CHAPTER 50
Gingivitis and Acute Necrotizing Ulcerative Gingivitis
(Trench Mouth)
Presentation
With mild gingivitis, the patient’s gums bleed easily and become red and swollen with increased sensitivity. As symptoms worsen, the gums begin to recede and take on a beefy red, inflamed color.
Further progression leads to the most severe periodontal infection, trench mouth, or acute necrotizing ulcerative gingivitis (ANUG). The patient complains of generalized severe pain of the gums, often with a foul taste or fetid odor. The gingiva will appear edematous and red, with a grayish necrotic membrane between the teeth. The gums bleed spontaneously or on gentle touch, and there is loss of gingival tissue, especially the interdental papillae. The teeth will eventually become loose, and the patient may become febrile and show signs of systemic infection with generalized weakness.
What To Do:
For the more severe forms of gingivitis, prescribe (in order of preference) tetracycline, penicillin V potassium, or erythromycin, 250 to 500 mg qid for 10 days. Do not use tetracycline in children younger than 8 years of age, because it may cause permanent discoloration of the teeth.
For milder cases, instruct the patient to rinse with warm saline every 1 to 2 hours, floss, and gently brush with sodium bicarbonate toothpaste. The use of a power toothbrush with rotating/oscillating motion is better than a manual brush.
In all cases, have the patient rinse his mouth with an antiseptic solution: Use chlorhexidine 0.12% oral rinse (PerioGard), 15 mL (1 tablespoon), swished in the mouth for 30 seconds, and spit out qid. Half-strength hydrogen peroxide may also be used as a mouth rinse.
For comfort, prescribe viscous lidocaine (Xylocaine) 2%. Rinse and spit 1 tbsp q6-8h.
A narcotic analgesic (hydrocodone [Vicodin]) may sometimes be required.
For definitive care and the prevention of periodontal disease, refer the patient for dental follow-up. The dentist will remove any dead gum tissue (débridement) to promote healing and help reduce pain. In severe cases, periodontal surgery may be required to restore gum tissue.
Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to speed the resolution of inflammation when teeth are being cleaned and scaled to remove plaque. With appropriate treatment, patients usually respond dramatically in 48 to 72 hours.
What Not To Do:
Do not obtain radiographs or diagnostic blood work. Gingivitis is a clinical diagnosis, and special testing is required only if the patient is very ill or not responding to initial therapy or when a more serious underlying disease is suspected.
Discussion
Gingivitis and trench mouth are infections of the gum tissue. The most common type of gingivitis involves the marginal gingiva and is brought on by the accumulation of microbial plaques in persons with inadequate oral hygiene. Eventually, the gingiva separates from the tooth, pockets develop, the periodontal ligaments break down, and, along with alveolar bone destruction, the teeth loosen and eventually fall out.
Acute necrotizing ulcerative gingivitis is also known as trench mouth or Vincent angina. This condition is usually seen in those patients who practice very poor oral hygiene, those who are under stress, those who smoke, and sometimes those who have immune deficiencies. The term trench mouth was coined in World War I, when ANUG was common among trench-bound soldiers.
ANUG is different from simple gingivitis in that it is an acute infection of the gingiva, with organisms such as Prevotella intermedia, alpha-hemolytic streptococci, Actinomyces species, or any number of different oral spirochetes. Systemic diseases that may simulate the appearance of ANUG include infectious mononucleosis, leukemia, aplastic anemia, and agranulocytosis.
Treatment of trench mouth is generally highly effective, and complete healing often occurs in a few weeks. Healing may take longer if the patient’s immune system is compromised, such as by HIV/AIDS.
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