What are the other Names for this Condition? (Also known as/Synonyms)

• Acute Septic Gingivitis
• Fusospirally Infection/Gingivitis
• Trench Mouth

What is Necrotizing Ulcerative Gingivitis? (Definition/Background Information)

• Necrotizing Ulcerative Gingivitis (NUG) is the mildest of the three forms of necrotizing periodontal disease, with involvement of the gums alone being noted. The other two forms include necrotizing ulcerative periodontitis and necrotizing stomatitis
• Necrotizing periodontal disease is a rare and very destructive form of periodontitis caused by bacteria. It is generally characterized by mouth ulceration and tissue death (necrosis), in addition to attachment loss and bone destruction. The condition has a sudden onset and is more common in HIV-infected individuals and malnourished children
• Necrotizing Ulcerative Gingivitis is described as the initial stage of the condition. If NUG is left untreated, it can progress to the more severe forms. NUG may be an acute condition (termed Acute Necrotizing Ulcerative Gingivitis or ANUG), which when ignored can result in recurrences or a chronic condition
• The risk factors that could predispose an individual to Necrotizing Ulcerative Gingivitis include diseases or disorders that compromises one’s immune system, smoking, inadequately treating gum diseases, diabetes, and the use of certain medication
• A dental professional may be able to diagnose Necrotizing Ulcerative Gingivitis by examining the symptoms, conducting blood tests and oral swab cultures, including via imaging techniques, which may be used to ascertain the extent of damage to the gums, teeth, and surrounding tissue
• The treatment plan for Necrotizing Ulcerative Gingivitis may involve oral cleaning, removal of plaque, to medication administration for bacterial infection. Surgery may be necessary for severe gum damage. The prognosis of the condition depends upon its severity and on the associated condition causing weak immunity (if any)

Who gets Necrotizing Ulcerative Gingivitis? (Age and Sex Distribution)

• Necrotizing Ulcerative Gingivitis is generally seen in individuals with poor immune function
• Reports indicate that the condition is more frequently seen among young malnourished children in developing countries
• It can affect both males and females
• No preference for any race or ethnic group is seen

What are the Risk Factors for Necrotizing Ulcerative Gingivitis? (Predisposing Factors)

The risk factors associated with Necrotizing Ulcerative Gingivitis may include: (In some cases, a combination of risk factors may be present)

• Conditions causing immunodeficiency including HIV infection (or AIDS), blood disorders such as leukemia and neutropenia, cancer, and poorly-controlled diabetes mellitus, are the primary risk factors
• Medications that lead to weak or suppressed immunity such as corticosteroids or cancer drugs
• In children and adults, severe malnutrition and nutritional deficiency disorders
• Smoking and tobacco use: Heavy and chronic tobacco use increases the risk of developing periodontitis to a great extent
• Generally, the older the age, the greater is the risk
• Physical and emotional stress
• Genetic susceptibility: Some individuals are more genetically predisposed and have a higher risk of developing severe forms of gum disease

Other predisposing factors that can cause or contribute to the condition may include:

• A positive family history of periodontal disease
• Early form of gum disease (or gingivitis), which is left untreated
• Changes in hormonal levels due to various health conditions
• Poor oral habits: This facilitates bacterial growth in the mouth thereby increasing the risk for developing periodontitis
• Certain diseases and disorders (heart diseases and rheumatoid arthritis)
• Some individuals can have abnormal teeth structure that may place the individual at a higher risk; this feature may run in certain families

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Necrotizing Ulcerative Gingivitis? (Etiology)

The main cause of Necrotizing Ulcerative Gingivitis is longstanding infection of the gum, teeth, and surrounding tissue, as a result of poor dental hygiene.

• Severe gum infection leads to plaque buildup on the affected teeth (or tooth). When this plaque is left on the teeth for extended periods of time, it hardens, and (usually gram-negative) bacteria in the mouth start to release toxins that damage the gums
• Over time as the plaque builds up, pockets form between the teeth and gums that lead to deeper infection of the gums. Eventually, this infection can spread to the ligaments and bone in the mouth causing degradation of these structures

Moreover, the role of some viruses (CMV and herpes) and fungi (Candida species) in disease development is seen. Due to this, the entire oral mucosa can be affected in addition to the soft tissue around teeth.

What are the Signs and Symptoms of Necrotizing Ulcerative Gingivitis?

The signs and symptoms associated with Necrotizing Ulcerative Gingivitis may include:

• Bleeding, which can take place in the absence of any activity or while brushing/cleaning teeth
• Mild to moderate pain that is always present; the pain increases with pressure (while brushing teeth or chewing food)
• Ulceration and tissue death causing loss of gum edges between teeth (loss of tip); the gum margins are predominantly involved
• White-surfaced necrotic surfaces on gums that bleed on slight trauma
• In a few individuals, foul-smelling breath and fever (low-grade) may be noted
• In some individuals, such symptoms may be immediately preceded by a burning sensation of the gums
• Especially in children, painfully swollen lymph nodes in the head and neck region, when the condition is severe
• Gums have receded such that teeth appear bigger (or longer); abnormal teeth with gaps in between them
• Having loose teeth (attachment loss)
• Increased tooth sensitivity, since the roots may be exposed
• Recurrence of the symptoms due to the presence of persistent ulcers

How is Necrotizing Ulcerative Gingivitis Diagnosed?

The diagnostic tests for Necrotizing Ulcerative Gingivitis may involve the following:

• An oral specialist (dental professional) will examine the symptoms and perform a physical exam on the mouth
• The specialist will look for plaque and tartar buildup and check how tender and how easily the gums bleed
• A thorough analysis of the individual’s medical history and medications being taken
• X-rays of the jaw, head, and neck area can be taken to detect the extent of bony involvement, which is caused by the inflammation
• An MRI scan or CT scan of the head and neck region can be used to detect the extent of the damage to the jaw, head, and neck
• Culture studies through oral swabs
• Tests to determine any underlying illness causing poor immune system such as certain blood conditions and HIV infection

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Necrotizing Ulcerative Gingivitis?

The possible complications associated with Necrotizing Ulcerative Gingivitis include:

• Severe emotional stress from cosmetic concerns
• More severe conditions are seen with HIV infection including:
  • EBV-associated oral hairy leukoplakia (OHL)
  • Kaposi sarcoma of the mouth
  • Oral fungal infection
• Loss of teeth
• Recurrence of the condition, especially when the underlying/associated conditions are not adequately treated
• Progression to necrotizing ulcerative periodontitis and necrotizing stomatitis with involvement of the supporting bone causing teeth severe destruction of the dental structures

How is Necrotizing Ulcerative Gingivitis Treated?

The main goal of treatment for Necrotizing Ulcerative Gingivitis is to avoid further damage to the teeth structure. The treatment may involve:

• Administration of pain-killing medications
• Administering systemic antibiotics (amoxicillin and metronidazole); or doxycycline, for those with penicillin allergy. Medications are required to combat bacterial infection
• Use of anti-viral and anti-fungal medication
• Debridement procedure to remove dead oral cavity tissue
• Scaling and polishing: Oral cleansing treatment by the dental professional and removal of the plaque. However, moderate to severe cases may require a sealant to level the surface of the teeth and avoid further plaque buildup
• Full mouth disinfection: In addition to scaling and cleaning of affected soft tissue, gum and root surfaces, an antiseptic agent (such as chlorhexidine) is used to disinfect the region
• Use of laser therapy and photodynamic therapy (for disinfection and elimination of bacteria)
• Periodontal surgery: For localized destruction and poor response to therapy, invasive procedures may be necessary. An open flap debridement procedure or pocket reduction surgery may be performed
• Surgical treatment for gum destruction include gingivectomy and gingivoplasty procedures
• Undertaking treatment for underlying (immune-suppressing) conditions

Therapy may include conservative measures including proper oral hygiene, stopping smoking, professional cleaning and removing plaque and addressing any factor (such as misaligned tooth or prosthetic dental device) that causes retention of plaque.

Regular visits for dental health checkups and maintaining good oral hygiene, such as brushing and flossing after each meal, are generally recommended.

How can Necrotizing Ulcerative Gingivitis be Prevented?

Currently, the best approach to prevent the development of Necrotizing Ulcerative Gingivitis is to maintain good oral hygiene and adequately treat underlying conditions.

• Good oral hygiene can be achieved by brushing the teeth twice daily and by flossing at least once a day
• Studies indicate that flossing before brushing is beneficial and recommended. Flossing loosens food particles in the teeth, making it easier to remove them with brushing
• Using recommended oral rinses and antiseptic mouthwashes
• Stopping smoking or chewing tobacco and substance abuse
• Create an awareness of the importance of oral health in children, from an early age
• Parents and caregivers are asked to periodically  check the mouth of children for detecting any early signs of gum disease or other dental health issues
• Controlling diabetes through lifestyle changes
• Have a well-balanced diet with lots of fruits and vegetables to avoid any nutritional imbalances
• Avoidance of sweets, sugary or carbonated drinks
• Be physically active and exercise regularly to remain healthy and stress-free; meditation and yoga may be beneficial
• Early and prompt treatment of mild gum disease or any dental health conditions can help prevent periodontitis (which is an advanced stage of gum disease)

Undertake regular visits to a dental health professional for a proper dental check-up and to prevent any tooth-related issues early.

What is the Prognosis of Necrotizing Ulcerative Gingivitis? (Outcomes/Resolutions)

The prognosis of Necrotizing Ulcerative Gingivitis (NUG) is dependent upon the severity of the signs and symptoms and associated complications, along-with the severity of the underlying illness. Typically, the prognosis may be assessed on a case-by-case basis.

• If NUG is treated promptly and adequately, then the outcomes are good in the absence of any underlying systemic disorder or disease
• However, in some cases, irreversible damage of gums and teeth-supporting structures may have occurred. But, the progression of the condition can be arrested
• Following a good oral hygiene regimen after treatment can help prevent recurrences. However, in the presence of underlying immunosuppressive conditions - recurrence or worsening of the condition is known to take place

Additional and relevant useful information for Necrotizing Ulcerative Gingivitis:

In order to prevent periodontitis, gingivitis or gum disease needs to be treated in the early stages.