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BASICS

  • Acute periodontal disease with necrosis of interdental papillae and gray pseudomembranous coating.
  • Caused by disruption of oral microbiome: Fusobacterium spp., Prevotella intermedia, spirochetes.
  • Viral coinfections common: EBV, HSV, CMV.
  • Synonyms: Vincent angina, trench mouth, fusospirochetal gingivitis, acute necrotizing ulcerative gingivitis (ANUG).

EPIDEMIOLOGY

  • Age: primarily 18–30 years in developed countries; malnourished children 3–14 years.
  • Incidence historically higher in military personnel due to stress and poor hygiene.
  • Prevalence <1% overall; higher in underdeveloped regions (up to 25% in sub-Saharan Africa).
  • Declined since WWII but still a concern in malnourished or immunocompromised populations.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Impaired host immunity from malnutrition or immunosuppression.
  • Disruption of normal oral flora leading to overgrowth of anaerobic bacteria producing tissue-damaging enzymes.
  • Stress hormones impair gingival microcirculation and immune function, worsening disease.
  • Behavioral factors like poor oral hygiene and tobacco use contribute.
  • Active herpesvirus infections increase bacterial attachment.

RISK FACTORS

  • Malnutrition
  • Immunosuppression (HIV, diabetes, chemotherapy, steroids, cancer)
  • Low socioeconomic status
  • Tobacco use
  • Poor oral hygiene and dental care
  • Orthodontic appliances
  • Psychological stress

GENERAL PREVENTION

  • Maintain proper oral hygiene and regular dental visits.
  • Adequate nutrition.
  • Smoking cessation.
  • Stress management.
  • Prompt treatment of underlying immunosuppressive conditions.

COMMONLY ASSOCIATED CONDITIONS

  • Malnourished patients, cancer treatment, HIV infection.
  • Bacteremia.
  • Tooth loss.
  • Chronic gingivitis.
  • Noma (cancrum oris).
  • Aspiration pneumonia.

DIAGNOSIS

History

  • Rapid onset of painful gingival ulcerations, bleeding.
  • Fetid breath, metallic taste.
  • Systemic symptoms: fever, malaise, regional lymphadenopathy.
  • Risk factors: tobacco, poor hygiene, malnutrition, immunosuppression.

Physical Exam

  • Fever, foul breath.
  • Gray pseudomembrane on gingiva.
  • Necrosis of interdental papillae ("punched out" lesions).
  • Gingival bleeding.
  • Cervical and submandibular lymphadenopathy.

DIFFERENTIAL DIAGNOSIS

  • Herpes simplex virus infection.
  • Recurrent aphthous stomatitis.
  • Medication reactions.
  • Oral malignancy.
  • Diphtheria.
  • Hematologic malignancies.
  • Primary syphilis.
  • Vitamin C deficiency.
  • Behçet disease, granulomatosis with polyangiitis.
  • Oral histoplasmosis.

DIAGNOSTIC TESTS & INTERPRETATION

  • Primarily clinical diagnosis.
  • Consider aerobic and anaerobic cultures if systemic involvement suspected.
  • Group A Streptococcus rapid antigen or throat culture.
  • Blood cultures if systemic illness present.
  • Dental radiographs if bony involvement suspected.
  • CT face/neck if deep tissue spread is a concern.
  • Biopsy rarely needed.

TREATMENT

General Measures

  • Control acute infection phase.
  • Gentle debridement with hydrogen peroxide swabs or chlorhexidine rinse.
  • Dental referral for ultrasonic or surgical debridement if needed.
  • Address malnutrition, immunosuppression, and smoking cessation.

Medication

  • Chlorhexidine gluconate 0.12%, 15 mL rinse twice daily.
  • Antibiotics for systemic symptoms or poor response:
  • Penicillin V potassium 250-500 mg PO q6h for 5-7 days.
  • Metronidazole 250-500 mg PO/IV q8h for 7-10 days.
  • Amoxicillin or amoxicillin-clavulanate.
  • Clindamycin for penicillin-allergic patients.
  • Combination therapy with metronidazole plus amoxicillin or penicillin sometimes used.

Additional Therapies

  • Warm saline rinses every 2 hours.
  • Sodium bicarbonate toothpaste.
  • Viscous lidocaine 2% rinse for pain.
  • NSAIDs or opioids for analgesia as needed.
  • Low-level laser therapy and photochemotherapy show promising adjunctive benefits.

ISSUES FOR REFERRAL

  • Severe disease needing surgical debridement.
  • Failure to respond to oral antibiotics.
  • Underlying immunodeficiency or systemic illness.

ONGOING CARE

  • Close dental and specialty follow-up.
  • Maintain good oral hygiene.
  • Balanced nutrition with multivitamin supplementation.

PATIENT EDUCATION

  • Emphasize twice-daily brushing and oral hygiene.
  • Tobacco cessation counseling.
  • Nutritional support.
  • Recognize early symptoms to prevent progression.

PROGNOSIS

  • Rapid improvement expected with treatment.
  • Without treatment, risk of progression to necrotizing periodontitis and noma.
  • Potential complications: malnutrition, dehydration, tooth loss, deep neck infections.

COMPLICATIONS

  • Rapid tissue destruction.
  • Necrotizing ulcerative periodontitis.
  • Cancrum oris (noma).
  • Systemic infections.

REFERENCES

  1. Dufty J, Gkranias N, Donos N. Necrotising ulcerative gingivitis: a literature review. Oral Health Prev Dent. 2017;15(4):321-327.
  2. Malek R, Gharibi A, Khlil N, et al. Necrotizing ulcerative gingivitis. Contemp Clin Dent. 2017;8(3):496-500.
  3. Marty M, Palmieri J, Noirrit-Esclassan E, et al. Necrotizing periodontal diseases in children: a literature review and adjustment of treatment. J Trop Pediatr. 2016;62(4):331-337.
  4. Atout RN, Todescan S. Managing patients with necrotizing ulcerative gingivitis. J Can Dent Assoc. 2013;79:d46.

ICD10

  • A69.1 Other Vincent's infections

Clinical Pearls

  • Diagnosis is clinical: oral pain, fetid breath, interdental papilla necrosis, gray pseudomembrane.
  • Key risk factors: immunosuppression, malnutrition, smoking, poor hygiene.
  • Treatment includes gentle debridement, chlorhexidine rinses, antibiotics if systemic signs.
  • Smoking cessation and nutrition improve outcomes.
  • Severe cases require specialist debridement to prevent rapid periodontium destruction.