Acute necrotizing ulcerative gingivitis
Background
Anatomy of the periodontium. The crown of the tooth is covered by enamel (A). Dentin (B). The root of the tooth is covered by cementum. C, alveolar bone. D, subepithelial connective tissue. E, oral epithelium. F, free gingival margin. G, gingival sulcus. H, principal gingival fibers. I, alveolar crest fibers of the periodontal ligament (PDL). J, horizontal fibers of the PDL. K, oblique fibers of the PDL.
- Also known as "trench mouth"
- Often abbreviated as ANUG
- Severe gingival disease that may spread to local soft tissue and bone
- Must distinguish from Herpes gingivostomatitis
- Herpes has more systemic signs, less bleeding, lack of interdental papilla involvement
- Bacteria involved: anaerobic fusobacterium and Borellia spirochete[1], Treponema, Selenomonas, Prevotella
- Vincent's angina is sometimes confused with ANUG, but the former is tonsillitis and pharyngitis, and the latter involves the gums. There is not currently a consensus on whether ANUG and Vincent's angina are separate entities or simply different presentations of the same entity
Associated Conditions[2]
- Immunosuppression, especially HIV
- Poor oral hygiene/nutrition/sleep
- Stress
- ETOH/tobacco use
- Age<21
- Caucasians
- malaria/measles/parasites
Clinical Features
Early
- Fever
- Halitosis
- Dental/mouth pain
- Gingival bleeding
- Teeth mobility
- Malaise
Secondary signs
- Fetid breath with metallic taste
- "Wooden teeth" feeling
- Regional lymphadenopathy
- Ulcerated, with grayish pseudomembrane or "punched out" interdental papillae
- Blunting of the typically pointed edges of the papillae
Differential Diagnosis
Dentoalveolar Injuries
Odontogenic Infections
- Acute alveolar osteitis (dry socket)
- Acute necrotizing ulcerative gingivitis (trench mouth)
- Dental abscess
- Periapical abscess
- Periodontal abscess
- Ludwig's angina
- Pulpitis (dental caries)
- Pericoronitis
- Peritonsillar abscess (PTA)
- Retropharyngeal abscess
- Vincent's angina - tonsillitis and pharyngitis
Other
Evaluation
- Usually clinical
Management
Organisms involved are polymycrobial but often include Fusobacterium necrophorum, Treponema spp, Selenomonas, and Prevotella
Uncomplicated Disease
- Amoxicillin/Clavulanate 875 mg PO two times daily AND
- Metronidazole 500mg PO three times daily x 7 days [3] OR
- Clindamycin 300mg PO three times daily OR
- Doxycycline 100 mg PO BID x 10 days[4]
- If allergic to penicillin, the use Ciprofloxacin 500mg twice daily AND metronidazole 500mg PO three times daily
Additional Therapies for the immunocompromised
For patient with AIDS or immunocompromised with risk of oral candidal infection then add:
- Nystatin oral rinse four times daily x 14 days OR
- Fluconazole 200mg PO daily x 14 days
Additional Therapies for all patients
- Chlorhexidine 0.01% oral rinse BID
- Hydrogen peroxide swishing (innexpensive home remedy)
- Ibuprofen 400-600mg 3 times daily for pain
- Magic Mouthwash (multiple variations) - 300cc of 1:1:1 viscous lidocaine 2%, Maalox, diphenhydramine 12.5mg/5ml elixir
For pain management, can consider inferior alveolar block or viscous lidocaine diluted and spread across the gums.
Consultation
ENT or OMFS consult for dental debridement may be required in severe infections
Disposition
Discharge
See Also
References
- ↑ J Periodontol. 1986 Mar;57(3):141-50. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. Johnson BD, Engel D.
- ↑ J Periodontol. 1986 Mar;57(3):141-50. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. Johnson BD, Engel D.
- ↑ Atout R. N. et al. Managing Patients with Necrotizing Ulcerative Gingivitis. J Can Dent Assoc 2013;79:d46. http://www.jcda.ca/article/d46. Accessed April 2015
- ↑ Walker C. et al. Rationale for use of antibiotics in periodontics. J Periodontol. 2002. 73(1):1188-96