A 32-year-old HIV-positive female smoker (14 pack-years) on bictegravir/emtricitabine/tenofovir (Bictarvy®) presents with 'bad breath.' Findings include blunted ulcerative papillae, generalized bleeding on probing, grey pseudomembrane on marginal gingiva, lymphadenopathy, foul breath, and temperature of 100.6°F. Which of the following factors can contribute to the development of this condition EXCEPT?

Correct answer: B. High glucose diet

• A. INCORRECT (smoking IS a contributing factor). Cigarette smoking is a major risk factor for necrotizing periodontal diseases. It impairs neutrophil function, reduces oxygen tension in gingival tissues, and promotes the growth of anaerobic bacteria.
• B. CORRECT — EXCEPTION. A high glucose diet is NOT a recognized contributing factor to necrotizing gingivitis (NUG/NUP). The established risk factors for necrotizing periodontal diseases are: psychological stress, smoking, immunocompromised states (HIV), malnutrition, and poor oral hygiene. Diet quality (high glucose) does not specifically predispose to necrotizing gingivitis.
• C. INCORRECT (HIV IS a contributing factor). HIV-induced immunosuppression (particularly low CD4 counts) dramatically increases susceptibility to necrotizing periodontal diseases. HIV patients are at high risk for NUG and NUP.
• D. INCORRECT (malnutrition IS a contributing factor). Malnutrition impairs immune function, wound healing, and oral tissue integrity, all of which predispose to necrotizing gingivitis. Vitamin C deficiency (scurvy) in particular worsens gingival health.