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Necrotizing Ulcerative Gingivitis, Emergency Medicine

Basics

Description

- Periodontal disease - Characterized by the "punched-out " appearance of the gingival papillae - Synonym(s): - Acute necrotizing ulcerative gingivitis - Trench mouth - Vincent disease - Fusospirochetal gingivitis

- Caused by an overgrowth of oral flora - Prevotella intermedia - Spirochetes - Predisposing factors (not required for diagnosis): - Poor oral hygiene/gingivitis - Immunodeficiencies (e.g., HIV) - Immunosuppression - Malnutrition - Smoking - Emotional and physical stress - Possible association with direct contact to certain chemicals (e.g., MDMA or ecstasy)

- Immunocompromise: - Leukemia - Agranulocytosis (malignant neutropenia) - HIV

- Institute outpatient therapy: - Remove predisposing factors - Dilute hydrogen peroxide rinses - Chlorhexidine gluconate (Peridex) - Antibiotics if indicated - Avoid irritants (spicy foods, hot beverages) - Analgesics for pain control - Improve oral hygiene with daily brushing and flossing of teeth

  • Periodontal disease
  • Characterized by the "punched-out " appearance of the gingival papillae
  • Synonym(s):Acute necrotizing ulcerative gingivitisTrench mouthVincent diseaseFusospirochetal gingivitis
  • Not contagious
  • Occurs most often in children and young adults in developing nations
  • Mainly occurs in sub-Saharan Africa
  • Rare; seen mostly in severely immunocompromised patients
  • Males > females
  • Can progress to more advanced disease:Necrotizing stomatitis:Similar to necrotizing ulcerative gingivitis with extension to the tongue and buccal mucosaNecrotizing ulcerative periodontitis:Similar to necrotizing ulcerative gingivitis with periodontal attachment loss and alveolar bone involvementOrofacial gangrene

Etiology

  • Caused by an overgrowth of oral flora
  • Prevotella intermedia
  • Spirochetes
  • Predisposing factors (not required for diagnosis):Poor oral hygiene/gingivitisImmunodeficiencies (e.g., HIV)ImmunosuppressionMalnutritionSmokingEmotional and physical stressPossible association with direct contact to certain chemicals (e.g., MDMA or ecstasy)

Diagnosis

Signs and Symptoms

  • Essential clinical features:Painful gingival lesions "Punched-out, " crater-like ulcers of the papillaeUlcers bleed easily or spontaneously
  • Nonessential clinical features: "Pseudomembrane " of necrotic debris covering the ulcerated areaFoul breathFever/malaise

History

  • Acute, generalized oral pain
  • Bleeding gums:Spontaneous or with minimal manipulation
  • Foul breath
  • Malaise
  • Low-grade fever

Physical Exam

  • Loss of interdental papillae (key clinical feature)
  • "Punched-out, " crater-like ulcers of the papillae
  • Necrotic debris often present over ulcerated surfaces
  • "Pseudomembrane " of inflammatory and necrotic cells
  • Covers ulcerative lesions
  • Leaves a bleeding surface when removed
  • Lymphadenopathy, particularly submandibular
  • Foul breath
  • Low-grade fever

Essential Workup

  • Consider systemic disease:
  • Other reasons for immunosuppression or immunocompromise
  • Rule out complications:Progression to necrotizing stomatitis or ulcerative periodontitisLesions extending to periodontal ligament and alveolar boneAlveolar bone destructionProgression to orofacial gangrene (noma)

Diagnosis Tests & Interpretation

Lab

Lab tests not clinically helpful

Imaging

Generally not indicated

Differential Diagnosis

  • Other diseases rarely have the essential clinical feature of "punched-out " interdental papillae with ulcerations.
  • Acute herpetic gingivostomatitis:Affects entire gingival, not just papillaeLow-grade fever commonly presentContagious
  • Viral:Viral infections: Epstein " Barr, varicella zoster virus
  • Thrush
  • Actinomycosis
  • Streptococcal/gonococcal gingivitis/stomatitis
  • Secondary syphilis
  • Diphtheria
  • Vesiculobullous disease
  • Pemphigoid
  • Pemphigus
  • Oral lichen planus
  • Systemic lupus erythematosus
  • Trauma:ToothpicksVigorous toothbrushing/flossing
  • Immunocompromise:LeukemiaAgranulocytosis (malignant neutropenia)HIV

Treatment

Initial Stabilization/Therapy

IV fluids for dehydration

Ed Treatment/Procedures

  • Administer systemic and topical pain management:Narcotics rarely necessaryViscous lidocaine
  • Debride pseudomembrane:Use gauze or cotton-tipped applicator soaked in diluted H2O2
  • Antibiotics (penicillin/metronidazole or clindamycin) when indicated:FeverLymphadenopathyConsider broad-spectrum antibiotics, antifungals, and antivirals in the immunosuppressed patient
  • Institute outpatient therapy:Remove predisposing factorsDilute hydrogen peroxide rinsesChlorhexidine gluconate (Peridex)Antibiotics if indicatedAvoid irritants (spicy foods, hot beverages)Analgesics for pain controlImprove oral hygiene with daily brushing and flossing of teeth

Medication

First Line

  • Oral rinses:Chlorhexidine gluconate (Peridex): 15 mL swish/spit BIDHydrogen peroxide (3% solution diluted in half): Rinse up to 12 times daily
  • Viscous lidocaine
  • Pain control:NSAIDs (e.g., ibuprofen), acetaminophen

Second Line

  • Metronidazole: 250 " 750 mg (peds: 30 mg/kg/24h) PO QID 7 days
  • Penicillin VK: 500 mg (peds: <12 yr, 25 " 50 mg/kg/24h) PO QID. 10 days
  • Clindamycin: 300 mg PO (peds: 6 " 8 mg/kg/24h) TID
  • Narcotic pain control

Follow-Up

Disposition

Admission Criteria

  • Extensive disease with systemic signs
  • Severe dehydration/inability to tolerate PO fluids
  • Evidence of orofacial gangrene (noma): Infection of mouth/face:70% mortality with no treatment

Discharge Criteria

Able to maintain hydration

Followup Recommendations

Urgent referral to a dentist or periodontist for deep scaling and debridement

Pearls and Pitfalls

  • Consider HIV or immunosuppression
  • If untreated, can progress rapidly

Additional Reading

  • Bermejo-Fenoll A, S ‘nchez-Perez A. Necrotising periodontal diseases. Med Oral Patol Oral Cir Bucal. 2004;9(suppl):108 " 114.
  • Califano JV. Position paper: Periodontal diseases of children and adolescents. J Periodontol. 2003;74:1696 " 1704.
  • Crystal CS, Coon TP, Kaylor DW. Images in emergency medicine. Acute necrotizing ulcerative gingivitis. Ann Emerg Med. 2006;47:225 " 229.
  • Dachs RJ, Tun Y. Painful oral ulcerations in a 51-year-old woman. Am Fam Physician. 2009;80:875.
  • Minsk L. Diagnosis and treatment of acute periodontal conditions. Compend Contin Educ Dent. 2006;27:8 " 11.
  • Miranda-Rius J, Brunet-Llobet L, Lahor-Soler E. Ecstasy (3, 4-methylenedioxymethamphetamine, MDMA) related necrotising ulcerative gingivitis. BMJ Case Rep. 2009. doi:10.1136/bcr.06.2008.0290
  • Parameter on acute periodontal diseases. American Academy of Periodontology. J Periodontol. 2000;71(5 suppl):863 " 866.
  • Shiboski CH, Patton LL, Webster-Cyriaque JY, et al. The Oral HIV/AIDS Research Alliance: Updated case definitions of oral disease endpoints. J Oral Pathol Med. 2009;38:481 " 488.

Codes

ICD9

  • 101 Vincents angina
  • 526.4 Inflammatory conditions of jaw
  • 528.1 Cancrum oris

ICD10

  • A69.0 Necrotizing ulcerative stomatitis
  • A69.1 Other Vincents infections
  • M27.2 Inflammatory conditions of jaws

SNOMED

  • 399050001 Acute necrotizing ulcerative gingivitis (disorder)
  • 306785007 Acute necrotizing stomatitis (disorder)
  • 235010005 Acute necrotizing ulcerative periodontitis (disorder)
  • 240675006 Vincents infection