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Severe Necrotizing Periodontitis in HIV-Infected Patient: Case Report and

Non-Surgical Treatment

Article  in  Clinical Advances in Periodontics · April 2020

DOI: 10.1002/cap.10105

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 CASE REPORT

Severe Necrotizing Periodontitis in HIV-Infected Patient: Case Report and

Non-Surgical Treatment
Ricardo R. S. Fonseca,∗ Carlos A. Carvalho,† Tânia M. S. Rodrigues,† Rosely M. S. Cavaleiro,‡ Silvio A. F. Menezes† and
Luiz F. A. Machado∗

Introduction: Necrotizing periodontitis (NP) is an atypical and painful form of periodontal disease, it is described by a
promptly progress of ulceration and destruction of periodontal tissues; the NP is commonly linked to HIV-positive patients.
The aim of this report is to present a rare case of severe necrotizing ulcerative periodontitis treated non-surgically.
Case Presentation: A 28-year-old dark skin female patient was referred to a dentistry college with the main
complaint of spontaneous gingival bleeding and enlargement, oral pain during deglutition and dental hypersensitivity.
Clinical and radiographic examination revealed generalized severe periodontal destruction, extensive bleeding, increased
biofilm presence and spontaneous suppuration. Medical exams were requested, red and white blood cells were evaluated
and among those exams an enzyme-linked immunosorbent assay for HIV-1 antibodies, the result reveled reagent to HIV-
1. The diagnosis of NP was assigned based on periodontal parameters such as necrosis and ulceration of the coronal
portion of interdental papillae and gingival margin. Treatment established was scaling and root planning plus antibiotics.
At 3 months of treatment the clinical and periodontal condition were stable.
Conclusion: This case report highlights a severe and generalized form of NP, where periodontal non-surgical
associated with antimicrobials resulted in elimination of the gingival enlargement, necrosis and ulceration of the coronal
portion of interdental papillae and significant improvement of periodontal parameters. Clin Adv Periodontics 2020;0:1–5.
Key Words: HIV; necrotizing ulcerative gingivitis; periodontal medicine; periodontitis.

Background the host immune defense, where pathological microor-

Periodontitis (Ps) is a multifactorial infectious disease,
caused by the interaction between the dental biofilm and
∗ Laboratory of Virology, Institute of Biological SciencesFederal Univer-
sity of Pará, Belém, PA, Brazil
† Department
of periodontology, University Center of State of Pará,
Belém, PA, Brazil
‡ Department of Special Needs Care, University Center of State of Pará,
Belém, PA, Brazil
Received September 4, 2019; accepted March 27, 2020
doi: 10.1002/cap.10105
ganisms, proinflammatory cytokines, oral dysbiosis, and
cytotoxic factors play a major role.1-3 The mechanism of
pathogenesis include the invasion of the gingival crevic-
ular fluid by bacteria, causing an intense inflammatory
response, which leads to destruction of periodontal tissues
and potentially resulting in tooth and bone loss.2,3
Host habits, such as poor oral hygiene, smoking, and
associated systemic diseases such as diabetes, autoim-
mune diseases, and acquired immunodeficiency syndrome
(AIDS) may predispose and aggravate the progression of
Ps.4 AIDS is a viral infection caused by the human immun-
odeficiency virus (HIV), which infects important cells in
the human immune system, such as T-helper cells (specif-
ically CD4+ T cells), macrophages,and dendritic cells,
which are essential for the development and function of

Clinical Advances in Periodontics, Vol. 0, No. 0, May 2020 1

C A S E R E P O R T

the immune response.5 HIV infection alters the immune

system, progressively impairing the immune response,
thereby favoring a more intense Ps, such as acute/chronic
periodontitis and its uncommon presentation as necrotiz-
ing periodontitis (NP).6,7
NP is defined as the most severe form of Ps because of
the rapid onset and disease progression. NP is character-
ized by extensive areas of tissue necrosis, as well as the
formation of deep periodontal pockets.8 Clinically, there
is spontaneous or provoked gingival bleeding, gingival
necrosis at marginal and interdental papillae, substantial
bone loss, tooth mobility, excessive salivation, metallic
mouth taste, foul odor, malaise and intense pain.7,8
Because NP is uncommon and the management of
FIGURE 1 Patient with diffuse and general gingival bleeding and necro-
HIV/AIDS patients can be very challenging because of sis.
their compromised immune system, this study aims to
describe an interesting case of NP in a HIV/AIDS patient
that was managed non-surgically and showed a very good
result.

Clinical Presentation
In May 2017 a 28-year-old female was referred to a
dentistry college in Northern Brazil by her general den-
tist with a complaint of spontaneous gingival bleeding
and gingival swelling, oral pain and dental hypersensi-
tivity (Fig. 1). A detailed medical history including blood
tests were requested. The results showed that her white
blood cells were composed by 20% of lymphocytes (489 FIGURE 2 Radiographic images at initial presentation.
cells/mm3 ), 8% of monocytes (260 cells/mm3 ) Basophils
her platelet count was 149,000/μL. The patient tested
positive to HIV in enzyme-linked immunosorbent assay vomiting, flu, and progressive weight loss for almost 3
and Western Blot. months.
A full dental investigation was carried out and showed The periodontal investigation included dental biofilm
severe bone loss in the buccal region, mobility in all ante- index, bleeding on probing, periodontal probing depth,
rior teeth and excessive dental biofilm formation (Fig. 1). clinical attachment loss, dental mobility and furca lesion.
On x-ray examination, it was observed extensive alveolar It was observed spontaneous gingival bleeding, severe
bone destruction (Fig. 2). Oral hygiene was very poor, the destruction of the alveolar bone, generalized periodontal
patient was sex worker and reported constant diarrhea, probing depth 5 mm, necrosis and ulceration of the

TABLE 1 Periodontal parameters at baseline

Baseline

Tooth 17 16 15 14 13 12 11 21 22 23 24 25 26 27
∗ †
PD B 10.5.7 5.8.5 5.5.5 5.5.5 8.7.8 8.9.6 - - 5.5.5 6.6.7 8.9.9 10.8.8 10.10.12 6.7.8
‡
P 6.7.8 5.5.5 4.5.4 5.6.6 7.8.8 7.7.5 - - 7.6.6 6.7.5 7.7.9 12.8.7 9.10.9 5.6.7
Furcation 0 0 - - - - - - - - - - 0 0
Mobility 1 1 3 1 1 2 - - 1 1 2 2 1 0

Tooth 47 46 45 44 43 42 41 31 32 33 34 35 36 37

PD∗ B† 5.3.5 8.8.5 10.10.9 8.8.8 4.5.5 10.11.10 9.9.10 12.10.12 10.10.10 5.6.5 10.9.10 10.11.12 8.11.9 4.4.3
L§ 4.5.4 5.5.5 11.10.11 7.8.7 4.4.4 10.9.9 10.10.9 12.11.11 9.9.9 6.4.5 11.11.10 12.10.9 10.10.9 3.3.3
Furcation 0 1 - - - - - - - - - - 1 0
Mobility 0 2 3 3 1 3 3 3 3 1 3 3 1 0
PD∗ = periodontal probing depth; B† = buccal; P‡ = palatal and L§ = lingual.

2 Clinical Advances in Periodontics, Vol. 0, No. 0, May 2020 Fonseca et al.

 C A S E R E P O R T

FIGURE 3 First session of scaling and root planing plus antibiotics. FIGURE 4 Three months of treatment.

coronal portion of interdental papillae and gingival mar-
gin, appearance of inverted papillae, tooth mobility, abun-
dant presence of dental biofilm and malodor (Table 1).
The patient agreed to participate in this study and signed
a consent form.
Case Management and Clinical Outcome
The patient was referred to a center for HIV management
to start antiretroviral therapy. Dental clinical intervention
included scaling and root planing plus antibiotics (SRP +
A) (7 days of 1500 mg amoxicillin and 750 mg metron-
idazole split in three daily doses) and instructions of oral
hygiene and biofilm control. After 1 week of treatment,
an important reduction in gingival swelling and bleeding
was observed (Fig. 3).
A total six session of SRP were planned and after
the fifth session a new detailed laboratory values were
requested and the leukocytes count was 6,230 μL, 40%
(2,560 cells/mm3 ) lymphocytes, 10% (528 cells/mm3 )
monocytes, 2% (260 cells/mm3 ) Basophils, hemoglobin
was 15.6 g/dL; and her platelet count was 219,000/μL,
along with a new periodontal clinical examination was
performed (Table 2). In 3 months of intense multidis-
ciplinary treatment there was a major improvement in
the medical condition of her immunosuppression and
periodontal parameters (Fig. 4). However, follow-up and
sixth session SRP could not be completed because of lack
of patient’s interest and motivation to complete further
treatment.
Attempts to contact the patients were unsuccessful. The
decision about the periodontal non-surgical treatment and
periodontal medicine were based on recommendations
from the American Academy of Periodontology published
in 2009.9
Discussion
In this article a case of NP in a HIV infected patient was
described after an intensive non-surgical dental treatment.
The patient was initially referred with spontaneous gin-
gival bleeding and tooth mobility and an undiagnosed
HIV infection. After dental and medical management,
an important improvement was achieved as a result of
combined efforts.
It is well-known that periodontal bacteria of the red
complex are main agents of NP.1,2 Furthermore, dis-
ease modifying factors such as HIV infection can pre-
dispose to a much more severe and difficult to treat
manifestation.11,12 Immunosuppression, increased viral

TABLE 2 Periodontal parameters at 3 months of treatment

3 Months

Tooth 17 16 15 14 13 12 11 21 22 23 24 25 26 27
∗ †
PD B 6,3,3 4,4,4 2,3,3 3,3,3 5,4,5 6,6,5 - - 4,4,4 3,3,3 6,6,7 8,6,5 8,8,10 4,4,4
‡
P 6,7,8 5,5,5 4,5,4 5,6,6 7,8,8 7,7,5 - - 4,5,5 3,3,3 4,4,5 9,6,6 6,8,8 4,4,4
Furcation 0 0 - - - - - - - - - - 0 0
Mobility 0 0 2 1 1 1 - - 1 0 1 1 0 0

Tooth 47 46 45 44 43 42 41 31 32 33 34 35 36 37

PD∗ B† 3,3,3 5,5,5 6,7,7 5,5,5 3,5,4 8,8,8 8,9,7 9,9,9 9,9,9 4,4,4 8,8,8 7,7,7 9,9,9 3,2,2
L§ 3,3,3 4,5,4 8,7,9 6,6,7 2,2,2 7,8,8 10,9,8 9,9,9 7,7,7 3,3,3 8,7,9 7,6,6 9,9,9 3,3,3
Furcation 0 0 - - - - - - - - - - 0 0
Mobility 0 0 0 0 0 2 2 2 2 0 2 2 0 0
PD∗ = periodontal probing depth; B† = buccal; P‡ = palatal and L§ = lingual.

Fonseca et al. Clinical Advances in Periodontics, Vol. 0, No. 0, May 2020 3

C A S E R E P O R T
load, pro-inflammatory infiltrate and reduction of anti-
inflammatory cytokines (e.g., interleukin-10) are all con-
tributing factors for the development of PD in periodonti-
tis in HIV-infected patients, which causes diffuse invasion
into the gingival tissue of opportunistic bacteria, fungi,
and other viruses.5
Because of its multifactorial causes, it is recommended
that PN should be treated beyond the perspectives of
microbiology and immunology, requiring intervention in
the socioeconomic aspects of the affected population.13
In this case, it was noticed that the patient neglected
her self-care and general health, which was probably a
reflex of her social environment. Poor oral hygiene habits,
chronic malnutrition and an untreated HIV infection were
together all contributors to the advanced NP described.10
Although simple, the periodontal treatment applied in
this case changed the progression of the NP, eliminating all
the main symptoms observed at admission. Dental plaque
and poor oral hygiene are linked to the severity of NP, and
biofilm control is essential to NP management in a direct
cause and effect relationship.10
Summary
Why is this case new
information?
What are the keys to successful
management of this case?
What are the primary limitations
to success in this case?
Acknowledgments
The authors contributed equally to this article. This study
was financed in part by the Coordination for the Improve-
ment of Higher Education Personnel – Brasil (CAPES) -
Finance Code 001.
Conflict of interest
The authors declare that there is no conflict of interest.
CORRESPONDENCE
Luiz F. A. Machado, Federal University of Pará, Belém, Augusto Correa
1 street; Neighborhood: Guama, PA, Brazil. E-mail: lfam@ufpa.br
References
1. Herrera D, Retamal-Valdes B, Alonso B, Feres M. Acute periodontal
lesions (periodontal abscesses and necrotizing periodontal diseases) and
endo-periodontal lesions. J Clin Periodontol 2018;45(suppl 20):S78-
S94.
4 Clinical Advances in Periodontics, Vol. 0, No. 0, May 2020
NP requires multifactorial approaches because of its
complex pathogenesis interaction.11 In this case, the initial
success observed can be acknowledged to the combined
intervention on the medical and dental health. These
efforts should be focused in rehabilitating the patient on
the best way possible.
Conclusion
When considering that AIDS is a modifying factor of
periodontitis and without multidisciplinary treatment can
lead to severe necrotizing diseases such as the presented
case, in the a short period of multidisciplinary treatment
we observed the decrease of viral load and improvement
in periodontal clinical parameters, the authors believe
that this considerable improvement was because of the
hygiene orientations, suitability of the oral cavity and
treatment with antiretrovirals evidencing that multidis-
ciplinary treatment is the best option in cases of HIV-
positive patients.
 To the best of the authors’ knowledge, this is the first report on the
literature about a generalized and atypical case of necrotizing
periodontitis in a HIV-infected patient.
 Biofilm and microbiological control, multidisciplinary treatment and
correct non-surgical periodontal medicine.
 Long-term follow-up was not available because of patient’s
non-compliance.
2. Socransky SS, Haffajee AD, Cugini MA, Smith C, Kent RLJr. Microbial
complexes in subgingival plaque. J Clin Periodontol 1998;25(2):134-
144.
3. Shaikh HFM, Patil SH, Pangam TS, Rathod KV. Polymicrobial synergy
and dysbiosis: an overview. J Indian Soc Periodontol 2018;22(2):101-
106.
4. Phiri R, Feller L, Blignaut E. The severity, extent and recurrence of
necrotizing periodontal disease in relation to HIV status and CD4+
T cell count. J Int Acad Periodontol 2010; 12(4): 98-103.
5. de Menezes S, Menezes T, Rodrigues T, Nogueira, B, Fonseca, R. Anal-
ysis of IL-10 in HIV-1 patients with chronic periodontitis in northern
Brazil. Braz J Oral Sci 2017;16:17072-17081.
6. Naidu GS, Thakur R, Singh AK, Rajbhandary S, Mishra RK, Sagtani
A. Oral lesions and immune status of HIV infected adults from eastern
Nepal. J Clin Exp Dent 2013;5(1):e1-e7.
7. Gonçalves LS, Gonçalves BM, Fontes TV. Periodontal disease in HIV-
infected adults in the HAART era: clinical, immunological, and micro-
biological aspects. Arch Oral Biol 2013;58(10):1385-1896.
8. Sontakke SA, Umarji HR, Karjodkar F. Comparison of oral manifes-
tations with CD4 count in HIV-infected patients. Indian J Dent Res
2011;22(5):732.
Fonseca et al.

9. Rosen PS; American Academy of Periodontology-Research, Scicence
and therapy Committee. Treatment of plaque-induced gingivitis,
chronic periodontitis, and clinical conditions. Pediatr Dent 2008-
2009;30(7 suppl):253-262.
10. Ramos MP, Ferreira SM, Silva-Boghossian CM, et al. Necrotizing
periodontal diseases in HIV-infected Brazilian patients: a clinical and
microbiologic descriptive study. Quintessence Int 2012;43(1):71-82.
11. Umeizudike KA, Savage KO, Ayanbadejo PO, Akanmu SA. Severe
presentation of necrotizing ulcerative periodontitis in a Nigerian
Fonseca et al.
View publication stats
C A S E R E P O R T
HIV-positive patient: a case report. Med Princ Pract 2011;20(4):
374-376.
12. Zia A, Mukhtar-Un-Nisar Andrabi S, Qadri S, Bey A. Necrotizing
periodontitis in a heavy smoker and tobacco chewer—A case report.
Singapore Dent J 2015;36:35-38.
13. Patton LL. Current strategies for prevention of oral manifestations of
human immunodeficiency virus. Oral Surg Oral Med Oral Pathol Oral
Radiol 2016;121(1):29-38.
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