Acute necrotizing ulcerative gingivitis (ANUG; colloquially known as trench mouth) is a

common, non-contagious infection of the gums with sudden onset. The main features are painful,
bleeding gums, and ulceration of inter-dental papillae (the sections of gum between adjacent teeth).
This disease, along with necrotizing (ulcerative) periodontitis (NP or NUP) is classified as
a necrotizing periodontal disease, one of the seven general types of periodontitis. The often severe
gingival pain that characterizes ANUG distinguishes it from the more common chronic
periodontitis which is rarely painful. ANUG is the acute presentation of necrotizing ulcerative
gingivitis (NUG), which is the usual course the disease takes. If improperly treated or neglected,
NUG may become chronic and/or recurrent. The causative organisms are mostly anaerobic bacteria,
particularly Fusobacteria and Spirocaete species. Predisposing factors include poor oral hygiene,
smoking, malnutrition, psychological stress and immunosuppression (sub-optimal functioning of the
immune system). When the attachments of the teeth to the bone are involved, the term NUP is used.
Treatment of ANUG is by debridement (although pain may prevent this) and antibiotics
(usually metronidazole) 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 synonym "trench mouth" arose during World War I as many soldiers developed
the disease, probably because of the poor conditions and extreme psychological stress.

Classification[edit]
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. Acute necrotizing ulcerative
gingivitis (ANUG) refers to the clinical onset of NUG. The word acute is used because usually the
onset is sudden.[1] Other forms of NUG may be chronic or recurrent.
Necrotizing ulcerative periodontitis (NUP) this is where the infection leads to attachment loss, and
involves only the gingiva, periodontal ligament and alveolar ligament.[1][2][3] Progression of the disease
into tissue beyond the mucogingival junction characterizises necrotizing stomatitis.

Signs and symptoms[edit]

In the early stages some patients may complain of a feeling of tightness around the teeth. [1] Three
signs/symptoms must be present to diagnose this condition:[1]

Severe gingival pain.[4]

Profuse gingival bleeding that requires little or no provocation. [1]

Interdental papillae are ulcerated with necrotic slough.[4] The papillary necrosis of NUG has
been described as "punched out".[1]

Other signs and symptoms may be present, but not always. [1]

Oral malodor (intraoral halitosis).

Bad taste (metallic taste).[4]

Malaise, fever and/or cervical lymph node enlargement are rare (unlike the typical features
of herpetic stomatitis).[4] Pain is fairly well localized to the affected areas.[4] Systemic reactions may be
more pronounced in children.[1] Cancrum oris (noma) is a very rare complication, usually in
debilitated children.[4] Similar features but with more intense pain may be seen in necrotizing
periodontitis in HIV/AIDS.[4]

Causes[edit]
Necrotizing periodontal disease is caused by a mixed bacterial infection that
includes anaerobes such as P. intermedia[3] and Fusobacterium as well as spirochetes, such
as Treponema.[4]
ANUG may also be associated with diseases in which the immune system is compromised,
including HIV/AIDS.[2] ANUG is an opportunistic infection that occurs on a background of impaired
local or systemic host defenses. The predisposing factors for ANUG are smoking, psychological
stress, malnutrition and immunosuppression.
Zones of infection have been described. These are (superficial to deep) the bacterial zone, the
neutrophil rich zone, the necrotic zone and the spirochetal zone.

Diagnosis[edit]
Diagnosis is usually clinical.[4] Smear for fusospirochaetal bacteria and leukocytes; blood picture
occasionally.[4] The important differentiation is with acute leukaemia or herpetic stomatitis.[4]

Treatment[edit]
Treatment includes irrigation and debridement of necrotic areas (areas of dead and/or dying gum
tissue), oral hygiene instruction and the uses of mouth rinses andpain medication. If there is
systemic involvement, then oral antibiotics may be given, such as metronidazole.[4] As these
diseases are often associated with systemic medical issues, proper management of the systemic
disorders is appropriate.[2]

Prognosis[edit]

Untreated, the infection may lead to rapid destruction of the periodontium 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
systems. This progression to noma is possible in malnourished susceptible individuals, with severe
disfigurement possible.

Epidemiology[edit]
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). [1]
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. [4] The disease
has occurred in epidemic-like patterns, but it is not contagious.[1]

ANUG (acute necrotizing ulcerative gingivitis): This is trench mouth, a progressive painful infection
with ulceration, swelling and sloughing off of dead tissue from the mouth and throat due to the
spread of infection from the gums.
Certain germs (including fusiform bacteria and spirochetes) have been thought to be involved, but
the full story behind this long-known disease is still not clear.
This condition is also called Vincent's angina after the French physician Henri Vincent (1862-1950).
The word "angina" comes from the Latin "angere" meaning "to choke or throttle."
As with most poorly understood diseases, Acute necrotizing ulcerative gingivitis goes by many other
names including acute membranous gingivitis, fusospirillary gingivitis, fusospirillosis, fusospirochetal
gingivitis, necrotizing gingivitis, phagedenic gingivitis, ulcerative gingivitis, Vincent's gingivitis,
Vincent's infection, and Vincent's stomatitis.

ute necrotizing ulcerative gingivitis is a painful infection of the gums. Symptoms

are acute pain, bleeding, and foul breath. Diagnosis is based on clinical findings.
Treatment is gentle debridement, improved oral hygiene, mouth rinses,
supportive care, and, if debridement must be delayed, antibiotics.
Acute necrotizing ulcerative gingivitis (ANUG) occurs most frequently in smokers and debilitated
patients who are under stress. Other risk factors are poor oral hygiene, nutritional deficiencies,
immunodeficiency (eg, HIV/AIDS, use of immunosuppressive drugs), and sleep deprivation. Some
patients also have oral candidiasis.

Symptoms and Signs

The usually abrupt onset may be accompanied by malaise or fever. The chief manifestations are

Acutely painful, bleeding gingivae

Excessive salivation

Sometimes overwhelmingly foul breath (fetor oris)

Ulcerations, which are pathognomonic, are present on the dental papillae and marginal gingiva.
These ulcerations have a characteristically punched-out appearance and are covered by a gray
pseudomembrane. Similar lesions on the buccal mucosa and tonsils are rare. Swallowing and talking
may be painful. Regional lymphadenopathy often is present.
Often, ANUG can manifest without a significant odor, and it also may manifest as a localized
condition.

Diagnosis

Clinical evaluation

Rarely, tonsillar or pharyngeal tissues are affected, and diphtheria or infection due to agranulocytosis
must be ruled out by throat culture and CBC when the gum manifestations do not respond quickly to
conventional therapy.

Treatment

Debridement

Rinses (eg, hydrogen peroxide, chlorhexidine)

Improved oral hygiene

Sometimes oral antibiotics

Treatment of ANUG consists of gentle debridement with a hand scaler or ultrasonic device.
Debridement is done over several days. The patient uses a soft toothbrush or washcloth to wipe the
teeth.
Rinses at hourly intervals with warm normal saline or twice/day with 1.5% hydrogen peroxide or
0.12% chlorhexidine may help during the first few days after initial debridement.
Essential supportive measures include improving oral hygiene (done gently at first), adequate
nutrition, high fluid intake, rest, analgesics as needed, and avoiding irritation (eg, caused by smoking
or hot or spicy foods). Marked improvement usually occurs within 24 to 48 h, after which
debridement can be completed.
If debridement is delayed (eg, if a dentist or the instruments necessary for debridement are
unavailable), oral antibiotics (eg, amoxicillin 500 mg q 8 h, erythromycin 250 mg q 6 h,
or tetracycline 250 mg q 6 h) provide rapid relief and can be continued until 72 h after symptoms
resolve.
Treatment of oral candidiasis is described elsewhere.

If the gingival contour inverts (ie, if the tips of papillae are lost) during the acute phase, surgery is
eventually required to prevent subsequent periodontitis.