BASICS
DESCRIPTION
- Inflammatory oral infection of the gingiva, characterized by gingival necrosis, bleeding, and pain
- Disease caused by Fusobacterium, Prevotella intermedia, spirochetes, and heavy growth of oral flora
- Concomitant infection with Epstein-Barr virus, herpes simplex virus, and type 1 human cytomegalovirus is common.
- Organisms invade gingiva and oral papillae with the formation of a pseudomembranous exudate.
- Clinical presentation includes ulceration, halitosis, pain, bleeding, and necrosis. It is differentiated from other periodontal diseases in that onset is rapid, papillae are ulcerated and appear "punched out, " and there is interdental necrosis (1).
- Synonym(s): Vincent angina; trench mouth; acute necrotizing ulcerative gingivitis
EPIDEMIOLOGY
Incidence
- Predominant age: 18 to 30 years in developed countries
- 3 to 14 years of age among malnourished children
Prevalence
- A Chilean study of 9,203 students aged 12 to 21 years revealed a prevalence of 6.7%.
- Overall prevalence decreases with age.
ETIOLOGY AND PATHOPHYSIOLOGY
- Impaired host immunologic response due to immunocompromise or malnutrition
- Loss of integrity of the oral mucosa
- Increased bacterial attachment with herpesvirus active infection
RISK FACTORS
- Poor oral hygiene
- Orthodontics (2)
- Infrequent or absent dental care
- Malnutrition
- Tobacco use
- Herpesvirus infection
- Immunosuppression
- Psychological stress
- Diabetes, especially if uncontrolled (3)
- Down syndrome
- Pregnancy (3)
GENERAL PREVENTION
- Regular dental care
- Proper oral hygiene
- Appropriate nutrition
- Prompt recognition and institution of therapy
- Stress management
COMMONLY ASSOCIATED CONDITIONS
- Bacteremia
- Osteomyelitis
- Tooth loss
- Noma/cancrum oris, which can be life-threatening.
- Aspiration pneumonia
DIAGNOSIS
HISTORY
- Acute onset of gingival ulcer
- Halitosis
- Painful, bleeding, and inflamed gingiva
- Fever
- Malaise
- History of immunosuppression chemotherapy, HIV infection
- History of herpesvirus infection
PHYSICAL EXAM
- Ulceration of the oral papillae
- Inflamed, erythematous gingiva
- Formation of gray, pseudomembranous exudate
- Necrotic tissue on gingiva and surrounding structures
- Cervical lymphadenopathy
DIFFERENTIAL DIAGNOSIS
- Herpes simplex virus
- Periodontitis
- Pericoronitis
- Medication side effects
- Oral malignancy
- Xerostomia
- Diphtheria
- Lymphoma/leukemia
- Primary syphilis
- Ascorbic acid deficiency
- Gingivitis
- Beh งet disease
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Diagnosis is primarily based on clinical exam, but if systemic illness or localized spread to surrounding tissues is suspected, the following studies should be considered:
- Aerobic and anaerobic cultures of inflamed or debrided tissue
- Group A strep rapid antigen detection assay
- Group A strep throat culture
- Blood cultures if systemic involvement
- Dental radiographs
- Facial radiographs or CT of the neck and sinuses if infection has progressed
TREATMENT
MEDICATION
- Decision regarding locus of treatment (outpatient or inpatient) and route (PO or IV) depends on the degree of systemic illness present and on the involvement of structures in the neck.
- Medication regimens provided below are for outpatient treatment.
First Line
- Penicillin V K 500 mg q6h for 7 to 10 days (4)[C] or
- Amoxicillin 500 mg TID for 7 days or
- Amoxicillin-clavulanate 875 mg q12h for 7 to 10 days if more concerned regarding complications
Second Line
- Metronidazole 500 mg q8h for 7 to 10 days or
- Erythromycin 500 mg BID for 7 days (if PCN allergy) (4)[C] or
- Clindamycin 450 mg q8h for 7 to 10 days (if PCN allergy) (1)[C]
ISSUES FOR REFERRAL
Patients can be evaluated and treated by oral surgeon, dentist/periodontist, or ear, nose, and throat specialist depending on patient preference and severity of infection.
ADDITIONAL THERAPIES
- Chlorhexidine gluconate 0.12% BID or salt water rinses (2)[C]
- Pain management with NSAIDs (5)[C]
SURGERY/OTHER PROCEDURES
- Debridement of inflamed and necrotic tissue
- Dental extraction
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Failure of oral antibiotics and disease progression
- Need for parenteral antibiotics and analgesia
- Inability to meet nutritional and/or hydration needs
IV Fluids
May be required if patient is unable to tolerate oral fluids
Discharge Criteria
- Arrest of disease progression and improvement at site
- Ability to tolerate oral antibiotics and fluids
- Oral analgesia is effective.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Frequent dental cleanings and examinations
DIET
- Proper nutrition
- Multivitamin supplementation
PATIENT EDUCATION
- Proper nutrition
- Appropriate oral hygiene
- Tobacco cessation
- Stress management
COMPLICATIONS
- Malnutrition
- Pain
- Poor dentition, tooth loss
- Systemic infection
- Involvement of soft tissues and structures of the neck
REFERENCES
11 Atout RN, Todescan S. Managing patients with necrotizing ulcerative gingivitis. J Can Dent Assoc. 2013;79:d46.22 Sangani I, Watt E, Cross D. Necrotizing ulcerative gingivitis and the orthodontic patient: a case series. J Orthod. 2013;40(1):77 " 80.33 Silk H. Diseases of the mouth. Prim Care. 2014;41(1):75 " 90.44 Edwards PC, Kanjirath P. Recognition and management of common acute conditions of the oral cavity resulting from tooth decay, periodontal disease, and trauma: an update for the family physician. J Am Board Fam Med. 2010;23(3):285 " 294.55 Hodgdon A. Dental and related infections. Emerg Med Clin North Am. 2013;31(2):465 " 480.
ADDITIONAL READING
- Carlson JA, Dabiri G, Cribier B, et al. The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. Am J Dermatopathol. 2011;33(5):433 " 460.
- Lopez R, Fernandez O, Jara G, et al. Epidemiology of necrotizing ulcerative gingival lesions in adolescents. J Periodontal Res. 2002;37(6):439 " 444.
- Marik PE. Pulmonary aspiration syndromes. Curr Opin Pulm Med. 2011;17(3):148 " 154.
- Porter SR. Diet and halitosis. Curr Opin Clin Nutr Metab Care. 2011;14(5):463 " 468.
- Slots J. Herpesviral-bacterial synergy in the pathogenesis of human periodontitis. Curr Opin Infect Dis. 2007;20(3):278 " 283.
CODES
ICD10
A69.1 Other Vincent 's infections
ICD9
101 Vincent 's angina
SNOMED
- 409865002 Vincent 's disease (disorder)
- 173599005 Acute necrotizing ulcerative gingivostomatitis (disorder)
CLINICAL PEARLS
- Poor oral hygiene and immunosuppression are key factors in infection.
- Early recognition and institution of therapy decrease complications.
- Penicillin is the drug of choice for patients not systemically ill.