Acute Necrotizing Ulcerative Gingivitis

Aka: Acute Necrotizing Ulcerative Gingivitis, ANUG, Trench Mouth, Vincent's Stomatitis, Vincent Angina, Noma, Cancrum oris

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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

  1. Herpes Gingivostomatitis
  2. Immune deficiency (e.g. Neutropenia, Leukemia)
  3. Vitamin C Deficiency (Scurvy)

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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