Necrotizing periodontal disease

You may have heard the term “necrotizing periodontal disease” (NPD) used to describe severe gum infections leading to destruction of periodontal tissues. But what exactly is necrotizing periodontal disease, what causes it, and how is it treated?

To begin with, the term “Necrosis” is used in medicine to describe the premature death of cells or tissues in a certain area of the body. The death could be caused by various factors such as injury, infection, lack of blood supply, toxins, or other damaging influences.

Consequently, the dead cells and tissues cannot perform their normal functions, and are often broken down by the body’s immune system. This process can lead to inflammation, and in some cases, it might require medical intervention to remove the dead tissue or to address the underlying cause of the necrosis.

Necrotizing periodontal diseases are infections characterized by necrosis, which is the death of gum tissue, periodontal ligaments, and alveolar bone.

Stages of Necrotizing periodontal diseases (NPDs)

NPDs encompass several stages, namely necrotizing gingivitis (NG), necrotizing periodontitis (NP), necrotizing stomatitis (NS), and the extreme noma or cancrum oris. The first two are the most common.

Despite their different names, these stages share a common origin and clinical presentation, marking them as parts of the same condition. Their key features include intense pain, tissue necrosis of the gums, ulcers between teeth, and, in advanced cases, even bone tissue death.

Here are the stages of progression of NPDs:

1. Necrotizing Ulcerative Gingivitis (NUG)

Necrotizing gingivitis, the most prevalent form, can progress into necrotizing periodontitis, particularly among those with weakened immune systems.

This stage is identified by localized tissue death in the areas between teeth, taking on a distinctive “punched-out” appearance. The disease can be reversed with prompt treatment. Other symptoms include painful, ulcerated, bleeding gums with halitosis (bad breath) and swelling. It typically affects the gingival papillae between teeth.

2. Necrotizing Ulcerative Periodontitis (NUP)

Besides gum necrosis, there is rapid breakdown of periodontal ligament and alveolar bone, leading to significant attachment loss.

Untreated necrotizing gingivitis can evolve into necrotizing periodontitis, causing rapid loss of periodontal attachment, formation of a pseudomembrane, and systemic symptoms like fever and lymphadenopathy (swelling).

3. Necrotizing Stomatitis (NS)

In its most severe manifestation, necrotizing stomatitis, the condition spreads to the alveolar bone, resulting in bone tissue death and possible sequestration.

4. Noma or cancrum oris

The extreme form, noma, affects malnourished children in underdeveloped regions, rapidly damaging facial tissues and potentially leading to fatal outcomes.

Causes of NPDs

Immunosuppression plays a pivotal role in NPDs. People with compromised immune systems, particularly those with HIV and a CD4 count below 200, are most susceptible to necrotizing periodontitis.

Other factors that may contribute to development of the condition include:

  • Leukemia, neutropenia, diabetes, and immunosuppressive therapy,
  • Smoking
  • Psychological stress
  • Malnutrition
  • Poor oral hygiene
  • Sleep disturbances

It is worth noting that the condition isn’t contagious, indicating that preexisting host factors are at the root of the issue.

Who is at risk of developing necrotizing periodontal diseases?

Globally, NPDs affect less than 1% of the population, primarily targeting young adults aged 18 to 30, malnourished children, and those with compromised immune systems.

Necrotizing periodontal diseases (NPDs) often stem from factors like weakened immune systems or increased stress, frequently compounded by smoking.

Malnutrition, especially in very young children with protein deficiency, plays a significant role in the disease’s prevalence among developing nations.

Other factors like tobacco smoking and poor oral hygiene contribute to the condition, particularly in emerging economies.

Symptoms of Necrosis in Gums 

Patients usually encounter severe pain, persistent bad breath, and a sudden onset of symptoms, particularly evident in cases of necrotizing periodontitis, which can lead to rapid loss of gum attachment.

As the disease progresses, additional symptoms like fever, fatigue, and swelling of regional lymph nodes may emerge.

NPDs result in painful lesions, prompting patients to discontinue oral hygiene practices and face issues like bad breath.

Intense pain may even affect eating and drinking habits, potentially worsening the fever and fatigue experienced.

Here is a summary of the signs and symptoms of necrotizing gingivitis and periodontitis:

  • Ulceration, redness and soreness of gums
  • Severe gum bleeding even with minimal disturbance
  • Halitosis or persistent bad breath
  • Painful, crater-like lesions between teeth and gum recession
  • Rapid bone loss in NUP revealed on x-rays
  • Nonspecific symptoms like malaise, fever, or lymphadenopathy
  • Alveolar bone death and possible sequestration in NS

Diagnosis and Evaluation

Seeing a dentist promptly for evaluation and treatment is critical to stop tissue necrosis and regain periodontal health. Diagnosing NPDs is primarily clinical, involving:

  • A check for lymphadenopathy and facial asymmetry
  • Biopsies often show unspecific inflammation
  • Radiographs reveal varying bone changes
  • CT scans help differentiate between different bone conditions
  • Blood tests are valuable for uncovering underlying conditions like leukemia and neutropenia

Treatment of Necrotizing Periodontitis

Treatment approaches include:

  • Professional plaque and calculus removal, often under anesthesia to access affected areas
  • Prescription antimicrobial mouth rinse (0.12% chlorhexidine)
  • Antibiotics like penicillin or metronidazole
  • NSAIDs for pain relied
  • Antiseptic chip or gel applied into gum pockets
  • Irrigation with saline or dilute hydrogen peroxide
  • Nutritional counseling for malnourished patients
  • Oral hygiene instructions

Ongoing management depends on the individual case. Immune disorders must be addressed, along with smoking cessation. Excellent oral hygiene and regular professional cleanings help prevent recurrence.

Addressing risk factors and underlying conditions is pivotal. Quitting smoking, reducing stress, and adopting proper nutritional habits help curb disease risk. NP patients may require medical consultation for underlying issues such as HIV.

Defects in both gum and bone tissues can hinder oral hygiene; post-acute treatment, surgical procedures like gingivoplasty or osteoplasty may be necessary to address these issues. Progress can be further enhanced by regular check-ups and ongoing maintenance.

Complications of NPDs

Necrotizing periodontal diseases can lead to various problems because of the damage they cause.

These problems include:

  • Losing teeth
  • More damage to the parts that hold teeth in place
  • Serious damage to the soft tissues in the mouth
  • The bone that supports teeth becoming exposed
  • Pieces of bone breaking off and getting stuck
  • Harmful bacteria getting into the bloodstream
  • Losing weight and becoming dehydrated

Final Thoughts

In essence, NPDs pose significant challenges to both oral health and overall well-being. Necrotizing gum infections require immediate treatment to halt rapid tissue destruction and bone loss. Seek care if you have painful, ulcerated and bleeding gums. Controlling these severe infections before permanent damage ensues is critical.

Recognizing risk factors, early diagnosis, and personalized treatment strategies, coupled with lifestyle modifications, play a pivotal role in managing these conditions and enhancing their prognosis.



  • Editorial team

    A team comprising oral health care professionals, researchers, and professional Writers, striving to impart you with the knowledge to improve your oral health, and that of your loved ones. 

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