Acute necrotizing ulcerative gingivitis: Difference between revisions
 
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==Background==
==Background==
[[File:Periodontium.png|thumb|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"
*Also known as "trench mouth"
*Often abbreviated as ''ANUG''
*Often abbreviated as ''ANUG''
*Severe gingival disease that may spread to local soft tissue and bone
*Severe gingival disease that may spread to local soft tissue and bone
*Must distinguish from [[Herpes gingivostomatitis]]
*Must distinguish from [[Herpes gingivostomatitis]]
*Bacteria involved: anaerobic fusobacterium and ''Borellia spirochete''<ref>J Periodontol. 1986 Mar;57(3):141-50. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. Johnson BD, Engel D.</ref>
**Herpes has more systemic signs, less bleeding, lack of interdental papilla involvement
**Herpes has more systemic signs, less bleeding, lack of interdental papilla involvement
*Bacteria involved: anaerobic fusobacterium and ''Borellia spirochete''<ref>J Periodontol. 1986 Mar;57(3):141-50. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. Johnson BD, Engel D.</ref>, 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<ref>J Periodontol. 1986 Mar;57(3):141-50. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. Johnson BD, Engel D.</ref>===
===Associated Conditions<ref>J Periodontol. 1986 Mar;57(3):141-50. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. Johnson BD, Engel D.</ref>===
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*[[Fever]]
*[[Fever]]
*Halitosis
*Halitosis
*Pain
*[[dental problems|Dental/mouth pain]]
*Gingival bleeding
*Gingival bleeding
*Teeth mobility
*Teeth mobility
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*Fetid breath with metallic taste
*Fetid breath with metallic taste
*"Wooden teeth" feeling
*"Wooden teeth" feeling
*Regional lymphadenopathy
*Regional [[lymphadenopathy]]
*Ulcerated, with grayish pseudomembrane or "punched out" interdental papillae
*Ulcerated, with grayish pseudomembrane or "punched out" interdental papillae
*Blunting of the typically pointed edges of the papillae


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Dental Problems DDX}}
{{Dental Problems DDX}}


==Evaluation==
==Evaluation==
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==Management==
==Management==
*Organisms involved are polymycrobial but often include Fusobacterium necrophorum, Treponema spp, Selenomonas, and Prevotella
{{ANUG Treatment}}
 
===Uncomplicated Disease===
*Antibiotics
**[[Amoxicillin]] 250mg 3 x daily for 7 days and/or
**[[Metronidazole]] 250mg 3 x daily for 7 days<ref>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</ref>
 
===Complicated Disease===
*Antibiotics
**[[Penicillin V]] 500mg PO q6 hours AND [[metronidazole]] 500mg PO q8 hours x 10 days '''or'''
**[[Amoxicillin]] 500mg PO TID for 10d plus [[metronidazole]] 250mg PO TID for 10d '''or'''
**[[Amoxicillin-clavulanate]] 500mg/125mg PO TID or 875mg/125mg PO BID for 10d '''or'''
**[[Clindamycin]] 150-300mg PO TID for 10d '''or'''
**[[Doxycycline]] 100mg PO BID for 10d<ref>Stephen J. et al Acute Necrotizing Ulcerative Gingivitis Empiric Therapy. http://emedicine.medscape.com/article/2028117-overview. Accessed April 2015</ref>
 
 
===Additional===
*Oral Treatment
**Chlorhexidine 0.01% oral rinse BID
**Hydrogen peroxide swishing (cheap home remedy)
*Pain
**[[Ibuprofen]] 400-600mg 3 times daily
**Mouth cocktail - 300cc of 1:1:1 viscous lidocaine 2%, Maalox, [[diphenhydramine]] 12.5mg/5ml elixir
*[[HIV]]+
**In addition to antibiotic regimen consider an oral anti-fungal or [[nystatin]]
**[[Fluconazole]] 200mg PO daily for 14 days


For pain management, can consider inferior alveolar block or viscous lidocaine diluted and spread across the gums.
===Consultation===
===Consultation===
ENT or OMFS consult for dental debridement may be required in severe infections
ENT or OMFS consult for dental debridement may be required in severe infections
==Disposition==
Discharge


==See Also==
==See Also==
*[[Dental Problems]]
*[[Dental problems]]


==References==
==References==
<references/>
<references/>
*ER Atlas


[[Category:ENT]]
[[Category:ENT]]
[[Category:ID]]
[[Category:ID]]

Latest revision as of 20:45, 7 August 2022

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]

Clinical Features

Mild presentation at the typical site on the gums of the lower front teeth.

Early

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

Other

Evaluation

  • Usually clinical

Management

Organisms involved are polymycrobial but often include Fusobacterium necrophorum, Treponema spp, Selenomonas, and Prevotella

Uncomplicated Disease

Additional Therapies for the immunocompromised

For patient with AIDS or immunocompromised with risk of oral candidal infection then add:

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

  1. ↑ J Periodontol. 1986 Mar;57(3):141-50. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. Johnson BD, Engel D.
  2. ↑ J Periodontol. 1986 Mar;57(3):141-50. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. Johnson BD, Engel D.
  3. ↑ 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
  4. ↑ Walker C. et al. Rationale for use of antibiotics in periodontics. J Periodontol. 2002. 73(1):1188-96
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