Doctor123.org

Vincent Stomatitis

BASICS

DESCRIPTION

- 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

  • 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 tissueGroup A strep rapid antigen detection assayGroup A strep throat cultureBlood cultures if systemic involvementDental radiographsFacial 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.