OVERVIEW

What is acute necrotizing ulcerative gingivitis?

Acute necrotizing ulcerative gingivitis refers to acute inflammation and necrosis occurring at the gingival margin and interdental papillae. This condition was first reported by Vincent in 1898, hence it is also called "Vincent gingivitis." During World War I, it became prevalent among frontline soldiers, earning it the name "trench mouth." The presence of large numbers of fusiform bacteria and spirochetes in affected areas also led to its designation as "fusospirochetal gingivitis." The incidence of this disease is gradually decreasing in China. Its characteristic features include sudden onset of halitosis, blunting of interdental papillae, and ulcerative necrotic sloughing of the gums. Pain is also a hallmark of necrotizing periodontal diseases.

Are acute necrotizing ulcerative gingivitis and chronic gingivitis the same condition?

No, they are different diseases.

• Chronic gingivitis has a prolonged course, lacks spontaneous pain or bleeding, involves no gingival necrosis, and does not produce a distinctive foul halitosis.

• Acute necrotizing ulcerative gingivitis presents with significant pain, rapid onset, short duration, necrotic lesions confined to the gingival margin and papillae, a characteristic foul odor, and may be accompanied by systemic symptoms in severe cases.

SYMPTOMS

What are the manifestations of acute necrotizing ulcerative gingivitis?

• It commonly occurs in young adults, particularly male smokers. It may also affect children with severe malnutrition or acute infectious diseases such as measles or kala-azar.

• The onset is sudden, with a course lasting from a few days to 1–2 weeks.

• Necrosis of the interdental papillae and gingival margins, especially in the lower front teeth, is a typical feature.

• In the early stage, the interdental papillae become red and swollen, with necrotic ulcers at the tips covered by pseudomembranes. The center of the papilla may appear crater-like, with the buccal and lingual sides remaining intact.

• The lesions may spread along the gingival margins to adjacent teeth, creating a moth-eaten appearance. The pseudomembranes can be easily removed, revealing bleeding surfaces underneath.

• In later stages, after the destruction of the interdental papillae, the gingival margins appear as if cut with a knife. The attached gingiva is usually unaffected.

• The affected gums bleed easily and are noticeably painful, with patients experiencing a sensation of teeth being forced apart or dull pain. A characteristic foul odor is often present. Severe cases may involve low-grade fever, fatigue, and submandibular lymphadenopathy.

How does acute necrotizing ulcerative gingivitis typically progress?

• Initially, the interdental papillae become red and swollen, with necrotic ulcers at the tips covered by pseudomembranes. The center of the papilla may appear crater-like, with the buccal and lingual sides remaining intact.

• Subsequently, the lesions spread along the gingival margins to adjacent teeth, creating a moth-eaten appearance. Upon removing the pseudomembranes, bleeding surfaces are exposed.

• In later stages, the interdental papillae are destroyed, leaving a knife-cut-like appearance.

What are the complications of acute necrotizing ulcerative gingivitis?

• Necrotizing gingivostomatitis: If untreated during the acute phase in immunocompromised patients, necrosis may extend to the lips and cheeks, leading to necrotizing gingivostomatitis.

• Noma (cancrum oris): In cases of extreme immunodeficiency, co-infection with Clostridium perfringens may cause rapid perforation and necrosis of the cheeks, potentially leading to fatal systemic toxicity. This condition is now extremely rare in China.

• Chronic necrotizing gingivitis: Incomplete treatment or recurrent episodes can result in severe destruction or complete loss of interdental papillae, forming a reverse scalloped appearance with separation of the buccal and lingual gingiva.

• Necrotizing ulcerative periodontitis: In immunocompromised patients with delayed treatment, the lesions may spread to periodontal tissues, causing alveolar bone resorption and tooth mobility.

CAUSES

What are the causes of acute necrotizing ulcerative gingivitis?

• The disease is caused by opportunistic infections of various microorganisms, often occurring in tissues and hosts with reduced local resistance. Among them, Fusobacterium, Spirochetes, and Prevotella intermedia are the predominant bacteria involved.

• Pre-existing chronic gingivitis or periodontitis is a significant predisposing factor for this condition.

• The vast majority of patients have a history of heavy smoking.

• Psychological stress, excessive fatigue, and other psychosomatic factors are closely related to the onset of this disease.

• Factors that lower immunity, such as vitamin C deficiency, systemic wasting diseases, and HIV/AIDS, are also associated with the occurrence of this condition.

DIAGNOSIS

How is acute necrotizing ulcerative gingivitis diagnosed?

The clinical manifestations of this disease include sudden onset, gingival pain, spontaneous bleeding, fetid oral odor, and characteristic necrosis of gingival papillae and margins, which can serve as diagnostic criteria. Bacteriological smear examination of the affected area aids in the diagnosis.

What tests are required for patients with acute necrotizing ulcerative gingivitis?

Diagnosis is primarily based on clinical manifestations, with bacteriological smear examination of the affected area performed when necessary.

What conditions should acute necrotizing ulcerative gingivitis be differentiated from?

It must be distinguished from chronic gingivitis, herpetic gingivostomatitis, gingival lesions in acute leukemia, gingival manifestations of AIDS, acute gingival papillitis, and acute multiple gingival abscesses.

TREATMENT

Which department should I visit for acute necrotizing ulcerative gingivitis?

Dentistry department. If the dentistry department has subspecialties, you should visit the oral mucosa department.

Does acute necrotizing ulcerative gingivitis require hospitalization?

No.

How is acute necrotizing ulcerative gingivitis treated?

• In the acute phase, first thoroughly remove necrotic tissue from the gingival papillae and margins under local anesthesia, and eliminate large supragingival calculus deposits.

• Apply 1%–3% hydrogen peroxide solution locally for wiping, rinsing, and repeated gargling. If necessary, apply topical anti-anaerobic agents after cleaning.

• Provide systemic supportive therapy such as vitamin C and protein. Severe cases may require oral metronidazole or tinidazole (anti-anaerobic drugs) for 2–3 days.

• Replace toothbrushes immediately, maintain oral hygiene, and establish good oral care habits to prevent recurrence. Supplement with antibiotics and antimicrobial mouthwashes (e.g., chlorhexidine gluconate mouthwash).

• Address and treat any underlying systemic factors.

• After the acute phase, promptly treat any pre-existing chronic gingivitis or periodontitis.

DIET & LIFESTYLE

What should patients with acute necrotizing ulcerative gingivitis pay attention to in their diet?

Maintain a balanced diet and regularly supplement nutrients rich in protein, vitamins A, D, C, as well as calcium and phosphorus. This can enhance the resistance and immunity of periodontal tissues and the individual against pathogenic factors.

What should patients with acute necrotizing ulcerative gingivitis pay attention to in daily life?

Quit smoking, relax, and actively treat systemic wasting diseases such as blood disorders or severe digestive diseases. Maintain good oral hygiene, brush teeth effectively twice daily (morning and night), and learn to use special cleaning tools like dental floss and interdental brushes.

Does acute necrotizing ulcerative gingivitis require follow-up? How is it conducted?

Yes, follow-up is necessary. Although acute necrotizing ulcerative gingivitis has a short course, it requires thorough treatment. Additionally, pre-existing chronic gingivitis or periodontitis must be treated and managed.

• Chronic gingivitis should be rechecked every six months to a year, while chronic periodontitis requires follow-up every 3–6 months.

• Follow-up includes disease assessment and basic examinations: plaque, calculus, probing depth, attachment level, and bleeding status.

• Necessary treatments, such as full-mouth scaling and oral hygiene guidance, will be provided based on examination results.

PREVENTION

Can acute necrotizing ulcerative gingivitis be prevented?

Yes, it can be prevented. With improved living standards and better personal oral hygiene, the incidence of this disease has gradually decreased. Preventive measures include:

• Quit smoking actively;

• Eat more fresh fruits and vegetables;

• Maintain good oral hygiene habits, including brushing teeth effectively twice a day (morning and night), and learning to use special cleaning tools like dental floss and interdental brushes;

• Undergo professional teeth cleaning once or twice a year to effectively prevent and control chronic gingivitis and periodontal disease;

• Engage in regular physical exercise, maintain a balanced lifestyle, and strengthen immunity.

How to avoid complications of acute necrotizing ulcerative gingivitis?

Boosting immunity, seeking early and standardized treatment, and maintaining strict oral hygiene are effective ways to prevent serious complications.