Necrotizing periodontal diseases is one of the three categories of

periodontitis Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main c ...

as defined by the American Academy of Periodontology/ European Federation of Periodontology 2017 World Workshop classification system. Necrotizing periodontal diseases are a type of inflammatory periodontal (gum) disease caused by bacteria (notably fusobacteria and

spirochaete A spirochaete () or spirochete is a member of the phylum Spirochaetota (also called Spirochaetes ), which contains distinctive diderm (double-membrane) Gram-negative bacteria, most of which have long, helically coiled (corkscrew-shaped or ...

species). The diseases appear to represent different severities or stages of the same disease process, although this is not completely certain. These diseases usually have a sudden onset. The mildest on the spectrum is

necrotizing gingivitis Necrotizing gingivitis (NG) is a common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of interdental papillae (the sections of gum between adjacent teeth). This disease, al ...

(NG), followed by the successively more severe conditions necrotizing periodontitis (NP), necrotizing stomatitis and finally cancrum oris (noma), which is frequently fatal.

Necrotizing gingivitis

Necrotizing gingivitis, is a common, non-contagious infection of the gums. If improperly treated necrotizing may become chronic and/or recurrent. In developed countries, necrotizing gingivitis occurs mostly in young adults with predisposing factors such as psychological stress, sleep deprivation, poor oral hygiene, smoking, immunosuppression and/or

malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...

. In developing countries, necrotizing gingivitis occurs mostly in malnourished children. Due to shared predisposing factors in a population (e.g. students during a period of examinations, armed forces recruits) necrotizing gingivitis is known to occur in epidemic-type patterns. This has led to the popular belief that necrotizing gingivitis is contagious, but this is not the case. The main features of necrotizing gingivitis are painful, bleeding gums and ulceration and necrosis of the

interdental papilla The interdental papilla, also known as the interdental gingiva, is the part of the gums (gingiva) that exists coronal to the free gingival margin on the mesial and distal surfaces of the teeth. The interdental papillae fill in the area betw ...

. There may also be intra-oral

halitosis Bad breath, also known as halitosis, is a symptom in which a noticeably unpleasant breath odour is present. It can result in anxiety among those affected. It is also associated with depression and symptoms of obsessive compulsive disorder. Th ...

, cervical

lymphadenitis Lymphadenopathy or adenopathy is a disease of the lymph nodes, in which they are abnormal in size or consistency. Lymphadenopathy of an inflammatory type (the most common type) is lymphadenitis, producing swollen or enlarged lymph nodes. In cl ...

(swollen lymph nodes in the neck) and

malaise In medicine, malaise is a feeling of general discomfort, uneasiness or lack of wellbeing and often the first sign of an infection or other disease. It is considered a vague termdescribing the state of simply not feeling well. The word has exist ...

. Treatment of the acute disease is by

debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), or by maggot therapy. In ...

and antibiotics, usually

metronidazole Metronidazole, sold under the brand name Flagyl and Metrogyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vagino ...

. Poor oral hygiene and other predisposing factors may need to be corrected to prevent recurrence. Necrotizing gingivitis is also known as trench mouth, as it was observed to occur in the mouths of front line soldiers during World War I.

Necrotizing periodontitis

Necrotizing periodontitis (NP) is where the infection leads to attachment loss (destruction of the ligaments anchoring teeth in their sockets), but involves only the

gingiva The gums or gingiva (: gingivae) consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lining of the ...

periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, are a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which they sit. It inserts into root cementum on one side and onto alveo ...

and alveolar ligament. If attachment loss is present in the disease, it is termed NP, unless the disease has progressed beyond the

mucogingival junction A mucogingival junction is an anatomical feature found on the intraoral mucosa. The mucosa of the cheeks and floor of the mouth are freely moveable and fragile, whereas the mucosa around the teeth and on the palate are firm and keratinized. Wher ...

. NP may be an extension of NG into the periodontal ligaments, although this is not completely proven. In the meantime, NG, NP, and NS are classified together under the term necrotizing periodontal diseases.

Necrotizing stomatitis

Progression of NP into tissue beyond the

characterizes necrotizing stomatitis. Atypical case reports describe NS development without prior NPD lesions.

Noma

Noma (also termed cancrum oris) is a necrotizing and destructive infection of the mouth and face, and therefore not strictly speaking a periodontal disease. In modern times, this condition usually occurs in malnourished children in developing countries. It may be disfiguring and is frequently fatal. It has been suggested that all cases of noma develop from pre-existing NG, but this is not confirmed. Furthermore, the vast majority of cases of NG and NP will not progress to the more severe forms, even without treatment.

Vincent's angina

Strictly speaking, Vincent's angina is not a necrotizing periodontal disease. However, Vincent's angina is widely confused with

(previously also called "Vincent's gingivitis"). Vincent's angina is

tonsillitis Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and en ...

and

pharyngitis Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse vo ...

, and does not typically involve the gums. Many publications using the term "Vincent's angina" date from the twentieth century, and the term is not so common in modern times. The condition is named after Jean Hyacinthe Vincent, a French physician who was working at the Paris

Pasteur Institute The Pasteur Institute (, ) is a French non-profit private foundation dedicated to the study of biology, micro-organisms, diseases, and vaccines. It is named after Louis Pasteur, who invented pasteurization and vaccines for anthrax and rabies. Th ...

. Vincent described a fusospirochetal infection of the pharynx and palatine tonsils, causing "ulcero-membranous pharyngitis and tonsillitis", which later became known as Vincent's angina. Later in 1904, Vincent described the same pathogenic organisms in "ulceronecrotic

gingivitis Gingivitis is a non-destructive disease that causes inflammation of the gums; ulitis is an alternative term. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also ...

Nomenclature

The necrotizing periodontal diseases used to include the words "acute" and "ulcerative" in their names (e.g., "necrotizing ulcerative gingivitis"). Neither term is included in the AAP/EFP 2017 World Workshop classification on Necrotizing Periodontal Diseases.

References

* J Lindhe, NP Lang, T Karring (editors) (2008) "Clinical periodontology and implant dentistry" 5th edition, Blackwell Munksgaard, pp. 413,459 * MG Newman, HH. Takei, PR Klokkevold, FA Carranza (editors) (2012) "Carranza's clinical periodontology" 11th edition, Elsevier/Saunders, p. 165 {{Gram-negative non-proteobacterial bacterial diseases Periodontology Periodontal disorders