Perio Diagnosis - Necrotizing Periodontal Disease

Necrotizing periodontal diseases is one of seven different categories of periodontitis used in the 1999 classification system from the American Academy of Periodontology. It is also one of the three different classifications of periodontal diseases and conditions which is included within the 2017 classification system.

The 1999 classification system includes the seven categories outlined below:

  • Gingivitis
  • Chronic Periodontitis
  • Aggressive Periodontitis
  • Periodontitis as a manifestation of systemic disease
  • Necrotizing Ulcerative Gingivitis/Periodontitis
  • Abscesses of the Periodontium
  • Combined Periodontic-Endodontic Lesions

Necrotizing periodontal diseases are a form of inflammatory periodontal or gum disease which is caused by the presence of bacteria. These diseases often have a sudden onset, which is why the term “acute” is often included in the diagnosis. The mildest form on the spectrum of the disease is called necrotizing ulcerative gingivitis (NUG). This is then followed by more severe conditions which include necrotizing ulcerative periodontitis (NUP), necrotizing stomatitis and finally, cancrum oris (noma), which is often fatal.

Necrotizing ulcerative gingivitis (NUG), which is also called necrotizing gingivitis (NG), is a common infection in the gums which is not contagious. Acute necrotizing ulcerative gingivitis (ANUG) is the acute form of NUG, and a natural progression of the disease when it is not treated. When it is not effectively treated, NUG can become chronic and even return. In developed countries, ANUG primarily occurs in young adults who have other contributing factors such as stress, sleep deprivation, poor oral hygiene, smoke, or do not have a good diet. In developing countries, ANUG is most prevalent in children who are malnourished. Because of the common predisposing factors found in a population, ANUG commonly occurs in an epidemic-type pattern. While ANUG is not contagious, this leads some people to believing that it is contagious. The primary symptoms of NUG is painful, bleeding gums, ulcers, and necrosis of the interdental papilla. Some patients may also experience halitosis, swollen lymph nodes, and general discomfort. The acute disease is treated by removing the infected tissue and with antibiotics. Patients may also need to correct poor oral hygiene or stop smoking to prevent the disease from returning. Another term used for ANUG is “trench mouth”, because in World War I, it occurred in the mouths of front line soldiers.

Necrotizing Ulcerative Periodontitis

Necrotizing ulcerative periodontitis (NUP), necrotizing periodontitis (NP), or acute necrotizing ulcerative periodontitis (ANUP) occurs when there is attachment loss due to the infection. The disease takes place in the gingiva, the periodontal ligament and the alveolar ligament. For most patients, the disease causes a loss of attachment. Because of this, many cases of ANUG may be called NUP. Although ANUG is typically used to define the condition. It is possible for NUP to be an extension of NUG, which can reach into the periodontal ligaments. NUG and NUP are often classified together under the more general term of necrotizing periodontal diseases.

Necrotizing Stomatitis

The progression of Necrotizing ulcerative periodontitis (NUP) into the tissue which is located past the mucogingival junction is a feature of necrotizing stomatitis. Necrotizing stomatitis has many common features with cancrum oris.

Cancrum Oris

Cancrum oris, or noma, is the necrotizing and destructive infection which takes place in the mouth and face. Because it can impact areas located outside the mouth, it is not exclusively a periodontal disease. This condition is often found in children from developing countries who are malnourished. The disease can cause disfiguration. It is also frequently fatal. While it has not been confirmed, some suggest cancrum oris develops from a pre-existing case of NUG. It is uncommon for cases of NUG or NUP to progress into a more severe form. This is true even when the patient fails to seek treatment.