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Necrotizing

Ulcerative
Periodontitis

Associate
professor
Dr Alaa Moustafa
Attia

Necrotizing
Ulcerative
Periodontitis
NUP may be an extension of
necrotizing ulcerative gingivitis
(NUG)
into
the
periodontal
structures, leading to periodontal
attachment and bone loss.
NUP and NUG may be different
diseases
Many authors suggested that the

Nomenclature
Term NUP was first adopted at
the 1989 World Workshop in
Clinical Periodontics.
Old
name
was
gingivoperiodontitis

NU

incidence
More cases of NUP were being
described
in
immunocompromised
patients,
especially
those
who
were

Differences of NUG/NUP The distinction between the two conditions (NUG and NUP) as separate diseases has not been clarified. . but they are distinguished by the presence or absence of attachment and bone loss.

Clinical features .

Show gingival crater on interdental papillae. clinical cases of NUP are defined by necrosis and ulceration of the coronal portion of the interdental papillae and gingival margin. . bright red marginal gingiva that bleeds easily.Clinical features of NUP 1 Similarity to NUG: Similar to NUG. with a painful.

Deep interdental osseous craters demonstrate periodontal lesions of NUP. Gingival marginal lesion destroys epithelium the and .Clinical features of NUP 2 NUP distinguished by: By the destructive progression of the disease that includes periodontal attachment and bone loss.

Clinical features of NUP 3 Periodontal pockets are formed because the junctional epithelial cells remain viable and can therefore migrate apically to cover areas of connective tissue loss. . Tooth mobility Ultimately tooth loss.

.Clinical features of NUP 4 NUP patients may present with: Oral malodor (foul odor) Fever Malaise lymphadenopathy.

A. white male patient. Buccal view of maxillary cuspid- . HIVnegative.Necrotizing ulcerative periodontitis in 45-year-old.

.Necrotizing ulcerative periodontitis in 45-year-old. HIVnegative. Palatal view of same area. white male patient. B.

Necrotizing ulcerative periodontitis in 45-year-old. white male patient. Note the deep craters associated with bone loss. . C. Buccal view of mandibular anteriors. HIV-negative.

NUP .

lips) . palate. floor of m. tongue..Clinical features of NUP 4 Complications of NUP & severe form of NUG: ======================= ==== Gangrenous (necrotic) stomatitis: extensive necrotic process to adjacent gingival mucosa (check.

Necrotic stomatitis .

Necrotic stomatitis .

Noma (cancrum oris) .

Noma (cancrum oris) .

Microscopic Finding .

Necrotic cells (necrotic zone). 4.Spirochetal infiltration zone. 3.Microscopic finding Commonly similar to NUG 1. . 2.Dense aggregations of PMNs (neutrophil-rich zone) .surface biofilm composed of a mixed microbial flora with different morphotypes and a subsurface flora with dense aggregations of spirochetes (bacterial zone).

HIV/AIDS Patients .

-NUP lesions found in HIV- .HIV/AIDS Gingival and Patients periodontal lesions with distinctive features are frequently found in patients with HIV infection and AIDS.Linear gingival erythema (LGE). and NUP are the most common HIV-associated periodontal conditions reported in the literature. and NUG. .

. .Exposure of bone and sequestration of bone fragments.HIV/AIDS Patients .Large areas of soft tissue necrosis.Other complications: . .HIV-positive NUP may be extremely rapid.NUP lesions in HIV-positive/AIDS patients can be much more destructive and frequently result in complications that are extremely rare in non-HIV/AIDS patients. .

Other author: suggested that NUP may be used as an indicator of HIV infection in undiagnosed patients. .HIV/AIDS Patients Some researchers: reported that the NUP to be a marker for immune deterioration and a predictor for the diagnosis of AIDS.

39 of 56 (69. asymptomatic South Africans was strongly correlated with HIV infection.HIV/AIDS Patients Shangase et al (2007) reported that a diagnosis of NUG or NUP in systemically healthy. Of patients presenting with NUG or NUP.6%) were subsequently found to .

Etiology .

gingivalis. . intermedia. P. P. and Campylobacter species compared with HIV-negative controls.Etiology of NUP Generally as NUG: 1.Bacteria role: NUP in HIV-positive patients demonstrated significantly greater numbers of the opportunistic fungus Candida albicans and a higher prevalence of A. actinomycetemcomitans. Fusobacterium nucleatum.

Commonly in HIV-positive and AIDS patients. both NUG and NUP lesions are more prevalent in patients with compromised or suppressed immune systems.Etiology of NUP Immunocompromised Status : Clearly. .

Some researchers: Found that urinary levels of 17hydroxycorticosteroid were higher in subjects with NUG than in all other subjects diagnosed with periodontal .Etiology of NUP Psychologic Stress Stress increases systemic cortisol levels. and sustained increases in cortisone have a suppressive effect on the immune response by microcirculation in gingiva and altered phagocytic functions.

cellimmunity. phagocytosis. Many of including mediated the host defenses.Etiology of NUP Malnutrition Direct evidence of the relationship between malnutrition and necrotizing periodontal disease is limited to descriptions of necrotizing infections in severely malnourished children. and .

Etiology of NUP Reduction of nutrients to cells and tissues results in immunosuppression and disease susceptibility. Malnutrition can predispose an individual to opportunistic infections or intensify the severity of .

Plaque and other local factors e.Smoking .Etiology of NUP Other factors .g. calculus .

Treatment .

Correction of the systemic condition as possible and consultation with patient’s physician . . 2.Treatment The treatment is mostly similar to NUG 1.Lavage of necrotic tissue and pseudomembrane under local anesthesia.

9.Oral hygiene instruction and patient motivation to control dental plaque.Antifungal and antiviral drugs 7.Maintenance recall visits to evaluate periodontal health and observe the recurrence of lesions. . 8.Antiseptic mouth wash (chlorhexidine) 6.Local and systemic antibiotics 5.4.Good nutrition and enhancement the psychic status.

Exercise Comparison between NUG and NUP .