Gingivitis Acute Conditions And Nonplaque-Induced Question And Answers

Nonplaque-induced Gingivitis Acute Conditions of Gingiva

Many of these non-plaque induced gingivitis are of sudden onset and hence may be classified under acute conditions of the gingiva.

• A variety of bacteria, viruses, and fungi have been shown to produce gingival disease and certain genetically transmitted disorders or mucocutaneous systemic conditions have resulted in an alteration of gingival tissue, structure, and metabolism.
• The gingiva may also exhibit allergic reactions to various chemicals and dental materials it may come in contact with or be traumatically injured by iatrogenic means or physical and chemical agents.

Read And Learn More: Periodontology Important Question And Answers

Bacterial Origin

Acute Necrotizing Ulcerative Gingivitis

Question 1: Describe the etiopathogenesis clinical characteristics of ANUG and add a note on its management.
Answer:

Acute necrotizing ulcerative gingivitis (ANUG) was earlier known as Vincent’s infection or Trench mouth.

Etiology

• It is primarily of bacteria origin. However actual disease manifestations seem to occur more often in patients with compromised immune response.
• The predominant bacteria are fusiform bacillus, spirochetes, T. microdentium, Borrelia vincentii, Fusobacterium and Treponema.

Predisposing Factors

The local predisposing factors (preexisting gingivitis, trauma) exert a greater influence in on the gingival tissues in the presence of systemic predisposing factors (nutritional deficiency, smoking, debilitating diseases such as syphilis, cancer, leukemia, AIDS, psychological factors).

Bacterial Origin Clinical Features

• Interdental papilla exhibit punched-out, create-like depressions that are covered by a greyish pseudomembrane that can be peeled off revealing an erythematous base.
• These ulcers are associated with pain, sometimes severe, gingival bleeding, fetid odor, and increased salivation.
• Lesions are extremely sensitive to touch and patients complain of pasty saliva, sometimes lymphadenitis, and fever.
• In severe cases, leukocytosis, headache, and mental depression may occur, with extreme cases even pneumonitis and meningitis have been reported.

Histopathology

• A non-specific acute inflammation in the epithelium spacing and connective tissue, with infiltration of the spirochetes into the tissues.
• The poor blood supply with the microorganismal infiltrate is responsible for the necrotic lesions seen in the interdental papilla.
• The areas surrounding the ulcers are hyperemic, with increased vascularity and neutrophil infiltration.
• The necrotic epithelial cells form the pseudomembrane that is in a mesh of fibrin.

Describe the management of Anug.

The goal of therapy is to alleviate acute symptoms, reduce microbial load, and necrotic tissue, correct systemic conditions, if present, and treatment of chronic disease.

Sequence of Treatment

Early Phase of Treatment

Evaluation of patient: Treat acutely involved areas, with topical anesthetic and use a moist cotton pallet to remove the pseudomembrane. H₂O₂ may be used to lease the pseudomembrane and the peroxide-based mouthwashes may be prescribed. The oxygenating agent has a strong microbicidal effect on the gram-negative spirochetes. Both topical and systemic analgesics are prescribed according to need.

• Remove superficial calculus
• Antibiotics such as metronidazole 400 mg thrice daily may be prescribed for a week depending on the severity of the lesion and presence of systemic symptoms.

Patients are also instructed to refrain from using alcohol and tobacco. Supplemental therapy in the form of vitamins may be given.

Evaluation: Improvement of local signs and symptoms, with alleviation of all systemic effects, are evaluated for the peroxide mouthwash may be discontinued when local signs, ulcerations, etc. improve. After this phase, a more thorough mechanical debridement may be undertaken.

Treatment plan for periodontal conditions.

• Gingivoplasty may be necessary after 6 weeks to correct the gingival cleft that sometimes forms after the acute phase subsides.

Pericoronal Abscess or Pericoronitis

Question 2: Describe the clinical features and management of pericoronitis.
Answer:

Pericoronal abscess is a localized infection within the tissue surrounding the crown of partially erupted teeth.

Pericoronal Abscess or Pericoronitis Clinical Features

Pericoronal abscess is most frequently seen about the mandibular 3rd molar. The soft tissue flap covering the partially erupted tooth becomes a site for food entrapment and favors bacterial growth.

• Further, the flap may also be traumatized by opposing teeth and together this leads to a chronically inflamed/abscessed pericoronal flip.
• The pericoronal abscess is associated with pain, sometimes radiating to the ear, and may result in difficulty in opening the mouth. Pericoronal abscess may occasionally lead to space infections and cellulitis

Treatment of Pericoronal Abscess

Tooth extraction may be required if the involved tooth is impacted or without a functional antagonist. Pericoronal flip excision is the treatment of choice when there is an antagonist’s tooth and the flap covering the tooth is comprised of the gingiva.

• The acute symptoms are initially treated with saline antiseptic irrigation, incision and drainage, and antibiotic therapy.
• The herpes viruses are associated with gingivostomatitis, varicella zoster infection, and recurrent oral herpes, particularly of the labial region.
• The virus may stay latent along the nerve supply and cause reinfection due to activation of immune suppression.
• Herpetic Gingivostomatitis and other Herpes Virus Infections

Question 3: Discuss herpetic gingivostomatitis and its management.
Answer:

Acute herpetic gingivostomatitis is caused by herpes simplex virus type I (HSV-I) and occurs at an early stage of life.

Pericoronal Abscess or Pericoronitis Clinical Features

Generalized gingivostomatitis presents as vesicles that occur almost throughout the oral cavity which rupture easily and result in multiple ulcerations, including in the gingiva.

• The ulcerations have a yellowish or grayish central area and are usually surrounded by an erythematous halo. These ulcerations are more commonly seen in the attached gingival and are usually self-limiting.
• There may be generalized soreness, associated with difficulty in eating and drinking.
• There may be cervical lymphadenopathy, high fever, and generalized malaise in some cases, and may occur following bouts of infection such as upper respiratory tract infections.
• Recurrent herpetic gingivostomatitis may sometimes occur in immunocompromised states.

Histopathology

Histologically, there is ballooning degeneration of the epithelial cells and acantholysis: and the formation of ‘thank cells’ that are isolated cells detached from the rest of the epithelium and nuclear inclusion bodies. There is acute inflammation around the ulcerated areas.

Pericoronal Abscess or Pericoronitis Treatment

Palliative therapy is largely sufficient and analgesics, topical and systemic may be prescribed as needed.

• Topical steroid-containing ointments are to be avoided as they may depress the immune system.
• Antiviral drugs such as Acyclovir are rarely necessary and may be necessary only in severe immunosuppression.

Question 3: Write a note on gingival diseases of fungal origin.
Answer:

Fungal infections of the oral cavity are relatively rare, conditions like candidiasis are seen in debilitated and immunocompromised individuals.

Generalized Gingival Candidiasis

Candidiasis of the gingiva can occur in various forms but the acute forms usually occur as scrapable white patches that leave behind a raw red area.

• They usually follow a bout of immuno depression or prolonged intake of broad-spectrum antibiotics such as tetracycline. It may be associated with HIV infection, uncontrolled diabetes, and adrenocortical insufficiency or prosthetic appliances.
• Treatment of acute oral candidiasis usually consists of topical clotrimazole for 7–10 days or systemic Nystatin.
• In more severe conditions, systemic amphotericin may be considered.

Question 4: Write a note on allergic reactions to the gingiva.
Answer:

Allergic reactions may manifest as vesiculobullous lesions but more commonly as ulcerations.

• These may occur in materials used in dentistry—such as restorative materials, food ingredients, dentifrices, or drugs.
• The various drug-induced reactions are described as stomatitis medicamentosa, venenata, field drug eruption, or contact allergy.
• These lesions occur as ulcerations that may initially occur as vesicles and may heal with pigmentation.

Physical, Chemical, And Thermal Injury

• Chemical injury of the gingiva often results from the use of phenol, silver nitrate, or formoterol that may be of iatrogenic origin.
• Self-application of drugs such as aspirin, and other balms may also lead to ulcerated or even necrotic areas. Thermal or physical injury may be iatrogenic or self-inflated.
• Gingival diseases of mucocutaneous origin will be dealt with in forthcoming chapters (desquamative gingivitis).

Generalized Gingival Candidiasis Conclusion

Non-plaque induced gingivitis are of varying etiologies and their therapy will differ accordingly. However, it must realized that plaque-induced secondary gingivitis may worsen the underlying condition.