Acute necrotizing ulcerative gingivitis is an inflammatory lesion of the gum tissue, accompanied by erosion, ulceration and necrosis of the gingival margin. The course of disease is characterized by sharp pain that makes it difficult to eat; bad breath; hyperemia, swelling and bleeding of the gums with the formation of ulcers; an increase in the patient’s body temperature and general malaise. The diagnosis is established on the basis of an examination of the oral cavity, functional tests, bacteriological examination of the separated ulcers, if necessary, radiography data. Treatment includes local oral treatment and general antibacterial therapy.
ICD 10
A69.1 Other infections of Vincent. Acute necrotizing ulcerative gingivitis
Meaning
Acute necrotizing ulcerative gingivitis (erosive-ulcerative gingivitis, ulcerative gingivitis) is a form of gingivitis that occurs with mainly destructive changes in the gum tissue. Pathology occurs less frequently in practical dentistry than other clinical and morphological forms of gum lesion, however, it proceeds much more severely, with the development of local and general changes. Disease is most often diagnosed at the age of 18-30 years. In most cases, the disease is acute, but under certain conditions it can turn into a subacute or chronic phase, as well as ulcerative stomatitis and periodontitis.
Causes
In most cases, acute necrotizing ulcerative gingivitis develops against the background of the previous course of catarrhal gingivitis under the influence of local and general causes. Local predisposing factors include:
- the presence of abundant soft plaque and tartar in the oral cavity, multiple dental caries,
- difficult teething (especially the third molars),
- smoking,
- chronic injuries of the oral cavity with destroyed teeth, sharp edges of fillings, incorrectly fitted orthopedic structures.
In some cases, persistent acute necrotizing ulcerative gingivitis is one of the early symptoms of AIDS. Among the general causes that provoke the development of ulcerative gingivitis, the most important are:
- transferred infectious diseases that reduce the body’s resistance: herpetic stomatitis, acute respiratory infections, angina;
- hypovitaminosis;
- radiation exposure;
- physical and mental fatigue, stress;
- hypothermia;
- diseases of the gastrointestinal tract, endocrine system and blood system (agranulocytosis, leukemia);
- severe food toxicoinfections;
- poisoning with salts of heavy metals.
Pathogenesis
A decrease in local and general protection creates conditions for the activation of microflora (mainly anaerobes and protozoa – fusobacteria, dental spirochetes), whose antigens cause an immune-inflammatory reaction of the gums, microcirculation disorders, increased thrombosis. Destructive processes in acute necrotizing ulcerative gingivitis are caused by the penetration of fusospirillary microflora to the connective tissue base of the gum.
Symptoms
Most often, gum damage is acute. In the prodromal period, lasting 1-2 days, subfebrility, sleep disorders, headache, dyspepsia phenomena may be noted. Against the background of pronounced catarrhal changes in the oral cavity, soreness and itching of the gums, their swelling and stagnant hyperemia, bleeding with minimal mechanical action develops.
Soon, ulcers are formed on a limited area of the gum, in the area of the tip of the gingival margin and gingival papillae, bordered by necrotic areas of white-gray color, which soon cover a significant area of the gum surface. When the necrotic film is removed, capillary bleeding occurs along the edges of the ulcer.
In addition to ulcerative defects, with this form of gingivitis, the appearance of a persistent, fetid putrid odor from the mouth is noted, regardless of the prescription of hygienic procedures. A change in the nature of saliva is characteristic (it becomes viscous and viscous), accumulation of food residues and abundant soft plaque in the interdental spaces. Due to pain in the gums, patients cannot chew food properly, talk, brush their teeth, which further aggravates local manifestations.
In the midst of clinical manifestations, the course of ulcerative gingivitis is accompanied by regional lymphadenitis, intoxication phenomena, and a pronounced violation of general well-being. Depending on the severity of destructive changes, the course of acute necrotizing ulcerative gingivitis can be mild, moderate and severe.
Diagnostics
In most cases, the diagnosis of acute necrotizing ulcerative gingivitis can be made unmistakably on the basis of a characteristic clinical picture. During examination and instrumental examination of the oral cavity, increased bleeding of the gums, the presence of plaque and supra-gingival tartar are revealed. The dentoalveolar joint is intact, there are no dentoalveolar pockets. Additional studies include:
- Evaluation of dental indices. The functional test of Schiller-Pisarev is positive, the hygiene index exceeds the norm, the papillary-marginal-alveolar index is greater than 0.
- Laboratory diagnostics. Important laboratory tests for ulcerative gingivitis are the determination of the level of secretory immunoglobulin A in saliva by ELISA, bacteriological examination of the ulcers released from the surface.
- Instrumental methods. To study microcirculation in periodontal tissues, rheoparodontography is performed. Orthopantomography is performed to assess the condition of the bone tissue.
Acute necrotizing ulcerative gingivitis, as an independent disease, should be differentiated from ulcerative-necrotic gum changes in blood diseases and HIV infection, as well as from periodontitis. The conclusion of other specialists (gastroenterologist, endocrinologist, immunologist, hematologist) on the patient’s state of health is important.
Treatment
Acute necrotizing ulcerative gingivitis therapy consists of local and general measures. Patients are recommended a gentle and fortified diet, abundant drinking. The beginning of treatment is preceded by professional cleaning of teeth, removal of dental deposits, removal of necrotic tissues; if necessary, grinding of sharp edges of teeth that can injure the gum. These manipulations should be carried out very carefully, under adequate local anesthesia. As means of topical therapy of ulcerative gingivitis are used:
- applications of anesthetics (novocaine, lidocaine), antimicrobials (chlorhexidine, metronidazole), proteolytic enzymes (trypsin, chymotrypsin);
- oral baths with antiseptics and herbal decoctions;
- periodontal applications of keratoplastic preparations (for example, oil solutions of vitamins A and E) are performed after the purification of ulcerative defects from necrotic masses.
Medical treatment of acute necrotizing ulcerative gingivitis is supplemented with physiotherapy (UFO, ultraphonophoresis, laser therapy). General therapy of acute necrotizing ulcerative gingivitis includes taking metronidazole, antihistamines, acetylsalicylic acid, vitamins.
Prognosis and prevention
With mild acute necrotizing ulcerative gingivitis, all gum changes are reversible. Moderate and severe course of ulcerative gingivitis can lead to irreversible deformations of the gingival contour and exposure of the necks of the teeth.
In the preventive plan, it is important to exclude all possible local and general factors predisposing to the development of this disease. It is necessary to pay increased attention to oral hygiene, including professional brushing of teeth, timely contact a periodontist in case of catarrhal gingivitis.
Literature
- Hu, J., Kent, P., Lennon, J. M., & Logan, L. K. Acute necrotising ulcerative gingivitis in an immunocompromised young adult. BMJ case reports, 2015.link
- Malek, R., Gharibi, A., Khlil, N., & Kissa, J. Necrotizing Ulcerative Gingivitis // Contemporary clinical dentistry, 8(3), 496–500.link
- Bedi, R., & Scully, C. Tropical Oral Health. Manson’s Tropical Infectious Diseases, 2014.
- Folayan M. O. The epidemiology, etiology, and pathophysiology of acute necrotizing ulcerative gingivitis associated with malnutrition link
- Pindborg J. J. Influence of service in armed forces on incidence of gingivitis // Journal of the American Dental Association, 1951; 42(5), 517–522. link
- Goldhaber P. A study of acute necrotising ulcerative gingivitis // IADR, 1957.
- Kwon, E.-Y., Choi, Y.-K., Choi, J., Lee, J.-Y., & Joo, J.-Y. Effective Management of Acute Necrotizing Ulcerative Gingivitis with Proper Diagnosis and Immediate Treatment // Journal of Korean Dental Science, 2016; 9 (2), 81–89.
- Loeb M., Reid M., Buchanan W., Bain, J. Necrotizing Ulcerative Gingivitis in the Setting of Vitamin B12 Deficiency: ACase Report // Oral health and dental management, 2017; 1-6.
