Clinical case
A 35-year-old smoker with poorly controlled HIV presents with intense gingival pain, spontaneous bleeding, halitosis, and visible loss of interdental papillae. Examination shows ulcerated necrotic gingiva with a grey pseudomembrane, deep interdental craters, and areas of interproximal attachment loss. Radiographs demonstrate localised crestal bone loss.
Pathophysiology
NUP shares the same opportunistic anaerobic and spirochaetal microbiology as NUG, but the host response is more profoundly impaired, allowing extension beyond the gingiva into the periodontal ligament and alveolar bone. This results in rapid soft tissue necrosis, attachment loss, and osseous destruction. In severe cases, exposed bone may be present, and further extension into adjacent oral mucosa may be termed necrotising stomatitis
Epidemiology and Risk Factors
NUP is less common than NUG and classically associated with significant impairment of host defence, especially untreated or advanced HIV infection, severe malnutrition, or other immunodeficiency states. It may also occur in smokers and patients with poor oral hygiene, heavy stress burden, or physical debilitation.
Non-modifiable | Modifiable |
|---|---|
Immunocompromised patients, for example:
| Smoking |
Diabetes mellitus | |
HIV | |
Poor plaque control | |
Psychological stress | |
Sleep deprivation |
Clinical Features
Symptoms | Signs |
|---|---|
Severe gingival pain | Bone loss |
Spontaneous or provoked gingival bleeding | "Punched-out" necrosis of interdental papillae |
Halitosis | Inflamed marginal gingiva |
Bad or metallic taste | Grey or yellow pseudomembrane over necrotic areas |
Difficulty eating or brushing | Tenderness on gentle probing |
Spontaneous or easy bleeding on manipulation | |
Fever is possible but uncommon |
Investigations
Primary investigations:
Clinical examination including periodontal examination with gentle probing
Assessment of oral hygiene and plaque retentive factors
Review of risk factors
Gold standard investigation:
There is no laboratory gold standard investigation for NUG, the diagnosis is primarily clinical
Investigations to consider:
Periapical or bitewing radiographs
Full periodontal charting once acute pain settles
Blood tests and further medical assessment if the disease is severe, recurrent or atypical, suggesting potential underlying immunosuppression
Differential diagnosis
Chronic periodontitis
Primary herpetic gingivostomatitis
Desquamative gingivitis
Scurvy
Acute leukaemia
Acute periodontal infection/abscess
Invasive fungal disease
Management
Acute Treatment (Day 1-3)
Gentle Debridement: Remove loose necrotic tissue and supragingival plaque using ultrasonic instruments (often requires local anaesthesia). Avoid aggressive probing or subgingival scaling initially.
Antimicrobial Rinses: Advise rinsing twice daily with 0.12%-0.2% Chlorhexidine gluconate or 1.5%-3% Hydrogen peroxide (diluted 1:1 with warm water) to reduce bacterial load.
Systemic Antibiotics: Prescribe only if systemic involvement (fever, malaise, lymphadenopathy) or severe immunodeficiency is present.
First Choice: Metronidazole 400mg-500mg, 3 times a day for 3–5 days.
Alternative: Amoxicillin 500mg, 3 times a day for 3 days.
Pain Relief & Supportive Care: Recommend analgesics (NSAIDs like Ibuprofen or Paracetamol). Recommend rest, high fluid intake, and avoiding tobacco, alcohol, and spicy foods.
Oral Hygiene Instruction (OHI): Advise gentle brushing with a soft toothbrush.