Gingivitis, Necrotizing Ulcerative (NUG)

Author: Fred F. Ferri, MD

Definition

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
Necrotizing ulcerative gingivitis

ICD-10CM CODE
A69.0		Necrotizing ulcerative stomatitis

Epidemiology & Demographics

Incidence:

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

Predominant Sex:

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.

Risk Factors:

•Poor oral hygiene
•Smoking/chewing tobacco
•Alcohol use
•Drug addiction
•Poor socioeconomic status
•Psychologic 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. 1.Dermatomyositis (DM)
2. 2.Steroid use
3. 3.HIV/AIDS
4. 4.Use of chemotherapeutic drugs
5. 5.Leukemia and other malignancies

Pathogenesis

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

Physical Findings & Clinical Presentation

•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. 1.Halitosis
2. 2.Alteration in taste, such as a metallic flavor
3. 3.Wooden teeth feeling
4. 4.Odynophagia
5. 5.Fever and fatigue
6. 6.Cervical lymphadenopathy

Etiology

•Polymicrobial
•Often caused by both Fusobacterium and spirochetes

Diagnosis ⬆ ⬇

•Based on the clinical features
•White blood cells 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

Treatment ⬆ ⬇

•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 h and metronidazole 250 to 500 mg orally every 8 h. 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 (½ 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 h 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 h of initiating antibiotics and supportive treatment is characteristic.
•Risk of recurrence is high.

section name header

Basic Information ⬇

Diagnosis ⬆ ⬇

Treatment ⬆ ⬇

Pearls & Considerations ⬆