Acute necrotizing ulcerative gingivitis

Background

Often abbreviated as ANUG

1. Severe gingival disease that may spread to local soft tissue and bone
2. Must distinguish from herpes gingivostomatitis
   1. Herpes has more systemic signs, less bleeding, lack of interdental papilla involvement
3. Associated with immunosuppression, especially HIV
   1. Other associations include poor oral hygeine/nutrition/sleep, stress, ETOH/tobacco use, age<21, Caucasians, malaria/measles/parasites

Clinical Features

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

• Triad of:
  • Pain
  • Ulcerated or "punched out" interdental papillae
  • Gingival bleeding
• Secondary signs:
  • Fetid breath
  • "Wooden teeth" feeling
  • Teeth mobility
  • Fever
  • Malaise

Differential Diagnosis

Dentoalveolar Injuries

• Dental fracture
• Dental subluxation
• Dental avulsion
• Bleeding dental socket

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

• Scurvy
• Gingival hyperplasia
  • Phenytoin
  • Cyclosporine
  • Nifedipine, Amlodipine
  • Leukemia

Diagnosis

• Usually clinical

Treatment

Antibiotics

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

Options

• Penicillin V 500 mg PO q6 hours AND Metronidazole 500mg PO q8 hours x 10 days OR
• Clindamycin 600 mg PO q8 hours OR
• Ampicillin/Sulbactam 3g IV q 6 hours daily

also nystatin oral rinses of 5ml q6 hrs daily for 14 days will help with concominent fungal infection

HIV positive

in addition to antibiotic regimen consider an oral anti-fungal or nystatin

• Fluconazole 200mg PO daily for 14 days

1. Chlorhexidine 0.01% oral rinse BID
2. Metronidazole 500mg PO TID

Consultation

ENT or OMFS consult for dental debridement may be required in severe infections

See Also

• Dental Problems

Source

• ER Atlas
• Tintinalli
• UpToDate