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.


  • 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


  • •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.


  • •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


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


  • •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


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