Etiology of NPD
A. Microorganisms. Necrotizing periodontal disease associated with
Treponema species, Selenomonas species, and Fusobacterium species, and Bacteroi-
des melaninogenicus ss. intermedius (Provotella intermedia).
B. Predisposing factors for NPD
1. Systemic diseases that reduce immunity, including HIV infection, leukemia, measles, chickenpox, tuberculosis, herpetic gingivostomatitis and malaria
2. Poor self-care (plaque biofilm control)
3. Emotional stress [23,24]
4. Lack of sleep, fatigue
5. Alcohol use
6. Caucasian origin
7. Cigarette Smoking is the most patients who experience NPD are smokers 
8. Increase of a level of personal stress
9. Poor nutrition
a. In North America, the results of the contest due to poor habits of young people, particularly students of colleges.
B. In developing countries, the results of the contest takes place in very young children, and appears to be associated with poor nutritional status, especially low protein intake.
10. Earlier gingivitis or tissues
11. Young age is a disease can occur at any age, but according to the obtained data, the average age of the NPD in the industrialized countries in the period between 22 and 24 years .
5. Treatment Necrotizing ulcerative gingivitis. The purpose of the acute phase of treatment is to eliminate the disease activity and to ease the pain and discomfort.
1. Periodontal instruments, as well as can be tolerated by the patient. Ultrasonic devices may be preferable. Use minimal pressure against fabrics, ultrasound tip is used to delete soft and mineral deposits.
2. Patient self-care instructions: teeth cleaning should be avoided in areas of open wounds to promote wound healing. Chemical plaque biofilm control can be used up until healing occurs. Twice daily rinsing 0.12% chlorhexidine solution is very effective.
3. Additional oxygen therapy using hydrogen peroxide (3%):
a. Used for mechanical cleaning necrotic areas and as a mouth rinse (equal instalments 3% hydrogen peroxide and warm water) [26-31]
B. Adjuvant therapy of oxygen results in early liquidation of anaerobic microorganisms pathogenic and less damage periodontal tissues in cases NPD .
4. Pain control
5. Additional antibacterial therapy is necessary for management of systemic symptoms (fever, swollen lymph nodes), or in patients with somatic diseases.
a. Metronidazole 250 mg (Flagyl) three times a day the first choice for treatment of necrotizing ulcerative gingivitis [19,20]. Other antibiotics such as penicillin and tetracycline are also effective.
B. In HIV-associated necrotizing ulcerative gingivitis, auxiliary use of metronidazole is reported to be extremely effective in reducing acute pain and promoting faster healing .
6. Patients with necrotizing ulcerative gingivitis should be seen daily, while acute symptoms persist. Appropriate treatment should ease the symptoms for a few days. After symptoms subside, the patient should be back in a week to complete periodontal clinical assessment and treatment planning.
B. Patient Education. Advising a patient for patients with necrotizing ulcerative gingivitis should include training on good nutrition, fluid intake, and Smoking cessation. Liquid food replacement, such as to provide or improve, can be recommended...