Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 6: Disease-Specific Treatment

Necrotizing Ulcerative Periodontitis and Gingivitis

Background

Necrotizing ulcerating periodontitis (NUP) is a marker of severe immunosuppression that affects the gums and extends to the underlying bone or periodontium. It may or may not be distinct from necrotizing ulcerative gingivitis (NUG), which is considered to be confined to the gums. This discussion will focus primarily on NUP, but the microbial profiles and treatment recommendations for these two periodontal diseases are similar.

NUP in HIV-infected individuals is believed to be an endogenous infection that progresses to necrosis of the gingiva. Pathogens may include anaerobic bacteria and fungi. NUP usually presents as "blunting" at interdental papillae, but rapidly progresses to destruction of underlying alveolar bone. It usually is associated with severe pain and spontaneous bleeding. Several case reports have described extensive destruction leading to exfoliation of teeth within 3-6 months of onset, with sequestration of necrotic alveolar bone and necrotic involvement of the adjacent mandible and maxilla. Patients may present with concomitant malnutrition due to inability to take food by mouth. The prevalence of NUP in the HIV-infected population has been reported as 0-5%. NUP is the most serious form of periodontal disease associated with HIV.

S: Subjective

The patient complains of painful, spontaneously bleeding gums, diminished or metallic taste, bad breath, or loose teeth (with a prevalence toward anterior teeth and first molars). "Deep jaw pain" is a common complaint and may reflect extension to adjacent mucosa.

O: Objective

Examine the oral cavity carefully. NUP and NUG present with fiery red, ulcerated gingival tissues, and grayish exudate. Teeth may be very loose or missing and there will be a fetid odor from the mouth. The ulcerated tissues can extend past the attached gingiva to the adjacent mucosa. Necrosis of adjacent bone also is common.

A: Assessment

The differential diagnosis includes other causes of gingival ulceration, such as herpes simplex virus, herpes zoster, cytomegalovirus, and Kaposi sarcoma. (See relevant chapters on these conditions.)

P: Plan

Treatment

Treatment usually is divided into the acute phase and the maintenance phase. The primary concern in the acute phase is pain control. For the maintenance phase, treatment is directed toward reducing the burden of potential pathogens, preventing further tissue destruction, and promoting healing.

• For uncomplicated NUP or NUG, perform local debridement with irrigation and periodontal curettage (extending below the marginal gingiva).
• Chlorhexidine gluconate rinse (0.12%) twice daily after brushing and flossing (the alcohol-free preparation is preferred).
• Antibiotic therapy (preferably narrow spectrum, to leave gram-positive aerobic flora unperturbed).
  • Metronidazole or penicillin is the drug of choice, 250 mg orally 3 times daily for 10-14 days.
  • Coadminister with amoxicillin-clavulanate (Augmentin) 875 mg orally twice daily for 10-14 days, if no hypersensitivity or allergy to either drug exists.
• Refer to a dentist for the following:
  • Removal of plaque and debris from the site of infection and inflammation
  • Debridement of necrotic hard and soft tissues, with a 0.12% chlorhexidine gluconate lavage

Patient Education

• Advise the patient of the following: Good oral hygiene is critical to arresting gum, periodontium, and tooth loss. Avoid smoking and try to eliminate emotional stress. When primary stabilization is achieved, resume daily brushing and flossing after every meal. This may be difficult during the acute phase, but it is very important to keep the mouth as clean as possible. Nutrition supplements (liquid diet, plus vitamins/minerals) are recommended.
• Frequent professional cleaning (every 2-3 months) may be needed during the maintenance phase.
• Patients taking metronidazole should not drink alcohol during treatment with metronidazole, and for at least 24-48 hours after last dose, in order to avoid severe nausea and vomiting from a disulfiram reaction.
• Instruct patients not to drink, eat, or rinse their mouths with water for 30 minutes after rinsing with chlorhexidine.
• Bleeding gums may transmit HIV (or hepatitis C) during "deep kissing" or other activities (oral-genital contact). Advise patients/clients to avoid exposing partners to HIV by taking all necessary precautions, including abstaining from risky activities until this condition is healed and stable (no oozing of oral fluids).

References

• American Academy of Periodontology, Committee on Research, Science and Therapy. Periodontal Considerations in the HIV-Positive Patient. Chicago: American Academy of Periodontology; 1994.
• Coogan MM, Greenspan J, Challacombe SJ. Oral lesions in infection with human immunodeficiency virus. Bull World Health Organ. 2005 Sep;83(9):700-6.
• Greenberg MS, Glick M, eds. Burket's Oral Medicine: Diagnosis and Treatment, 10th Edition. Hamilton, Ontario: BC Decker; 2003:61-63.
• Greenspan D, Greenspan J, Schiodt M, et al. AIDS and the Mouth. Copenhagen: Munksgaard; 1990:106.
• Kroidl A, Schaeben A, Oette M, et al. Prevalence of oral lesions and periodontal diseases in HIV-infected patients on antiretroviral therapy. Eur J Med Res. 2005 Oct 18;10(10):448-53.
• Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003 Dec;31:28-29.
• Petersen PE, Bourgeois D, Ogawa H, et al. The global burden of oral diseases and risks to oral health. Bull World Health Organ. 2005 Sep;83(9):661-9.
• Reznik DA. Oral manifestations of HIV disease. Top HIV Med. 2005 Dec-2006 Jan;13(5):143-8.
• Winkler JR, Murray PA, Grassi M, et al. Diagnosis and management of HIV-associated periodontal lesions. J Am Dent Assoc. 1989 Nov;Suppl:25S-34S.