Acute Necrotizing Ulcerative Gingivitis
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Necrotizing gingivitis (NG) is a common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of interdental papillae (the sections of gum between adjacent teeth). This disease, along with necrotizing periodontitis (NP) and necrotizing stomatitis, is classified as a necrotizing periodontal disease, one of the three general types of gum disease caused by inflammation of the gums (periodontitis). The often severe gum pain that characterizes NG distinguishes it from the more common
gingivitis Gingivitis is a non-destructive disease that causes inflammation of the gums; ulitis is an alternative term. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also ...
or chronic periodontitis which is rarely painful. If NG is improperly treated or neglected, it may become chronic and/or recurrent. The causative organisms are mostly
anaerobic bacteria An anaerobic organism or anaerobe is any organism that does not require molecular oxygen for growth. It may react negatively or even die if free oxygen is present. In contrast, an aerobic organism (aerobe) is an organism that requires an oxygenat ...
, particularly Fusobacteriota and
spirochete A spirochaete () or spirochete is a member of the phylum Spirochaetota (also called Spirochaetes ), which contains distinctive diderm (double-membrane) Gram-negative bacteria, most of which have long, helically coiled (corkscrew-shaped or ...
species. Predisposing factors include poor oral hygiene, smoking, poor nutrition, psychological stress, and a weakened immune system. When the attachments of the teeth to the bone are involved, the term NP is used. Treatment of NG is by removal of dead gum tissue and
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
s (usually
metronidazole Metronidazole, sold under the brand name Flagyl and Metrogyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vagino ...
) in the acute phase, and improving oral hygiene to prevent recurrence. Although the condition has a rapid onset and is debilitating, it usually resolves quickly and does no serious harm. The informal name trench mouth arose during
World War I World War I or the First World War (28 July 1914 – 11 November 1918), also known as the Great War, was a World war, global conflict between two coalitions: the Allies of World War I, Allies (or Entente) and the Central Powers. Fighting to ...
as many soldiers developed the disease, probably because of the poor conditions and extreme psychological stress.


Signs and symptoms

In the early stages some affected people may complain of a feeling of tightness around the teeth. Three signs/symptoms must be present to diagnose this condition: * Severe gum pain. * Profuse gum bleeding that requires little or no provocation. * Interdental papillae are ulcerated with
dead Death is the end of life; the irreversible cessation of all biological functions that sustain a living organism. Death eventually and inevitably occurs in all organisms. The remains of a former organism normally begin to decompose sho ...
tissue. The papillary necrosis of NG has been described as "punched out". Other signs and symptoms may be present, but not always. * Foul breath. * Bad taste (metallic taste).
Malaise In medicine, malaise is a feeling of general discomfort, uneasiness or lack of wellbeing and often the first sign of an infection or other disease. It is considered a vague termdescribing the state of simply not feeling well. The word has exist ...
,
fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...
and/or cervical lymph node enlargement are rare (unlike the typical features of herpetic stomatitis). Pain is fairly well localized to the affected areas. Systemic reactions may be more pronounced in children. Cancrum oris (noma) is a very rare complication, usually in debilitated children. Similar features but with more intense pain may be seen in necrotizing periodontitis in
HIV/AIDS The HIV, human immunodeficiency virus (HIV) is a retrovirus that attacks the immune system. Without treatment, it can lead to a spectrum of conditions including acquired immunodeficiency syndrome (AIDS). It is a Preventive healthcare, pr ...
.


Causes

Necrotizing periodontal diseases are caused by a mixed
bacterial infection Pathogenic bacteria are bacteria that can cause disease. This article focuses on the bacteria that are pathogenic to humans. Most species of bacteria are harmless and many are beneficial but others can cause infectious diseases. The number of t ...
that includes
anaerobe An anaerobic organism or anaerobe is any organism that does not require molecular oxygen for growth. It may react negatively or even die if free oxygen is present. In contrast, an aerobic organism (aerobe) is an organism that requires an oxygenat ...
s such as '' P. intermedia'' and ''
Fusobacterium ''Fusobacterium'' is a genus of obligate anaerobic, Gram-negative, non-sporeforming bacteria belonging to Gracilicutes. Individual cells are slender, rod-shaped bacilli with pointed ends. ''Fusobacterium'' was discovered in 1900 by Courmont an ...
'' as well as spirochetes, such as '' Treponema''. Necrotizing gingivitis may also be associated with diseases in which the
immune system The immune system is a network of biological systems that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to bacteria, as well as Tumor immunology, cancer cells, Parasitic worm, parasitic ...
is compromised, including HIV/AIDS. Necrotizing gingivitis is an
opportunistic infection An opportunistic infection is an infection that occurs most commonly in individuals with an immunodeficiency disorder and acts more severe on those with a weakened immune system. These types of infections are considered serious and can be caused b ...
that occurs on a background of impaired local or systemic host defenses. The predisposing factors for necrotizing gingivitis are smoking, psychological stress,
malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...
, and immunosuppression. Regarding
malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...
, the fact that vitamin C deficiency is associated with gum disease, loosening of teeth, and poor wound healing shows how poor nutrition can predispose to oral disease; in such a circumstance, immune defenses against bacterial attack are most likely lower than usual. It is thus plausible that poor rations and supply line interruptions in World War I contributed to the incidence of trench mouth. The following zones of infection have been described (superficial to deep): the bacterial zone, the neutrophil rich zone, the necrotic zone and the spirochetal zone.


Diagnosis

Diagnosis is usually clinical. Smear for fusospirochaetal bacteria and
leukocytes White blood cells (scientific name leukocytes), also called immune cells or immunocytes, are cells of the immune system that are involved in protecting the body against both infectious disease and foreign entities. White blood cells are genera ...
; blood picture occasionally. The important differentiation is with acute
leukemia Leukemia ( also spelled leukaemia; pronounced ) is a group of blood cancers that usually begin in the bone marrow and produce high numbers of abnormal blood cells. These blood cells are not fully developed and are called ''blasts'' or '' ...
or herpetic stomatitis.


Classification

Necrotizing gingivitis is part of a spectrum of disease termed necrotizing periodontal diseases. It is the most minor form of this spectrum, with more advanced stages being termed necrotizing periodontitis, necrotizing stomatitis, and the most extreme, cancrum oris. Necrotizing periodontitis (NP) is where the infection leads to attachment loss, and involves only the gingiva, periodontal ligament and alveolar ligament. Progression of the disease into tissue beyond the mucogingival junction characterizes necrotizing stomatitis.


Treatment

Treatment includes irrigation and
debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), or by maggot therapy. In ...
of necrotic areas (areas of dead and/or dying gum tissue),
oral hygiene Oral hygiene is the practice of keeping one's oral cavity clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and adopting good hygiene habits. It is important that oral hygiene be carr ...
instruction and the uses of mouth rinses and
pain medication An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in so ...
. If there is systemic involvement, then oral antibiotics may be given, such as
metronidazole Metronidazole, sold under the brand name Flagyl and Metrogyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vagino ...
. As these diseases are often associated with systemic medical issues, proper management of the systemic disorders is appropriate.


Prognosis

Untreated, the infection may lead to rapid destruction of the
periodontium The periodontium () is the specialized tissues that both surround and support the teeth, maintaining them in the maxillary and mandibular bones. Periodontics is the dental specialty that relates specifically to the care and maintenance of the ...
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 system Immunodeficiency, also known as immunocompromise, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that affec ...
s. This progression to noma is possible in malnourished susceptible individuals, with severe disfigurement possible.


Epidemiology

In developed countries, this disease occurs mostly in young adults. In developing countries, NUG may occur in children of low socioeconomic status, usually occurring with malnutrition (especially inadequate protein intake) and shortly after the onset of viral infections (e.g.
measles Measles (probably from Middle Dutch or Middle High German ''masel(e)'', meaning "blemish, blood blister") is a highly contagious, Vaccine-preventable diseases, vaccine-preventable infectious disease caused by Measles morbillivirus, measles v ...
). Predisposing factors include smoking, viral respiratory infections and immune defects, such as in HIV/AIDS. Uncommon, except in lower socioeconomic classes, this typically affects adolescents and young adults, especially in institutions, armed forces, etc., or people with HIV/AIDS. The disease has occurred in epidemic-like patterns, but it is not contagious.


History

Necrotizing gingivitis has been observed for centuries.
Xenophon Xenophon of Athens (; ; 355/354 BC) was a Greek military leader, philosopher, and historian. At the age of 30, he was elected as one of the leaders of the retreating Ancient Greek mercenaries, Greek mercenaries, the Ten Thousand, who had been ...
observes sore mouth and foul smelling breath in Greek soldiers in the 4th century BC. Hunter describes the clinical features of necrotizing gingivitis in 1778, differentiating it from
scurvy Scurvy is a deficiency disease (state of malnutrition) resulting from a lack of vitamin C (ascorbic acid). Early symptoms of deficiency include weakness, fatigue, and sore arms and legs. Without treatment, anemia, decreased red blood cells, gum d ...
(avitaminosis C) and chronic periodontitis. Jean Hyacinthe Vincent, a French physician working at the Paris
Pasteur Institute The Pasteur Institute (, ) is a French non-profit private foundation dedicated to the study of biology, micro-organisms, diseases, and vaccines. It is named after Louis Pasteur, who invented pasteurization and vaccines for anthrax and rabies. Th ...
describes a fusospirochetal infection of the
pharynx The pharynx (: pharynges) is the part of the throat behind the human mouth, mouth and nasal cavity, and above the esophagus and trachea (the tubes going down to the stomach and the lungs respectively). It is found in vertebrates and invertebrates ...
and
palatine tonsil Palatine tonsils, commonly called the tonsils and occasionally called the faucial tonsils, are tonsils located on the left and right sides at the back of the throat in humans and other mammals, which can often be seen as flesh-colored, pinkish ...
s, causing "ulcero-membranous pharyngitis and tonsillitis", which later became known as Vincent's angina. Later in 1904, Vincent describes the same pathogenic organisms in "ulceronecrotic gingivitis". Vincent's angina is sometimes confused with NUG, however the former is tonsillitis and pharyngitis, and the latter involves the gums, and usually the two conditions occur in isolation from each other. The term trench mouth evolved because the disease was observed in front line soldiers during World War I, thought to be a result at least partly because of extreme psychologic stress they were exposed to. The same condition was appearing in civilians during periods of bombing raids, who were away from the front line, and who had relatively good diets during wartime due to rationing, so it is assumed that psychologic stress was the significant causative factor. It has also been associated with high tobacco use in the army. Many other historical names for this condition (and Vincent's angina) have occurred, including: "acute membranous gingivitis", "fusospirillary gingivitis", " fusospirillosis", "fusospirochetal gingivitis", "phagedenic gingivitis", "Vincent stomatitis", "Vincent gingivitis", and "Vincent infection". In the late 1980s-early 1990s, it was originally thought that some necrotizing periodontal diseases seen in severely affected AIDS patients were strictly a
sequela A sequela (, ; usually used in the plural, sequelae ) is a pathological condition resulting from a disease, injury, therapy, or other trauma. Derived from the Latin word meaning "sequel", it is used in the medical field to mean a complication or ...
of
HIV The human immunodeficiency viruses (HIV) are two species of '' Lentivirus'' (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the im ...
, and it was even called HIV-associated periodontitis. It is now understood that its association with HIV/AIDS was due to the immunocompromised status of such patients; it also occurs with higher
prevalence In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
in association with other diseases in which the
immune system The immune system is a network of biological systems that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to bacteria, as well as Tumor immunology, cancer cells, Parasitic worm, parasitic ...
is compromised. The 1999 American Academy of Periodontology Classification termed the condition "necrotizing ulcerative periodontitis". The "ulcerative" descriptor was removed from the name, because ulceration is considered to be secondary to the necrosis.


See also

*
Canker sore Aphthous stomatitis, or recurrent aphthous stomatitis (RAS), commonly referred to as a canker sore or salt blister, is a common condition characterized by the repeated formation of benign and non- contagious mouth ulcers (aphthae) in otherwise ...
*
Mouth ulcer A mouth ulcer (aphtha), or sometimes called a canker sore or salt blister, is an ulcer that occurs on the mucous membrane of the oral cavity. Mouth ulcers are very common, occurring in association with many diseases and by many different mechanis ...


References


External links

{{Authority control Periodontal disorders Conditions of the mucous membranes Necrosis Trench warfare