ANUG

Acute Necrotising Ulcerative Gingivitis

1. Clinical feature and management of ANUG Keumyi Chin

2. Contents Introduction Clinical Feature Diagnosis Management Prognosis Referred books

3. Introduction- ANUG? Definition Microbial disease of the gingiva in the context of an impaired host response. Characterized by the death and sloughing of gingival tissue Presents with characteristics sign and symptoms

4. Introduction Severe necrosis of the free gingival margin, the crest of the gingiva and interdental papilla Vs A. B

5. introduction Also known as TRENCH MOUTH because of its prevalence in the soldiers working in trenches during WW1 . Vincent’s disease Fusospirochetal gingivitis

6. Clinical feature H/o repeated remissions and exacerbation Recur in previously treated Pt Site? - single - group - widespread. Tissue destruction – longstanding disease immunosuppressed pt Bone loss occurs => NU P

7. Clinical feature - oral signs 1 Punched out Crater like depressions at the crest of interdental papillae, may extend up to marginal gingiva

8. Clinical feature -2 Surface of gingival craters is covered by a gray pseudo membrane + necrotic tissue debris Age b/w 15 – 35yrs Pain, interdental ulceration , and gingival bleeding are the diagnostic triad Interdental papillae - inflamed, edematous, and hemorrhagic.

9. Clinical feature -3 Spontaneous gingival hemorrhage after slight stimulation fetid odor and increased salivation Progressively destroy the gingiva and periodontal tissue

10. Clinical feature – oral Sx Constant radiating, gnawing pain intensified by eating spicy or hot foods and chewing Metallic taste to saliva Extremely sensitive to touch Excessive amount of pasty saliva

11. Clinical feature – systemic sign & Sx Regional lymphadenopathy Slight elevation of temp. Severe case - high fever Leukocytosis GI disturbance Tachycardia Loss of appetite Sever in children

12. Stages of progression of NUG Given by pindborg et al. Lesion starts as Erosion of the tip of the interdental papilla The lesion involving entire papilla & marginal gingiva Attached gingiva also involved Exposure of the bone with complete loss of interdental papilla, marginal gingiva , and attached gingiva .

13. Stages of NUG By Horning and Cohen 1. necrosis of the tip of the interdental papilla 2. necrosis of the entire papilla 3. necrosis extending to gingival margin(NUP) 4. necrosis extending to attached gingiva

14. 5. necrosis extending into buccal or labial mucosa( necrotizing stomatitis ) 6. necrosis exposing alveolar bone 7. necrosis perforating skin or cheek( noma )

15. diagnosis Based on clinical findings of gingival pain, ulceration, and bleeding Microscopic examination of a bacterial smear or biopsy specimen does not give specific picture. Histologic picture greatly resembles marginal gingivitis, periodontal pockets, pericoronitis or primary herpetic gingivostomatitis

16. Treatment - objective 1. alleviation of acute inflammation by reducing microbial load & removal of necrotic tissue 2. alleviation of genenralized sx – fever& malaise 3. correction of systemic conditions that contributes to the initiation or progression of the gingival change

17. first visit 1) first visit Goal- reduce microbial load & remove necrotic tissue Complete evaluation of the pt Treatment of acute lesion is primary goal. Topical anesthetic applied 2-3min > gently swabbed. Remove pseudo membrane and nonattached surface debris cleaning with warm water

18. Ultrasonic scaling may be preferable, with minimal pressure against the soft tissue Sub gingival scaling and curettage are C/I at this time This may extend the infection to the deeper tissues and cause bacteremia

19. Antibiotic regimen Amoxicillin 500mg O 6hr 10days Erythromycin 500mg 6hr Metronidazole 500mg twice daily 7days

20. Patient instruction No tobacco . Alcohol. Smoking Rinse -mixture of 3% hydrogen peroxide and warm water every 2hrs or twice daily with o.12% chlorhexidine solution Get adequate rest . Avoid excessive physical exertions Confine tooth brushing to the removal of surface debris with a bland dentifrice and an ultra soft brush An analgesic such as NSAID – ibuprofen

21. Second visit 2 days after the first visit Pt is evaluated for resolution of signs and Sx Lesion - erythematous without a superficial pseudo membrane Shrinkage of the gingiva may expose previously covered calculus, which is gently removed. Instructions are given same as previously

22. Third visit 5 days after the second visit - pt is evaluated for resolution of Sx , and a comprehensive plan for the management of the pt’s periodontal conditions is formulated Hydrogen peroxide rinse – discontinued Chlorhexidine mouthwash – continued 2 or3 wks Supportive therapy ( e.g rest, appropriate fluid intake, soft nutritious diet)

23. Repeat scaling & root planning (if required) Reinstructed – plaque control measures Pt counseling – nutrition and smoking cessation Appointments should be scheduled for t/t Chronic gingivitis Periodontal pockets Pericoronal flap Local irritants Patient is reevaluated after 1 month.

24. Additional treatment considerations Contouring of gingiva as adjunctive procedure nutritional supplement

25. Contouring of gingiva Periodontal plastic surgery Reshaping the gingiva surgically Indication? Loss of interdental bone Irregularly aligned teeth Loss of entire papilla Formation of a shelf like gingival margin Why? To restore normal gingival architecture Esthetic concern

26. Referred books Carranza’s clinical periodontology vol. 1 ( pg. 133 -138) Carranza’s clinical periodontology vol.2 ( pg. 607- 610) Textbook of periodontology and oral implantology (pg. 167-171)

27. Thank you