II. Pathophysiology

  1. Acute fusospirochetal infection of the Gingiva

III. Risk Factors

  1. Emotional stress
  2. HIV Infection
  3. Tobacco Abuse
  4. Poor Oral Hygiene
  5. Nutritional deficiency

IV. Findings: Signs and symptoms

  1. Systemic symptoms
    1. Fever
    2. Malaise
    3. Lymphadenopathy
  2. Mnemonic: "3 B's"
    1. Bad breath (Halitosis, Fetor Oris from tissue necrosis)
    2. Bad taste
    3. Gingival Bleeding
  3. Painful Gingivitis
    1. Redness
    2. Swelling
    3. Oral Ulcers
  4. Specific oral findings
    1. Punched out lesions on interdental papillae
    2. Mucus membranes covered with grayish necrotic pseudomembrane
      1. Surface bleeds when removed

V. Differential Diagnosis

VI. Management

  1. Good Oral Hygiene
  2. Refer to Dentistry for debridement
  3. Antibiotics (if systemic symptoms)
    1. IV protocol
      1. Metronidazole 500 mg IV every 6 hours AND Penicillin G 4 million units every 4 hours OR
      2. Alternative: Clindamycin 600 mg IV every 8 hours
    2. Oral protocol
      1. Metronidazole 500 mg orally four daily for 7 days AND Penicillin VK 500-1000 mg orally every 6 hours OR
      2. Alternative: Clindamycin 300-450 mg orally four times daily

VII. Complications

  1. Noma (Cancrum oris, gangenous Stomatitis)
    1. Severe ANUG progression with mucous membrane gangrene seen in malnourished patients, especially children
    2. Results in facial soft tissue and bone destruction and facial disfigurement
  2. Oropharyngeal infectious spread
    1. Soft Palate and oropharynx (Vincent's Angina)
    2. Tonsils (Vincent's Tonsillitis)
    3. Larynx or trachea (Vincent's Laryngotracheitis)

VIII. References

  1. (2019) Sanford Guide, accessed on IOS 11/24/2019
  2. Broderick and Deak (2015) Crit Dec Emerg Med 29(1): 2-8
  3. Atout (2013) J Can Dent Assoc 79:d46 [PubMed]

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Ontology: Necrotizing Ulcerative Gingivitis (C0017575)

Definition (NCI) A bacterial infectious process affecting the gums. It is characterized by the development of necrotic, ulcerated, and painful lesions with creation of pseudomembranes extending along the gingival margins.
Definition (MSH) An acute or chronic GINGIVITIS characterized by redness and swelling, NECROSIS extending from the interdental papillae along the gingival margins, PAIN; HEMORRHAGE, necrotic odor, and often a pseudomembrane. The condition may extend to the ORAL MUCOSA; TONGUE; PALATE; or PHARYNX. The etiology is somewhat unclear, but may involve a complex of FUSOBACTERIUM NUCLEATUM along with spirochetes BORRELIA or TREPONEMA.
Concepts Disease or Syndrome (T047)
MSH D005892
ICD10 A69.1
SnomedCT 240675006, 171847006, 30896000, 266145002, 186961005, 278519005, 186962003, 186960006, 154391003, 266213004, 399050001, 172697005, 173599005
English Gingivitis, Necrotizing Ulcerative, Mouth, Trench, Trench Mouth, Ulcerative Gingivitis, Necrotizing, Vincents Infection, Infection, Vincent's, ANUG - Acute necro ulcer ging, AUG - Acute ulcer gingivitis, Acute necrotis ulcertve gingiv, Acute necrt ulcer gingivostom, VINCENTS INFECT, acute necrotizing ulcerative gingivitis, Vincent's gingivitis (diagnosis), acute necrotizing ulcerative gingivitis (diagnosis), Vincent Angina, Vincent infection, Necrotizing ulcerative (acute) gingivostomatitis, Necrotizing ulcerative (acute) gingivitis, Gingivitis, Necrotizing Ulcerative [Disease/Finding], ulcerative gingivostomatitis, vincent's stomatitis, stomatitis vincent's, anug, trench mouth, vincent's gingivitis, vincent's infection, angina vincent, vincent angina, vincent's angina, vincents angina, acute necrotizing gingivitis, gingivitis necrotizing ulcerative, mouth trench, necrotizing gingivitis, Acute Membranous Gingivitides, Phagedenic Gingivitides, Vincent Gingivitis, Acute Necrotizing Ulcerative Gingivitis, Fusospirilloses, Gingivitides, Acute Membranous, Membranous Gingivitides, Acute, Fusospirillary Gingivitis, Phagedenic Gingivitis, Gingivitis, Phagedenic, Vincents Stomatitis, Fusospirillosis, Stomatitis, Vincent's, Vincent Stomatitis, Acute Membranous Gingivitis, Gingivitis, Acute Membranous, Membranous Gingivitis, Acute, Fusospirillary Gingivitides, Gingivitis, Vincent's, Vincent's Stomatitis, Gingivitides, Fusospirillary, Gingivitides, Phagedenic, Gingivitis, Fusospirillary, Vincent's Gingivitis, Vincents Gingivitis, vincent's infection (diagnosis), Fusospirochetosis, Acute necrotising ulcerative gingivitis (disorder), Acute necrotising ulcerative gingivostomatitis (disorder), (Vincent's angina) or (trench mouth), (Vincent's angina) or (trench mouth) (disorder), Necrotising gingivitis, Necrotizing gingivitis, Gingivitis, Necrotizing ulcerative, Vincent Infection, Vincent's Infection, Infection, Vincent, Trench mouth, Vincent's infection, ANUG, Acute necrotizing ulcerative gingivitis, Acute necrotizing ulcerative stomatitis, Spirochaetal stomatitis, Vincent's gingivitis, Vincent's stomatitis, ANUG - Acute necrotising ulcerative gingivitis, ANUG - Acute necrotizing ulcerative gingivitis, AUG - Acute ulcerative gingivitis, Acute necrotising ulcerative gingivitis, Acute necrotising ulcerative gingivostomatitis, Acute necrotizing ulcerative gingivostomatitis, Acute ulcerative gingivitis, Spirochetal stomatitis, Acute necrotising ulcerative stomatitis, Acute necrotizing ulcerative gingivitis (disorder), Acute necrotizing ulcerative gingivostomatitis (disorder), Acute ulcerative gingivitis (disorder), Acute ulceromembranous gingivitis, Vincent's infection (disorder), fusospirillosis, gingivitis; acute, necrotizing, gingivitis; necrotizing ulcerative, gingivitis; vincent's, infection; vincent's, acute; gingivitis, necrotizing, necrotizing ulcerative; gingivitis, spirochetal; stomatitis, stomatitis; spirochetal, vincent's; infection, vincent's; stomatitis, Acute necrotising ulcerative gingivitis [Ambiguous], Acute necrotising ulcerative gingivostomatitis [Ambiguous], Acute necrotizing ulcerative gingivitis (disorder) [Ambiguous], Early acute necrotising gingivitis, Early acute necrotizing gingivitis, Vincent's disease, Necrotizing Ulcerative Gingivitis, Vincent's infection, any site
Dutch necrotiserende gingivitis, loopgraafmond, Plaut-Vincent; infectie, Plaut-Vincent; stomatitis, acuut; gingivitis, necrotiserend, gingivitis; Plaut-Vincent, gingivitis; acuut, necrotiserend, gingivitis; necrotiserend ulceratief, infectie; Plaut-Vincent, necrotiserend ulceratief; gingivitis, spirocheten; stomatitis, stomatitis; spirocheten, Gingivitis, necrotiserende ulceratieve, Necrotiserende ulceratieve gingivitis, Ulceratieve gingivitis, necrotiserende, Vincent-infectie, Loopgraafmond
French Angine de Vincent, Gingivite nécrosante, Gingivite ulcéreuse, Gingivite de Vincent, Gingivite ulcéreuse nécrosante, Maladie de Vincent, Gingivite ulcéro-nécrotique, Gingivite ulcéronécrotique
German nekrotisierende Gingivitis, Mundfaeule, Plaut-Vincent-Infektion, Gingivitis, nekrotisierende ulzeröse, Plaut-Vincent-Gingivitis
Italian Gengivite necrotizzante, Gengivite ulcerosa, Infezione di Vincent, Bocca da trincea, Gengivite ulcerosa necrotizzante
Portuguese Gengivite necrosante, Angina de Vincent, Boca de Trincheira, Gengivite Ulcerativa Necrosante, Infecção de Vincent
Spanish Gingivitis necrotizante, Boca con surcos, boca de trinchera, fusoespiroquetosis, estomatitis ulcerativa necrosante aguda, estomatitis ulcerativa necrotizante aguda, estomatitis espiroquetal, gingivitis ulcerativa aguda, gingivitis ulcerativa necrotizante aguda, gingivitis ulcerativa necrotizante aguda (trastorno), estomatitis de Vincent (trastorno), estomatitis de Vincent, gingivitis de Vincent, gingivitis ulcerativa aguda necrotizante (trastorno), gingivitis ulcerativa aguda necrotizante, gingivitis ulcerativa necrosante aguda (trastorno), gingivitis ulcerativa necrosante aguda, gingivitis ulcerosa aguda necrosante (trastorno), gingivitis ulcerosa aguda necrosante, gingivitis ulcerosa aguda, gingivoestomatitis ulcerosa aguda necrosante (trastorno), gingivoestomatitis ulcerosa aguda necrosante, infección de Vincent (trastorno), infección de Vincent, Boca de Trinchera, Gingivitis Ulcerosa Necrotizante, Infección de Vincent
Japanese 壊死性歯肉炎, ザンゴウコウナイエン, エシセイシニクエン, 潰瘍性偽膜性アンギナ, 急性壊死性潰瘍性歯肉炎, ワンサンアンギナ, ワンサンのアンギナ, ヴィンセン口内炎, 壊死性潰瘍性歯肉炎, 潰瘍性口内炎, Vincent感染症, 口内炎-塹壕, プラウ・ワンサン口内炎, プローアンギナ, プローのアンギナ, ヴァンサン感染症, 壊死性潰瘍性歯ぎん炎, 口内炎-スピロヘータ, ざんごう口内炎, ヴァンサン口内炎, 紡錘菌口内炎, 口内炎-Plaut-Vincent, スピロヘータ口内炎, プロー-ヴァンサン口内炎, ワンサン口内炎, 壊死性潰瘍性口内炎, 塹壕口内炎, ヴィンセン感染症, 口内炎-潰瘍性, え死性潰瘍性歯肉炎, 口内炎-プロー-ヴァンサン, 口内炎-紡錘菌, ワンサン感染症, 歯肉炎-壊死性潰瘍性, Plaut-Vincent口内炎
Swedish Gingivit, nekrotiserande ulcerös
Czech gingivitida nekrotizující ulcerózní, Zákopová ústa, Nekrotizující gingivitida, Nekrotizující zánět dásně, Vincentova infekce, Vincentova stomatitida, fusospirilóza
Finnish Kuolioituva haavainen ientulehdus
Russian VENSANA-SIMANOVSKOGO ANGINA, SIMANOVSKOGO-PLAUTA-VENSANA ANGINA, STOMATIT IAZVENNYI, VENSANA INFEKTSIIA, ANGINA VENSANA, GINGIVIT IAZVENNO-NEKROTICHESKII, АНГИНА ВЕНСАНА, ВЕНСАНА ИНФЕКЦИЯ, ВЕНСАНА-СИМАНОВСКОГО АНГИНА, ГИНГИВИТ ЯЗВЕННО-НЕКРОТИЧЕСКИЙ, СИМАНОВСКОГО-ПЛАУТА-ВЕНСАНА АНГИНА, СТОМАТИТ ЯЗВЕННЫЙ
Croatian GINGIVITIS, NEKROTIČNI ULCEROZNI
Polish Zapalenie dziąseł wrzodziejące, Angina Plaut-Vincenta, Zapalenie jamy ustnej wrzodziejąco-martwicze
Hungarian Gingivitis necrotisans, Necrotizáló gingivitis, Necrotisalo fekélyes gingivitis
Norwegian Akutt nekrotoserende gingivitt, Nekrotiserende ulcerativ gingivitt, Vincents gingivostomatitt, Nekrotiserende ulcerøs gingivitt, NUG

Ontology: Noma (C0028271)

Definition (NCI) Gangrene of the mucous membranes of the mouth leading to ulcers and destruction of the soft tissues of the face and bones. It usually occurs in malnourished children in areas of poor sanitation and immunocompromised patients.
Definition (MSH) A severe gangrenous process occurring predominantly in debilitated and malnourished children, especially in underdeveloped countries. It typically begins as a small vesicle or ulcer on the gingiva that rapidly becomes necrotic and spreads to produce extensive destruction of the buccal and labial mucosa and tissues of the face, which may result in severe disfigurement and even death. Various bacteria have been implicated in the etiology. (Dorland, 27th ed)
Concepts Disease or Syndrome (T047)
MSH D009625
ICD9 528.1
ICD10 A69.0
SnomedCT 196528007, 266427007, 18116006, 399050001
English Gangrenous Stomatitides, Noma, Nomas, Stomatitides, Gangrenous, Stomatitis, Gangrenous, Cancrum Oris, cancrum oris, cancrum oris (diagnosis), gangrenous stomatitis (diagnosis), gangrenous stomatitis, Noma [Disease/Finding], noma, nomas, Gangrenous stomatitis (disorder), Noma (& [cancrum oris] or [gangrenous stomatitis]), Noma (& [cancrum oris] or [gangrenous stomatitis]) (disorder), Cancrum oris, Acute gangrenous stomatitis, Gangrenous stomatitis, Cancrum oris (disorder), gangrenous; stomatitis, stomatitis; gangrenous, Gangrenous Stomatitis
Dutch cancrum oris, noma, gangraenosa; stomatitis, stomatitis; gangraenosa, Cancrum oris, Noma, Stomatitis gangraenosa
French Stomatite gangréneuse, Noma, Stomatite gangreneuse, Cancrum oris
Italian Gangrena orale, Noma
Portuguese Cancro bucal, Cancro Oral, Cancrum Oris, Estomatite Gangrenosa, Noma
Spanish Cáncer bucal, cancrum oris, cancrum oris (trastorno), noma (trastorno), noma, Úlcera Gangrenosa, estomatitis gangrenosa aguda, estomatitis gangrenosa, Noma, Cancrum Oris, Estomatitis Gangrenosa
Swedish Fuktig ansiktsbrand
Japanese エソセイコウナイエン, スイガン, 水癌, 壊疽性口内炎, ノーマ, 口内炎-壊疽性
Czech noma, Noma, Gangréna úst
Finnish Nooma
Russian NOMA, STOMATIT GANGRENOZNYI, НОМА, СТОМАТИТ ГАНГРЕНОЗНЫЙ
Polish Zapalenie policzka i jamy ustnej zgorzelinowe, Rak wodny
Hungarian Noma, Ulcerogangrenosus stomatitis
Croatian CANCRUM ORIS, STOMATITIS. GANGRENOZNI, NOMA
Norwegian Noma
German Noma, Wangenbrand, Cancer aquaticus, Cancrum oris, Gangränöse Stomatitis, Stomatitis, gangränöse

Ontology: Vincent Angina (C1527368)

Definition (MSH) VINCENT INFECTION where the lesions spread to the SOFT PALATE and OROPHARYNX.
Concepts Disease or Syndrome (T047)
MSH D005892
ICD9 101
ICD10 A69.1
SnomedCT 186963008, 266146001, 171847006, 154391003, 266213004, 186964002, 186960006, 30896000, 399050001
English Vincent's angina NOS, Vincent's angina (diagnosis), Vincent angina - pharyngitis, Vincent's angina NOS (disorder), Angina - Vincents, Plaut's angina, Plaut-Vincent angina, Angina, Vincent, Anginas, Vincent, Vincent's angina - pharyngitis (disorder), angina; vincent's, Vincent's angina, Vincent's angina - pharyngitis, Vincent's Angina, Vincent Angina, Vincents angina
Dutch angina van Plaut-Vincent, angina van Plaut, angina; Plaut-Vincent, Vincent-angina
French Angine ulcéro-membraneuse, Angine de Plaut-Vincent, Angine de Vincent
German Plaut-Angina, Plaut-Vincent-Angina, Vincent-Angina
Italian Angina di Plaut, Angina di Plaut-Vincent, Angina di Vincent
Portuguese Angina de Plaut-Vincent, Angina de Plaut, Angina de Vincent
Spanish Angina de Plaut-Vincent, Angina de Plaut, Angina de Vincent, angina de Vincent, SAI, angina de Vincent (trastorno), angina de Vincent, SAI (trastorno), angina de Vincent, angina de Vincent (concepto no activo), faringitis - angina de Vincent (trastorno), faringitis - angina de Vincent
Japanese プラウ口峡炎, プラウ・ワンサン口峡炎, ワンサン口峡炎, プラウコウキョウエン, プラウワンサンコウキョウエン, ワンサンコウキョウエン
Czech Plautova angína, Vincentova angína, Plaut-Vincentova angína
Croatian VINCENTOVA ANGINA
Hungarian Vincent-angina, Plaut-Vincent angina, Plaut-angina