NECROTIZING ULCERATIVE GINGIVITIS: ETIOLOGY, CLINICAL FEATURES, AND TREATMENT
Author: Sanketh DS, MDS
Necrotizing ulcerative gingivitis (NUG) also called Vincent’s infection is a type of gingivitis that has characteristic signs and symptoms. This disease commences by primarily involving the free gingival margin and the interdental papilla. Pain, interdental ulceration and bleeding are considered to be diagnostic.This disease was previously designated as “Acute necrotizing ulcerative gingivitis (ANUG)”. But investigators have discontinued the use of the term “Acute” in ANUG, because there is no chronic form of this disease.
NUG is considered to be a poly-microbial infectious disease occurring along with other predisposing factors causing severe destruction of the tissues. In the 1904, French physician Jean Vincent, identified fusiform bacillus, and a spirochete, Borrelia vincentii in plaque samples from affected tissues. It is now known that, other organisms like Prevotella intermedia, Treponema spp and Porphyromonas gingivalis are also found. It is apparent that, fusiform bacillus, now known as Fusobacterium nucleatum and Borrelia vincentii are present in healthy oral cavities and other diseases like herpetic gingivostomatitis. This reiterates the fact that, predisposing factors, may trigger an imbalance in the host-fusospirochetal relationship, leading to an increased numbers of these organisms causing the disease.
Psychological stress and immunosuppression/ decreased resistance to infection are implicated to be an important predisposing factor causing NUG. This was apparent during World War I when soldiers in the battlefield trenches under poor hygienic conditions and inadequate diet suffered from NUG in large numbers and the disease was nicknamed “trench mouth”.
Other predisposing conditions may include, smoking, local trauma, poor oral hygiene, poor nutritional status, inadequate sleep and upper respiratory tract infections. Also, patients with severe immunosuppression due to HIV may suffer from NUG.
NUG usually occurs in the young to middle aged and may also affect children with poor nutritional status in developing countries. NUG is very rare in a normal/healthy population (0.1%) but its prevalence increases in a stressed population.
NUG commences on the interdental papilla which is painful and haemorrhagic and progresses classically to develop “punched-out” areas of erosion which bleed when touched. These ulcers are subsequently covered with a pseudo-membranous necrotic slough. It begins by involving any interdental papilla and the ulceration may spread to other gingival margins. Patients may have severe gingival pain and bleeding leading to difficulty in eating. Another characteristic of this disease is a metallic taste of the saliva and fetid odour that may be very uncomfortable. Fever, malaise and lymphadenopathy may be other features.
If this process involves the periodontium with a loss of attachment, it is called as Necrotizing ulcerative periodontitis and if it involves adjacent soft tissues, is called Necrotizing ulcerative stomatitis. This may even progress to extend through the mucosa to involve the skin of the face. The disease is then termed Noma or cancrum oris.
This condition may be treated by cleansing the oral cavity with warm salt water rinses, chlorhexidine and diluted hydrogen peroxide. This may be supplemented with thorough scaling and polishing. Topical anaesthesia may be required for the debridement procedures. NUG may regress in many cases without the need for antibiotics, though antibiotics like penicillin and metronidazole may be useful if coupled with debridement. Re-contouring of the punched out papillae may be required.
Patients should be given oral hygiene instructions and any predisposing factors like smoking must be stopped and stress, reduced. NUG recurs with considerable frequency and hence patients should be under a regular follow-up, to check for hygiene and rule out recurrence.
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