Journal of Dental Pathology and Medicine
Open Access

Necrotizing periodontal diseases; Necrotizing gingivitis; Necrotizing periodontitis; Necrotizing stomatitis; Periodontal infection; Immunocompromised; Oral microbiota; Acute periodontitis; Fusobacterium; Treponema; HIV; Halitosis; Periodontal therapy

Introduction

Necrotizing periodontal diseases (NPDs) encompass a spectrum of inflammatory conditions affecting the gingival and periodontal tissues [1,2]. This group includes necrotizing gingivitis (NG), necrotizing periodontitis (NP), and necrotizing stomatitis (NS). NPDs are characterized by tissue necrosis, severe pain, and rapid progression, and they are frequently associated with systemic conditions such as immunosuppression, malnutrition, and poor oral hygiene [3]. This article provides a detailed review of the etiology, clinical manifestations, risk factors, diagnostic methods, and treatment strategies for NPDs. Necrotizing periodontal diseases represent some of the most aggressive forms of periodontal conditions [4]. Though relatively uncommon in the general population, they are more frequently encountered in individuals with compromised immune systems, including patients with HIV/AIDS, malnourished individuals, and those under severe physical or emotional stress [5,6]. NPDs can cause rapid and extensive tissue destruction, requiring prompt diagnosis and treatment to prevent irreversible damage. This review aims to provide a comprehensive overview of NPDs, focusing on their clinical presentation, pathogenesis, and management. The American Academy of Periodontology (AAP) classifies NPDs into the following categories, Necrotizing Gingivitis (NG), a localized infection affecting the gingival tissues only [7]. Necrotizing Periodontitis (NP), progresses beyond the gingiva to involve the periodontal ligament and alveolar bone. Necrotizing Stomatitis (NS), the most severe form, involving deeper oral tissues and potentially spreading to the lips, cheeks, and oral mucosa [8].

Etiology and pathogenesis

The pathogenesis of NPDs is multifactorial, involving microbial, host, and environmental factors.

The key periodontal pathogens implicated in NPDs include,

• Treponema species (spirochetes)
• Fusobacterium nucleatum
• Prevotella intermedia
• Porphyromonas gingivalis

These anaerobic bacteria thrive in necrotic tissue and contribute to tissue destruction through the release of proteolytic enzymes and toxins.

Immune dysfunction plays a critical role in NPDs. Individuals with weakened immune responses, such as HIV/AIDS patients, are at increased risk. Impaired neutrophil function, decreased salivary flow, and increased inflammatory cytokines also contribute to disease severity.

Poor oral hygiene, plaque accumulation exacerbates bacterial overgrowth.

Stress, psychological stress reduces immune competence, making individuals more susceptible.

Malnutrition, deficiencies in vitamins (especially vitamin C and B-complex) impair healing and immune function.

Smoking, nicotine reduces blood flow to the gums, promoting tissue necrosis.

Systemic conditions, diabetes, leukemia, and other chronic diseases are linked to increased NPD susceptibility.

NPDs present with distinct clinical signs, including,

Intense gingival pain, the hallmark symptom, often disproportionate to the tissue damage.

Punched-out, crater-like lesions, characteristic necrosis of the interdental papillae.

Spontaneous bleeding, even minor stimuli can trigger bleeding.

Grayish pseudomembrane, a layer of necrotic tissue covering the gingiva.

Fetid odor, a distinct halitosis due to tissue necrosis.

Lymphadenopathy and fever, systemic involvement in severe cases.

Diagnosis

The diagnosis of NPDs is based on clinical examination and patient history. Key diagnostic steps include,

• Visual and physical examination, identification of necrotic tissue, gingival cratering, and pain.
• Microbiological testing, culture or DNA-based tests can identify specific pathogens.
• Radiographic imaging, to evaluate alveolar bone loss in necrotizing periodontitis.
• Blood tests, screening for underlying systemic conditions (e.g., HIV, diabetes).

Treatment and management

The management of NPDs involves both local and systemic interventions.

Mechanical debridement, removal of necrotic tissue using ultrasonic scalers or manual curettes.

Irrigation, use of antiseptic solutions (chlorhexidine 0.12% or hydrogen peroxide) to reduce bacterial load.

Pain management, topical anesthetics and systemic analgesics (NSAIDs) for pain relief.

Metronidazole (250 mg three times daily for 7 days) is the first-line antibiotic.

Combination therapy with amoxicillin and metronidazole may be used in severe cases.

Oral hygiene improvement, education on proper brushing, flossing, and use of antiseptic mouthwash.

Nutritional support, addressing malnutrition through dietary supplements (e.g., vitamin C, B-complex).

Smoking cessation, encouraging patients to quit smoking to prevent recurrence.

Systemic disease control, managing underlying conditions such as diabetes or HIV.

Complications

If left untreated, NPDs can lead to,

Alveolar bone loss, rapid destruction of periodontal tissues.

Tooth mobility and loss, due to periodontal ligament and bone damage.

Systemic spread, in rare cases, NPDs can progress to necrotizing stomatitis or noma, which can be life-threatening.

Preventing NPDs involves,

Regular dental check-ups, early detection and management of gingival inflammation.

Good oral hygiene practices, brushing twice daily, flossing, and using antiseptic mouthwash.

Healthy lifestyle, maintaining a balanced diet and managing stress levels.

Immune support, adequate nutrition and control of systemic conditions.

Conclusion

Necrotizing periodontal diseases, though relatively rare, can have severe oral and systemic consequences. Prompt diagnosis and comprehensive management are essential to prevent irreversible tissue damage and tooth loss. Improved oral hygiene practices, lifestyle modifications, and management of systemic conditions are key to reducing the incidence and severity of NPDs.