1. Dr Jaffar Raza Syed Page 1
Acute Gingival Infections
CLASSIFICATION
a. Traumatic lesions of gingiva:
âą Physical injury
âą Chemical injury
b. Viral infections:
âą Acute herpetic gingivostomatitis
âą Herpangina
âą Hand, foot and mouth diseases
âą Measles
âą Herpes varicella/zoster virus infections
âą Glandular fever
c. Bacterial infections:
âą Necrotizing ulcerative gingivitis
âą Tuberculosis
âą Syphilis
d. Fungal diseases:
âą Candidiasis
e. Gingival abscess
f. Aphthous ulceration
g. Erythema multiforme
h. Drug allergy
2. Dr Jaffar Raza Syed
NECROTIZING ULCERATIVE GINGIVITIS (NUG)
Also known as
âșVincentâs infection
âș Trench mouth
âș Acute ulceromembranous gingivitis
It is an inflammatory,destructive disease of the gingiva, which presents characteristic
signs and symptoms
âșSudden onset,
âșmay be followed by an episode of
âșLong hours of working withou
âșpsychologic stress.
NECROTIZING ULCERATIVE GINGIVITIS (NUG)
Acute ulceromembranous gingivitis
It is an inflammatory,destructive disease of the gingiva, which presents characteristic
may be followed by an episode of debilitating diseases or ARTI.
without adequate rest,
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It is an inflammatory,destructive disease of the gingiva, which presents characteristic
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Signs and Symptoms
âșPunched out, crater-like depressions at the crest of the interdental
papillae, subsequently involving marginal gingiva and rarely attached gingiva
âșgrayish pseudomembranous slough
âșgingival hemorrhage or pronounced bleeding on the slightest stimulation.
âșFetid odor and increased salivation.
âșextremely sensitive to touch
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âșconstant radiating, gnawing pain that is intensified by eating spicy or hot foods
and chewing
âșmetallic foul taste
âșpasty saliva
âșlocal lymphadenopathy
âșelevation in temperature
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Clinical Course
if left untreated, it may lead to destruction of the periodontium, and denudation of
roots (NUP), combined with severe toxic
Etiology
fusospirochetal organisms
âșfusiform bacillus
âșspirochetes
if left untreated, it may lead to destruction of the periodontium, and denudation of
, combined with severe toxic systemic complications.
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if left untreated, it may lead to destruction of the periodontium, and denudation of
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Local Predisposing Factors
Most important predisposing factors are:
i. Pre-existing gingivitis
ii. Injury to the gingiva
iii. Smoking
Systemic Predisposing Factors
âșNutritional deficiency
âșDebilitating diseases
âșPsychosomatic factors ï activation of the hypothalamic pituitary adrenal axis ï
â cor sol levels ï â lymphocyte and polymorphonuclear leukocytes func on
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Relationship of Bacteria to the Characteristic Lesions
four zones
1. Zone IâBacterial zone:
It is the most superficial zone, consists of varied bacteria, including a few Spirochetes of
the small, medium-sized and large types.
2. Zone IIâNeutrophil-rich zone:
Contains numerous leukocytes predominantly neutrophils with bacteria including
spirochetes of various types.
3. Zone IIIâNecrotic zone:
Consists of a dead tissue cells, remnants of connective tissue fragments, and numerous
spirochetes.
4. Zone IVâZone of spirochetal infiltration:
Consists of a well preserved tissue infiltrated with spirochetes of intermediate and
large-sized without other organisms.
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Treatment
Treatment for Non-ambulatory Patients
Day 1:
a. gently removing the necrotic pseudomembrane with a pellet of cotton saturated with
hydrogen peroxide (H2O2).
b. Advised bed rest and rinse the mouth every 2 hours with a diluted 3 percent
hydrogen peroxide (H2O2).
c. Systemic antibiotics like penicillin or metronidazole can be prescribed.
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Day 2:
After 24 hours, a bedside visit should be made. The treatment again includes gently
swab the area with hydrogen peroxide, instructions of the previous day are repeated.
Day 3: Most cases, the condition will be improved, start the treatment for ambulatory
patients.
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Treatment for Ambulatory Patients
First visit:
âștopical anesthetic
âșgently swabbed with a cotton pellet to remove pseudomembrane and
non-attached surface debris.
âșarea is cleansed with warm water
âșsuperficial calculus is removed with ultrasonic scalers.
âșAntibiotics prescription
âșSubgingival scaling and curettage are contraindicated
Instructions to the patient
1. Avoid smoking and alcohol.
2. Rinse with 3 percent hydrogen peroxide and warm water for every two hours.
3. Confine toothbrushing to the removal of surface debris with a bland dentifrice,
use of interdental aids and chlorhexidine mouth rinse are recommended.
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Second visit:
âșScalers and curettes are added to the instrumentarium.
âșShrinkage of the gingiva may expose previously covered calculus which is
gently removed.
âșSame instructions are reinforced.
Third visit:
âșScaling and root planing are repeated,
âșPlaque control instructions are given.
âșHydrogen peroxide rinses are discontinued.
Fourth visit:
âșOral hygiene instructions are reinforced
âșthorough scaling and root planing are performed.
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Fifth visit:
âșAppointments are fixed for treatment of chronic gingivitis, periodontal pockets
and pericoronal flaps, and for the elimination of all local irritants.
âșPatient is placed on maintenance program.
Further Treatment Considerations
1. Gingivoplasty.
2. Systemic antibioticsâonly in patients with toxic systemic complications.
3. Supportive systemic treatmentâcopious fluid consumption and administration
of analgesics and adequate bed rest.
4. Nutritional supplementsâvitamin B/C supplements.
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ACUTE HERPETIC GINGIVOSTOMATITIS (AHG)
âșviral infection of the oral mucous membrane caused by HSV I and II
âșoccurs most frequently in infants and children younger than 6 years of age but is
also seen in adults.
Clinical Features
1. appears as a diffuse, shiny erythematous, involvement of the gingiva and
the adjacent oral mucosa with varying degrees of edema and gingival bleeding.
2. In its initial stage it may appear as discrete, spherical, clusters of vesicles dispersed in
different areas, e.g. labial and buccal mucosa, hard palate, pharynx and tongue. After
approximately 24 hours the vesicles rupture and form painful shallow ulcers with
scalloped borders and surrounding erythema.
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3. Diffuse, edematous, erythematous enlargement of the gingiva with a tendency
towards bleeding is seen.
4. The course of the disease is 7 to 10 days.
3. Diffuse, edematous, erythematous enlargement of the gingiva with a tendency
4. The course of the disease is 7 to 10 days.
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3. Diffuse, edematous, erythematous enlargement of the gingiva with a tendency
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Oral Symptoms
1. Generalized soreness of the oral cavity which interferes with eating and drinking.
2. The ruptured vesicles are sensitive to touch, thermal changes and food.
Extraoral and Systemic Signs and Symptoms
âșfever
âșloss of appetite
âșmyalgia
âșCervical lymphadenopathy
âșAfter the primary infection the virus remains
occurs it causes Herpes labialis (cold so
âșIt is associated with prodrome of
vesicle formation and ulceration
of the oral cavity which interferes with eating and drinking.
2. The ruptured vesicles are sensitive to touch, thermal changes and food.
d Systemic Signs and Symptoms
After the primary infection the virus remains latent in the nerve tissue. If reactivation
occurs it causes Herpes labialis (cold sore).
It is associated with prodrome of tingling and itching on the corners of lip followed by
formation and ulceration
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of the oral cavity which interferes with eating and drinking.
2. The ruptured vesicles are sensitive to touch, thermal changes and food.
in the nerve tissue. If reactivation
on the corners of lip followed by
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Diagnosis
âșpatientsâ history and the clinical findings
âșbiopsy
Differential Diagnosis
1. Necrotizing ulcerative gingivitis
2. Erythema multiforme
3. Stevens-Johnson syndrome
4. Aphthous stomatitis (Canker sores).
Treatment
âștopical lignocaine for pain relieve
âșAcyclovir at 15 mg/kg five times a day for 5
âștopical antiviral medications such as 5% acyclovir cream or 3%
cream applied three to five times a day
patientsâ history and the clinical findings
1. Necrotizing ulcerative gingivitis
4. Aphthous stomatitis (Canker sores).
topical lignocaine for pain relieve
Acyclovir at 15 mg/kg five times a day for 5-7 days
topical antiviral medications such as 5% acyclovir cream or 3% Penciclovir
cream applied three to five times a day
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Penciclovir
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Recurrent Aphthous Stomatitis (RAS
common condition which is characterized by
âșmultiple recurrent small, round or ovoid ulcers with circumscribed
âșerythematous halo, and yellow or gray floors
âștypically presenting first in childhood or adolescenc
âșThe lesions may occur anywhere in the oral cavity, the
are common sites
âșItâs a painful lesion and may occur as a
scattered throughout the mout
Recurrent Aphthous Stomatitis (RAS)
common condition which is characterized by
recurrent small, round or ovoid ulcers with circumscribed
, and yellow or gray floors
typically presenting first in childhood or adolescence
The lesions may occur anywhere in the oral cavity, the buccal and labial
lesion and may occur as a single lesion or as lesions
throughout the mouth
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recurrent small, round or ovoid ulcers with circumscribed margins,
buccal and labial mucosae
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Types
Minor aphthae:
âșIs the most common affecting about 80% of patients with RAS
âșulcers are round or oval usually <5 mm in diameter with a
gray-white pseudomembrane and an erythematous halo.
âșThe ulcers heal within 10-14 days without scarring.
Major aphthae:
âșIs a rare severe form of Aphthous ulcer.
âșUlcers are oval and may exceed 1 cm in diameter.
âșUlcers persist for up to 6 weeks and often heal with scarring.
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Herpetiform aphthae:
âșleast common variety
âșcharacterized by multiple recurrent crops of widespread small, painful ulcers.
âșAs many as 100 ulcers may be present at a given time,
âșeach measuring 2-3 mm in diameter.
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Etiology
âșUnknown
âșlinked to RAS are genetic predisposition,
âșHematinic deficiencies,
âșImmunologic abnormalities,
âșstress,
âșfood allergy
âșgastrointestinal disorders.
âșPredisposing factors include hormonal disturbances, trauma, cessation of
smoking and menstruation
Treatment
âștopical lignocaine
âșTopical steroids like Triamcinolone and Clobetasol
âșsystemic steroids and Thalidomide to reduce the number of ulcers and recurrences.
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PERICORONITIS
ïšacute infection which refers to inflammation of
of an incompletely erupted tooth.
ïšIt occurs most frequently in the mandibular
Types
ïšAcute,
ïšsubacute or chronic
acute infection which refers to inflammation of gingiva and surrounding soft tissues
erupted tooth.
It occurs most frequently in the mandibular third molar area.
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gingiva and surrounding soft tissues
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Signs and Symptoms
ïšmarkedly red, edematous suppurating lesion that is extremely tender with
radiating pain to the ear, throat and floor of the mouth
ïšfoul taste and inability to close the jaws.
ïšswelling of the cheek
ïšinterferes with complete jaw closure
ïšflap is traumatized by contact with the opposing jaw and inflammatory involvement
is aggravated.
ïštoxic systemic complications such as fever, leukocytosis and malaise
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Complications
ïšLocalized ï pericoronal abscess or cyst formation
ïšmay spread posteriorly into the oropharyngeal area and medially into
the base of the tongue, making it difficult for the patient to swallow
ïšPeritonsillar abscess formation, cellulitis and Ludwigâs angina are the
potential complications
Treatment
The treatment of pericoronitis depends on:
âą Severity of the inflammation.
âą The systemic complications, and
âą The advisability of retaining the involved tooth
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First Visit
ïšwarm water flush + topical anesthetic agent
ïšflap is reflected with a scaler and the underlying debris is also removed
ïšhourly rinses instructions
ïšcopious fluid intake
ïšsystemic antibiotics
ïšIf the gingival flap is swollen and fluctuant an antero-posterior incision to
establish drainage is made with a No. 15 bard parker blade
ïšfollowed by insertion of 1/4th inch gauze wick
ïšIn the next visit, determination is made as to whether the tooth is to be retained
or extracted