Necrotizing Ulcerative Gingivitis causes, predisposing factors, symptoms and treatment

Necrotizing Ulcerative Gingivitis causes, predisposing factors, symptoms and treatment

Necrotizing Ulcerative Gingivitis causes, predisposing factors, symptoms and treatment 

Necrotising ulcerative gingivitis also called as

  • Vincent’s infection 
  • Trench mouth
  • Acute ulceromembranous gingivitis
  • Phagedenic gingivitis
  • Fusospirochetal gingivitis
  • Acute ulcerative gingivitis

Necrotizing ulcerative gingivitis is a common specific type of gingivitis. The disease manifests both acute and recurrent phases. This inflammatory condition involves primarily the free gingival margin, the crest of the gingiva and the interdental papillae. On rare occasions the lesions spread to the soft palate and tonsillar areas, and in such instances the term Vincent’s angina has been applied.

The short form of acute necrotizing ulcerative gingivitis is ANUG. Acute necrotizing ulcerative gingivitis occurs in an epidemic pattern, sweeping through groups of persons in close contact, especially those living under the similar conditions. The trench mouth word is originated because the disease was especially prevalent among the troops in the trenches during the First World War. Similar sporadic outbreaks also occurred during second world war. Though this condition is uncommon in developed countries nowadays there has been a global increase associated with HIV infection.

The pattern of the spread of the disease, in many instances indicated that it was a contagious infection, but this is not accepted now. It occurs in groups of persons can be explained on the basis of similar predisposing conditions among the members of the group, which may cause gingivitis to develop in each, even though there is no actual contact between them.

Necrotizing ulcerative gingivitis may occur at any age, but is reportedly more common among young and middle aged adults, 15-35 years old. In developing countries, it is seen almost exclusively in children, related to poverty and malnutrition.

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What are the causes of Necrotizing ulcerative gingivitis?

It is an endogenous, polymicrobial infection causing destructive inflammation due to the coexistence of several predisposing factors.  It is caused by a fusiform bacillus and Borrelia Vincentian a spirochete. These organisms may be present in small numbers in the healthy gingival flora. Both microorganisms dominate in this fusospirochetal disease, although other spirochetes, fusiforms and filamentous organisms are also found. It is likely that a number of factors disturb the host parasite relationship facilitating overgrowth of the organisms of the fusospirochetal complex.

What are the Predisposing factors for Necrotizing ulcerative gingivitis?

Sychological stress plays an important role in the development of necrotizing ulcerative gingivitis, since there is an increased frequency of the disease in people in the military services. Other predisposing factors include immunosuppression, smoking, upper respiratory tract infection, local trauma, poor nutritional status and poor oral hygiene.

HIV positive persons suffer from a severe form of necrotizing ulcerative gingivitis as the immune function deteriorated and this progress to HIV associated periodontitis.

Decreased resistance to infection is one of the most important predisposing factors in the development of necrotizing ulcerative gingivitis 

What are the symptoms of Necrotizing ulcerative gingivitis?

  • The disease is characterised by the development of painful, hyperaemic gingiva and sharply pushed out crater like erosionsof the interdental papillae and the free gingiva bleedwhen touched and generally become covered by a greyish green, necrotic pseudomembrane.
  • The ulceration tends to spread and may eventually involve all gingival margins.
  • It begins rateher commonly at a single isolated focus with a rapid onset.
  • A fetid odour ultimately develops that is extremely unpleasant.
  • The patient almost always complains of an inability to eat because of the severe gingival pain and the tendency for gingival bleeding.
  • The pain is that of superficial pressure. The patient usually suffers from headache, malaise and a low grade fever.
  • Excessive salivation with the presence of a metallic taste to the saliva is often noted.
  • Regional lymphadenopathy is usually present.
  • In advanced and more serious cases, there may be generalised or systemic manifestations, which may include leukocytes is, gastrointestinal disturbances and tachycardia

What is the cause for the recurrence of the Necrotizing ulcerative gingivitis?

After the necrotizing ulcerative gingivitis is cured, the crests of the onterdentlpapillae, which have been destroyed leaving a hollowed out area, constitute an area which retains debris and  microorganisms and can serve as an incubation zone. Such area, along with gingival flaps of erupting third molars, are ideal locations for organisms to persist and in many cases, the recurrence necrotizing ulcerative gingivitis will begin here.

Smears of material from the gingiva of necrotizing ulcerative gingivitis shows vast numbers of fusiform  bacilli and an oral spirochete, verious other spirochetes, filamentous organisms, vibrios, cocci, desquamated epithelial cells and varying numbers of polymorphonuclear leucocytes. The relative numbers of microorganisms present vary with the stage of the disease.

What is the treatment for Necrotizing ulcerative gingivitis?

The treatment of necrotizing ulcerative gingivitis is extremely varied, depending upon the individual dentists experience with the disease. Some prefer to treat this condition conservatively instituting only superficial cleansing of the oral cavity in the early acute stage of the disease with chlorhexidine, diluted hydrogen peroxide or warm saline water. This is followed by thorough scaling and polishing. Topical anaesthesia may require to reduce the pain during this procedure. Antibiotics are also advised along with local treatment. The usual case of necrotizing ulcerative gingivitis begins to subside in 48 hours with adequate treatment and there may be little evidence afterwards of the presence of the disease. Sometimes there may be considerable destruction of tissue, interdental papillae and marginal gingiva and this may be evidenced after regression of the disease by the punched out appearance of the interproximal gingiva and the apparent gingival recession. Recontouring  of gingival papillae is usually required, this can be accomplished by proper use of round toothpicks or by gingivoplasty. Treatment cannot be considered complete until the gingiva tissue contours almost normal. Necrotizing ulcerative gingivitis recurs with considerable frequency in patients who have already been treated.

Possible viva voice questions in Necrotizing Ulcerative Gingivitis:-

  • Why Necrotizing ulcerative gingivitis is called as Trench mouth

During world war 1, when the troops suffered severely from the disease. It was here that the term trench mouth originated, since the disease was especially prevalent among the troops in the trenches. When the allied troops living under poor sanitary conditions in the trenches and inadequate diet are the causes for this disease.

  • What are the predisposing factors for this disease?

Psychological stress, Immunosupression, smoking, upper respiratory tract infection, local trauma, poor nutritional status and poor oral hygiene.

  • What are the microorganisms found in this disease?

Fusiform bacillus and Borrelia Vincentian-a spirochete 

  • What are the symptoms or clinical features?

Painful, hyperaemic gingiva and sharply punched out crater likeerosions of the interdental papillae, gingival bleeding, gingiva covered by greyish green, necrotic pseudo membrane, excessive salivation, metallic taste.

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