Stress-Induced Necrotizing Gingivitis Resolved Aesthetically with Laser-Assisted Gingivoplasty

Introduction

Stress in any form is said to afflict all the body systems and the oral cavity in particular. This association has a long history;Pindborg as early as in the 1940s had detected it among soldiers of World War II in trenchers, thereby giving it the name “Trench mouth”.

Necrotizing periodontal diseases are classified based on the extent of involvement as necrotizing gingivitis, necrotizing periodontitis, and necrotizing stomatitis.¹ The different categories of necrotizing periodontal diseases are stages of the same disease with common etiology and clinical characteristics.² Some of the common terminologies for it include Vincent’s disease, necrotizing gingivo-stomatitis, fuso-spirochaetal stomatitis, ulcerative membranous gingivitis, necrotizing ulcerative gingivitis, and acute necrotizing ulcerative gingivitis.

The clinical signs of necrotizing gingivitis are punched-out lesions, linear gingival erythema, spontaneous bleeding, and an unmistakable oral malodor. Sometimes systemic manifestations like fever, malaise, and lymphadenopathy can also be observed. The predisposing factors for necrotizing diseases are young age, a change in lifestyle, psychological problems, malnutrition, prolonged stress with insufficient rest, and smoking; all of which lead to poor maintenance of oral hygiene.³

A heterogeneous group of microorganisms that are anaerobic and have a high proliferating rate such as motile spirochetes, Fusobacterium, and subsets of Treponema pallidum and Prevotella intermedia contribute to the aggressive clinical picture of the disease.4 Defects in leukocytes and immune function may also be associated with disease occurrence.¹

The key feature which helps in diagnosis is the ulceration and necrosis of free gingiva. The starting point of the lesions is the interdental papilla that shows a “punched-out” lesion along with “linear gingival erythema”, separating the healthy and the diseased gingiva. It is mostly seen in the mandibular anterior region. Bleeding on probing is usually spontaneous or occurs after minimal provocation. Pain is usually gnawing in nature and prompts a visit to the dental clinic. The bouts of pain increase with eating and along with oral hygiene practices.

There is a rare incidence of necrotizing diseases of the periodontium in developed countries. Young adults and immunodeficient people have a higher incidence of necrotizing disease.⁵ The symptoms start abruptly and keep recurring at times.

The present case study is of a male patient with typical symptoms of the necrotizing ulcerative disease of the gingiva and was treated sequentially using a traditional approach as well as a laser to accentuate the aesthetic outcomes.

Case Report

Patient information

A 24-year-old male patient was referred to the Department of Periodontology at the Krishnadevaraya College of Dental Sciences and Hospital, Bangalore, India. The patient came with a chief complaint of intense and persistent gingival pain, spontaneous bleeding, and severe malodor for 1 year which has increased in severity in the past 2 weeks. The patient’s weight was 60 kg and he measured 182 cm in height. He was pursuing dance in an art school. The patient had a history of excessive stress during the past few months due to approaching exams and improper intake of nutrition. The patient also reported an elevated body temperature of 1020 F two days before presentation and there was a negative history of drug allergies, medications, or systemic conditions.

Clinical and Diagnostic Findings

Extra-oral examination

On extra-oral examination, no gross facial asymmetry was detected, lips were competent, submandibular lymph nodes were tender on palpation bilaterally and a rise in body temperature was detected.

Intra-oral examination

Clinical findings

Upon intra-oral examination, maintenance of oral hygiene was found to be poor and could be elicited with heavy accretions on the tooth surface (both plaque and calculus). There was visible suppuration associated with a fetid odor. The oral lesions showed extreme tenderness on periodontal probing. A finer examination of the gingiva revealed a whitish-grey pseudo membrane that covered a part of the attached gingiva along with spontaneous bleeding. A typical punched out ulceration was seen in relation to teeth 13,12,11,21,22,23 (numbered as per univerisal system) . There was also an aberrant labial frenal attachment in the maxilla which worsened the symptoms in the maxillary arch.(Figure 1)

Radiographic findings

Periapical radiographs were taken from teeth 13 to 23 and they showed a corresponding crestal bone loss. (Figure 2).

Lab investigations

Basic hematological examination revealed a normal picture. A Humanimmunodeficieny virus (HIV) serological test was advised keeping in mind the fact that necrotizing periodontal diseases are one of the common manifestations of HIV. The test for HIV was negative.

Therapeutic Interventions

First Visit

A staged protocol of treatment was followed as in all necrotizing gingival diseases. Local factors were removed superficially using a local anesthetic spray (lignocaine). Education and motivation of the patient about the condition and specific instructions in the maintenance of oral hygiene were rendered. Removal of the necrotic slough was done under local anesthesia by using small gauze pellets dipped in 3% H₂ O₂ . This procedure was repeated in all the afflicted oral areas. Saline irrigation was carried out to dislodge the debris. Ultrasonic scaling was impossible due to extreme distress to the patient. Thus he was instructed to use a soft brush, a combination of 3% concentration of hydrogen peroxide mixed with an equal quantity of sterile warm water four times daily (Figure 3).

After one week mouth rinse of 0.2% chlorhexidine was advised to be used twice a day. The patient was prescribed systemic metronidazole (400 mg) tablets thrice daily for 3 days, an analgesic, vitamin complexes, and a follow-up appointment was scheduled. A recall visit was scheduled 3 days later for a re-evaluation of clinical symptoms (Figure 4).

On Seventh day

After 7 days the patient reported that the symptoms were resolved with complete healing of ulceration and disappearance of the necrotic slough. A slight papillary, inflammatory enlargement was remaining in the maxillary anterior teeth. The specific oral hygiene measures were emphasized with the addition of interdental aids like brushes and floss to thoroughly maintain all areas plaquefree. Additionally, the patient was prescribed chlorhexidine mouth rinse 0.2% twice a day for the next 10 days. Referral of the patient for a psychiatric assessment of stress levels was advised (Figure 5).

Maintenance phase

After the etiotrophic phase, the patient was put on supportive periodontal therapy to enhance the therapeutic interventions. Initially, weekly follow-up for the first 3 months and then three monthly follow-ups were scheduled.

Surgical phase

Due to the prevailing Corona virus disases 2019 (COVID-19) scenario, the patient reported to the hospital after 6 months instead of 3 months. Upon revaluation, surgery was scheduled to observe the aberrations in the maxillary anterior gingival margins. Basic hematological investigations were carried out. Local anesthesia (2% lignocaine with 1:80000 adrenaline) and diode laser (A.R.C FOX laser of 810 nm with an energy output of 1.8 W using optic fiber of 300 µm) was utilized to provide beveled margins and to obtain a physiologically conducive gingival (Figure 6&7). The final gingival architecture contributed to improved aesthetics. One month post laser gingivoplasty pictures are presented in Figure 8. 

Discussion

Necrotizing ulcerative gingivitis is localized to the investing tissue (gingiva) without involving the other supporting tissues of the periodontium. This disease runs progressively and later involves the entire attachment apparatus leading to their loss eventually.⁷

According to the oral regions affected, Horning and Cohen1 classified seven stages of necrotizing periodontal disease, ranging from necrosis of the papilla tip (stage I) to necrosis that perforates the skin of the cheek (stage VII). This classification accords with the general view that necrosis involves interdental papilla and marginal gingiva and extends into the attached gingiva. It is stage IV and the present case falls into this category.

Literature^8,9 supports that conservative local therapy is sufficient for the treatment of necrotizing ulcerative gingivitis (NUG) unless it is associated with a systemic condition like HIV. Accordingly, the treatment consists of the complete elimination of local irritants with scaling root planning (SRP) and a strict oral hygiene maintenance regimen. But the pain is the overriding feature that makes it almost impossible to do a thorough mechanical debridement. Thus in the present study, a staged approach was followed with several weekly visits.

Clinical experience has shown that along with professional maintenance, patient motivation and compliance form an integral element to the success of periodontal treatment. Keeping this in mind, the current case was instructed about the pivotal role of self-care in the maintenance of oral hygiene. Additional motivational approaches included a demonstration on models, illustrative photographs, and radiographs. The patient’s comprehension seemed satisfactory as shown by improved scores in the O’Leary index.¹⁰ The ultimate challenge was to ensure the patient’s adherence to frequent recall visits i.e weekly, biweekly and monthly.

The insidious role of stress in the onset and progression of necrotizing gingivitis in the current case is quite obvious. Our evidence-based systematic staged approach showed excellent results. In addition to the traditional mode, the utilization of laser as the final aesthetic surgical step gave a successful outcome both from the clinical point of view as well as patient satisfaction.

Conflict of interest

None