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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.
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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]].
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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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| ==Risk Factors== | | ==[[Roseola epidemiology and demographics|Epidemiology and Demographics]]== |
| 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]]
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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]]== |
| ===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 screening|Screening]]== |
| *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=== | | ==[[Roseola natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| *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 | |
| | 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]]. 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>
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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=== | |
| *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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| *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.<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>
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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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| NUG is primarily a clinical diagnosis therefore laboratory investigation for confirmation of the diagnosis is not done.
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| ====Dental X-Ray====
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| *X-Rays are useful to look for the extent of osseus involvement of the infection.
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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]].<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>
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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.<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>
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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===
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| *Regular follow up and with the dentist for the duration of the treatment.
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| ==References== | | ==Case Studies== |
| {{Reflist|2}}
| | [[Roseola case study one|Case #1]] |