Necrotizing Ulcerative Gingivitis

Necrotizing Ulcerative Gingivitis

Necrotizing ulcerative gingivitis (NUG) is a distinct, painful infectious disease primarily of the interdental and marginal gingiva. It is characterized by a symptom triad that includes gingival pain, ulcer, and bleeding.

Synonyms

• NUG
• Trench mouth
• Acute necrotizing ulcerative gingivitis (ANUG)
• Vincent stomatitis
• Fusospirochetal gingivitis
• Acute ulcerative gingivitis

How common is Necrotizing Ulcerative Gingivitis?

• Unlike in the developing world, NUG is seen rarely in developed countries.

Predominant Gender

• Slightly more prevalent in males than in females because the latter group tend to have better oral hygiene.

Predominant Age

• •Occurs in the second and third decades of life in the developed world.
• •In contrast, it affects young children more often in developing countries.

What increase the risk – Risk Factors

• •Poor oral hygiene
• •Smoking/chewing tobacco
• •Alcohol use
• •Drug addiction
• •Poor socioeconomic status
• •Psychological stress
• •Preexisting gingivitis
• •Lack of sleep
• •Malnutrition
• •Overcrowding
• •Living near livestock
• •History of prior NUG
• •Recent illness
• •Underlying systemic diseases
• •Acatalasia
• •Various infections such as measles, malaria, and infestation with intestinal parasites
• •Trauma
• •Immunosuppression:
  • 1.Dermatomyositis (DM)
  • 2.Steroid use
  • 3.HIV/AIDS
  • 4.Use of chemotherapeutic drugs
  • 5.Leukemia and other malignancies

What causes Necrotizing Ulcerative Gingivitis?

• •Polymicrobial
• •Often caused by both Fusobacterium and spirochetes

Pathogenesis

• •Unknown
• •For the most part, it appears to result from an opportunistic infection in a host with lowered resistance

What are the Clinical Features?

• •Onset of the disease is usually sudden
• •Severe gingival pain
• •Gingival tissue is inflamed, edematous, friable, and necrotic; the normal pointed interdental papillae are blunted, but there is no loss of attachment
• •Gingival bleeding with little or no provocation
• •Punched out ulcerations are seen along the interdental papillae around the anterior incisors and posterior molars. A grayish-white pseudomembrane often covers these ulcers. These punched out ulcers along the pseudomembrane are pathognomonic of NUG
• •Other features include:
  • 1.Halitosis
  • 2.Alteration in taste, such as a metallic flavor
  • 3.Wooden teeth feeling
  • 4.Odynophagia
  • 5.Fever and fatigue
  • 6.Cervical lymphadenopathy

 How is this Diagnosed?

• •Based on the clinical features
• •WBC may be elevated
• •Gram stain and aerobic/anaerobic culture
• •Dental x-ray or x-ray of face to check on the extent of the disease
• •HIV testing is recommended for patients’ refractory to antibiotic therapy

Differential Diagnosis

• •Gingivitis
• •Acute herpetic gingivostomatitis
• •Aphthous stomatitis
• •Chronic periodontal disease
• •Desquamative gingivitis
• •Gonococcal and streptococcal gingivostomatitis
• •Oral candidiasis
• •Ludwig angina
• •HIV-associated idiopathic ulcerations

 How is this treated?

• •Improve oral hygiene by flossing and brushing at least twice a day.
• •Improve nutrition and hydrations.
• •Eliminate contributing factors such as smoking, alcohol, carbonated beverages, spicy/hot foods, poor nutrition, stress, and so on.
• •Antibiotic coverage for 5 to 10 days. Most recommend oral penicillin V 250 to 500 mg orally every 6 to 8 hr and metronidazole 250 to 500 mg orally every 8 hr. Tetracycline is given instead of penicillin in patients allergic to the latter. As an alternative one could give only clindamycin instead of the drug combination of penicillin and metronidazole.
• •Rinsing the mouth at least twice a day with warm saline (1/2 teaspoon of salt in 1 cup of water), 0.12% chlorhexidine, or dilute 3% hydrogen peroxide (mixed half and half with water).
• •Pain is controlled with oral pain medications and topical application of 2% viscous lidocaine (15 ml oral rinse every 6 to 8 hr as needed) to the inflamed gum.
• •Surgical debridement is needed in severe cases.
• •Scaling and root planing following the resolution of infection and the acute inflammation.
• •At times reconstructive surgery may be needed.

Complications

• •Cancrum oris (noma) results when NUG involves the deeper tissue
• •Vincent angina from the involvement of tonsils and pharynx
• •Necrotizing ulcerative periodontitis
• •Loss of teeth
• •Periodontal abscess
• •Alveolar bone destruction
• •Disfigurement
• •Cellulitis
• •Dehydration/malnutrition

Prognosis

• •Dramatic relief of symptoms within 24 hr of initiating antibiotics and supportive treatment is characteristic.
• •Risk of recurrence is high.

Prevention

• •Good oral hygiene
• •Use of power toothbrush is better than a manual brush
• •Good general health including proper nutrition, sleep, and exercise
• •Routine dental checks
• •Avoidance of smoking and alcohol
• •Stress management

Patient Education

Not a communicable disease