Acute Necrotizing Ulcerative gingivitis (ANUG)

Introduction:

·      Acute necrotizing ulcerative gingivitis is a microbial disease of the gingiva in a patient with an impaired host response characterized by severe necrosis of the free gingival margin, the crest of the gingiva and interdental papilla.

·      Also called a ‘Trench Mouth’, ‘Vincent’s disease’, ‘Vincent’s angina’, ‘Phagedenic gingivitis’.

Etiology:

·       Mixed bacterial infection that includes anaerobes such as Prevotella intermedia and Fusobacterium as well as spirochetes, such as Treponema.

Risk factors:

A.    Local Factors:

i.Contributing to accumulation of bacteria

o   Pre-existing gingivitis

o   Poor oral hygiene

o   Overhanging restorations

o   Malpositioned  teeth

o   Calculus

o   Food impaction

ii.Contributing to local ischemia

o   Cigarette smoking

o   Alcoholism

B.     Systemic factors:

i.                    Immunocompromised state (eg. HIV/AIDS, Leukemia, cyclic neutropenia)

ii.                  Systemic diseases (eg. Type I DM)

iii.                Emotional Stress

iv.                Hormonal imbalance (eg. Puberty, mensuration cycles)

v.                  Nutritional deficiency

Pathogenesis of ANUG

Clinical Features:

o   Males are most commonly affected in their 2^nd decade of life.

o   Commonly seen in children and in females during menarche.

o   Most commonly marginal gingiva and interdental papillae of upper premolar-canine region are involved which later becomes diffuse.

Oral signs:

·         Punched-out, craterlike depressions at crest of interdental papillae

• Subsequently extending to marginal gingiva, rarely to attached gingiva and oral mucosa
• Surface of gingival craters covered by gray, pseudomembranous slough, demarcated from remainder of gingival mucosa by pronounced linear erythema
• In some cases lesions  denuded of surface pseudo-membrane, exposing gingival margin which is red, shiny and hemorrhagic
• Characteristic lesions may progressively destroy gingiva and underlying PD tissues
• Spontaneous gingival hemorrhage or pronounced bleeding after slightest stimulation
• Fetid odor and Increased salivation

Oral symptoms:

• Lesions  extremely sensitive to touch
• Patient complains of constant radiating,  gnawing pain  intensified by eating spicy or hot foods and chewing
• Metallic foul taste
• Patient conscious of excessive amount of pasty saliva

Extra oral & systemic signs & symptoms

·         In mild & moderate stages of disease

o   Local lymphadenopathy & slight elevation in temperature

·         In severe cases

o   High fever, increased pulse rate, leucocytois, loss of appetite & general lassitude.

o   Systemic reactions are more severe in children.

o   Insomnia, constipation, gastro-intestinal disorders, headache, & mental depression sometimes accompany the condition.

o   In very rare cases, severe squeal such as gangrenous stomatitis & noma have been described.

Staging of ANUG
According to Horning & Cohen
            Stage 1- necrosis of the top of the interdental papilla.

Stage 2- necrosis of entire papilla

Stage 3- necrosis extending to the gingival margin.

Stage 4- necrosis extending to the attached gingiva.

Stage 5– necrosis extending to labial & buccal mucosa.

Stage 6- necrosis exposing alveolar bone.

Stage 7– necrosis perforating skin of cheek

According to Pindborg et al (1967)

Stage I – only tip of interdental papilla is affected

Stage 2 – marginal gingiva is affected with punched out papilla

Stage 3 – attached gingiva also affected

Stage 4 – exposure of bone

Management:

Treatment of NUG should follow an orderly sequence, as described in the following paragraphs.

A.    First Visit:

·         At the first visit, the clinician should obtain a general impression of the patient's background, including information regarding recent illness, living conditions, dietary background, type of employment, hours of rest, and mental stress. The patient's general appearance should be observed, as well as apparent nutritional status.

Local debridement:

·         Treatment during this initial visit is confined to the acutely involved areas, which are isolated with cotton rolls and dried.

·         A topical anesthesia is applied, and after 2 or 3 minutes the areas are gently swabbed with a cotton pellet to remove the pseudomembrane and nonattached surface debris.

·         Each cotton pellet is used in a small area and is then discarded; sweeping motions over large areas with a single pellet are not recommended.

·         After the area is cleansed with warm water, the superficial calculus is removed.

·         Ultrasonic scalers are very useful for this purpose, since they do not elicit pain, and the water jet aids in the lavage of the area.

·         Subgingival scaling and curettage are contraindicated at this time because of the possibility of extending the infection to deeper tissues, and also of causing a bacteremia.

·          Unless an emergency exists, procedures such as extractions or periodontal surgery are postponed until the patient has been symptom free for a period of 4 weeks, to minimize the likelihood of exacerbating the acute symptoms

·         The patient is also told to rinse the mouth every 2 hours with a glassful of an equal mixture of warm water and 3% hydrogen peroxide.  Twice-daily rinses with 0.12% chlorhexidine are also very effective.

Antibiotic and Analgesics therapy:

·         Patients with moderate or severe NUG and local lymphadenopathy or other systemic symptoms are placed on an antibiotic regimen of penicillin, 500 mg orally every 6 hours.

·         For penicillin-sensitive patients, other antibiotics, such as erythromycin (500 mg every 6 hours are prescribed.

·         Metronidazole (500 mg twice times daily for 7 days), is also effective.

·          Control pain with analgesics: ibuprofen 400-600 mg 3 times daily

·          Antibiotics are continued until the systemic complications or the local lymphadenopathy has subsided.

·         Patient is recalled after 1-2 days.

Instructions to the patient

·         The patient is discharged with the following instructions :

·         Avoid tobacco, alcohol, and condiments.

·         Rinse with a glassful of an equal mixture of 3% hydrogen peroxide and warm water every 2 hours and/or twice daily with 0.12 % chlorhexidine solution.

·         Pursue usual activities, but avoid excessive physical exertion or prolonged exposure to the sun as required in golf, tennis, swimming, or sunbathing.

·         Confine tooth brushing to the removal of surface debris with a bland dentifrice; overzealous brushing and the use of dental floss or interdental cleaners will be painful.

·         Chlorhexidine mouth rinses are also very helpful in controlling plaque throughout the mouth.

Second Visit:

·         At the second visit, 1 to 2 days later, the patient's condition is usually improved; the pain is diminished or no longer present.

·         The gingival margins of the involved areas are erythematous, but without a superficial pseudomembrane.

·         Scaling is performed if sensitivity permits. Shrinkage of the gingiva may expose previously covered calculus, which is gently removed.

·         The instructions to the patient are the same as those given previously.

Third Visit:

·At the next visit, 1 to 2 days after the second, the patient should be essentially symptom free. There may still be some erythema in the involved areas, and the gingiva may be slightly painful on tactile stimulation.

·Scaling and root planing are repeated.

·The patient is instructed in plaque control procedures which are essential for the success of the treatment and the maintenance of periodontal health.

·The hydrogen peroxide rinses are discontinued, but chlorhexidine rinses can be maintained for two or three weeks.

Subsequent Visit:

In subsequent visits, the tooth surfaces in the involved areas are scaled and smoothed, and plaque control by the patient is checked and corrected if necessary.

Unfortunately, treatment is often stopped at this time because the acute condition has subsided, but this is when comprehensive treatment of the patient's chronic periodontal problem should start.

Appointments are scheduled for the treatment of chronic gingivitis, periodontal pockets, and pericoronal flaps, as well as for the elimination of all forms of local irritation.

Patients without gingival disease other than the treated acute involvement are dismissed for 1 week.

If the condition is satisfactory at that time, the patient is dismissed for 1 month, at which time the schedule for subsequent recall visits is determined according to the patient's needs. 

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