Dr Ashish singh et al . / IJRID Volume 5 Issue 5 Sep.-Oct.

2015

Available online at www.ordoneardentistrylibrary.org ISSN 2249-488X

Case report

INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY

Case report on ANUG

Dr Ashish singh*, Dr Aditya sinha , Dr Jithendra k d , Dr Satendra sharma, Dr Mohit garg

K.D Dental College & Hospital Mathura UP

Received: 11 Aug. 2015; Revised: 9 Sep. 2015; Accepted: 5 Oct. 2015; Available online: 5 Nov. 2015

ABSTRACT
Acute Necrotizing Ulcerative Gingivitis (ANUG) is a distinct and specific disease. This disease entity has been
described as far back as the days of Hippocrates and is known by many synonyms. With the advent of antibiotics
and with improved nutritional status, the incidence has decreased and even become extinct in developed countries
In developing countries, however, the condition is still a commonly diagnosed clinical lesion because of the
persistently poor nutritional status. This case report showing the patients diagnosed as special form of distraction of
gingiva within 5days & treatment of this condition which called as ANUG
Keywords- Acute Necrotizing Ulcerative Gingivitis (ANUG), ANUP

INTRODUCTION

Acute Necrotizing Ulcerative Gingivitis (ANUG), now classified as Necrotizing Periodontal Disease according
to the 1999 American Academy of Periodontics classification system, is a distinct and specific disease
characterized by rapidly progressive ulceration typically starting at the tip of the interdental papilla, spreading
along the gingival margins, and going on to acute destruction of the periodontal tissue1,2.

This disease entity has been described as far back as the days of Hippocrates and is known by many synonyms
such as trench mouth, Vincents disease, and Vincents gingivostomatitis
In developing countries ANUG remains a commonly diagnosed clinical lesion3,4. This is of the existing poor
nutritional status, stress living conditions, poor oral hygiene, and a state of debilitation often resulting from
endemic contagious diseases In developing nations where the standard of living is gradually on the decline, this
disfiguring oral lesion becomes very important clinically as more and more children are exposed to the risk
factors which lead to the development of ANUG4-6
Etiology and Pathophysiology

Plaut & Vincent introduced the concept that NUG is caused by a specific bacteria namely, fusiform bacillus &
spirochetal orgnaisms . More recently , Loesche & colleagues described

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a constant & variable flora associated with ANUG ,Constant flora is composed of Fusospirochetal organisms &
also Bacteroides intermedius.
There are some systemic predisposing factors like Nutritional deficiency, debilitating disease & Psychosomatic
factors also with some local predisposing factors like pre-existing gingivitis ,injury to gingiva & smoking

STRESS SMOKING

Increased Corticosteroid Pre-existing gingivitis

Immunosuppression Increased bacterial growth

Nutritional deficiency ANUG

debilitating diseases

STAGES - INVOLVEMENT OF LESION

1- Necrosis of the tip of interdental papilla

2- Necrosis of the entire papilla
3- Necrosis extending to gingival margin
4- Necrosis extending to the attached gingiva
5- Necrosis extending into buccal or labial mucosa
6- Necrosis exposing alveolar bone
7- Necrosis perforating skin of cheek

ZONES- classified by Listgarten & Collegues

Zone 1- Bacterial zone - superficial zone
Zone 2- Neutrophil-rich zone
Zone 3- Nectrotic zone
Zone 4- Zone of spirochetal infiltration

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Treatment -
1- Non-ambulatory patient- with the symptoms of generalized systemic complications
2- Ambulatory patient - with no serious systemic complications 7
Case report

Two patients of Age 25 yr old reported to the periodontology OPD of K.D Dental college & hospital with chief
complaint of Severe pain & bleeding gums with burning sensation of gingiva since 5 days.
On extraoral examination there was no gross facial asymmetry detected, lips was competent, submandibular
lymph nodes are tender on palpation and local rise in temperature was detected.
Patient gave the history of elevated temperature for 1 week. On intraoral examination poor oral hygiene was
noticed with plaque and calculus deposition. There was no marginal gingiva and interdenta papilla because
there was necrosis of the interdental papillae occur.
There was traumatic bite in anterior teeth. Intraoral periapical radiograph revealed no bone loss in lower
anterior teeth. But in both case there is necrosis extending upto the attached gingiva this show the Stage 4
condition without no bone involvement thus this condition purely a ANUG not ANUP

pre-operative images

Patient first Patient second

a) Stage 4- Lesion involving in lower anterior teeth in both case but no bone involvement was seen.

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OPG showing no bone loss

In the first visit after thorough examination only conservative treatment like removal of local factors and
maintenance of oral hygiene was planned. Trauma relieved in anterior teeth by selective grinding Supragingival
scaling was attempted a thoroughly as the condition allowed. Patients was advised to take adequate rest, proper
diet and maintain proper oral hygiene. they was prescribed amoxicillin 500 mg thrice in a day for 5 days and
local application of gel containing metronidazole three-four times day. they were also instructed to rinse with
3% H2O2 & sterile warm water (1:1) four times a day and also with 0.12% chlorhexidine rinses to maintain
oral hygeine as they were unable to clean her teeth with brush. Patients recalled on second day and again
supragingival scaling was done After 3 days the patients was re-evaluated and scaling and curettage was
performed. After 7 days patients was almost symptom free so thorough scaling & root planing was done. 3%
H2O2 rinses were now discontinued but 0.12% chlorohexidine rinses continued. Patient was re-evaluated after
one month & a good response was found in the form of healing of necrotic areas and reduction in the size of
gingival craters. Patient was kept on maintenance with instructions of oral hygiene and proper nutrition.

After phase I-

Patient - First

b) Image after phase I

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 Dr Ashish singh et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015

Patient - Second

c) Images after phase I

post-operative image after 1wk

Discussion

An eminent Bio statistician was contacted Necrotizing ulcerative gingivtis is an inflammatory destructive disease of the
gingiva ,which presents characteristic signs and symptoms. This disease entity was present as early as 400BC in Greek
soldiers, but it was first described by Plaut in 1894 and
Vincent in 18968,9. It is caused mainly by Fusiform bacilli and Spirochetes. In the present case report we have discussed
the pre-treatment and post treatment clinical picture of ANUG and its management. The predisposing factor in our case
report is stress & pre-existing gingivitis with smoking .These both patients are unemployed , & live in stressful condition ,
with history of pre-existing gingivits
Stress is believed to predispose to ANUG by causing an elevation in adrenocortical secretion. It also causes the release
of substance P, a peptide hormone which suppresses both specific and non specific immunity10,11. It also affects patients
moods resulting in changes in oral hygiene and nutrition.
Schluger who described ANUG as a disease of filth believes that a low standard of oral hygiene is the most single factor
contributing to ANUG. However, he does not state the presence of the disease is always a result of lack of oral hygiene
on the part of the patient but that plaque and debris accumulation occurs due to discomfort withoral hygiene practices.
Mentioned frequently in the literature is smoking as a predisposing factor to ANUG. Pindborg and Goldhabeg found 98%
of their patients were smokers.

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Kardachi and Clarke cite reports that local and systemic catecholamines are released in response to nicotine and
hypothesized the effect of cathecolamine super-imposed on psychological and physiological stress
Conclusion
Modalities of treating ANUG over the years is almost as varied as its synonyms though they all center on
reducing the bacteria flora. The use of antibiotics in the management of ANUG has
been strongly advocated. Metrondazole has also been found to be as effective as penicillin in causing remission
of the clinical symptoms, and this was parallel with reduction in the proportionof bacteria species associated
with the disease12.
However, the highly preventable ANUG entails implementing measures aimed at eradicating malnutrition,
improving oral hygiene status, and minimizing damage to oral mucosa as well as avoiding contamination of the
oral environment by a heavy load of Bacteroidacease, particularly
F. necrophorum.
References
1. Emslie RD. Cancrum oris. Dental Practitioner and Dental Record 1963: 13:481-495.
2. Enwonwu CO. Nutritional disease in the tropics. In: Prabhu SR et al., (eds) Oral diseases in the tropics.
Oxford University Press, 1992: 309-324.
3. Chandra RK. 1990 McCollum Award lecture. Nutrition and immunity: lessons from the past and new insights
into the future. Am J Clin Nutr. 1991 May;53(5):1087-101.
4. Enwonwu CO. Epidemiological and biochemical studies of necrotizing ulcerative gingivitis and noma
(cancrum oris) in Nigerian children. Arch Oral Biol. 1972 Sep;17(9):1357-71. No abstract available.
5. Tempest MN. Cancrum oris. Br J Surg. 1966 Nov;53(11):949-69. No abstract available.
6. Pindborg JJ, Bhat M, Roed-Peterson B. Oral changes in South Indian children with severe protein
deficiency. J Periodontol. 1967 May-Jun;38(3):218-21
7. Essentials of clinical periodontology & periodontics Shantipriya reddy
8. Goldberg HJ. Acute necrotizing ulcerative gingivitis. J Oral Ther Pharmacol. 1966 May;2(6):451-9.
9. Shields WD. Acute necrotizing ulcerative gingivitis. A study of some of the contributing factors and their
validity in an Army population. J Periodontol. 1977 Jun;48(6):346-9.
10.Kowolik MJ, Nisbet T. Smoking and acute ulcerative gingivitis. A study of 100 patients. Br Dent 11.Fitch
HB, Bethart H, Alling CC, et. al. Acute necrotising ulcerative gingivitis. J Periodontol. 1963;
34:422-425
12. Horning GM. Necotizing gingivostomatitis: NUG to noma. Compend Contin Educ Dent. 1996
Oct;17(10):951-4, 956, 957-8 passim; quiz 964. Review.

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