Periodontal+Case+4+-+Necrotizing+Ulcerative+Periodontitis

= Case #4 - Necrotizing Ulcerative Periodontitis =

**Ms. NUPP**
 **__Overview:__ ** NUP stands for necrotizing ulcerative periodontitis. Caranaza describes it as soft tissue necrosis, rapid periodontal destruction, and interproximal bone loss. This condition is usually seen preceding NUG which is necrotizing ulcerative gingivitis. There is a distinguishing factor of bone and periodontal attachment loss. This condition is painful for patients and needs immediate treatment. This is also seen in AIDS patients as a type of ulcerative and rapid progressing form of periodontitis.

A 32 year old re-care patient, who has not been seen in over a year, comes into your office complaining, "My gums really hurt, I can't eat or even brush my teeth anymore because it hurts so much!" While reviewing the medical history, you notice that there is no systemic conditions noted that could be possible etiologies for this conditon, however, when asked if this has ever occured before the patient replied, " Yes, about a year ago, the same thing happened!" While reviewing the previous notes, the clinician notices a previous episode two years prior and the patient had the same symptoms, however, no bone loss had occurred and it was noted in the patients chart that he was treated for NUG. The clinician asks the patient if they have recently been sick and she replies saying, " Yeah, I had a real bad cold about a week ago and my Dr. gave me antibiotics for an upper respiratory tract infection". The patient says that she feels tired, worn down and cant eat. She complains of bad breath and a metalic taste in her mouth that will not go away, as well.
 * __Medical History:__ **

Free: generalized erythematous, hemorrhagic and sloughing, loss of architectural structure, puched out interdental papillas on maxillary upper/lower anterior regions and glossy. Attched: generalized erythmetous, firm, shinny, and loss of stippling.
 * __Gingival Description:__ **

Due to **//__severe pain__//** of gingival tissues gathering of assessments will be difficult, some cases will require full mouth anesthesia so assessments can be made. With out anesthesia patient will not be able to tolerate assessments.
 * __Assessment Findings:__ **


 * MBI**: 79%. **BOP:** 84%. **Probing depths:** gen. 5-7's with loc. 8mm pockets. **Mobilty:** +1 from 6, 9-11, 14, 18, 19, and 23-26. **Fremitus:** + from 6-11. **Recession:** 2mm. on facial of #6, 3mm on facial of #11, 2mm on facial/lingual of #'s 23-27. PI: 100%.
 * Calculus code:** 4 quads of medium.
 * ADA III:** localized IV
 * AAP:** generalized moderate chronic perio with localized severe, due to plaque and calculus.

Clinician will need to explain NUP to the patient and correlate it with the past NUG condition presented two years prior. An explanation of how NUG/NUP is triggered will need to be expalined, such as with the upper respiratory tract infection the patient just recovered from. The patient will need to be told the severity of the condition and the bone loss that has occured from this condition. The clinician should explain the importance of the multiple visits needed to get the NUP condition under control. The clinician should then explain the treatment plan to the patient in detail. Oral hygiene for this patient will differ as the patients condition improves.
 * __OHI:__ **


 * __Treatment Planning__: According to Carranza **
 * Appt: 1**

Thorough evaluation of the patient's medical history will need to be evaluated for past episodes and possible etiologies and frequency of occurance. Possible referral to patient's physician may be neccessary to check for possible systemic conditions as an underlying risk factor for NUP.

Has this ever happened before? If so, what were your symptoms?Do you remember what medication(s) the Dentist perscribed at the time? Did you finish taking the medication(s)?
 * Questions to ask Patient:**

Specific questions should be asked to rule out possible etiologic factors such as: Are the recurrences associated with specific factors, such as menstruation, particular foods, exhaustion, mental stress. or recent recovery from an illness?

Gather assements (without use of instruments due to patients level of discomfort) (only gingival description) Explain local causes and control factors Place topical and wait 2-3 minutes Remove nonattached surface debris with moistened cotton pellot Superficial calculus removed with ultrsonic scalers Pt should return in 1-2 days and explained thoroughly about condition not resolving once pain stops

**Appt. 2** Gather assesments (note any improvment of changes in gingival health) OHI: Using disclosing tablet see if biofilm is still predominant. Review brushing technique with soft tooth brush moistened with warm water, (if this is too painful wait till patient has been anesthetized). Removal of causitive factor continued (ex: nutritional counsling follow up) FM anesthetic FM de-plaque Diluted hydrogene perioxide mixture swabbed on gingiva Home instructions: have patient rinse with warm salt water every two hours if improvment of condition is noted. If less painful have patient contiue to brush at least 2 days with soft toothbrush moistened with warm water. Continue with chlorahexadine rinse as instructed prior. Have patient return in 5 days

Gather assesments (note any change of gingival health a remarkable improvment should be present within patients first 24 hours of tx, by this apt patient should be in less pain and/or discomfort and the pseudomembrance should be gone and tissue enlargment reduced, pt should be symptom free) OHI: Use disclosing tablet to show patient missed areas of plaque, emphasize thorough brushing of entire dentition using circular movment Removal of causative factor FM anesthetic FM de-plaque Hydrogen peroxide rinses are discontinued Continue home instructions of rinsing with salt water 2x day, if less painful have patinent remove bacteria by soft tooth brush using improved OHI skills, and at least 2x day. Have patient start to floss if less painful. Chlorahexadine rinses can be maintained for the next 2 or 3 weeks.
 * Appt. 3**

OHI: Use disclosing tablets to see areas of retention and improvment on brushing technique. Emphasize two minutes of brushing 2x a day with complete sucular motion at a 45 degree angle. Show patient "C" cup flossing technique and make sure they are implimenting after each meal. Removal of causitive factor assesed UR quadrant anesthetized UR quad scaled Irrigate UR quad with CHX rinse. UL, LL, LR quad anesthetized (with topical) UL, LL, LR quad de-plaqued Home instructions: Have patient rinse with warm salt water every two hours.
 * Appt. 4**

Observe and note any gingival improvment. OHI: Introduce interproximal aids such as "tee pee" brush for diastemeas present interproximal to #8/9, and mandibular anterior teeth. Recomend waxed floss for tighter contact areas that might be present. Have patient rinse with warm salt water and mouthrinse before and after flossing to reduce spread of bacteria. Causative factor removal assesed. LR quad anesthetized LR quad scale Irrigate with CHX rinse UL, LL quad anethetized with topical UL, LL quad de-plaqued Check UR quad for plaque and calculus and remove as necessary with or without anesthesia depending on patients comfort level. Instruct patient to continue brushing and flossing vigourously and use warm salt water rinse daily as well as mouth wash.
 * Appt. 5**

Observe gingiva and note any improvments or any lack of improvment. OHI: Depending on patients improvment modify brushing and flossing techinque (or if much improved) continue with introduction of new interproximal aide such as the reach flosser. Causitive factor removal assessed. UL quad anesthetized UL quad scale Irrigate with CHX LL quad anesthetized LL quad de-plaqued Re-assess UR, LR quads If necessary deplaque UR, LR quads Instruct patient to rinse with warm salt water and continue brushing and flossing as instructed.
 * Appt. 6**

OHI: use disclosing tablets to assess residule plaque accumulation and in what areas to improve oral hygiene. Causative factor removal assesed. LL quad anesthetized LL quad scale Irrigate with CHX Assess plaque and caclulus in UR, LR, and UL quad If necessary deplaque. Send patient home with disclosing tablets to assess biofilm and plaque accumulation. Instruct patient to rinse with warm salt water and take Ibuprofen for inflamation. Have patient return in 4 weeks to re-evaluate.
 * Appt. 7**

3 month recall
 * Appt. 8**


 * __Additional treatment:__ **

After patient is completed with acute phase of NUP regular appointments for basic treatment are planned. The gingiva is evaluated and repeated scaling and debridment are performed as needed to complete that part of the treatment. Make sure caustive factor such as stress, diet, smoking or illness is removed to remove NUP and decrease the chances of recurrence of NUP. When the gingiva and bony crater from NUP remain after the initial healing phase and are not treated, they are vulnerable to continuing disease and reccurence of NUP. Biofilm and debris can collect in inter proximal areas or mishapen areas, faulty restorations and overhangs causing these areas to be difficult to clean with a necessary increase in biofilm control in these areas to prevent reccurence.

__** Questions: **__  1. NUP precedes NUG. NUP can also occur by itself without preceding NUG. a. both statements are true. b. both statements are false. c. first sentence is true, and second sentence is false. d. first sentence is false, and second sentence is true.

2. In severe NUP if an antibiotic is necessary which would be the best choice to prescribe to the patient? a. penicillin b. cephalosporin c. metronidazole d. ciprofloxacin

3. NUP is a tissue destruction that doesn’t involve significantly deep pockets because: A- The overgrowth of gingival tissue due to the medications B- The necrosis that occurs at the marginal soft tissues C- Tissue is erythmatous and bulbous. D- There is no bone loss associated with NUP.

4. All of the following are predisposing factors for NUP except A- Actinobacillus actinomycetemcomitans. B- AIDS patients C- Psychological stress D- Diabetes Mellitus E- Malnutrition. 

5- most data implicates similar microbial components in both chronic periodontits and NUP, studies have identified the presence of candida organism and human herpes virus in NUP patients a. both statements are true. b. both statements are false. c. first sentence is true, and second sentence is false. d. first sentence is false, and second sentence is true.

6- the treatment outcome for NUP patients depend MOSTLY on: a- patient's OH, and patient's compliance b- patient's perio assessments c-the treatment of the systemic disease that predisposed NUP d- all of the above

7- the of the followings are common in NUP EXCEPT: a- punched out papilla b- painful and bleeding gum c- rapid attachment loss progression d- interdental papilla necrosis.

8- NUP is a rapidly progressive form of periodontists, it occurs more frequently in HIV positive individuals. a. both statements are true. b. both statements are false. c. first sentence is true, and second sentence is false. d. first sentence is false, and second sentence is true.

9- therapy of NUP include: a- local debridement b- scaling and Root planning c- in office irrigation ex: Chlorohexidine d- home use of irrigation e- all of the above f- a,c,d only

10- NUP can progress rapidly and may lead to tooth exfoliation therefor systemic antimicrobial treatment is the only effective way to control the progression of this disease. a. both statements are true. b. both statements are false. c. first sentence is true, and second sentence is false. d. first sentence is false, and second sentence is true.