Periodontics · patient case question
All of the following are appropriate management steps for the 21-year-old EXCEPT:
Patient case: Punched-Out Papillae and a Tight Face
Patient: Two patients in the same session
Chief Complaint: (1) A 21-year-old student: “My gums are killing me and my breath is horrible.” (2) A 47-year-old woman referred with progressive facial tightness.
Background: Patient 1: final examinations week, sleeping four hours a night, smoking a pack a day, has not brushed properly in days. Patient 2: known systemic sclerosis, increasing difficulty opening her mouth.
Medications: Patient 1: none. Patient 2: nifedipine, omeprazole.
Vital Signs: Patient 1: T 100.6°F, HR 92, cervical lymphadenopathy. Patient 2: within normal limits.
Findings: Patient 1: punched-out, cratered, necrotic interdental papillae covered by a grey pseudomembrane, with spontaneous bleeding and severe pain. — Patient 2: taut shiny perioral skin with radial furrowing, maximum opening 26 mm, and on radiographs a uniformly WIDENED periodontal ligament space around multiple teeth which are firm and asymptomatic.
Show answer and explanation
Correct answer: A. Incisional biopsy of the necrotic papillae
- A. CORRECT — this is the EXCEPTION. BIOPSY has no role in necrotizing ulcerative gingivitis. The diagnosis is CLINICAL, made on the triad of pain, interdental necrosis and bleeding. Biopsy is unnecessary, adds trauma to already necrotic tissue, and delays treatment. It is indicated only if the lesion fails to respond as expected, raising the possibility of another diagnosis.
- B. This IS appropriate and is the cornerstone of treatment. Gentle ultrasonic or hand debridement under topical or local anaesthesia removes the pseudomembrane and biofilm. Aggressive instrumentation on day one is avoided because the tissues are exquisitely tender.
- C. This IS appropriate here. Antibiotics are NOT routine for localized NUG, but are indicated where there are SYSTEMIC signs — fever, malaise, lymphadenopathy — which this patient has. METRONIDAZOLE is the drug of choice because it targets the fusospirochaetal anaerobic flora.
- D. This IS appropriate. Chlorhexidine gives chemical plaque control while mechanical cleaning is too painful to perform properly. Hydrogen peroxide rinses are also traditionally used.
Note: Predisposing factors form the classic mnemonic picture: stress, smoking, immunosuppression, malnutrition and poor oral hygiene. NUG in a patient with none of these should prompt HIV testing. Long-term: the interdental craters persist and often need gingivoplasty once acute symptoms settle.