Sandbox: Reddy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Synonyms and keywords: Vincent’s disease, fusospirochetal gingivitis, trench mouth, acute ulcerative gingivitis, necrotizing gingivitis, acute necrotizing ulcerative gingivitis, ANUG

Historical Perspective

• In 1894, Plaut described NUG for the first time.
• In 1896, Vincent described the pathogenesis of NUG as an endogenous, opportunistic fusospirochetal infection.

Classification

There is no classification for NUG.

Pathophysiology

Pathogenesis

• Necrotizing ulcerative gingivitis causes necrosis of the gingival crest which is described as "punched out" ulcerated papillae resulting in gingival bleeding and pain.
• NUG affects the interdental and marginal soft tissue and has minimal osseous involvement when compared to periodontitis.

Microscopic Pathology

• The features characteristic of NUG on microscopic examination include neutrophil rich, necrotic, and spirochetal infiltration zones are unique to NUG.
• The biopsy of the gingiva under the electron microscopy demonstrate four zones and include:
  • Bacterial zone: This zone demonstrates many different morphological types of high bacterial load, including the presence of spirochetes.
  • Neutrophil rich zone: Below the bacterial zone, a neutrophil rich zone is demonstrated.
  • Necrotic zone: This zone demonstrates disintegrated cells, with the presence of spirochetes and fusiform bacteria.
  • Spirochete infilteration zone: The zone demonstrates tissues infiltrated by spirochetes which are present in high number. Absence of other other bacteria is characteristic.

Causes

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 doesnot always help to make the diagnosis of NUG.

• Prevotella intermedia
• Fusobacterium sp
• Treponema - T. vincentii and T. buccalis
• Selenomonas sp.

Risk Factors

The following risk factors predispose patients to develop NUG:

• Acute psychological stress
• Immune suppression
• Smoking
• Malnutrition
• Pre-existing gingivitis
• Trauma
• Poor oral hygiene
• Alcohol consumption

Natural History, Complications and Prognosis

Complications

• Destruction of gingival papillae
• Interdental gingival crater formation in the anterior gingiva is disfiguring.
• Recurrence

Diagnosis

History and Symptoms

To make the diagnosis of NUG the traid of interproximal necrosis, bleeding, and pain must be present. Absence of any one of the features rules out the diagnosis of NUG.

More common symptoms

• Pain is the presenting symptom in all the patients.
• Gingival bleeding

Less common symptoms

• Lymphadenopathy
• Bad breath-halitosis
• Fever
• Malaise

Treatment

Medical Therapy

• Medical therapy is a definitive treatment option, it is used to in addition with gingivoplasty or scaling or curretage procedures.
• Chlorhexidine gluconate, a topical chemotherapeutic agent has shown to improve outcomes after surgical treatment.
• Periodic chlorhexidine rinses are used during the period of wound healing of the damaged gingiva after scaling or curretage procedures.
• Antiboiotic therapy with penicillin or metronidazole for a period of 7 to 10days is recommended to control bacterial growth.

Surgical Therapy

• Debridement of the plaque by scaling and root planing, periodic curretage and gingivoplasty are the primary treatment options for NUG.
• 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.
• 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.
• 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.