A distinct form of periodontal disease due to inflammatory infection of the gingiva, characterized by pain, ulcerations, and necrotizing damage to interdental papillae
- Caused by an imbalance of oral flora, resulting in predominance of anaerobic bacteria that invade the gingival mucosa and form a gray pseudomembranous exudate
- Clinical presentation includes oral pain, fetid breath, gingival ulcerations, necrosis, and bleeding
- Differentiated from other periodontal diseases by rapid onset, pain, ulcerated gingival mucosa, and “punched out” crater-like lesions of interdental papillae (1)
- Most common bacteria include Fusobacterium, Prevotella intermedia, and spirochetes. Concomitant infection with Epstein-Barr virus, herpes simplex virus, and type 1 human cytomegalovirus is common.
- Synonym(s): Vincent angina; Vincent disease; trench mouth; fusospirochetal gingivitis; acute necrotizing ulcerative gingivitis (ANUG); necrotizing ulcerative gingivitis (NUG)
- Necrotizing gingivitis, necrotizing periodontitis, and necrotizing stomatitis are classified together under the umbrella term necrotizing periodontal disease (NPD).
- Predominant age: 18 to 30 years in developed countries
- Malnourished children ages 3 to 14 years
- Affects both genders with similar frequency
- Historically, incidence increased in military personnel due to poor battlefield conditions and psychological stress (1)
- True prevalence is unknown, but the probable overall prevalence is <1% (1).
- Overall decline in worldwide prevalence since World War II (1)
- Rare disease in developed countries; however, in recent data, the prevalence rate was 6.7% in Chilean students between 12 and 21 years and approaching 25% in children in sub-Saharan African countries (2),(3).
- Prevalence is low in healthy children up to age 18 years and more common in people aged 18 to 30 years; increased prevalence with malnutrition, immunocompromise, poor oral hygiene, and smoking
Etiology and Pathophysiology
- Impaired host immunologic response due to immunocompromised state or malnutrition
- Disruption of normal oral flora with predominance of invasive anaerobic bacteria (Treponema spp., Selenomonas spp., Fusobacterium spp., and P. intermedia) (2)
- Endogenous bacteria produce metabolites such as collagenase, endotoxins, and fibrinolysin that destroy tissue, leading to loss of integrity and necrosis of the gingival mucosa and interdental papillae (4).
- Stress increases adrenocortical hormones and reduces gingival microcirculation and salivary flow, which alters leukocyte and lymphocyte function. Stress may also result in behavioral changes that lead to poor oral hygiene and malnutrition (2).
- Increased bacterial attachment with active herpesvirus infection
- Immunosuppression (HIV, cancer, chemotherapy, steroid use)
- Underlying systemic diseases
- Lower socioeconomic status
- Tobacco use
- Alcohol use
- Poor oral hygiene, infrequent or absent dental care
- Herpesvirus infection
- Psychological stress
- Appropriate nutrition
- Proper oral hygiene
- Regular dental care
- Prompt recognition and institution of therapy
- Management of medical problems such as cancer and HIV infection
- Smoking cessation
- Stress management
Commonly Associated Conditions
- Seen most commonly in malnourished patients, patients undergoing cancer treatment, or those from underdeveloped countries
- HIV infection
- Vitamin deficiencies
- Tooth loss
- Chronic gingivitis
- Noma (cancrum oris), which can be life-threatening
- Aspiration pneumonia
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