Hydrogen peroxide rinse is discontinued after 2-3 weeks. www.indiandentalacademy.com
  25. 25. • Subsequent visit :• The tooth surface is scaled & smoothned and plaque control by patient is checked and corrected if necessary.• Appointments are scheduled for the Rx of the gingivitis, periodontal pockets, and pericoronal flaps as well as for elimination of all forms of local irritation. GIGIVOPLASTY IS DONE IF THE LOST GINGIVAL ARCHITECTURE IS NOT REGAINED AFTER NONSURGICAL THERAPY www.indiandentalacademy.com
  26. 26. • PRIMARY HERPETIC GINGIVOSTOMATITIS• Caused by herpes simplex virus type I• Occurs commonly in children and infants younger than 6 yrs. of age, but is also seen in adolescents and adults.• Males - females www.indiandentalacademy.com
  27. 27. • It Is Usually Asymptomatic. After Primary Infection, The Virus Ascends Through Sensory And Autonomic Nerves And Persists In Neuronal Ganglia That Innervate The Site As Latent HSV.• Secondary Manifestations Occur As A Result Of Various Stimuli Such As Sunlight, Trauma Fever Or Stress.• Secondary Manifestations Include Herpes Labials Herpes Genitals, Ocular Herpes And Herpetic Encephalitis. www.indiandentalacademy.com
  28. 28. • CLINICAL FEATURES :• Oral signs :• Diffuse, erythematous shiny involvement of gingiva and adjacent oral mucosa.• Varying degree of edema and gingival bleeding.• In initial stage → discrete spherical gray vesicles are seen• on gingiva, labial and buccal mucosa, soft• palate, pharynx tongue etc.,• After about 24 hrs vesicles repture forming painful ulcers with red, elevated, halo like margin and a depressed, yellowish or grayish white central portion.• Course of disease limited to 7 to 10 day• Scarring dos not occur in areas of healed www.indiandentalacademy.com ulcerations.
  29. 29. www.indiandentalacademy.com
  30. 30. • Oral symptoms• Generalized soreness• Inability to eat and drink• Painful and sensitive to touch, thermal changes, foods such as condiments and fruit juices and action of coarse foods.• Extra oral & systemic signs and symptoms• Cervical adentis• Fever →101o to 105o (38.3oc to 40.6o c)• Generalized malaise www.indiandentalacademy.com
  31. 31. • History• Recurrent acute infection• Episode may occur after febrile disease as pneumonia, meningitis, influenza typhoid.• It also tends to occurring during periods of anxiety, stress or exhaustion as well as during menstruation.• Also occur during early stage of infections mononucleosis www.indiandentalacademy.com
  32. 32. • HISTOPATHOLOGY :• The virus target the epithelial cells which show ‘ballooning degeneration’ consisting of acantholysis nuclear cleaning and nuclear enlargement. These cells are called Tzank cells• Infected cells fuse forming multinucleated cells and intercellular edema that leads to formation of an intra epithelial vesicles that rupture and develop a secondary inflammatory response with a fibropurulent exudate.• Discrete ulcerations resulting from rupture of the vesicles have a central portion of acute inflammation, with varying degree of purulent exudate, surrounded by a zone rich in engorged blood vessels. www.indiandentalacademy.com
  33. 33. • DIAGNOSIS :• Patient’s history• Clinical findings• Virus culture• Immunologic list using monoclonal antibodies or DNA hybridization techniques www.indiandentalacademy.com
  34. 34. • DIFFERENTIAL DIAGNOSIS :• Primary herpetic ginginostomatitis• Erythema multifome• Stevens - Johnson Syndrome• Bullous lichen planus• Desquamative gingivitis• Recurrent apthous stomatitis www.indiandentalacademy.com
  35. 35. • COMMUNICABILITY :• It is contagious• Most adults develop immunity due to infection during childhood www.indiandentalacademy.com
  36. 36. • Rx OF ACUTE HERPETIC GINGIVOSTOMATITIS• Various medications have been used to treat herpetic gingivostomatitis with little success, these included local application and also escharotics, vitamins, radiation and antibiotics and also acyclovirs.• Rx consist of palliative measures alone.• Removal of plaque, food debris and superficial calculus to reduce gingival inflammation.• Tropical application of local anesthetics for symptomatic relief eg : lidocaine hydrochloride• Else asprin or a NSAID agent can be given systematically.• Application of local antibiotics to prevent opportunistic infection especially in immuno- compromised patients.• The patient must be informed that the disease is contagious thus precautions must be taken. www.indiandentalacademy.com
  37. 37. • PERICORONITIS• Periocoronitis refers to inflammation of gingiva in relation to the crown of an incompletely erupted tooth.• Occurs most commonly in mandibular III molar area.• TYPES :• Acute• Subacute• Chronic www.indiandentalacademy.com
  38. 38. www.indiandentalacademy.com
  39. 39. • CLINICAL FEATURES :• Space between crown and overlying gingival flap shows accumulation of food debris and bacteria; causing inflammation.• Inflammatory fluid and cellular exudate increase the bulk of the flap, which then may interefere with complete closure of jaws or can be traumatized by contact with opposing jaw, aggregate the inflammatory involvement.• Clinically it is seen as a markedly red, swollen, suppurating lesion that is exquisitely tender, with radiating pain to the ear, throat and floor of the mouth. www.indiandentalacademy.com
  40. 40. Patients is extremely uncomfortable because of a foultaste and an inability to close the jaws, in addition topain.Swelling of check in the region of angle of jaw andlymphadenitis are seen.Patient may also have toxic systemic symptoms suchas fever, leukocytosis and malaise. www.indiandentalacademy.com
  41. 41. • COMPLICATIONS :• Pericoronal abscess formation• May spread pericoronal into the oropharangeal area and medialy to base of tongue, making it difficult for patient to swallow.• Depending of severity these may be the involvement of submaxillary, posterior cervical, deep cercial and retropharyngeal lymph nodes.• Peritondillar absecess formation, cellulitis and ludwig’s angina are infrequent but potential sequelre of acute periocoronitis www.indiandentalacademy.com
  42. 42. • Rx of acute pericoronitis• Rx depends on severity of inflammation, the systemic complications and the advisability of retaining the involved tooth• Persistant symptom free periocoronal flaps should be removed as a preventive measure against subsequent acute involvement• Specific Rx• Gently flushing the area with warm water to removed debris and exudate www.indiandentalacademy.com
  43. 43. • Swabbing with antiseptic after elevating the flap gently from the tooth with a scaler• Then the dentist has to decide whether the tooth is to be retained or extracted.• If it is decided to retain tooth, the periocoronal flap is removed using periodontal knives on electro surgery.• After removal of the flap, a periodontal pack is applied which is removed after I week. www.indiandentalacademy.com

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