The treatment of acute gingival disease entails the alleviation of the acute symptoms and elimination of all other periodontal disease, both chronic and acute, throughout the oral cavity. Treatment is not complete if periodontal pathologic changes or factors capable of causing them are still present.
Necrotizing ulcerative gingivitis (NUG) results from an impaired host response to a potentially pathogenic microflora. Depending on the degree of immunosuppression, NUG may occur in a mouth essentially free of other gingival involvement or may be superimposed on underlying chronic gingival disease. Treatment should include the alleviation of the acute symptoms and the correction of the underlying chronic gingival disease. The former is the simpler part of the treatment, whereas the latter requires more comprehensive procedures.
The treatment of NUG consists of (1) alleviation of the acute inflammation by reducing the microbial load and removal of necrotic tissue, (2) treatment of chronic disease either underlying the acute involvement or elsewhere in the oral cavity, (3) alleviation of generalized symptoms such as fever and malaise, and (4) correction of systemic conditions or factors that contribute to the initiation or progression of the gingival changes. Chapter 26 provides further information on the management and treatment of NUG in patients with acquired immunodeficiency syndrome (AIDS).
At the first visit, the clinician should do a complete evaluation of the patient, including a comprehensive medical history with special attention to recent illness, living conditions, dietary background, cigarette smoking, type of employment, hours of rest, risk factors for human immunodeficiency virus (HIV), and psychosocial parameters (e.g., stress, depression). The patient is questioned regarding the history of the acute disease and its onset and duration, as follows:
The examination of the patient should include general appearance, presence of halitosis, presence of skin lesions, vital signs including temperature, and palpation for the presence of enlarged lymph nodes, especially submaxillary and submental nodes.
The oral cavity is examined for the characteristic lesion of NUG (see Chapters 17 and 24), its distribution, and the possible involvement of the oropharyngeal region. Oral hygiene is evaluated, with special attention to the presence of pericoronal flaps, periodontal pockets, and local factors (e.g., poor restorations, distribution of calculus). Periodontal probing of NUG lesions is likely to be very painful and may need to be deferred until after the acute lesions are resolved.
The goals of initial therapy are to reduce the microbial load and remove necrotic tissue to the degree that repair and regeneration of normal tissue barriers are reestablished. Treatment during this initial visit is confined to the acutely involved areas, which are isolated with cotton rolls and dried. A topical anesthetic is applied, and after 2 or 3 minutes the areas are gently swabbed with a moistened cotton pellet to remove the pseudomembrane and nonattached surface debris. Bleeding may be profuse. Each cotton pellet is used in a small area, then discarded; sweeping motions over large areas with a single pellet are not recommended. After the area is cleansed with warm water, the superficial calculus is removed. Ultrasonic scalers are very useful for this purpose because they do not elicit pain, and the water jet and cavitation aid in lavage of the area.
Subgingival scaling and curettage are contraindicated at this time because these procedures may extend the infection into the deeper tissues and may also cause bacteremia. Unless an emergency exists, procedures, such as extractions or periodontal surgery, are postponed until the patient has been symptom free for 4 weeks, to minimize the likelihood of exacerbating the acute symptoms.
Patients with moderate or severe NUG and local lymphadenopathy or other systemic signs or symptoms are placed on an antibiotic regimen of amoxicillin, 500 mg orally every 6 hours for 10 days. For amoxicillin-sensitive patients, other antibiotics are prescribed, such as erythromycin (500 mg every 6 hours) or metronidazole (500 mg twice daily for 7 days). Systemic complications should subside in 1 to 3 days. Antibiotics are not recommended in NUG patients who do not have systemic complications.
4. Confine toothbrushing to the removal of surface debris with a bland dentifrice and an ultrasoft brush; overzealous brushing and the use of dental floss or interdental cleaners will be painful. Chlorhexidine mouth rinses are also helpful in controlling plaque throughout the mouth.
6. Patients who have systemic complications, such as high fever, malaise, anorexia, and general debility and who have been put on an antibiotic treatment are told that bed rest is necessary, as well as copious fluid consumption and administration of analgesics for relief of pain.
Patients are asked to report back to the clinician in 1 to 2 days. The patient should be advised of the extent of total treatment that the condition requires and warned that treatment is not complete when pain stops. The patient should be informed of the presence of chronic gingival or periodontal disease, which must be eliminated to reduce the likelihood of recurrence of the acute symptoms.
A large variety of drugs have been used in the treatment of NUG.3 Topical drug therapy, however, is only an adjunctive measure; no drug, when used alone, can be considered complete therapy. Systemic antibiotics, when used, also reduce the oral bacterial flora and alleviate the oral symptoms,11,12 but they are only an adjunct to the complete local treatment that the disease requires. In patients treated by drugs alone or by systemic antibiotics alone the acute painful symptoms often recur after treatment is discontinued.
At the second visit, 1 or 2 days after the first visit, the patient is evaluated for amelioration of signs and symptoms. The patient’s condition is usually improved; the pain is diminished or no longer present. The gingival margins of the involved areas are erythematous but without a superficial pseudomembrane.
Scaling is performed if necessary and sensitivity permits. Shrinkage of the gingiva may expose previously covered calculus, which is gently removed. The instructions to the patient are the same as those given previously.
At the next visit, approximately 5 days after the second visit, the patient is evaluated for resolution of symptoms, and a comprehensive plan for the management of the patient’s periodontal conditions is formulated. The patient should be essentially symptom free. Some erythema may still be present in the involved areas, and the gingiva may be slightly painful on tactile stimulation (Figure 41-1, A and B). The patient is instructed in plaque control procedures (see Chapter 46), which are essential for the success of the treatment and the maintenance of periodontal health. The patient is further counseled on nutrition, smoking cessation, and other conditions or habits associated with a potential recurrence. The hydrogen peroxide rinses are discontinued, but chlorhexidine rinses can be maintained for 2 or 3 weeks. Scaling and root planing are repeated if necessary. Unfortunately, the patient often discontinues treatment because the acute condition has subsided; however, this is when comprehensive treatment of the patient’s chronic periodontal problem should start.