Acute necrotising ulcerative gingivitis(ANUG)

Acute necrotising ulcerative gingivitis(ANUG)

is an infectious disease of the gingiva causing gingival bleeding, gingival ulceration and pain.

History 

Necrotizing ulcerative gingivitis had been recognized in the 4th century BC by Xenophon, who mentioned that Greek soldiers were affected with “sore mouth and foul smelling breath”. In 1778, Hunter described the clinical features of this disease and differentiated it from scurvy and chronic periodontitis. 

Synonyms

Vincent’s disease

Fusospirochetal gingivitis

Trench mouth

Acute ulcerative gingivitis

Necrotizing gingivitis

ETIOLOGY

Role of bacteria

A specific infectious disease should be associated with a specific etiology. The bacterial etiology of Necrotizing ulcerative gingivitis provides one of our strongest examples of a primarily bacterial etiology in a periodontal disease.

Plaut in 1894 and Vincent in 1896 first proposed this bacterial etiology.

They both reported that fusiform-spirochete bacteria flora were associated with lesions of  NUG.

Loesche et al

Constant flora

P. intermedia

Fusobacterium

Treponema

Variable flora

Role of host response

Immunodeficiency

Nutritional deficiency

Alcohol/drug abuse

Stress

CLINICAL FEATURES  

Oral signs  

→Punched - out , crater like depressions at the crest of the interdental papillae

→Surface of craters covered by gray , psuedomembranous slough

    

Other clinical signs

→Spontaneous gingival hemorrhage

→Fetid odor

→Increased salivation

→Punched out interdental papilla

→Lesions with progressive tissue destruction

Oral symptoms

→Lesions sensitive to touch

→Radiating , gnawing pain 

→“Metallic” foul taste 

→“Pasty” saliva

Systemic signs & symptoms

High fever

Lymphadenopathy

Pulse rate

Leukocytosis

Loss of appetite

CLINICAL COURSE

( Pindborg et al )

Erosion of tip of papilla

Lesion extending to marginal gingiva

Lesion extending to attached gingiva

Exposure of bone

( Horning and cohen )

• Stage 1 : necrosis of tip of papilla

• Stage 2 : necrosis of entire papilla

• Stage 3 : necrosis ext to gingival margin

• Stage 4 : necrosis ext to attached gingiva

• Stage 5 : necrosis ext to labial or buccal mucosa

• Stage 6 : necrosis exposing alveolar bone

• Stage 7 : necrosis perforating skin of cheek

( Listgarten 1965 )

Bacterial zone

Neutrophil rich zone

Necrotic zone

Spirochetal infiltration zone

Histopathology

Surface epithelium replaced by meshwork of fibrin

Necrotic epithelial cells & PMN’s etc

Connective tissue is extremely hyperemic ,with engorged capillaries and dense infiltration of PMN’s

DIAGNOSIS

 a) Clinical findings

 b) Bacterial smear

 c) Biopsy specimen

a) Clinical findings

     Gingival pain

     Ulceration Bleeding

b) Bacterial smear used for

     Differential diagnosis of ANUG from

     Diphtheria

     Thrush

     Actinomycosis

c) Biopsy specimen used for

    Differential diagnosis of ANUG from

    Tuberculosis

     Neoplastic disease

Differential diagnosis

1. Herpetic gingivostomatitis

2. Chronic periodontitis

3. Desquamative gingivitis

4. Diphtheritic & syphilitic lesions

5. Agranulocytosis

Antimicrobial treatment recommendations

1. Amoxicillin 500 mg PO TID for 10d plus  metronidazole 250 mg PO TID for 10d or

2. Amoxicillin-clavulanate 500 mg/125 mg PO TID or 875 mg/125 mg PO BID for 10d or

3. Clindamycin 150-300 mg PO TID for 10d or

4. Doxycycline 100 mg PO BID for 10d

Adjunctive therapy

1. Saline rinses can help to speed resolution; oral rinses with a hydrogen peroxide 3% solution may be of benefit 

2. Chlorhexidine 0.12% oral rinse 15 mL BID

3. For (HIV)-positive patients, consider nystatin rinse 5 mL QID or  fluconazole 200 mg PO daily for 7-14d

4. Patients with ANUG should be given a topical anesthetic and nonsteroidal anti-inflammatory drugs (NSAIDs), because pain control is very important in allowing the patient to perform good oral hygiene