Necrotizing Periodontal Diseases: A Diagnosis Not to be Missed
Year: 2024
Type: article
Abstract: Dear Editor, Gingiva has four zones- marginal, attached, interdental, and alveolar gingiva. Necrotizing periodontal diseases are a group of infectious diseases of gingiva with less than 1% prevalence.[1] The precise etiology is unknown. However, it is believed to be polymicrobial. The organisms are normal commensals of the oral cavity, and become pathogenic when host immunity is reduced. Early and accurate diagnosis is pivotal in preventing devastating complications, including cancrum oris.[2] A 20-year-old female was referred from the Ear-Nose-Throat department for painful ulcers over the gums. She had developed the lesions three days back that simultaneously involved both the upper and lower gums. Past medical history revealed a history of recent abortion, and the patient was on oral prednisolone and dapsone for linear Immunoglobulin A disease for two months. Her family history was unremarkable. There was no history of tuberculosis, trauma, or dental procedures before the appearance of lesions. There was no history of illicit drug use or prior chemotherapy in the patient. On oral cavity examination, there were three ulcers of size ranging from 1.8 cm × 0.8 cm to 1.2 cm × 0.7 cm over the gingiva around upper and lower incisor and lower molar teeth areas, with necrotic slough covering the ulcer [Figure 1a and b]. General and systemic examination did not reveal any abnormality. A provisional diagnosis of necrotizing periodontal disease was kept based on acute onset deep ulcers in the gingival and periodontal area and a history of immunosuppression, and the patient was admitted for detailed evaluation. The slough was debrided and sent for bacterial and anaerobic culture and sensitivity. Radiological investigations did not reveal the involvement of underlying bony and dental tissue. Biopsy from the necrotic area yielded no viable tissue for pathological examination. The patient was started on oral levofloxacin 750 mg once daily and metronidazole 400 mg thrice daily empirically. Slough culture showed Pseudomonas aeruginosa, and anaerobic culture had no growth. Slough for fungal culture did not reveal any growth. A complete blood count revealed a total leucocyte count of 22,600/mm3 and neutrophilia of 93%. Erythrocyte sedimentation rate, C-reactive protein, and serum procalcitonin were raised. The human immunodeficiency virus, Venereal Disease Research Laboratory, and Treponema pallidum hemagglutination assay test were negative. As per the sensitivity report, injectable imipenem (500 mg) with cilastatin (500 mg) twice daily were added, along with supportive therapy in the form of oral pantoprazole, iron, folic acid, calcium with vitamin D3, and chlorhexidine mouth rinse. Oral prednisolone and dapsone were stopped during the course of the disease. All the antibiotics were continued for 14 days and stopped. There was a complete improvement in ulcers with a complete disappearance of pain after 20 days of therapy [Figure 2a and b].Figure 1: (a) Ulcers with necrotic slough on the gingiva around the lower incisor. (b) Ulcers with necrotic slough on the gingiva around the upper incisorFigure 2: (a) Complete healing of the ulcer on the lower gingiva after 20 days. (b) Complete healing of the ulcer on the upper gingiva after 20 daysThe common microorganisms associated with necrotizing periodontal disease are Fusobacterium necrophorum, Prevotella intermedia, Fusobacterum nucleatum, Porphyromonas gingivalis, and Treponema Selemonas species. A combination of anaerobes (Bacteroides and Fusobacterium species) and aerobes (Pseudomonas aeruginosa and Staphylococcus aureus) has been isolated from necrotizing periodontal disease, progressing to cancrum oris.[2] The impairment of host immune responses that facilitate bacterial pathogenicity plays an important role in the development of necrotizing periodontal disease. The most important factors implicated are mental/emotional stress, undernutrition, insomnia, addiction to alcohol and tobacco, poor oral hygiene, pre-existing gingival disease, human immunodeficiency virus infection, leukemia, diabetes mellitus, neutropenia, pregnancy, and scurvy.[1,3] The three essential findings to diagnose necrotizing periodontal disease include rapidly developing stomatitis, bleeding from the gingiva, and most specifically, ulceration and necrosis of the interdental papillae. Other findings are halitosis and pseudomembrane formation over the gingiva, which may be associated with systemic symptoms such as body aches and enlarged lymph nodes. Without proper treatment, rare complications like necrotizing ulcerative periodontitis and cancrum oris (noma) may develop, which can be fatal.[1] In our case, both the pregnant status of the patient and oral prednisolone may have played a role in decreasing the patient’s immune status, and poor oral hygiene may have contributed to acquiring infection. The differential diagnoses of this condition include chemotherapy-induced mucositis, herpes simplex virus-induced and human immunodeficiency virus-induced gingivostomatitis, invasive fungal infection, scurvy, desquamative gingivitis, and gingivitis due to illicit drug use (meth-mouth).[4] Histopathology of the necrotizing periodontal disease typically shows four zones: a superficial bacterial zone, a neutrophil-rich zone, a necrotic zone, and a spirochaetal/bacterial infiltration zone.[5] The management of necrotizing periodontal disease includes eliminating predisposing factors, maintaining oral hygiene, using antimicrobial mouthwash, debriding necrotic tissue, and administering systemic antibiotics.[6] In our case, debridement followed by administration of sensitive injectable antibiotics in the form of imipenem with cilastatin led to complete healing of the lesion. In conclusion, our patient suffered from Pseudomonas infection, presenting as necrotizing periodontal disease. By reporting this case, we want to highlight this rare entity caused by an unusual organism like Pseudomonas aeruginosa among immunosuppressed individuals, and the role of microbiological investigations in promptly managing this entity to prevent its fatal complications. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Institution: All India Institute of Medical Sciences Bhubaneswar
Language: English
Subfield: Periodontics
Field: Dentistry
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4403217873