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
- 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 mucosa
- Necrotizing ulcerative periodontitis:
- Similar to necrotizing ulcerative gingivitis with periodontal attachment loss and alveolar bone involvement
- Orofacial gangrene
Etiology
- 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)
Diagnosis
Signs and Symptoms
- Essential clinical features:
- Painful gingival lesions
- "Punched-out, " crater-like ulcers of the papillae
- Ulcers bleed easily or spontaneously
- Nonessential clinical features:
- "Pseudomembrane " of necrotic debris covering the ulcerated area
- Foul breath
- Fever/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 periodontitis
- Lesions extending to periodontal ligament and alveolar bone
- Alveolar bone destruction
- Progression 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 papillae
- Low-grade fever commonly present
- Contagious
- 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:
- Toothpicks
- Vigorous toothbrushing/flossing
- Immunocompromise:
- Leukemia
- Agranulocytosis (malignant neutropenia)
- HIV
Treatment
Initial Stabilization/Therapy
IV fluids for dehydration
Ed Treatment/Procedures
- Administer systemic and topical pain management:
- Narcotics rarely necessary
- Viscous lidocaine
- Debride pseudomembrane:
- Use gauze or cotton-tipped applicator soaked in diluted H2O2
- Antibiotics (penicillin/metronidazole or clindamycin) when indicated:
- Fever
- Lymphadenopathy
- Consider broad-spectrum antibiotics, antifungals, and antivirals in the immunosuppressed patient
- 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
Medication
First Line
- Oral rinses:
- Chlorhexidine gluconate (Peridex): 15 mL swish/spit BID
- Hydrogen 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