Clinical Guide > Oral Health > NUP and NUG

Necrotizing Ulcerative Periodontitis and Gingivitis

January 2011

Chapter Contents


Necrotizing ulcerating periodontitis (NUP) is a marker of severe immunosuppression that affects gingival tissues (gums) and extends to the underlying bone or periodontium. It may or may not be distinct from necrotizing ulcerative gingivitis (NUG), which is considered to be confined to the gingiva. This discussion will focus primarily on NUP, but the microbial profiles and treatment recommendations for these two periodontal diseases are similar.

NUP in HIV-infected individuals is believed to be an endogenous infection that progresses to necrosis of the gingiva. Pathogens may include anaerobic bacteria and fungi. NUP usually presents as "blunting" or ulceration of the interdental papillae, but rapidly progresses to destruction of underlying alveolar bone. It usually is associated with severe pain and spontaneous bleeding. Several case reports have described extensive destruction leading to exfoliation of teeth within 3-6 months of onset, with sequestration of necrotic alveolar bone and necrotic involvement of the adjacent mandible and maxilla. Patients may present with concomitant malnutrition resulting from inability to take food by mouth. The prevalence of NUP in the HIV-infected population has been reported as 0-5%. NUP is the most serious form of periodontal disease associated with HIV.

S: Subjective

The patient complains of painful, spontaneously bleeding gums, diminished or metallic taste, bad breath, or loose teeth (with a prevalence toward anterior teeth and first molars). "Deep jaw pain" is a common complaint and may reflect extension to adjacent mucosa.

O: Objective

Examine the oral cavity carefully. NUP and NUG present with fiery red, ulcerated gingival tissues, and grayish exudate. Teeth may be very loose or missing and there will be a fetid odor from the mouth. The ulcerated tissues can extend past the attached gingiva to the adjacent mucosa. Necrosis of adjacent bone also is common.

A: Assessment

The differential diagnosis includes other causes of gingival ulceration, such as herpes simplex virus, herpes zoster, and cytomegalovirus. (See relevant chapters on these conditions.)

P: Plan


Treatment usually is divided into the acute phase and the maintenance phase. The primary concern in the acute phase is pain control. For the maintenance phase, treatment is directed toward reducing the burden of potential pathogens, preventing further tissue destruction, and promoting healing.

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