Important Aspects of Necrotizing Ulcerative Gingivitis

This sample essay on Necrotising Ulcerative Gingivitis reveals arguments and important aspects of this topic. Read this essay’s introduction, body paragraphs and the conclusion below.

Acute Necrotising Ulcerative Gingivitis (ANUG) is an acute or recurrent gingivitis of young and middle-aged adults characterised clinically by gingival erythema and pain, fetid odour, necrosis and sloughing of interdental papillae and marginal gingiva which gives rise to a grey pseudomembrane; fever, regional lymphadenopathy, and other systemic manifestations may also be present. According to Keys and Bartold (2000) ANUG primarily affects young adults of 18 to 30 years and is now relatively uncommon.

This disease has been described as far back as the days of Hippocrates and is known by many synonyms. Shiloah (2008) describes ANUG as having a complex aetiology. Various micro-organisms are often present in the areas of the gingival tissues in large numbers and are felt to play a significant but poorly defined role in the pathogenesis. Furthermore, numerous studies have hypothesized on the significance of secondary predisposing aetiological factors, including poor oral hygiene, stress, smoking, alcohol consumption, impaired chemotaxis, general debilitation and malnutrition.

Folayan (2004) argues that with the advent of antibiotics and with improved nutritional status, the incidence had been virtually eliminated in developed countries. However, with the increasing incidence of severe immunodeficiency conditions such as Acquired Immunodeficiency Syndrome (AIDS) the lesion has once more, become a well recognized and often encountered clinical entity in developed countries.

In developing countries, the condition remains a commonly diagnosed clinical lesion because of the persistently poor nutritional status.

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ANUG will not kill an individual and is not contagious, however, the condition if allowed to progress can, particularly in less developed countries, lead to teeth loss and become so painful that the individual may become extremely malnourished which may cause subsequent organ failure and death. Additionally, Church and Elsayed (2002) argue that ‘dental infections are the most common infectious diseases affecting humans worldwide.

The signs and symptoms of acute necrotizing ulcerative gingivitis can include:

1.  Severe gum pain.
2.  Bleeding from gums when pressed even delicately.
3.  Red or swollen gums.
4.  Pain when eating or swallowing.
5.  A gray film on your gums.
6.  Crater-like sores (ulcers) on the gums between the patient’s teeth (interdental papillae).
7.  A complaint of a foul taste in the patient’s mouth.
8.  Bad breath.
9.  Fever.
10.  Swollen lymph nodes around the patient’s head, neck or jaw.

ANUG symptoms can develop quickly. Initially there may be symptoms of a gum problem other than ANUG, such as gingivitis or periodontitis. But all forms of gum disease can be serious and most tend to get worse without treatment. A dental examination should identify the probable diagnosis of ANUG, with a swab taken from the affected area to confirm the presence of ANUG causing bacteria. It is standard practice to immediately prescribe a broad-based antibiotic before the results of the swab are received, to do otherwise may allow the disease to progress considerably.

This can be administered orally in tablet form, although direct application to the infected areas in the form the gel is also common practice. Malnourished individuals are immuno-compromised and this can affect the person’s susceptibility to infection, which would exacerbate the gingival response to the presence of bacterial plaque. The most widely studied nutritional deficit has been lack of vitamin C, or scurvy, in which the gum is bright red, swollen, ulcerated and presents a tendency to bleed.

The patient is likely to first present to a dentist or doctors complaining of severe pain and bleeding, or may present to Accident & Emergency as predisposing factors that are associated with ANUG mean that the patient is unlikely to have a current relationship with a dentist. An initial examination by a Dentist will quickly determine that the patient has gingivitis.

Alpagot (2003) identifies that there are specific micro-organisms that play a role in the disease (described as Necrotizing Ulcerative Gingivitis – NUG) and an initial swab sample of the area, sent for microbiological determination may identify the specific micro-organism. Furthermore, differential diagnosis must be made as similar signs and symptoms present with ANUG and herpetic gingivostomatitis / aphtous stomatitis. The below table shows the path for differential diagnosis to be followed.

Schwartz and Arlin (1986) note that herpetic gingivostomatitis is a contagious viral infection and is therefore treated in a completely different manner.

ANUG is caused by the combination of various factors, including the presence of the relevant micro-organisms such as Bulleidia extructa, Dialister spp, Fusobacterium spp, Streptococcus spp, Veillonella spp. Associated factors / predisposing factors include immuno-compromise, fatigue, emotional stress, smoking and poor oral hygiene. (Shiloah, 2008) Gingivitis is caused by poor or inferior oral hygiene, which allows dental plaque, which is mostly composed of live bacteria and micro-organisms, to accumulate on the teeth.

The plaque is normally concentrated between the teeth and around the necks of the teeth at or below the gum line. The body fights the bacteria or micro-organisms causing the gums around and between the teeth to become inflamed, due to the greater concentration of blood vessels close to the surface, bleeding may occur. If the patients immune system is depressed (through various factors previously mentioned) then, instead of simply becoming inflamed, the bacteria/micro-organisms start to ‘eat’ or dissolve the gingiva tissue. As the bacteria / micro-organisms attack the living tissue, it becomes necrotic, smelling extremely foul and the patient’s breath becomes fetid.

Shiloah (2008) emphasises the importance of early treatment for a full recovery. Whilst Alpagot (2003) proposes that if left untreated ANUG can progress into Necrotizing Ulcerative Periodontitis (NUP), this involves severe damage to the gingiva, periodontal tissue and can cause bone damage; the likely outcome is the loss of teeth in the affected area, which can spread to the whole of the mouth. Furthermore, if still left untreated NUP can progress to necrotizing stomatitis, which can be potentially life threatening.

Necrotizing stomatitis is an extremely destructive infection that stretches beyond the mucogingival junction into the contiguous palato-pharyngeal or mucous tissues. The stages of periodontal disease are shown in the below diagram. If the disease is allowed to progress, teeth will be lost, which may require the patient being treated by a prosthodentist for the fitting of dentures or the insertion of implants. The remainder of the treatment plan would be carried out by a General Dental Practioner, although referral to a specialist Periodontist may be needed if complications or re-infection occur.

Shiloah(2008), Folayan (2004), Keys & Bartold (2000) and Alpagot (2003) all identify the principles of treatment to be the removal of calculus and plaque from the area using ultrasonic descaling. Where the use of local anaesthesia will be required due to the pain that the patient will already be experiencing considerable pain. The use of antibiotics (Metronidazole) is also identified to reduce the actual infection and any possibility of its spreading to the cheeks, gums and the jaw bone.

The use of chlorhexidine mouth washes to improve dental hygiene is also seen as a sensible adjunctive therapy. Subsequently, the minimisation of the associated factors is also beneficial to stop any subsequent recurrence of the disease. This will require considerable lifestyle changes for the patient, ranging from improved dental hygiene, stress reduction and stopping smoking. These are considerable issues and unfortunately the rate of reoccurrence is relatively high. (Mirbod & Ahing, 2000)

There are few ethical issues surrounding the treatment of ANUG, which is relatively inexpensive and straightforward to instigate. However, considerable lifestyle changes will be requested, if the patient fails to change their ways and remove the factors that increase their disposition to this disease the dentist treating the patient can have significant affect on the disease by intensifying dental treatment.

Unfortunately, the patient is not compelled to attend a dentist, although there are numerous programmes associated within UK Dental Schools to give free treatment to people whose socio-economic situation pre-disposes them to the risk factors discussed earlier, there are also significant efforts to improve the dental hygiene of people in Third World countries. The one significant ethical issue is the association of ANUG with HIV+ or AIDS, however the association is not finite. Although, Folayan (2004) argues that in less developed countries, where HIV testing is not always available, the presence of ANUG could be used to identify potential HIV status.

The clinical features of ANUG include necrosis of the crest of the marginal gingival tissues and the interdental papillae. Destruction of tissue is rapid and is associated with spontaneous bleeding, fetid breath and pain. ANUG is caused by infection by micro-organisms and bacteria, allied to associated factors including stress, smoking and poor oral hygiene. ANUG is usually self-limiting, but left untreated, it may spread laterally and apically to involve the entire gingival complex, including the loss of teeth and possible death through infection of further areas.

ANUG is characterized by damage to the interdental papillae. The surfaces of the lesions are often covered with a gray or grayish pseudomembrane. ANUG is generally accompanied by systemic symptoms including high fever, malaise and lymphadenopathy. While the diagnosis of ANUG is usually straightforward, other oral mucosal lesions may be confused with ANUG such as primary herpetic gingivostomatitis and other erosive gingival lesions. ANUG is occasionally indicative of an immuno-compromised system.

Due to the pain associated with ANUG, emergency treatment can sometimes pose a challenge. Management of infection and removal of local factors may be achieved with local anaesthesia and gentle debridement of the affected tissues with ultrasonic and hand instruments. The patient should be instructed to use a chlorhexidine mouthwash and the adjunctive use of antibiotics. If the treatment plan is concluded and effort made to minimise the associated factors of stress, malnutrition, smoking and poor oral hygiene then the prognosis is excellent.