HIV associated Necrotizing Ulcerative Periodontitis - NUP
NUP is necrotizing, ulcerative, rapidly progressive form of periodontitis seen in HIV individuals. NUP may be generalized or localized and manifest as a continuation of NUG in which periodontal attachment loss and bone loss occurs. There is marked necrosis of soft tissue, rapid destruction of periodontium and interproximal bone loss in NUP. The osseous structures of the periodontium are affected in NUP. NUP might be seen after marked CD4+ cell depletion.

The clinical features seen are intense pain, interproximal gingival necrosis, and craters in soft tissues. Spontaneous bleeding and joint pain are often complained by the patients. Destruction of the periodontium and bone may be extremely extensive and quick. Untreated NUP may extend into the adjacent tissues and expose the alveolar bone. When this occurs, the condition has been called Necrotizing Stomatitis. Bone is usually exposed resulting in necrosis and sequestration.

The necrotizing lesions show spontaneous resolution on treatment, resulting in painless and deep interproximal craters that are difficult to clean and may lead to conventional periodontitis (Glick et al, 2000). Data indicates a similar microbiota in both NUP and chronic periodontitis. Patients with NUP were more likely to have CD4+ lymphocyte counts below 200/mm3 and it is agreed that NUP is a predictive marker for severe immunodeficiency.

It is proposed that NUP might be a good marker of immune suppression. The progress of periodontal disease in HIV infected patients need a detailed investigation as the HIV infection get chronic.

The etiology of NUP is undetermined, but a mixed fusiform-
spirochete bacterial flora appears to play an important part. Because bacterial pathogens alone are not responsible for causing the disease, some predisposing “host” factors may be necessary. NUP is regularly associated with a diagnosis of AIDS or a positive HIV condition. NUP can progress quickly to tooth exfoliation, so treatment should include local debridement local antiplaque agents and systemic antibiotics. Early diagnosis and treatment of NUP are decisive because the osseous defects that occur in later stages are highly difficult to treat, even with extensive surgical procedure.

Treatment recommendations include systemic antibiotics(such as metronidazole , tetracycline, clindamycin, amoxicillin, and amoxicillin-clavulanate potassium) combined with debridement of necrotic tissues. Simultaneous administration of an antifungal agent should be considered as systemic antibiotics increase the patient’s risk for candidiasis. Patient’s oral hygiene maintenance and necessary periodontal therapies are done in periodic appointments in the acute and healing stages of NUP. A detailed periodontal examination should be done at each recall session for any patient with a history of NUP. Past severity of disease, plaque control, and case stabilization when determining the frequency of recall visits must be considered as periodontal maintenance programs for HIV patients are individualized..

A favorable treatment response is observed when HIV-associated periodontal disease is in the earliest stages. Repeated episodes of the disease is seen in patients who have been treated for NUP, especially with poor oral hygiene levels. NUP can be localized, insidious, and not always related to plaque. After clinical stabilization, recall visits are usually scheduled every 3 months to prevent recurrence.