If I suspect acute necrotizing ulcerative gingivitis (ANUG) but there is no necrotic tissue, how should I manage the patient?

Management of Suspected ANUG Without Visible Necrotic Tissue

Primary Recommendation

If you suspect ANUG but cannot identify necrotic tissue on examination, you should still initiate treatment for acute gingivitis with antimicrobial therapy and mechanical debridement, while closely monitoring for disease progression over 24–48 hours. The absence of visible necrosis does not exclude early-stage ANUG, and delaying treatment risks progression to frank tissue destruction 1, 2.

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Diagnostic Approach

Key Clinical Features to Confirm or Refute ANUG

Even without obvious necrosis, look for these cardinal signs:

• Severe gingival pain disproportionate to visible findings 1, 3
• Spontaneous gingival bleeding on minimal provocation 1, 4
• Halitosis (foul breath) 1, 3
• Punched-out appearance of interdental papillae, even if subtle 4, 3
• Systemic symptoms: fever, malaise, cervical or submandibular lymphadenopathy 1, 5

Predisposing Factors That Raise Suspicion

• Recent psychological stress or sleep deprivation 1, 3
• Smoking 5
• Poor oral hygiene 3, 5
• Immunosuppression (HIV, malnutrition, immunosuppressive medications) 1, 3
• Young adult age group or military/high-stress environments 3

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Initial Management Strategy

Immediate Antimicrobial Therapy

Start treatment empirically if clinical suspicion is high, even without visible necrosis:

• Chlorhexidine 0.12–0.2% oral rinse twice daily as first-line local antimicrobial 2, 4
• Systemic antibiotics if the patient has systemic symptoms (fever, lymphadenopathy) or if the disease appears more severe 4
  • Metronidazole is the traditional choice for fusospirochetal infections 3
  • Penicillin-based antibiotics are an alternative 4

Mechanical Debridement

• Perform gentle scaling and removal of superficial plaque/calculus at the initial visit 2, 3
• Avoid aggressive instrumentation in acutely painful areas, but do remove gross deposits 2
• Schedule thorough scaling and root planing once acute symptoms subside 2, 3

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Monitoring and Re-evaluation

24–48 Hour Follow-Up

This is the critical decision point:

• If symptoms improve (reduced pain, bleeding, halitosis), continue conservative management with chlorhexidine rinses and oral hygiene instruction 2, 4
• If symptoms worsen or necrosis becomes visible, escalate to more aggressive debridement and ensure systemic antibiotics are on board 4, 3
• If there is no response to initial therapy after 24–48 hours, reconsider the diagnosis:
  • Rule out other causes of painful gingival ulceration (e.g., herpetic gingivostomatitis, pemphigus, drug reactions) 6
  • Consider referral to a periodontist or oral medicine specialist for biopsy if the clinical picture remains unclear 6

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Common Pitfalls and How to Avoid Them

Pitfall 1: Waiting for Frank Necrosis Before Treating

• Early ANUG may present with pain, bleeding, and halitosis before obvious tissue destruction 1, 2
• Initiating antimicrobial rinses and gentle debridement at the first suspicion prevents progression to irreversible papillary loss 2, 4

Pitfall 2: Over-reliance on Antibiotics Alone

• Mechanical removal of plaque and calculus is essential; antibiotics without debridement will not resolve the infection 2, 3
• Chlorhexidine rinses are highly effective and should be the cornerstone of early treatment 2, 4

Pitfall 3: Ignoring Predisposing Factors

• Address modifiable risk factors (smoking cessation, stress management, improved oral hygiene) to prevent recurrence 1, 3, 5
• Screen for immunosuppression (HIV testing if risk factors present) in patients with atypical or recurrent presentations 1, 3

Pitfall 4: Delaying Surgical Correction

• If interdental craters develop after the acute phase resolves, gingivoplasty may be required to eliminate niches for bacterial recolonization and prevent recurrence 2, 4
• However, surgery is performed only after complete resolution of acute inflammation 2, 4

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Long-Term Maintenance

• Meticulous oral hygiene is the only way to prevent recurrence 4
• Schedule periodic scaling and maintenance visits every 3–4 months initially, then adjust based on patient compliance and disease stability 2
• Continue chlorhexidine rinses intermittently (e.g., 2-week courses every few months) if the patient remains at high risk 2

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When to Refer

• Lack of improvement after 48 hours of appropriate therapy 4, 3
• Systemic toxicity (high fever, severe malaise, rapid progression) suggesting necrotizing fasciitis or deeper infection 6
• Diagnostic uncertainty requiring biopsy to exclude autoimmune, viral, or neoplastic causes 6
• Recurrent episodes despite optimal local management, suggesting underlying immunodeficiency 1, 3