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Necrotizing Ulcerative Periodontitis in a HIV


Seronegative Patient A Case Report

Article June 2014

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Syed Wali Peeran Karthikeyan Ramalingam


Sebha University Surendera Dental College & Research Institute
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Case Reports in Odontology
Journal homepage: http://www.casereportsinodontology.org

Necrotizing Ulcerative Periodontitis in a HIV Seronegative Patient A Case Report


[PP: 05-09]
Syed Wali Peeran Karthikeyan Ramalingam
Department of Periodontology and Oral Implantology Department of Oral Pathology & Microbiology
Faculty of dentistry, Sebha University Faculty of dentistry, Sebha University
Sebha, Libya Sebha, Libya
drrkn79@gmail.com

Syed Ali Peeran Yasmen Elhadi Elamin Elsadek


Department of Oral and maxillofacial Prosthodontics Faculty of Dentistry, Sebha University
Faculty of Dentistry, Jazan University Sebha, Libya
Jazan, KSA

ARTICLE INFO ABSTRACT


Article History
Paper received on: Necrotizing ulcerative periodontitis (NUP) is characterized by soft tissue
03/03/2014 necrosis, rapid periodontal destruction, and interproximal bone loss.
Accepted after review on: Unlike other periodontal diseases, it presents with substantial necrosis of
02/04/2014
gingival tissues, and loss of periodontal ligament and alveolar bone.
Published on:
01/06/2014 Herewith, we present a case report of NUP in a patient of Libyan origin.
To the best of our knowledge, it is the first case report from Libya in
Keywords
Necrotizing ulcerative English literature.
periodontitis, HIV
seronegative, Libyan origin

Cite this article as: Syed, W. P., Ramalingam, K., Syed, A. P., & Elsadek, Y. E. (2014) Necrotizing Ulcerative
Periodontitis in a HIV Seronegative Patient A Case Report. Case Reports in Odontology. 1(1), 05-09 Retrieved
from http://www.casereportsinodontology.org
Case Reports in Odontology Volume: 1 Issue: 1 January-June, 2014

he was a heavy smoker, smoking 50


Introduction cigarettes per day and had been smoking for
Necrotizing ulcerative periodontitis 15 years. Past medical history revealed
(NUP) is the most severe inflammatory episodes of heavy stress. Past dental history
periodontal disorder caused by plaque revealed that he had experienced mobility of
bacteria. Unlike conventional periodontitis, multiple teeth with spontaneous exfoliation
NUP is characterized by clinical features and extraction of affected teeth. HIV
such as soft tissue ulceration and necrosis serostatus was negative.
usually arising from the interdental papillae, The intraoral examination revealed severe
profuse bleeding on provocation, and pain.1 ulcerations and necrosis of the marginal
Compared to chronic or aggressive gingiva and the interdental papillae of the
periodontitis, one of the most important mandibular central incisors, where the
features of NUP is the rapid and severe loss alveolar bone was exposed (Figure 1). There
of clinical attachment and alveolar bone was severe necrosis involving the gingiva of
within a few days or weeks 2. The prevalence right maxillary molars (Figure 2), left
for NUP is about 0.5% and decreases with maxillary premolars and molars (Figure 3)
age.3, 4 along with left mandibular third molar
In addition to the presence of human regions. The affected teeth exhibited severe
immunodeficiency virus (HIV), other mobility. He was also partially edentulous
predisposing factors for NUP are history of with multiple missing posterior teeth and had
NUP, poor oral hygiene, inadequate sleep, extensive alveolar bone loss as shown in
unusual psychologic stress, poor diet, recent OPG (Figure 4).
illness, alcohol abuse, and smoking. Usually, The patient was advised acute phase
one of these factors alone is not sufficient to management with removal of soft &
establish disease, except for HIV4. Although mineralized deposits through complete oral
a characteristic bacterial flora of spirochetes prophylaxis. He was also advised oral rinse
and fusobacteria can be isolated from these with 0.12% chlorhexidine. The patient has
lesions, it still remains unclear whether these not yet returned for initiating the treatment
bacteria are primarily involved in causing the regimen.
disease.5
Herewith, we report the first case Discussion
report of NUP from Libya in English Bacterial plaque is the main etiological
literature. factor of periodontal disease6. The
characteristics of NUP include acute and
Case Report intense pain, abundant gingival hemorrhage,
A 32-year-old male patient of Libyan halitosis, loss of periodontal insertion, and
origin, reported to the outpatient department occasional bone exposure. Crater-like lesions
of Faculty of Dentistry, Sebha University, are formed in the gingival tissue, while
Sebha, Libya. He complained of severe oral necrosis and ulcerations are seen in
pain, intermittent swelling of the cervical interproximal papillas, which are directly
lymph nodes and fever. He also complained associated with the regions of bone loss.7, 8
of severe mobility of his teeth and difficulty NUP is more frequently seen as a localized
in mastication. Personal history revealed that lesion, with areas of gingival tissue necrosis,
Cite this article as: Syed, W. P., Ramalingam, K., Syed, A. P., & Elsadek, Y. E. (2014) Necrotizing Ulcerative
Periodontitis in a HIV Seronegative Patient A Case Report. Case Reports in Odontology. 1(1), 05-09 Retrieved
from http://www.casereportsinodontology.or
Page | 6
Case Reports in Odontology Volume: 1 Issue: 1 January-June, 2014

surrounded by areas of unaffected tissue. The irrigation with 10% povidone-iodine, or 2%


formation of periodontal pockets is rare, and sodium iodide mixed in equal proportions
the crestal bone loss coincides with gingival with 10 volumes of oxygenated water. These
necrosis, leading to the exposure of alveolar substances have antimicrobial activity and
bone and areas of intra-septal bone immediately reduce discomfort. Oral hygiene
sequestration. Pain is often described as a instructions along with analgesics like
profound tooth ache or as pain in the paracetamol 500mg every 4 hours and anti-
bones of the mouth that does not yield to inflammatory drugs like ibuprofen 400-
analgesics.9, 10 Spontaneous nocturnal 600mg every 8 hours, can be given for relief
hemorrhage may also be seen6. The of fever, necrosis, bone exposure, or severe
pathogenesis of the NUP appears to involve pain10.
diverse etiologic factors like malnutrition, The antibiotic of choice is
tobacco smoking, intravenous drug use, metronidazole 500 mg every 12 hours or 250
psychological stress, and mg every 6 hours, for 7 days 11. Mouth
immunosuppression, the latter two being washes with 0.12% chlorhexidine gluconate
interrelated through the hypothalamic every 8 h must also be recommended to
pituitaryadrenal axis 11. Our patient prevent and control plaque formation10.
presented with history of excessive smoking The second stage includes mechanical
along with stress episodes. debridement to remove calculus and necrotic
The clinical appearance of NUP can be tissues6. The third stage consists of
very variable. Initial lesions may not show maintenance and follow-up. The follow-up is
radiographic evidence of bone loss and tooth performed initially every month, which can
mobility. Moderate NUP generally involves be postponed to every three months after the
the entire attached gingiva with partial bone stabilization of the periodontal condition10.
exposure and sequestration to the Microscopic studies and cultivation of
mucogingival junction. Severe NUP the predominant microbes associated with
manifests as extensive necrosis of gingival NUG have consistently found significant
tissue and alveolar bone that extends beyond levels of Prevotella intermedia,
the mucogingival junction. Widespread bone Fusobacterium sp., and Treponema sp.
loss and significant tooth mobility leads to Several investigators have also reported high
loss of the involved teeth10. Our patient had a recovery rates of microbes not generally
history of teeth mobility and exfoliation of associated with the indigenous oral microbial
those mobile teeth. He also presented with flora, e.g. Enterococcus sp., Clostridium sp.,
extensive necrosis of multiple quadrants with Klebsiella sp., Pseudomonas sp.,
bone destruction and mobility of teeth. Enterobacter sp and Candida sp 12.
Differential diagnosis of NUP could Nowadays, lasers are used in dentistry
include Acute herpetic gingivostomatitis, as an adjunct to new therapies in order to
Desquamative gingivitis, Agranulocytosis, obtain better results, improved treatments
Leukemia, Noma & Necrotizing stomatitis. and consequently faster healing of injured
NUP does not respond to conventional tissues.11 Low level laser therapy has been
treatment6. The treatment of NUP is shown to be efficient in cicatrization,
performed in stages. In the first session, reducing inflammatory conditions and
symptomatic pain relief is achieved with accelerating tissue repair. Lasers can benefit

Cite this article as: Syed, W. P., Ramalingam, K., Syed, A. P., & Elsadek, Y. E. (2014) Necrotizing Ulcerative
Periodontitis in a HIV Seronegative Patient A Case Report. Case Reports in Odontology. 1(1), 05-09 Retrieved
from http://www.casereportsinodontology.or
Page | 7
Case Reports in Odontology Volume: 1 Issue: 1 January-June, 2014

in alleviation of severe, uncontrollable pain 6. Shulten EA, Kate RW, Van Der Wall I. Oral
with its analgesic and anti-inflammatory Manifestations of Hiv Infection In 75 Dutch
effects. 10 Healing effects of laser may be Patients. J Oral Pathol Med 1989; 18:42-46.
based on the improvement of local 7. Kenrad B, Rindum JL, Pindbord JJ. Oral
Findings in 23 Patients with Antibodies
microcirculation and stimulation of fibroblast
against Hiv (Human Immunodeficiency
proliferation, yielding a more organized Virus). Tandlaegerbladet 1987; 91:100-102.
production of collagen fibers, increasing 8. Souza LB, Pinto LP, Medeiros AMC, Arajo
granulation tissue, and promoting a Jr RF, Mesquita OJX. Manifestaes Orais
concomitant and rapid epithelial healing 12. em Pacientes com AIDS em uma Populao
Brasileira. Pesq Odont Brs, 2000; 14:1: 79-
Conclusion 85.
We have reported a rare presentation 9. Winkler JR, Murray RA, Greenspan D,
Greenspan JS. Aids Virus Associated With
of NUP in a HIV seronegative patient. The Periodontal Disease. J Dent Res 1986; 65:
etiology of our patient could be attributed to Abstract 139.
smoking and episodes of stress accompanied 10. Elcio MG, Rosemary BM, Jose JM, Nicolau
with poor oral hygiene. The true cause of T. Use of GaAlAs Laser in the Treatment of
such diseases could be elucidated only with Necrotizing Ulcerative Periodontitis in
further microbiological and immunological Patients Seropositive for HIV/AIDS. J Oral
evaluation. Laser Application 2007; 7: 55-64.
11. Cobb CM, Ferguson BL, Keselyak NT, Holt
References LA, Macneill SR, Rapley JW. A TEM/SEM
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Dompkowski D, Van Dyke TE. Acute Necrotic Gingival Papillae of HIV-
necrotizing ulcerative gingivitis: Risk factors Seropositive, Necrotizing Ulcerative
involving host defense mechanisms. Periodontitis. J Periodont Res 2003; 38:147-
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2. Ouhayoun JP, Goffaux JC, Sawaf MH, 12. Giovani EM, et al. Effects of low-level laser
Shabana AH, Collin C, Forest N. Changes in therapy in HIV/AIDS positive patients after
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3. Liu RK, Cao CF, Meng HX, Gao Y.
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Periodontol 2001; 72:15451553.
4. Tiitta O, Luomanen M, Hietanen J, Virtanen
I. Tenascin expression in mucocutaneous
diseases and related lesions of human oral
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1045.
5. Johnson BD, Engel D. Acute necrotizing
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57:141150.
Cite this article as: Syed, W. P., Ramalingam, K., Syed, A. P., & Elsadek, Y. E. (2014) Necrotizing Ulcerative
Periodontitis in a HIV Seronegative Patient A Case Report. Case Reports in Odontology. 1(1), 05-09 Retrieved
from http://www.casereportsinodontology.or
Page | 8
Case Reports in Odontology Volume: 1 Issue: 1 January-June, 2014

Legends:

Figure: 3 Clinical picture showing gingival necrosis


Figure:1 Clinical picture showing extensive gingival and bone loss in left maxillary posterior region.
necrosis in mandibular incisor region. Pseudomembrane is absent due to recent usage of
Pseudomembrane is absent due to recent usage of oxygenating mouthrinse.
oxygenating mouthrinse.

Figure: 4 Orthopantomograph showing wide-spread


Figure:2 Clinical picture showing severe bone loss bone loss in mandibular anterior region, maxillary
with gingival necrosis in right maxillary molar and mandibular posterior region.
region. Pseudomembrane is absent due to recent
usage of oxygenating mouthrinse.

Cite this article as: Syed, W. P., Ramalingam, K., Syed, A. P., & Elsadek, Y. E. (2014) Necrotizing Ulcerative
Periodontitis in a HIV Seronegative Patient A Case Report. Case Reports in Odontology. 1(1), 05-09 Retrieved
from http://www.casereportsinodontology.or
Page | 9

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