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| {{CMG}}; {{AE}} {{AKI}} | | {{Roseola}} |
| | {{CMG}}:{{AE}}{{DAMI}} |
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| {{SK}} Vincent’s disease, fusospirochetal gingivitis, trench mouth, acute ulcerative gingivitis, necrotizing gingivitis, acute necrotizing ulcerative gingivitis, ANUG
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| ==Overview==
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| ==Historical Perspective== | | ==[[Roseola overview|Overview]]== |
| *The first description of NUG was recorded in Xenophon's troops in fourth century B.C, with features of painful decaying between the [[teeth]].
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| *In 1894, Plaut described NUG for the first time.
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| *In 1896, Vincent described the [[pathogenesis]] of NUG as an endogenous, opportunistic fusospirochetal infection. He used topical [[iodine]] applications and rinses of [[boric acid]] solution for treatment.
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| *From 1900 to 1920 [[oxidising]] agents such as [[chromic acid]] were used for the treatment of NUG.
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| *In 1930, Hirschfeld proposed that [[debridement]] and use of [[sodium perborate]] rinses were useful for the treatment of NUG till the [[inflammation]] reduced.
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| *In 1949, Schluger treated his patients with deep and thorough [[curettage]], followed by [[hydrogen peroxide]] and water rinses for six to eight weeks.
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| *In 1968, Goldhaber reported that periodic scalings and rinses with [[hydrogen peroxide]] helped with maintaining good oral [[hygiene]].
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| *In 1984, Stevens described the triad of criteria for the diagnosis of NUG, which include acute [[necrosis]] and [[ulceration]] of the [[interdental papillae]], [[pain]], and [[bleeding]].
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| ==Classification== | | ==[[Roseola historical perspective|Historical Perspective]]== |
| There is no classification for NUG.
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| ==Pathophysiology== | | ==[[Roseola classification|Classification]]== |
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| ===Pathogenesis=== | | ==[[Roseola pathophysiology|Pathophysiology]]== |
| *Pathogenesis of NUG is unclear and is explained in relation to the presence of [[predisposing factors]].
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| *The presence of predisposing factors such as, acute [[stress]], pre-existing [[gingivitis]], [[immunosuppression]], [[corticosteriod]] use, poor oral [[hygiene]] result in bacterial overgrowth and followed by invasion.
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| *The overgrowth of bacteria results in the formation of a plaque. A plaque is a [[biofilm]] which begins to form within 24 hours if it is not regularly removed. This [[biofilm]] once formed can minimize the effect of host defense and [[antibiotic]] penetration promoting bacterial overgrowth.
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| *Invasion of the bacteria into the [[gingiva]] results in NUG.
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| *Necrotizing ulcerative gingivitis causes [[necrosis]] of the [[gingival]] crest which is described as "punched out" ulcerated papillae resulting in gingival [[bleeding]] and [[pain]].
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| *NUG affects the interdental and marginal soft tissue and has minimal [[osseous]] involvement when compared to [[periodontitis]].
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| ===Microscopic Pathology=== | | ==[[Roseola causes|Causes]]== |
| *The features characteristic of NUG on microscopic examination include [[neutrophil]] rich, [[necrotic]], and [[spirochetal]] infiltration zones are unique to NUG.
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| *The biopsy of the [[gingiva]] under the electron microscopy examination demonstrate four zones and include:
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| **'''Bacterial zone: ''' This zone demonstrates many different morphological types of high bacterial load, including the presence of [[spirochetes]].
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| **'''Neutrophil rich zone:''' Below the bacterial zone, a [[neutrophil]] rich zone is demonstrated.
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| **'''Necrotic zone:''' This zone demonstrates disintegrated cells, with the presence of [[spirochetes]] and [[fusiform bacteria]].
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| **'''Spirochete infilteration zone:''' The zone demonstrates tissues infiltrated by [[spirochetes]] which are present in high number. Absence of other other [[bacteria]] is characteristic.
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| ==Causes== | | ==[[Roseola differential diagnosis|Differentiating Any Disease from other Diseases]]== |
| NUG is a [[polybacterial]] infection and the exact causative organisms are not identified, however the following organisms have been identified in most of the patients. The following is a list of organisms are associated with NUG, the presence of these organisms does not always help to make the diagnosis of NUG.
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| *[[Prevotella]] intermedia
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| *[[Fusobacterium]] [[species]]
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| *[[Treponema]] [[species]] - [[T. vincentii]] and [[T. buccalis]]
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| *[[Selenomonas]] [[species]]
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| ==Risk Factors== | | ==[[Roseola epidemiology and demographics|Epidemiology and Demographics]]== |
| The following risk factors predispose patients to develop NUG:
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| *Acute psychological [[stress]]
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| *[[Immunosuppression]]
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| *[[Smoking]]
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| *[[Malnutrition]]
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| *Pre-existing [[gingivitis]]
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| *[[Trauma]]
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| *Poor oral [[hygiene]]
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| *[[Alcohol consumption]]
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| ==Epidemiology and Demographics== | | ==[[Roseola risk factors|Risk Factors]]== |
| ===Age===
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| *Trench mouth mostly impacts individuals who are 35 years of age or younger.<ref name="urlEchocardiogram (Cardiac Ultrasound) - Diagnostic Tests - Cardiovascular Health Services - Heart & Vascular Institute">{{cite web |url=http://www.wkhs.com/heart/services/diagnostic_tests/echocardiogram_cardiac_ultrasound.aspx?chunkiid=230670#treatment |title=Echocardiogram (Cardiac Ultrasound) - Diagnostic Tests - Cardiovascular Health Services - Heart & Vascular Institute |format= |work= |accessdate=October 25, 2016}}</ref>
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| *In particular, trench mouth seems to affect teenagers most.<ref>{{cite book | last = Gibson | first = Alisa M. | last = Benko | first = Kip R. | title = Head, Eyes, Ears, Nose, and Throat Emergencies | publisher = Elsevier| location = Philadelphia, PA | year = 2013 | isbn = 9781455770830 }}</ref>
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| ===Developed Countries=== | | ==[[Roseola screening|Screening]]== |
| *In developed countries, trench mouth occurs mostly in young adults.<ref name="book123">{{Citation
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| | last1 = Lindhe
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| | first1 = Jan
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| | last2 = Lang
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| | first2 = Niklaus
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| | last3 = Karring
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| | first3 = Thorkild
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| | lastauthoramp = yes | |
| | title = Clinical Periodontology and Implant Dentistry
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| | publisher = Wiley-Blackwell
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| | place = Hoboken, New Jersey
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| | edition = 5
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| | year = 2008
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| }}</ref>
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| ===Developing Countries=== | | ==[[Roseola natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| *In developing countries, trench mouth may occur in children of low socioeconomic status, usually occurring with [[malnutrition]] (especially inadequate protein intake) and shortly after the onset of [[viral infections]], such as [[measles]].<ref name="book123">{{Citation
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| | last1 = Lindhe
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| | first1 = Jan
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| | last2 = Lang
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| | first2 = Niklaus
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| | last3 = Karring
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| | first3 = Thorkild
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| | lastauthoramp = yes
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| | title = Clinical Periodontology and Implant Dentistry
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| | publisher = Wiley-Blackwell
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| | place = Hoboken, New Jersey | |
| | edition = 5
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| | year = 2008
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| }}</ref>
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| ==Natural History, Complications and Prognosis==
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| ===Natural History===
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| In the early stages some patients may complain of a feeling of tightness around the [[teeth]]. If three signs are present, the diagnosis of trench mouth can be assumed. These include:<ref>{{cite book | last = Lindhe | first = Jan | last = Lang | first = Niklaus | last = Karring | first = Thorkild | title = Clinical Periodontology and Implant Dentistry| publisher = Wiley-Blackwell| location = New Jersey | year = 2008 | isbn = 978-1405160995 }}</ref>
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| *Severe [[gingival]] [[pain]]
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| *Profuse gingival [[bleeding]] that requires little or no provocation
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| *[[Ulcerated]] interdental [[papillae]] with necrotic slough.
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| ===Complications===
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| *Destruction of [[gingival]] papillae
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| *Interdental [[gingival]] crater formation in the anterior gingiva is disfiguring.
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| *[[Recurrence]]
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| *Loss of [[teeth]]
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| *[[Pain]]
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| *[[Periodontitis]]
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| *Spread of [[infection]]
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| ===Prognosis===
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| Untreated, the infection can lead to rapid destruction of the [[periodontium]] and can spread, as necrotizing [[stomatitis]] or [[noma]], into neighbouring tissues in the [[cheeks]], [[lips]] or the bones of the [[jaw]]. As stated, the condition can occur and be especially dangerous in people with weakened [[immune systems]]. This progression to noma is possible in [[malnourished]] susceptible individuals, with severe disfigurement possible.<ref name="pmid3514841">{{cite journal |vauthors=Johnson BD, Engel D |title=Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment |journal=J. Periodontol. |volume=57 |issue=3 |pages=141–50 |year=1986 |pmid=3514841 |doi=10.1902/jop.1986.57.3.141 |url=}}</ref>
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| ==Diagnosis== | | ==Diagnosis== |
| | | [[Roseola history and symptoms|History and Symptoms]] | [[Roseola physical examination|Physical Examination]] | [[Roseola laboratory findings|Laboratory Findings]] | [[Roseola electrocardiogram|Electrocardiogram]] | [[Roseola chest x ray|Chest X Ray]] | [[Roseola CT|CT]] | [[Roseola MRI|MRI]] | [[Roseola echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Roseola other imaging findings|Other Imaging Findings]] | [[Roseola other diagnostic studies|Other Diagnostic Studies]] |
| ===History and Symptoms===
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| To make the diagnosis of NUG the traid of interdental [[necrosis]], [[bleeding]], and [[pain]] must be present. Absence of any one of the features rules out the diagnosis of NUG.
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| ====More common symptoms====
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| *[[Pain]] is the presenting symptom in all the patients.
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| *[[Gingival]] bleeding
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| ====Less common symptoms====
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| *[[Lymphadenopathy]]
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| *[[Bad breath]]-[[halitosis]]
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| *[[Fever]]
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| *[[Malaise]]
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| *Red or [[swollen]] gums
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| *Pain when eating or swallowing
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| *A gray film/gray residue on gums
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| *Crater-like sores ([[ulcers]])
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| *Loss of gum tissue in between the [[teeth]]
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| ===Physical Examination===
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| ===Vital Signs===
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| *[[Fever]]
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| ===HEENT===
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| Oral examination findings suggesting NUG include:
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| *Interdental [[gingival]] necrotic ulcers, which appear like punched out lesions
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| *[[Bleeding]] [[gums]] with minimal pressure
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| *Red or swollen [[gums]]
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| *A gray film on [[gums]]
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| *Crater-like ([[ulcers]])
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| * [[Lymphadenopathy]]
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| *[[Halitosis]]
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| ===Laboratory Findings===
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| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
| | [[Roseola medical therapy|Medical Therapy]] | [[Roseola surgery|Surgery]] | [[Roseola primary prevention|Primary Prevention]] | [[Roseola secondary prevention|Secondary Prevention]] | [[Roseola cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Roseola future or investigational therapies|Future or Investigational Therapies]] |
| *Medical therapy is not a definitive treatment option, it is used to in addition with [[gingivoplasty]], [[scaling]] or [[curettage]] procedures..<ref name="pmid10875694">{{cite journal |vauthors= |title=Parameter on acute periodontal diseases. American Academy of Periodontology |journal=J. Periodontol. |volume=71 |issue=5 Suppl |pages=863–6 |year=2000 |pmid=10875694 |doi=10.1902/jop.2000.71.5-S.863 |url=}}</ref>
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| *[[Chlorhexidine gluconate]], a topical chemotherapeutic agent has shown to improve outcomes after surgical treatment.
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| *Periodic [[chlorhexidine]] rinses are used during the period of wound healing of the damaged [[gingiva]] after [[scaling]] or [[curettage]] procedures.
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| *[[Antibiotic]] therapy with [[penicillin]] or [[metronidazole]] for a period of 7 to 10 days is recommended to control [[bacterial growth]].
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| For any signs of systemic involvement, the recommended antibiotics that can provide rapid relief include:
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| *[[Amoxicillin]], 250 mg 3x daily for 7 days {{withorwithout}} [[Metronidazole]], 250 mg 3x daily for 7 days
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| If debridement is delayed:<ref name="123urlAcute Necrotizing Ulcerative Gingivitis (ANUG) - Dental Disorders - Merck Manuals Professional Edition">{{cite web |url=http://www.merckmanuals.com/professional/dental-disorders/periodontal-disorders/acute-necrotizing-ulcerative-gingivitis-anug |title=Acute Necrotizing Ulcerative Gingivitis (ANUG) - Dental Disorders - Merck Manuals Professional Edition |format= |work= |accessdate=October 25, 2016}}</ref>
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| *[[Amoxicillin]] 500 mg every 8 hours for 3 days
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| *[[Erythromycin]] 250 mg every 6 hours for 3 days
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| *[[Tetracycline]] 250 mg every 6 hours for 3 days
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| ===Surgical Therapy===
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| *[[Debridement]] of the [[plaque]] by [[scaling]] and [[root planing]], periodic [[curettage]] and [[gingivoplasty]] are the primary treatment options for NUG.<ref>{{Cite web | title =Managing Patients with Necrotizing Ulcerative Gingivitis
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| | url = http://www.jcda.ca/article/d46}}</ref>
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| *Repeated [[curettage]] and good [[plaque]] control can result in regeneration of destroyed [[papillae]]. It is an effective treatment option, but is associated with recurrence as the patients fail to adhere the repeated follow-up visits once the symptoms resolve.
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| *In patients with anterior [[gingival]] involvement [[scaling]] and [[planing]] is a good option for treatment as it has a good esthetic result compared to gingivoplasty. [[Scaling]] and [[root planing]] should be done periodically to stimulate the regeneration of the [[interdental papillae]] and to reduce the need for [[gingivoplasty]]. Therapy must be continued for a period of 9 months and the success rates of gingival regeneration are variable.
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| *Repeated episodes of NUG can result in [[gingival]] deformities, to avoid this complication [[gingivoplasty]] can be done for adequate [[plaque]] control and recreate physiologic [[gingival]] form and contour.
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| ==Prevention==
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| ===Primary Prevention===
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| Effective measures of primary prevention strategies for trench mouth include:
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| * Good general [[health]]
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| * Good [[nutrition]]
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| * Good [[oral hygiene]], including thorough tooth brushing and flossing. [[Antiseptic]] [[mouthwash]] such as [[chlorhexidine]] 0.12% decreases [[bacterial]] count and is effective when used in combination with good mouth care
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| * Mechanisms to cope with [[stress]]
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| * [[Smoking cessation]]
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| ===Secondary Prevention=== | | ==Case Studies== |
| ==References==
| | [[Roseola case study one|Case #1]] |
| {{Reflist|2}}
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