Necrotizing+Ulcerative+Periodontitis

= **Case #4 - Necrotizing Ulcerative Periodontitis** =

http://www.doctorspiller.com/aids.html

** Medical History **
=== Patient’s last prophylaxis and exam including bite wings were on 7/11/08. FMX was taken on 7/05/2006. Patient presents with bleeding and painful gums, frequent cold sores (HIV related), frequent ulcers in oral cavity, and loose mandible anterior teeth as well as on the maxillary molars. Patient had pneumonia in 5/2007. Patient states he has frequent cold sores monthly. Patient states that he was diagnosed with HIV in 2003. Patient states that he had his childhood vaccinations. ===

** Medications: ** Efavirenz, Zidovudine, and Lamivudine.
=== __Efavirenz:__ treatment of HIV-1 infections in combination with at least 2 other antiretroviral agents. //Dental implications://No information available to require special precautions. //Dental contraindications:// Abnormal taste, dizziness. === === __Zidovudine__ : treatment of HIV-1 infections in combination with at least 2 other antiretroviral agents //Dental implications//:no information available to require special precautions //Dental contraindications:// taste perversion, oral pigmentation, dysphagia and mouth ulcers === === __Lamivudine__ : treatment of HIV infection when antiviral therapy is warranted; should always be used with multi-drug regimen. //Dental implications:// no information available to require special precautions. //Dental contraindications:// No significant effects or complications reported ===

An overview of Necrotizing ulcerative periodontitis
Necrotizing ulcerative periodontitis (NUP) is an acute form of periodontal disease. This necrotic disease rapidly destroys the periodontium. NUP appears the same as necrotizing ulcerative gingivitis (NUG). The distinguishing factor is that NUP has attachment loss because it effects the periodontium and is usually associated with an immune compromised disease such as HIV or malnutrition. The clinical features of NUP include ulcerations and a necrotic marginal and/or interdental papilla resulting in a “punched out” appearance. The interdental papilla may bleed and be painful and is usually blunted or cratered. The tissue is also covered by a yellowish or gray pseudomembrane.

The necrosis extends from the gingiva to the periodontal ligament and the alveolar bone. Multiple untreated exposures to NUG may result in NUP. NUP is usually associated with the immune compromised. This may cause malaise and fever. The bacteria associated with NUP are the same as in NUG. They include //A. a//, //P. gingivalis//, //P. intermedia//, Fusobacterium species, and spirochetal microorganisms. The initial treatment of NUP requires oral hygiene instructions and thorough scaling and root planing. In immunosuppressed patients such as those that are HIV positive, it is advisable to recommend the use of an antimicrobial mouth rinse containing chlorhexidine to assist in the reduction of the microbial plaque. In HIV positive patients, NUP can cause rapid tissue and bone destruction.

Free gingiva: generalized erythemic, edematous, flaccid, hemorrhagic, and cratered. Attached gingiva: generalized erythemic, firmly bound down to underlying bone, edematous, smooth, and hemorrhage. (This is a general description for a person with N.U.P and possibly NUG, due to the necrotic eroding painful tissue. Besides the immune suseptability, it is extremely painful for the patient to maintain this at home. OHI would defiantly be altered.)
 * Gingival Description**

MBI: 69% BOP: 100% Probing depths: generalized 3-5mm Recession: 2mm on the buccal aspect of 2, 14, and 23-27; 3mm on the lingual aspect of 2; 2 mm on the lingual aspect of 3, 14, 22, and 27 Mobility: + on 2-6; class I on 22, 23, 26, and 27; class II on 24 and 25 Fremitus: + on 2, 3, 6-11, 14, and 15 Furcations: Class II on buccal aspect of 3, 14, 15, 30, and 31. Class II on 14 mesiolingual and distolingual Calculus code: light medium generalized ADA III AAP: Necrotizing periodontal disease
 * Assessments**


 * OHI**: Teach Bass technique, CHX rinse, water pic use, and nutritional counseling as well a education to make the patient awear of the conditions and possiably avoid flare ups.

Appt 1: send med-consult regarding HIV Appt 2: received med-consult, RMH, assessments, 4 BWXs, DDS exam, 2nd check in Appt 3: PI & OHI, 1/2 mouth scale with anesthesia, CHX Appt 4: 1/2 mouth scale with anesthesia, CHX, and fluoride Appt 5: 3-month recare
 * Treatment plan**

The prognosis of NUP depends on the plaque and any secondary factors that exist which include a HIV positive status. The damage from NUP is not reversible, leaving the patient with 3-4mm of attachment loss. However, the patient's HIV is controlled which allows the prognosis to be fair for this patient. If at any time the patient’s HIV becomes uncontrolled or progresses to AIDS, the clinical assessments would need to be reevaluated and the prognosis could quickly change to poor.

Questions
1. All of the following are clinical manifestations of NUP EXCEPT: a. A "punched out" interdental papilla b. A yellowish or gray pseudo membrane that covers the tissue c. Fever or malaise of the patient d. Pseudopockets with no attachment loss

2. The primary bacteria involved in NUP include which of the following: a. //A. a.// b. //P. gingivalis// c. //P intermedia// d. All of the above

3. Recurrent NUP allow for gingival craters welcome further tissue breakdown, which leads to periodontal pocket formation. Biofilm and debris collects easily in the misshapen proximal areas, which are difficult to clean. a. Both statements are TRUE. b. Both statements are FALSE. c. The first statement is TRUE; the second statement is FALSE. d. The first statement is FALSE; the second statement is TRUE.

4. Abscesses can occur in the patient with NUP, an abscess is called gingival when it is located in the deeper periodontal tissues. An abscess is periodontal when it is located in the marginal area. a. Both statements are TRUE. b. Both statements are FALSE. c. The first statement is TRUE; the second statement is FALSE. d. The first statement is FALSE; the second statement is TRUE.

5. NUP is a marker of severe immunosuppression that affects the gums and extends to the underlying bone and periodontium. It may or may not distinct from necrotizing ulcerative gingivitis (NUG). a. Both statements are TRUE. b. Both statements are FALSE. c. The first statement is TRUE; the second statement is FALSE. d. The first statement is FALSE; the second statement is TRUE.

6. Pathogens in NUG and NUP are similar. Pathogens may include anaerobic bacteria and fungi. a. Both statements are TRUE. b. Both statements are FALSE. c. The first statement is TRUE; the second statement is FALSE. d. The first statement is FALSE; the second statement is TRUE.

7. What is the common complaint that may reflect extension to alveolar process? a. Bleeding while brushing b. Toothache c. Loose teeth d. Deep jaw pain

8. What are common signs and symptoms present intraorally? a. Bleeding upon probing b. High percentage of Marginal Bleeding Index c. Fiery red, inflamed and ulcerated gingival tissue, and grayish exudate. d. Fistula present with profuse exudate

9. What is an important recommendation for a NUP patient if he is taking metronidazole? a. Floss gently b. No alcohol consumption during treatment with metronidazole c. Use mouth rinse with alcohol to control population of bacteria d. Use interproximal brush, not regular floss

10. Treatment usually is divided into the acute phase and maintenance phase. The primary concern in acute phase is pain control and the maintenance phase is to reduce the burden of potential pathogens, prevent further tissue destruction and promote healing. a. Both statements are TRUE. b. Both statements are FALSE. c. The first statement is TRUE; the second statement is FALSE. d. The first statement is FALSE; the second statement is TRUE.

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