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Oral & Dental Health

Acute Necrotizing Ulcerative Gingivitis/Periodontitis/Stomatitis (ANUG)

An acute, painful infection of the gingiva characterized by necrosis and ulceration of the gingival papillae. Necrotizing Periodontitis involves attachment loss, Necrotizing Stomatitis extends into adjacent tissues, and Noma (Cancrum Oris) is the most severe form with extensive facial destruction.

Also known as: ANUG, Trench Mouth, Vincent's Gingivitis, Necrotizing Periodontitis, Necrotizing Stomatitis, Noma (severe form), Cancrum Oris (severe form)

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Referral and warning signs

When to refer

Refer to Dentist/Periodontist (HC4/RR) for debridement, management, and follow-up. URGENT referral needed for: Signs of Noma/Cancrum Oris, Severe systemic symptoms, Rapid progression, Poor response to initial treatment, Immunocompromised patients.

Red flags

  • Rapid tissue destruction extending beyond gums.
  • Bone exposure.
  • Signs of Noma (facial swelling, necrosis).
  • Severe systemic illness / sepsis.
  • Airway compromise (if swelling extensive).

Signs and symptoms

  • Sudden onset of severe gum pain.
  • Spontaneous gum bleeding.
  • Characteristic: Punched-out, crater-like ulcers covered with greyish pseudomembrane, especially affecting the interdental papillae.
  • Necrosis (tissue death) of gingival margins.
  • Foul breath (fetor oris) / Metallic taste.
  • Increased salivation.
  • Sensation of teeth being wedged apart.
  • Fever, malaise, lymphadenopathy (often present).
  • In severe forms (stomatitis/noma): rapid extension to involve cheek mucosa, bone exposure, eventual tissue sloughing and facial disfigurement.

Risk factors

  • Poor oral hygiene.
  • Pre-existing gingivitis.
  • Psychological stress.
  • Smoking.
  • Malnutrition (especially protein and vitamin deficiency).
  • Immunosuppression (especially HIV infection).
  • Debilitating systemic illness.
  • Poor sleep.

Diagnosis

Clinical assessment

Based on characteristic clinical findings: painful, bleeding gums with necrotic, ulcerated interdental papillae covered by a grey pseudomembrane, often accompanied by foul odour and systemic symptoms.

Differential diagnosis

  • Primary Herpetic Gingivostomatitis (viral vesicles preceding ulcers, more diffuse).
  • Chronic Gingivitis/Periodontitis.
  • Agranulocytosis / Leukemia (oral ulceration).
  • Specific infections (Syphilis, TB).
  • Desquamative gingivitis (autoimmune).

Investigations

  • Usually clinical diagnosis.
  • Consider HIV testing.
  • Assess nutritional status.
  • FBC (if systemic illness severe).

Diagnostic criteria

Clinical triad of gum pain, bleeding, and characteristic interdental papillary necrosis/ulceration.

Management

Non-pharmacological management

  • Gentle Debridement: Careful removal of necrotic tissue and pseudomembrane using cotton pellets soaked in hydrogen peroxide or saline (may require topical/local anaesthesia).
  • Oral Hygiene: Gentle brushing once acute phase subsides, emphasize meticulous hygiene long-term.
  • Nutritional Support: Address malnutrition.
  • Stress Reduction / Smoking Cessation.
  • Management of Underlying Conditions (HIV, Diabetes).

Pharmacological treatment

  • Antimicrobial Mouth Rinses: (Essential to reduce bacterial load and aid debridement)
  • - Hydrogen Peroxide 3% diluted 1:1 with water (or 6% diluted 1:4) rinse TID. (LOC: HC2+)
  • - Chlorhexidine 0.12% or 0.2% mouthwash BID. (LOC: HC2+)
  • - Warm Salt water rinses TID.
  • Systemic Antibiotics: (Target anaerobic fusospirochetal complex)
  • - Metronidazole 400mg PO Q8H for 5-7 days. (Child: 10-12.5mg/kg Q8H). (LOC: HC2+)
  • - PLUS/OR Amoxicillin 500mg PO Q8H (Child: 25mg/kg Q8H) - especially if deeper tissue involvement or systemic signs pronounced.
  • Analgesia: Paracetamol or NSAIDs.
  • Management of Noma: Requires hospital admission, IV antibiotics, extensive debridement, nutritional support, and later reconstructive surgery.

Monitoring

Close follow-up (e.g., 24-48 hours initially) to assess response to treatment, continue debridement. Address underlying risk factors.

Complications

  • Rapid destruction of gingival tissue and periodontal attachment (bone loss).
  • Tooth loss.
  • Progression to Necrotizing Periodontitis or Stomatitis.
  • Noma (Cancrum Oris) - severe facial disfigurement, high mortality.
  • Systemic spread of infection (rare).

Prevention

  • Maintain good oral hygiene.
  • Adequate nutrition.
  • Stress management.
  • Smoking cessation.
  • Management of systemic conditions (HIV).

Patient education

  • Explanation of the acute infection and its causes/risk factors.
  • Critical importance of meticulous oral hygiene.
  • Need for debridement and antibiotics.
  • How to use mouth rinses.
  • Importance of addressing risk factors (smoking, stress, nutrition, HIV).
  • Need for follow-up dental care to manage underlying gum issues.

Uganda-specific notes

ANUG is strongly associated with HIV infection and malnutrition in Uganda. Early recognition and treatment with Metronidazole +/- Amoxicillin, debridement, and hygiene measures are crucial. Noma is a devastating complication seen in severely malnourished children.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.2.6

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