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| {{CMG}}; {{AE}} {{AKI}} | | {{Roseola}} |
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| {{SK}} Vincent’s disease, Fusospirochetal gingivitis, Trench mouth, Acute ulcerative gingivitis, Necrotizing gingivitis, Acute necrotizing ulcerative gingivitis, ANUG, NUG, Necrotizing ulcerative gingivitis
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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]].<ref name="pmid18016160">{{cite journal| author=Hampp EG| title=Vincent's Infection-A Wartime Disease: Observations on the Oral Spirochetal Flora Present in Vincent's Infection. | journal=Am J Public Health Nations Health | year= 1945 | volume= 35 | issue= 5 | pages= 441-50 | pmid=18016160 | doi= | pmc=1625444 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18016160 }} </ref>
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| *In 1894, Plaut described NUG for the first time.<ref name="pmid9673160">{{cite journal| author=Socransky SS, Haffajee AD| title=Evidence of bacterial etiology: a historical perspective. | journal=Periodontol 2000 | year= 1994 | volume= 5 | issue= | pages= 7-25 | pmid=9673160 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9673160 }} </ref>
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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.<ref name="pmid24738591">{{cite journal| author=Herrera D, Alonso B, de Arriba L, Santa Cruz I, Serrano C, Sanz M| title=Acute periodontal lesions. | journal=Periodontol 2000 | year= 2014 | volume= 65 | issue= 1 | pages= 149-77 | pmid=24738591 | doi=10.1111/prd.12022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24738591 }} </ref>
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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]].<ref name="pmid3514841">{{cite journal| author=Johnson BD, Engel D| title=Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. | journal=J Periodontol | year= 1986 | volume= 57 | issue= 3 | pages= 141-50 | pmid=3514841 | doi=10.1902/jop.1986.57.3.141 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3514841 }} </ref>
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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.<ref name="pmid25219100">{{cite journal| author=Mizrahi Y| title=[NUG--necrotizing ulcerative gingivitis: a review]. | journal=Refuat Hapeh Vehashinayim (1993) | year= 2014 | volume= 31 | issue= 3 | pages= 41-7, 62 | pmid=25219100 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25219100 }} </ref>
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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.<ref name="pmid15143484">{{cite journal| author=Lovegrove JM| title=Dental plaque revisited: bacteria associated with periodontal disease. | journal=J N Z Soc Periodontol | year= 2004 | volume= | issue= 87 | pages= 7-21 | pmid=15143484 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15143484 }} </ref>
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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]].<ref name="pmid24738591">{{cite journal| author=Herrera D, Alonso B, de Arriba L, Santa Cruz I, Serrano C, Sanz M| title=Acute periodontal lesions. | journal=Periodontol 2000 | year= 2014 | volume= 65 | issue= 1 | pages= 149-77 | pmid=24738591 | doi=10.1111/prd.12022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24738591 }} </ref>
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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.<ref name="pmid18016160">{{cite journal| author=Hampp EG| title=Vincent's Infection-A Wartime Disease: Observations on the Oral Spirochetal Flora Present in Vincent's Infection. | journal=Am J Public Health Nations Health | year= 1945 | volume= 35 | issue= 5 | pages= 441-50 | pmid=18016160 | doi= | pmc=1625444 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18016160 }} </ref>
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| *The biopsy of the [[gingiva]] under the electron microscopy examination demonstrate four zones and include:<ref name="pmid14326701">{{cite journal| author=LISTGARTEN MA| title=ELECTRON MICROSCOPIC OBSERVATIONS ON THE BACTERIAL FLORA OF ACUTE NECROTIZING ULCERATIVE GINGIVITIS. | journal=J Periodontol | year= 1965 | volume= 36 | issue= | pages= 328-39 | pmid=14326701 | doi=10.1902/jop.1965.36.4.328 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14326701 }} </ref> <ref name="CobbFerguson2003">{{cite journal|last1=Cobb|first1=Charles M.|last2=Ferguson|first2=Brett L.|last3=Keselyak|first3=Nancy T.|last4=Holt|first4=Lorie A.|last5=MacNeill|first5=Simon R.|last6=Rapley|first6=John W.|title=A TEM/SEM study of the microbial plaque overlying the necrotic gingival papillae of HIV-seropositive, necrotizing ulcerative periodontitis|journal=Journal of Periodontal Research|volume=38|issue=2|year=2003|pages=147–155|issn=0022-3484|doi=10.1034/j.1600-0765.2003.02011.x}}</ref>
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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.<ref name="pmid3514841">{{cite journal| author=Johnson BD, Engel D| title=Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. | journal=J Periodontol | year= 1986 | volume= 57 | issue= 3 | pages= 141-50 | pmid=3514841 | doi=10.1902/jop.1986.57.3.141 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3514841 }} </ref><ref name="Ryan1983">{{cite journal|last1=Ryan|first1=Michael E.|title=Acute Necrotizing Ulcerative Gingivitis in Children With Cancer|journal=Archives of Pediatrics & Adolescent Medicine|volume=137|issue=6|year=1983|pages=592|issn=1072-4710|doi=10.1001/archpedi.1983.02140320068015}}</ref><ref name="pmid9673160">{{cite journal| author=Socransky SS, Haffajee AD| title=Evidence of bacterial etiology: a historical perspective. | journal=Periodontol 2000 | year= 1994 | volume= 5 | issue= | pages= 7-25 | pmid=9673160 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9673160 }} </ref>
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| *[[Prevotella]] intermedia<ref name="pmid6122728">{{cite journal| author=Loesche WJ, Syed SA, Laughon BE, Stoll J| title=The bacteriology of acute necrotizing ulcerative gingivitis. | journal=J Periodontol | year= 1982 | volume= 53 | issue= 4 | pages= 223-30 | pmid=6122728 | doi=10.1902/jop.1982.53.4.223 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6122728 }} </ref><ref name="pmid14871191">{{cite journal| author=Gmür R, Wyss C, Xue Y, Thurnheer T, Guggenheim B| title=Gingival crevice microbiota from Chinese patients with gingivitis or necrotizing ulcerative gingivitis. | journal=Eur J Oral Sci | year= 2004 | volume= 112 | issue= 1 | pages= 33-41 | pmid=14871191 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14871191 }} </ref>
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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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| ==Differential Diagnosis== | | ==[[Roseola epidemiology and demographics|Epidemiology and Demographics]]== |
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| ==Risk Factors== | | ==[[Roseola risk factors|Risk Factors]]== |
| The following risk factors predispose patients to develop NUG:<ref name="pmid9673175">{{cite journal| author=Murayama Y, Kurihara H, Nagai A, Dompkowski D, Van Dyke TE| title=Acute necrotizing ulcerative gingivitis: risk factors involving host defense mechanisms. | journal=Periodontol 2000 | year= 1994 | volume= 6 | issue= | pages= 116-24 | pmid=9673175 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9673175 }} </ref><ref name="pmid266582">{{cite journal| author=Shields WD| title=Acute necrotizing ulcerative gingivitis. A study of some of the contributing factors and their validity in an Army population. | journal=J Periodontol | year= 1977 | volume= 48 | issue= 6 | pages= 346-9 | pmid=266582 | doi=10.1902/jop.1977.48.6.346 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=266582 }} </ref>
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| *Acute psychological [[stress]]<ref name="RenersBrecx2007">{{cite journal|last1=Reners|first1=M|last2=Brecx|first2=M|title=Stress and periodontal disease|journal=International Journal of Dental Hygiene|volume=5|issue=4|year=2007|pages=199–204|issn=1601-5029|doi=10.1111/j.1601-5037.2007.00267.x}}</ref>
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| *[[Immunosuppression]]<ref name="pmid1532056">{{cite journal| author=Thompson SH, Charles GA, Craig DB| title=Correlation of oral disease with the Walter Reed staging scheme for HIV-1-seropositive patients. | journal=Oral Surg Oral Med Oral Pathol | year= 1992 | volume= 73 | issue= 3 | pages= 289-92 | pmid=1532056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1532056 }} </ref>
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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]]<ref name="pmid8295093">{{cite journal| author=Taiwo JO| title=Oral hygiene status and necrotizing ulcerative gingivitis in Nigerian children. | journal=J Periodontol | year= 1993 | volume= 64 | issue= 11 | pages= 1071-4 | pmid=8295093 | doi=10.1902/jop.1993.64.11.1071 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8295093 }} </ref>
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| *[[Alcohol consumption]]
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| ==Epidemiology and Demographics== | | ==[[Roseola screening|Screening]]== |
| ===Incidence and Prevalence===
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| *It is difficult to conduct epidemiological studies on NUG due to the variability of descriptions of the disease.<ref name="pmid18016159">{{cite journal| author=Dean HT, Singleton DE| title=Vincent's Infection-A Wartime Disease: Preliminary Considerations on the Epidemiology of Ulcerative Gingivostomatitis. | journal=Am J Public Health Nations Health | year= 1945 | volume= 35 | issue= 5 | pages= 433-40 | pmid=18016159 | doi= | pmc=1625430 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18016159 }} </ref><ref name="pmid12472838">{{cite journal| author=Lopez R, Fernandez O, Jara G, Baelum V| title=Epidemiology of necrotizing ulcerative gingival lesions in adolescents. | journal=J Periodontal Res | year= 2002 | volume= 37 | issue= 6 | pages= 439-44 | pmid=12472838 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12472838 }} </ref><ref name="pmid27830369">{{cite journal| author=Dufty J, Gkranias N, Petrie A, McCormick R, Elmer T, Donos N| title=Prevalence and treatment of necrotizing ulcerative gingivitis (NUG) in the British Armed Forces: a case-control study. | journal=Clin Oral Investig | year= 2016 | volume= | issue= | pages= | pmid=27830369 | doi=10.1007/s00784-016-1979-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27830369 }} </ref>
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| ===Age=== | | ==[[Roseola natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| *NUG is common in individuals younger than 35 years of age.<ref name="pmid6592176">{{cite journal| author=Stevens AW, Cogen RB, Cohen-Cole S, Freeman A| title=Demographic and clinical data associated with acute necrotizing ulcerative gingivitis in a dental school population (ANUG-demographic and clinical data). | journal=J Clin Periodontol | year= 1984 | volume= 11 | issue= 8 | pages= 487-93 | pmid=6592176 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6592176 }} </ref>
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| ===Developed Countries===
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| *In developed countries, NUG 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
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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
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| | edition = 5
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| | year = 2008
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| }}</ref>
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| ===Developing Countries===
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| *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
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| | edition = 5
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| | year = 2008 | |
| }}</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]]. The presence of the following triad suggests NUG:<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> <ref name="pmid23524550">{{cite journal| author=Sangani I, Watt E, Cross D| title=Necrotizing ulcerative gingivitis and the orthodontic patient: a case series. | journal=J Orthod | year= 2013 | volume= 40 | issue= 1 | pages= 77-80 | pmid=23524550 | doi=10.1179/1465313312Y.0000000037 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23524550 }} </ref><ref name="pmid9533316">{{cite journal| author=Horning GM| title=Necotizing gingivostomatitis: NUG to noma. | journal=Compend Contin Educ Dent | year= 1996 | volume= 17 | issue= 10 | pages= 951-4, 956, 957-8 passim; quiz 964 | pmid=9533316 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9533316 }} </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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| *[[Noma]]<ref name="pmid2269918">{{cite journal| author=Osuji OO| title=Necrotizing ulcerative gingivitis and cancrum oris (noma) in Ibadan, Nigeria. | journal=J Periodontol | year= 1990 | volume= 61 | issue= 12 | pages= 769-72 | pmid=2269918 | doi=10.1902/jop.1990.61.12.769 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2269918 }} </ref>
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| *[[Recurrence]]
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| *Loss of [[teeth]]<ref name="MacCarthyClaffey1991">{{cite journal|last1=MacCarthy|first1=Denise|last2=Claffey|first2=Noel|title=Acute necrotizing ulcerative gingivitis is associated with attachment loss|journal=Journal of Clinical Periodontology|volume=18|issue=10|year=1991|pages=776–779|issn=0303-6979|doi=10.1111/j.1600-051X.1991.tb00071.x}}</ref>
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| *[[Pain]]
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| *[[Periodontitis]]
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| ===Prognosis===
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| Prognosis of NUG is variable with treatment, majority of the patients have good response to the treatment and few of them do not respond to the treatment. In patients with treatment, recurrence is the most common factor affecting the outcome. In patients with [[immunosuppresion]], the prognosis is poor and it progresses to [[noma]].<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.<ref name="pmid23524550">{{cite journal| author=Sangani I, Watt E, Cross D| title=Necrotizing ulcerative gingivitis and the orthodontic patient: a case series. | journal=J Orthod | year= 2013 | volume= 40 | issue= 1 | pages= 77-80 | pmid=23524550 | doi=10.1179/1465313312Y.0000000037 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23524550 }} </ref>
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| ====More common symptoms====
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| *[[Pain]] is the presenting symptom in all the patients.<ref name="pmid13701428">{{cite journal| author=FRANKL SN| title=Herpetic gingivostomatitis and necrotizing ulcerative gingivitis in the child and adolescent. | journal=Clin Proc Child Hosp Dist Columbia | year= 1960 | volume= 16 | issue= | pages= 282-5 | pmid=13701428 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13701428 }} </ref> <ref name="pmid15912925">{{cite journal| author=Jiménez LM, Duque FL, Baer PN, Jiménez SB| title=Necrotizing ulcerative periodontal diseases in children and young adults in Medellín, Colombia, 1965--2000. | journal=J Int Acad Periodontol | year= 2005 | volume= 7 | issue= 2 | pages= 55-63 | pmid=15912925 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15912925 }} </ref>
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| *[[Gingival]] bleeding
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| ====Less common symptoms====
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| *[[Lymphadenopathy]]<ref name="pmid23524550">{{cite journal| author=Sangani I, Watt E, Cross D| title=Necrotizing ulcerative gingivitis and the orthodontic patient: a case series. | journal=J Orthod | year= 2013 | volume= 40 | issue= 1 | pages= 77-80 | pmid=23524550 | doi=10.1179/1465313312Y.0000000037 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23524550 }} </ref><ref name="pmid10863377">{{cite journal| author=Novak MJ| title=Necrotizing ulcerative periodontitis. | journal=Ann Periodontol | year= 1999 | volume= 4 | issue= 1 | pages= 74-8 | pmid=10863377 | doi=10.1902/annals.1999.4.1.74 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10863377 }} </ref>
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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:<ref name="pmid15912925">{{cite journal| author=Jiménez LM, Duque FL, Baer PN, Jiménez SB| title=Necrotizing ulcerative periodontal diseases in children and young adults in Medellín, Colombia, 1965--2000. | journal=J Int Acad Periodontol | year= 2005 | volume= 7 | issue= 2 | pages= 55-63 | pmid=15912925 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15912925 }} </ref><ref name="pmid15580128">{{cite journal| author=Bermejo-Fenoll A, Sánchez-Pérez A| title=Necrotising periodontal diseases. | journal=Med Oral Patol Oral Cir Bucal | year= 2004 | volume= 9 Suppl | issue= | pages= 114-9; 108-14 | pmid=15580128 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15580128 }} </ref>
| |
| *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===
| |
| NUG is primarily a clinical diagnosis therefore laboratory investigation for confirmation of the diagnosis is not done.<ref name="pmid24738591">{{cite journal| author=Herrera D, Alonso B, de Arriba L, Santa Cruz I, Serrano C, Sanz M| title=Acute periodontal lesions. | journal=Periodontol 2000 | year= 2014 | volume= 65 | issue= 1 | pages= 149-77 | pmid=24738591 | doi=10.1111/prd.12022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24738591 }} </ref>
| |
| ====Dental X-Ray====
| |
| *X-Rays are useful to look for the extent of osseus involvement of the infection.<ref name="pmid10863377">{{cite journal| author=Novak MJ| title=Necrotizing ulcerative periodontitis. | journal=Ann Periodontol | year= 1999 | volume= 4 | issue= 1 | pages= 74-8 | pmid=10863377 | doi=10.1902/annals.1999.4.1.74 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10863377 }} </ref>
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|
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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>
| |
| *[[Chlorhexidine gluconate]], a topical chemotherapeutic agent has shown to improve outcomes after surgical treatment.<ref name="pmid8558402">{{cite journal| author=Horning GM, Cohen ME| title=Necrotizing ulcerative gingivitis, periodontitis, and stomatitis: clinical staging and predisposing factors. | journal=J Periodontol | year= 1995 | volume= 66 | issue= 11 | pages= 990-8 | pmid=8558402 | doi=10.1902/jop.1995.66.11.990 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8558402 }} </ref>
| |
| *Periodic [[chlorhexidine]] rinses are used during the period of wound healing of the damaged [[gingiva]] after [[scaling]] or [[curettage]] procedures.
| |
| *[[Antibiotic]] therapy with [[penicillin]] or [[metronidazole]] for a period of 7 to 10 days is recommended to control [[bacterial growth]].<ref name="Loesche1999">{{cite journal|last1=Loesche|first1=W.J.|title=The Antimicrobial Treatment of Periodontal Disease: Changing the Treatment Paradigm|journal=Critical Reviews in Oral Biology & Medicine|volume=10|issue=3|year=1999|pages=245–275|issn=1045-4411|doi=10.1177/10454411990100030101}}</ref>
| |
| For any signs of systemic involvement, the recommended antibiotics that can provide rapid relief include:<ref name="pmid10863376">{{cite journal| author=Rowland RW| title=Necrotizing ulcerative gingivitis. | journal=Ann Periodontol | year= 1999 | volume= 4 | issue= 1 | pages= 65-73; discussion 78 | pmid=10863376 | doi=10.1902/annals.1999.4.1.65 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10863376 }} </ref>
| |
| *[[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>
| |
| *[[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===
| |
| *[[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
| |
| | url = http://www.jcda.ca/article/d46}}</ref>
| |
| *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.<ref name="pmid10863376">{{cite journal| author=Rowland RW| title=Necrotizing ulcerative gingivitis. | journal=Ann Periodontol | year= 1999 | volume= 4 | issue= 1 | pages= 65-73; discussion 78 | pmid=10863376 | doi=10.1902/annals.1999.4.1.65 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10863376 }} </ref>
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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.<ref name="AxelssonLindhe1991">{{cite journal|last1=Axelsson|first1=P.|last2=Lindhe|first2=J.|last3=Nystrom|first3=B.|title=On the prevention of caries and periodontal disease. Results of a 15-year longitudinal study in adults|journal=Journal of Clinical Periodontology|volume=18|issue=3|year=1991|pages=182–189|issn=0303-6979|doi=10.1111/j.1600-051X.1991.tb01131.x}}</ref>
| |
| *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.<ref name="pmid10863376">{{cite journal| author=Rowland RW| title=Necrotizing ulcerative gingivitis. | journal=Ann Periodontol | year= 1999 | volume= 4 | issue= 1 | pages= 65-73; discussion 78 | pmid=10863376 | doi=10.1902/annals.1999.4.1.65 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10863376 }} </ref>
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| | |
| ==Prevention==
| |
| ===Primary Prevention===
| |
| Effective measures of primary prevention strategies for trench mouth include:
| |
| * Good general [[health]]
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| * Good [[nutrition]]
| |
| * 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
| |
| * Mechanisms to cope with [[stress]]
| |
| * [[Smoking cessation]]
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| | |
| ===Secondary Prevention===
| |
| *Regular follow up and with the dentist for the duration of the treatment.
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|
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|
| ==References== | | ==Case Studies== |
| {{Reflist|2}}
| | [[Roseola case study one|Case #1]] |