Typical Presentation of Stress Associated Vincent Angina – A Case Report

ulcerative gingivitis in a 24 year old male, describing the clinical features, treatment approach, and successful outcomes. past and Abstract Necrotizing periodontal diseases are the most severe rapidly destructive, non-communicable, periodontal infection of complex etiology. The diagnosis is based on clinical and radiological features. Necrotizing periodontal lesions are confined to periodontal tissues, including gingiva, periodontal ligament, and alveolar bone. The pathognomonic clinical characteristics are the typical punched out appearance, interproximal craters and spontaneous bleeding. The predisposing factors include host factors, such as psychological stress, immunosuppression, a smoking habit, and poor oral hygiene. If it is left untreated, it may spread laterally and apically to involve the entire gingival complex. In this case report, we presented a 24- year old male with necrotizing gingivitis and no systemic disease with a history of intense stress. The case report describes the clinical diagnosis of Necrotizing ulcerative periodontitis (NUP) and its therapeutic management by conservative oral treatment and regular psychological follow up.


Introduction
Necrotizing periodontal diseases (NPD) are the most severe inflammatory periodontal disorders associated with bacterial plaque. It usually has a rapid, aggressive onset, a multifactorial, complex etiology and runs an acute course [1]. They are classified as necrotizing gingivitis, periodontitis, or stomatitis according to the severity of progression of disease and tissue involvement [2]. Classical clinical features in necrotizing periodontitis (NP) are characterized by the presence of punched out, ulcerated and necrotic lesions that may be covered by a pseudo membrane of necrotic tissue [3]. The ulcerations are extremely painful and show spontaneous bleeding. An important feature of NP is the rapid and severe loss of clinical attachment and alveolar bone within a few days or weeks. Secondary clinical features include the presence 385 history of drug allergies, current medications, or significant health problems. Presence or absence of Vincent's angina symptoms is mentioned in Table 1. Also, Table 2 shows predisposing factors of the disease.

Extra-oral examination
On extra oral examination, there was no gross facial asymmetry detected, lips were competent, bilateral submandibular lymph nodes were tender on palpation and local rise in body temperature was detected.

Intra-oral examination
Clinical findings: On intraoral examination, poor oral hygiene was recorded with plaque, heavy calculus deposits, visible suppuration associated with fetor oris. The oral lesions were extremely tender hindering periodontal probing. Examination of the gingiva revealed a thin pseudo-membrane that covered a part

At Seventh day
After seven days the patient was almost symptom free. The ulcers had healed and necrotic slough was completely absent. Slight inflammatory enlargement was seen in the maxillary anterior labial and tip of interdental papilla ( Figure 5). Oral hygiene instructions were reinforced with prescription of interdental brushes and dental floss to perform mechanical plaque control. Additionally, he was advised to use Chlorhexidine mouth rinse 0.12% twice a day for further 10 days. Patient was referred to a psychologist to rule out his stress due to his profession. Patient was advised to maintain oral health by regular dental visits and strict oral hygiene practice.

Maintenance phase
After the completion of the cause-related therapy phase, the patient was enrolled in a periodontal maintenance program to optimize the therapeutic interventions which was done by the patient's adherence to the recall system of weekly followup appointments. Monthly follow-up for the first 3 months post treatment were done and at each visit, the oral hygiene instructions were emphasized. The findings at multiple follow-up examinations showed that periodontal health and function were successfully re-established and there was no evidence of progressive attachment loss ( Figure   6).

Discussion
Necrotizing periodontitis (NP) is a necrotizing periodontal disease that has an acute onset and requires urgent treatment [1]. invasion [5]. Predisposing systemic factors such as AIDS, diabetes, chemotherapy or leukemia are described in the literature to be associated with most cases of NUP [6][7][8]. In our patient a systemic disease was ruled out since biological analysis was normal and he was otherwise healthy.
This case report describes an acute presentation of necrotizing gingivitis associated with poor oral hygiene, malnutrition, and lack of sleep which are all related to intense psychological stress.
Many pathways have been suggested to explain study evaluated the association between levels of the stress-related steroid hormones and periodontitis and reported that high serum levels of cortisol were associated with periodontitis severity [9]. Host immune response to periodontal pathogens may be reduced by increasing the adrenocortical activity, which lead to altered cytokine profile and affected cells recruitment of macrophages and fibroblasts [10].
Stress also causes reduction of tissue matrix metalloproteinase levels, which leads to impaired tissue turnover. During stress periods, the subject's behavior also change and can lead patients to neglect oral hygiene. Malnutrition related to extreme stress has also been reported as a predisposing factor for necrotizing periodontal diseases. The basis for this interaction has been termed 'proteinenergy malnutrition', implying a marked reduction in antioxidant nutrients and an altered acute-phase response against infection [5]. The management strategy for NP lesions were followed in two phases: acute and maintenance phase treatment. The acute phase dealt with removal of local irritating factors. The patient's positive response to the intervention within one week could be attributed to several factors: use of systemic antibiotics like metronidazole, which has been described as the first antibiotic choice because it is active against strict anaerobes, proper oral hygiene, use of vitamin complexes and adequate rest.

Conclusion
Necrotizing ulcerative lesions, although uncommon, can cause severe pain and discomfort to the patient. It is always associated with underlying systemic illness and hence thorough history recording and clinical examination becomes the key to successful diagnosis and treatment.