Description

• A distinct form of periodontal disease due to inflammatory infection of the gingiva, characterized by pain, ulcerations, and necrotizing damage to interdental papillae
• Caused by an imbalance of oral flora, resulting in a predominance of invasive anaerobic bacteria, such as Fusobacterium, Prevotella intermedia, and spirochetes
• Concomitant infection with Epstein-Barr virus, herpes simplex virus, and type 1 human cytomegalovirus is common.
• Organisms invade gingiva and interdental papillae and form a gray pseudomembranous exudate.
• Clinical presentation includes pain, fetid breath, gingival ulcerations, bleeding, and interdental papillary necrosis. It is differentiated from other periodontal diseases by rapid onset, pain, ulcerated gingival mucosa, and “punched out” interdental papillary necrosis.
• Synonym(s): Vincent angina; Vincent’s disease; trench mouth; fusospirochetal gingivitis; acute necrotizing ulcerative gingivitis (ANUG); necrotizing ulcerative gingivitis (NUG)
• Necrotizing gingivitis, necrotizing periodontitis, and necrotizing stomatitis are classified together under the umbrella term necrotizing periodontal disease (NPD).

Epidemiology

Incidence

• Predominant age: 18 to 30 years in developed countries
• Malnourished children ages 3 to 14 years
• Affects both genders with similar frequency
• Historically, incidence increased in military personnel exposed to battlefield conditions (1)

Prevalence

• True prevalence is unknown, but probable overall prevalence <1% (1).
• Rare disease in developed countries; however, in recent data prevalence rate was 6.7% in Chilean students between 12 and 21 years and approaching 25% in children in sub-Saharan African countries (2),(3).
• Prevalence is low in healthy children up to age 18 years and more common in persons aged 18 to 30 years. Increased prevalence with malnutrition, immunocompromise, poor oral hygiene, and smoking

Etiology and Pathophysiology

• Impaired host immunologic response due to immunocompromised state or malnutrition
• Disruption of normal oral flora with predominance of invasive anaerobic bacteria (Treponema spp., Selenomonas spp., Fusobacterium spp., and Prevotella intermedia) (2)
• Loss of integrity and necrosis of the gingival mucosa and interdental papillae
• Increased bacterial attachment with active herpesvirus infection

Risk Factors

• Malnutrition
• Immunosuppression (HIV, cancer and chemotherapy)
• Diabetes
• Lower socioeconomic status
• Tobacco use
• Poor oral hygiene, infrequent or absent dental care
• Orthodontics
• Herpesvirus infection
• Psychological stress

General Prevention

• Appropriate nutrition
• Proper oral hygiene
• Regular dental care
• Prompt recognition and institution of therapy
• Management of medical problems such as cancer and HIV infection
• Smoking cessation
• Stress management

Commonly Associated Conditions

• Seen most commonly in malnourished patients, patients undergoing cancer treatment, or those from underdeveloped countries
• HIV infection
• Vitamin deficiencies
• Bacteremia
• Osteomyelitis
• Tooth loss
• Chronic gingivitis
• Dehydration
• Noma (cancrum oris), which can be life-threatening
• Aspiration pneumonia