Acute Necrotizing Ulcerative Gingivitis: Clinical Features and Management
Clinical Features
Acute necrotizing ulcerative gingivitis (ANUG) presents with three pathognomonic features: painful gingival ulceration, spontaneous gingival bleeding, and characteristic necrosis of the interdental papillae. 1, 2
Primary Clinical Characteristics
- Interdental papillae necrosis with characteristic "punched-out" appearance is the most diagnostic feature 1, 2
- Severe gingival pain that is disproportionate to clinical appearance 1
- Spontaneous gingival bleeding without provocation 2
- Halitosis (foul breath) due to tissue necrosis 1
- Pseudomembrane formation covering ulcerated areas 3
Secondary Clinical Features
- Systemic manifestations including fever, malaise, and regional lymphadenopathy may be present 1, 2
- Rapid onset and progression distinguishes ANUG from chronic periodontal disease 1, 4
- Metallic taste reported by patients 3
Predisposing Factors to Assess
- Immunocompromised status (HIV infection is a major risk factor) 1, 2
- Psychological or physiological stress (historically common in military personnel) 2, 4
- Poor oral hygiene and pre-existing gingivitis 2, 3
- Malnutrition and poor living conditions 2, 3
- Smoking and substance abuse 3
Microbiological Profile
- Predominant anaerobic bacteria: Bacteroides intermedius and Fusobacterium species 2
- Spirochetes are predominantly associated with the infection 3
- Mixed aerobic/anaerobic infection with majority gram-negative organisms 2
Management Algorithm
Phase 1: Immediate Acute Phase Treatment (Day 1)
The primary goal is to halt disease progression immediately and control pain through gentle mechanical debridement combined with antimicrobial therapy. 1, 3
Local Mechanical Therapy
- Gentle superficial debridement of necrotic tissue using ultrasonic scalers or hand instruments 3
- Avoid aggressive scaling during acute phase as it increases pain and tissue trauma 5
- Remove only loose necrotic tissue and superficial calculus 5, 3
Antimicrobial Mouthwash Therapy
- 0.12% chlorhexidine gluconate mouthwash 10 mL twice daily as first-line antiseptic 5, 3
- Dilute chlorhexidine by 50% if soreness is excessive 6
- Hydrogen peroxide 1.5% mouthwash 10 mL twice daily as alternative antiseptic 6
Pain Management
- Benzydamine hydrochloride oral rinse every 3 hours, particularly before eating 6, 7
- Viscous lidocaine 2% (15 mL per application) for topical anesthesia if benzydamine insufficient 6, 7
Systemic Antibiotic Therapy
- Metronidazole 400-500 mg three times daily for 3-5 days for severe cases with systemic involvement 3
- Amoxicillin 500 mg three times daily as alternative or in combination for severe infections 3
- Reserve antibiotics for cases with fever, lymphadenopathy, or extensive tissue involvement 3
Phase 2: Subacute Phase Treatment (Days 3-7)
Once acute symptoms subside, transition to more thorough mechanical therapy while maintaining antimicrobial support. 1, 5
- Comprehensive scaling and root planing after acute inflammation resolves 5
- Continue chlorhexidine rinses for 2-4 weeks total 5
- Oral hygiene instruction with emphasis on gentle brushing technique 3
- Nutritional counseling to address deficiencies 1
Phase 3: Treatment of Pre-existing Conditions (Weeks 2-4)
Address underlying chronic gingivitis or periodontitis that predisposed to ANUG. 1
- Complete periodontal debridement of all quadrants 1
- Professional prophylaxis every 2-4 weeks initially 5
- Address modifiable risk factors including smoking cessation and stress management 1, 3
Phase 4: Surgical Correction (Months 2-3)
Surgical intervention is reserved only for persistent gingival craters that do not regenerate spontaneously. 5
- Allow 6-8 weeks for spontaneous papillae regeneration before considering surgery 5
- Gingivoplasty to eliminate residual craters only if conservative therapy fails 1, 5
- Avoid premature surgical intervention as papillae may regenerate with periodic scaling and antimicrobial rinses alone 5
Phase 5: Maintenance (Ongoing)
Long-term maintenance prevents recurrence and ensures stable outcomes. 1
- Professional cleanings every 3-4 months indefinitely 1
- Daily chlorhexidine rinses during stress periods or illness 5
- Monitor for recurrence at interdental papillae 1
Critical Pitfalls to Avoid
- Do not perform aggressive debridement during acute phase as this increases pain and tissue damage 5, 3
- Do not delay treatment as ANUG can progress to necrotizing ulcerative periodontitis (NUP) or noma without intervention 2
- Do not perform elective surgery on acute lesions; wait for resolution and assess for spontaneous regeneration 5
- Do not overlook systemic factors particularly HIV status in patients with severe or recurrent ANUG 1, 2
- Do not prescribe antibiotics routinely for mild cases; reserve for severe infections with systemic involvement 3